When health insurance won’t cover your pregnancy

A few weeks after my first prenatal exam, I got a letter from my health-insurance company. It informed me that my pregnancy would not be covered because I wasn’t insured at the time of conception. The fact that I did not know that I was pregnant at the time of conception was irrelevant. I had a complicated pregnancy with preeclampsia, which raised my blood pressure and caused my kidneys to function poorly. Because I required a month of hospitalization and numerous tests, the costs were exorbitant. But I was fortunate. My baby was healthy and my previous insurance company paid the initial bills through the waiting period.

For Tina (right), in Pittsburgh, the solution was not so easy. She, too, developed preeclampsia, as well as gestational diabetes, another high-risk condition. About five months into her pregnancy, she began receiving doctors’ bills and was informed that her individual insurance policy did not cover maternity care. In addition to the mounting financial stress, her mother was diagnosed with cancer, and she had a death in the family. The emotional toll did not help her medical condition. But a newspaper reporter took on her story, and, in the end, the insurance company agreed to cover her bills.

But what about all the women who are not as lucky as Tina and I am?

Gardasil vaccine: Don’t let the headlines fool you

Each time a new vaccine is released a flurry of stories soon follows, featuring tragically ill patients and implying a cause-and-effect relationship between the vaccine and the illness. This time media attention is focused on Gardasil, the vaccine that prevents sexually transmitted infections for four strains of human papillomavirus (HPV) that cause roughly 70 percent of cervical cancers and 90 percent of genital warts. Since the vaccine was approved in 2006 for females ages 9 to 26, there have been more than 26 million doses given worldwide and nearly 16 million of those distributed in the U.S. Today the news media are focusing on adverse events, including 31 reported cases of Guillain-Barré syndrome (GBS) collected by the Centers for Disease Control and Prevention’s Vaccine Adverse Event Reporting System (VAERS) between June 2006 and April 2008. As a neurologist, I am well aware of how devastating this usually transient paralytic illness can be, but I was nevertheless outraged when I read careless headlines earlier this month, including: "Is HPV Vaccine to Blame for a Teen’s Paralysis?" and "HPV Vaccine Linked to Teen’s Paralysis?"

"In general, when it comes to vaccine-related illnesses, it's important to distinguish among observations that are true, true and unrelated, and events that are causally linked," says Kenneth C. Gorson, M.D., a neuromuscular specialist and professor of neurology at Tufts University School of Medicine. "In order to investigate whether the vaccine is in fact related to GBS, there needs to be a careful epidemiological study assessing the prevalence of GBS in a cohort of the population who has been vaccinated compared to a matched, unvaccinated control group." He also says that GBS cases have to be verified (only 10 of the 31 have been confirmed by the CDC), and that the illness must occur within six weeks of vaccination to be considered vaccine-related.

Prescription for disaster

Diabetes, epilepsy, and high blood pressure are treatable conditions thanks to medications that can keep them under control. But for many Americans, like Kathy from Earlville, N.Y., who doesn’t have health insurance and doesn’t quite qualify for Medicaid, they are simply unaffordable. As she put it, she’s committing suicide slowly because diabetes affects all her organs. Sacrificing her health because she can’t afford her medicine is something no one should have to do. And yet this unfortunate scenario is playing out all too often from coast to coast.

I saw another troubling example of this in a recent e-mail forwarded to me by a neurologist colleague. The young woman wrote to say that she took two types of epilepsy medicine for almost 10 years, which cost her $45 a month. But with a new job came a new health plan, and now she says she has to pay more than $450 a month for the same drugs. She says she has to choose which bills to pay: rent, food, gas for her car, or medicine. “I have no money,” she writes. The worst part is that she is no longer taking any medicine for her epilepsy because she can’t afford the brand-name drugs, and generic versions aren’t available. She says she has applied for a prescription drug assistance program but has been denied because she has health insurance.

A recent USA Today/Kaiser Family Foundation/Harvard School of Public Health survey revealed that in the past two years, 29 percent of respondents have not filled a prescription because of the cost, 23 percent have skipped doses or cut pills in half to make a prescription last longer, and 16 percent say payment for prescription drugs is a serious problem for them and their families.

Even those with “good” prescription plans have seen a rise in co-payments, with average co-pays rising from $8 to $11 for generic drugs, $15 to $22 for preferred drugs, $20 to $35 for nonpreferred drugs, and fourth-tier drug co-pays rising from $48 to $74. Prescription drug assistance programs are designed to help people who don’t have health insurance or drug coverage pay for their prescription medicines, but people like the woman with epilepsy, who has a poor plan, and Kathy, who has some assets, fall between the cracks.  As the Cover America Tour is finding out, flaws in our health-care system have placed many people in no-win situations. Which would you choose to forgo…food, rent, or medications?

—Orly Avitzur, M.D., medical adviser to Consumers Union

When it's smart to e-mail your doc—and when it's not

As more and more doctors and patients exchange e-mail, protocols for a good, workable electronic relationship are being developed. E-mail "conversation" is great for non-emergency matters: problems or advice about a chronic disease, an appointment, test results, clarification of some item that came up during an office encounter, an overlooked question, a medication side effect, or any question requiring only a yes or no answer. And most often, it's a direct link to your doctor, without a telephone intermediary such as a nurse or assistant.

If you are interested in e-mailing your doctor, ask if he or she uses e-mail to communicate with patients, and if not, why not? If you do get that address, here are some ways to make your cyber-relationship run smoothly:

• Keep messages brief and to the point. A laundry list of concerns is better addressed in an office visit. It also helps if the subject line of your e-mail contains some clue as to its content, such as "medication question from YOUR NAME."
• Ask about security. Discuss security with your doctor beforehand to make sure it is adequate on both sides. Find out if you doctor uses special encrypted messaging software.  Ask if anyone else in your doctor's office reads his or her e-mail. If the email is on your work computer, your employer may have the right to access it. Your doctor may also ask if your home email is private or shared with others. HIPAA privacy laws would preclude the use of the latter.
• Use proper identification. Many e-mail addresses provide no clue as to the sender's real name, so be sure to sign your messages with yours. And since practices frequently include patients with duplicate names, also include your birth date and address.
• Know your doctor's turnaround time. Is he or she online practically every waking minute, or only checking messages every couple of days? The answer will help you determine when you should call rather than e-mail.
• Reread your message carefully. And recheck the To: box. Once you hit that "send" key, it's gone.
• Print out and save your e-mail questions and answers. Your doctor should do the same so they become part of your medical record.
• Never, ever use e-mail for an urgent or emergency situation. That's why 911 was invented.

—Marvin M. Lipman, M.D., chief medical advisor

Medical insurance booby traps

When Austin, Texas resident, Bill (right), went to the emergency room for an injury, he did the right thing. He called his insurance company and confirmed that the hospital was in-network. As he told our Cover America Tour, after receiving the bill, he discovered that the doctor who treated him was out of network. Andrea, from Murphy, Texas, was also faced with a large bill after her infant son was treated in the neonatal intensive care unit by a physician who, it was later revealed, did not participate in her plan. Anyone can fall victim to our fragmented health delivery system. It's happened to me more than once.

I'd like to consider myself a savvy health care consumer—I run a medical practice and handle all my family’s health insurance claims. But when I went for an annual mammogram and received a bill for the radiologist’s fee a few weeks later, I learned that the radiologists had left my plan much as Bill did. No mention had been made by the out-patient billing department when I called for pre-admission clearance (and confirmed my insurance information), by the radiology department (when I arrived and filled out more insurance forms), nor, needless to say, by my insurance company through a letter of notification. And when I had a Pap smear at my gynecologist’s office, and blood work drawn at another hospital just two years ago, I discovered again that I wasn’t covered. The analyses were performed by non-participating vendors even though I had made sure that the hospital phlebotomy lab and my doctor were in-network.

Father’s Day Special—savings include lives and limbs

Many men—and especially those of you who read Consumer Reports—take great care of their cars. You know that, if properly serviced at specified intervals, they can last a very long time. You check the engine oil monthly, wash the body every week, service the brakes and rotate the tires. You take your automobiles in for regular tune-ups and for repair at the first sign of trouble. So why should the average male—be he husband, father, brother, or son—treat his body with any less care?

In an American Academy of Family Physicians (AAFP) Harris Interactive survey of over 1,000 men taken last June, more than half admitted that they hadn’t seen their primary care physicians for a physical within the past year. Thirty-six percent admitted that they put off going to a doctor until they got really sick and 23% thought that because they were healthy they have no reason to make an appointment.

But by avoiding the doctor you just lose the opportunity of catching problems early. Conditions that could have been prevented—kidney damage from high blood pressure, heart disease from high cholesterol, or circulation problems from diabetes, to name a few—may become life-threatening when discovered late. Many diseases are "silent" and, if you wait until you get sick, it may be too late.

Health Ratings Center: In response to your questions

I wrote a couple of weeks ago about the need for a Health Ratings Center and had some great reader feedback. In response, I'm addressing a couple of the questions here.

Steve, we are currently evaluating the feasibility of rating doctors, as it's a topic we know could help consumers greatly. There is good existing information on certain surgeries and on doctor groups that could provide some basis, however it is very difficult to rate individual doctors because there's a lack of consistent and accurate doctor data.

There are some exceptions, though, and we are hoping that these exceptions will help us move in the right direction.

There are various websites that provide user reviews of doctors. While this anecdotal information can provide interesting information, and might at some point be part of a Consumer Reports Health community, it is unlikely to be part of a Health Ratings Center initiative.

You pose an interesting question about newsletters, Wayne. For full disclosure, we publish a health newsletter, Consumer Reports onHealth. We are aware of the many health newsletters out there and frankly, we share your concerns. For us, the most important issue for credibility is whether a publication bases its advice on evidence and expert opinion and is independent of industry influence. We're concerned about newsletters that are mainly a vehicle for selling products or espousing a single point of view that is not based on available scientific evidence. If you feel this is the case or if advertising is a prominent part of a newsletter you should exercise caution just as you would with any commercial publication.

There are a variety of information products we are considering rating so your comment is helpful in encouraging those discussions. Thanks, and I look forward to hearing any further suggestions.

—John Santa, MD, MPH, Director, Consumer Reports Health Ratings Center

Cialis AdWatch—deconstructing the ED drug ad

The United States Coast Guard is rightly proud of its longstanding motto, Semper Paratus (Latin for Always Ready). But the term took on a new meaning in January, when the Food and Drug Administration (FDA) approved the new once daily 2.5 mg and 5mg doses of tadalafil (Cialis), one of three oral drugs available for the treatment of erectile dysfunction. The drug, manufactured by pharmaceutical giant Eli Lilly and the third in a new class of drugs known as phosphodiesterase (PDE) inhibitors, was originally approved in 2003 for use on an "as you need it" basis.

In this, our third video in the Consumer Reports AdWatch series, we dissect a recent Cialis ad and tell you some information that the ad doesn't. Our accompanying Web piece also outlines some preventive measures you should consider before asking your doctor for a drug treatment.

Affectionately known as "The Weekender," Cialis differs from its two predecessors, sildenafil (Viagra) and vardenafil (Levitra) by having a chemical structure that prolongs its effect for up to 36 hours. That's more than seven times longer than its brother drugs. The advertising moguls (Eli Lilly spent close to $152 million promoting Cialis to the public in 2007) explain the drug's longer half-life by touting the advantages of sexual spontaneity and avoiding having to plan sexual relations in advance. And now, with the approval of the daily dose, the impotent male can be semper paratus for any opportunity.

Getting a Second Life—in an online health community

A few weeks ago, I was invited to the home of a patient with multiple sclerosis (MS). Dressed in a belted black suit with a chic pink scarf tied around her neck, Kat es corted me into her cabin.  The room was warm with soft pillows, Native American artwork and colorful Southwestern carpets. A fire was crackling in the stone hearth and incense was burning nearby. I sat down on one of the mats arranged in a large circle. Soon, twenty other members had joined us, one in a wheelchair, and all dressed with   flair. Wearing a T-shirt and blue jeans, I stood out as the newbie. Although I had attended quite a few support groups over the years—many of them online—none had prepared me for this mind-bending experience. It was my first day at Second Life, a three-dimensional virtual community, and on my computer screen, my avatar self was still learning how to walk and talk.

Launched in 2003, Second Life has a medical facility built in partnership with Cisco, and a Virtual Healthcare Island created by IBM. As of April 1st, the site had over 6 million unique registered users, 50,000 to 60,000 of whom are online at any given time. At Second Life, real physicians collaborate on research projects, medical students receive training, and robust health information libraries are staffed by professional librarians.

On my second day I attended a stroke lecture given by Lawrence Whitehurst, MD, FAAFP, a family practitioner and founder of the Second Life Medical Association (SLMA). It included a thorough discussion of warning signs, risk factors and treatment, and was quite similar in content to other talks on stroke prevention that I had been to in the past. Instead of receiving questions from a live audience, Dr. Whitehurst fielded multiple instant messages asking questions like: Is an aneurysm a type of stroke? What is termed a stroke rather than a TIA (transient ischemic attack)? An Ob/Gyn physician inquired, "So what are the latest thoughts on risks related to the oral contraceptive pill?"

Why do we need a Health Ratings Center?

At Consumer Reports we've been rating health products and services for over 70 years including treadmills, supplements, HMOs and gyms. More recently we've added Treatment Ratings for hundreds of conditions, Best Buy Drugs and Natural Medicine Ratings.

Health is part of our mission and because the health marketplace is complicated it often serves up differing opinions about what choices are best. To help you make decisions, you need clear information that’s free of advertising, conflicts of interest and other types of bias. With big money behind virtually every aspect of your health care, you need no-nonsense and trustworthy information to help you be a savvy health care consumer and to help you communicate more effectively with your doctor.

That's why we've created the Consumer Reports Health Ratings Center. The Health Ratings Center will collaborate with top researchers and world-class experts on topics ranging from hospital safety and quality to maternity care and prevention. With these experts, the Center will analyze and assess data and information, then present it in a visual rating or comparison you can use when making important health care decisions.

The first project for The Health Ratings Center is a web tool based on the Dartmouth Atlas of Health Care data on the inpatient care of patients with severe chronic illnesses. As I've written about before, more treatment isn’t always the best option, and this tool allows you to compare how much care you’ll get at hospitals where you live.

What's in their medicine cabinet?

What makes medicine cabinets content so interesting that a rumored 40% of us resort to snooping in them while at parties? This curiosity has been the subject of serious relationship advice (don’t commit until you know), intense dramas (with subsequent overdoses) and a variety of sitcoms.

When Jerry Seinfeld snuck a peek in his date’s medicine cabinet, he discovered fungicide and before letting the romance go any further, he set out to uncover her ailment. In a Southwest Airlines commercial, a woman reaches inside the cabinet only to have all the shelves collapse. Even Oprah acknowledged the temptation when she let viewers on a tour of her Chicago apartment take a look at her guest bathroom’s medicine cabinet.

Like Oprah, more than 6,000 Consumer Reports readers were also willing to share the content of their medicine cabinet and the results were as follows:

Drug money—and the price you could be paying

Dr. John Santa discusses the financial relationships between doctors and the pharmaceutical industry.

What’s wrong with promoting prescription drugs to doctors?

If you notice a lot of pens and scratch pads in your doctor’s office with logos on them, if you’re frequently offered free samples or often notice drug company "detailers" in the waiting room, you may be more likely to be treated with a new brand-name drug when an older standby would be just as good, cheaper, and maybe even safer. Free drug samples can end up costing more in the long run because eventually a prescription has to be written for that expensive drug. Those logos are very effective for brand-name recall. You might want to ask about your doctor’s policy on seeing drug representatives. I used to work in a big practice where about one-quarter of the doctors regularly saw drug representatives. They were more likely to prescribe the latest and most expensive drugs. But that’s just the start of the substantial and influential financial relationships between doctors and the pharmaceutical industry.

What more is there?

Physicians could virtually exist on the free meals delivered to their offices on a daily basis if they wanted to. One pharma detailer wrote an article about setting up a latte cart to get her foot in the door; doctors were more than happy to exchange a few minutes of their time for a free latte. Or you get invited to dinner at a nice restaurant for a "medical education" speech, and at the end of the night are handed an envelope with $100 inside. Or you participate in "research" that drug companies farm out to doctor’s offices. You don't have to do anything except follow their protocol, and they'll pay you $300 or $400 for every patient you put in the study. Doctors deny it, but the evidence is clear that these financial relationships lead to significant increases in prescribing and sales. If they didn't, the drug companies wouldn’t spend an estimated $20 billion a year on them.

Have you ever taken drug money?

Mother's Day: Stay healthy—heed your own advice

Mothers give their children quite good advice: eat your breakfast, go to bed, and, when needed, take your medicine. We schedule yearly visits to the pediatrician, call for appointments at the first sign of infection, and make sure that vaccinations are kept up-to-date.

But when it comes to our own health, we often toss all wisdom aside, getting too little sleep, eating on the run forgetting to schedule an annual physical. And when I ask patient-moms which regular doctor they see, most will admit they haven’t gotten around to finding one yet. We could feel lousy for weeks before we seek care, and by the time we schedule a visit, we’re at the end of our ropes.

A few years back, I ignored a minor shoulder injury. Even though the pain was severe enough to wake me up at night, I continued to carry a heavy laptop for months. When I finally saw an orthopedist, he told me I had an enormous bone spur. I could have avoided the damage if I had gone to him earlier and followed a few easy restrictions. All the sleep deprivation also took its toll—I was tired at work, and at home, too.

When we’re sick and run down, our patience runs thin, and our mothering tends to suffer along with our health. As they say before takeoff, put your own oxygen mask on first—you’ll be less help to your children if you’re not ready yourself. So, mothers, get enough rest, eat balanced meals, and don't forget to take your calcium. And for this Mother’s Day focus on health—if not for yourself, for your family’s sake.

—Orly Avitzur, M.D., medical adviser to Consumers Union

Read more on women's health at our Women's Condition Center—and take a peek at gift ideas for Mother's Day.

What’s in your medicine bottle? Your prescription may not be what the doctor ordered!

Just last week, two patients asked me how they could tell if they were getting the right drug. Their pharmacy benefits plan had mailed them their refills, but the drugs looked totally different. In the case of my migraine patient, Leslie, 80 milligrams of Inderal® was now a blue capsule whereas in the past it had always been a yellow tablet. "How do I know if I’m getting the right thing?" she asked.

It's a good question and consumers have a right to be concerned. Years ago when my brother developed bronchitis, he was given a script for the antibiotic Vibrax® (a drug no longer prescribed) by our family physician. By the time he had finished the bottle, his cough was worse and he was even more run down, so the doctor's office phoned in another course of treatment. It wasn't until my brother picked up the pills from the pharmacy and saw that they looked different that he discovered that he had been taking Librax®, a sedating medication, by mistake—the "V" on the original prescription had been mistaken by the pharmacist for an "L."

Thirty years later, more than three-fourths of physicians are still scribbling prescriptions and look-alike and sound-alike errors are still being made. Although digital tools such as handheld prescribing devices and electronic health records are now available, only about 20 percent of us use them, and alas, our handwriting has not improved.

5 ways to cut costs while staying healthy

The government may not want to use the "R" word, but there’s no question that the economy is in trouble. It's affecting all of us and causing us to tighten our belts. When it comes to medical care, telltale signs come early. Reports of increasing numbers of elective surgeries have been attributed to fear of potential loss of insurance coverage, similar to when rumors of company cutbacks surface. Routine and preventive care visits decline, and in my practice, I see more patients forgoing referrals to physical therapy because of the frequent co-pays.

Taking care of your health during a recession poses quite a challenge. If you’re healthy, you want to stay that way, and if not, you want to make sure that your treatment is not jeopardized. So what can you trim without sacrificing quality? Consumer Reports has a wealth of information on how to get the best value when it comes to your health.

• Ask your doctor about pill splitting. It can save money because pharmacies often charge the same amount for a particular drug regardless of its dose. There’s no harm in splitting pills as long as your doctor agrees with the idea, you learn how to do it properly, you split only pills that are scored, never split extended- or continued-release tablets, and use a safe pill splitting device, available at most pharmacies for around $5.
• Look into a prescription assistance program. If you need medicines (especially for a chronic condition) and have no health insurance, limited insurance, or lack drug coverage under your current health insurance policy you may qualify for assistance.
• Consider switching to a generic prescription drug. Consumer Reports Best Buy Drugs can help you find the most safe and effective drug for your condition and give you the best value for your health. Not only are generic medications proven and more affordable alternatives, but the newest brand name drugs have less of a track record for safety.
• Put your fancy gym club membership on hold. As the Consumer Reports survey on health clubs showed, you can pay up to $95 per month for name brand chains and still not get a quality experience. Try out your local Y or community center—which got higher marks in our survey than most big chains—or change some habits: take the stairs, park at a distance, walk the dog. As an inexpensive pedometer shows, those steps soon add up.
• Shop smart. Although it’s tempting to reach for inexpensive processed foods on the supermarket shelf, resist the temptation. It’s important to remember to eat healthy foods including fresh fruits and vegetables. Warehouse club supermarkets fared very well in terms of price on the 2005 Consumer Reports Grocery Store Shopper Survey of 24,000 respondents. Those that gave our readers the biggest bang for the buck (subscribers only) were Aldi, WinCo, Trader Joe’s, Market Basket, Cost­co, Shoppers Food Warehouse, Wal-Mart, and Stater Bros. (These chains are a good choice if your top concern is low prices, and service and the quality of meat, produce, and fresh-baked goods are less important.) Use the FDA’s free nutritional label training program to find information that will help you stay healthy by selecting the right foods when you shop.

—Orly Avitzur, M.D., medical adviser to Consumers Union

Preventing MRSA: Why I wear a bowtie

I made my debut as a medical intern on a hot first of July morning long, long ago, wearing a brand-new white suit, white bucks, and a multicolored imported silk Countess Mara necktie. I think I recall some applause on the part of a few patients who had known me as a lowly medical student just a day or so before.

Before long my first admission arrived—a middle-aged truck driver with severe headaches, fever, and a skin rash. Since meningitis was a prime suspect, I told the nurses to set up for a spinal tap. Following the hospital house staff hierarchy protocol, my immediate superior, the assistant resident, did the tap while I held the patient in position.

As he lay on his right side facing me, I slid one hand behind his flexed knees and the other over his neck to keep him from moving. As the spinal needle hit home, he gave a grunt. At once I felt a warm, wet sensation spread over my chest and the strong odor of urine permeated the air. My beautiful Countess Mara tie was now a sodden, blotchy mess. I showered, changed my shirt, and switched to wearing bow ties. Little did I realize that by making that permanent change in my daily dress code, I would probably be saving lives. Indeed, I had made the right move for the wrong reason.

Germ carriers
That incident came to mind when I read an article in the British Medical Journal a couple of years ago reporting that neckties worn by doctors in hospitals were implicated as carriers of such dread organisms as Clostridium difficile (a bacterium capable of causing severe diarrhea, fever, and dehydration) and methicillin-resistant Staphylococcus aureus, the much-feared MRSA. The report, based on the author’s review of several papers in the medical literature, prompted the British Medical Association’s head of science and ethics to say: "It’s up to individuals, but what we’re saying to doctors is that ties are a potential reservoir and they’re unnecessary. Doctors have to recognize the potential risk."

Although the initial focus was on the necktie, attention rapidly turned to other potentially germ-laden items of attire and adornment, such as the traditional white coat, long-sleeved shirts, wristwatches, bracelets, dangling earrings, long fingernails, beards, and long hair. Also on the list were the doctor’s tools of the trade—the stethoscope and blood pressure cuff.

Doctors, it seems, are walking arsenals of pathogens. While all of the above may be capable of harboring organisms that can cause disease, hard evidence is not easy to find. Nevertheless, it is up to you as a savvy patient to be aware of the potential risk for life-threatening infections carried on your physician's attire and tools. And you should require that any physician treating you keeps those risks to a minimum. A dirty white coat or an otoscope with the previous patient's earwax on it might raise suspicions that all is not well and invite a few inquiries on your part.

The infection chain
But all of those possible routes of disease transmission pale in comparison with the human hand, the only part of the body that can come in contact with every other body part, including the heavily contaminated parts—the genitals, mouth, skin, and rectum. When that hand belongs to a doctor examining sick patients, the risk of cross-contamination and disease transmission is magnified.

Common sense, backed up by strong evidence, suggests that hand washing is the single most important measure that can be taken to prevent the spread of infection. Yet our nation has not taken this simple task to heart. Studies and polls indicate that a significant number of people exit public rest rooms without washing their hands.

Health professionals are no exception. In one of many studies done in hospital settings, hand washing took place in only 48 percent of possible opportunities. Nurses had the distinction of out-distancing doctors, 52 percent to 30 percent.

The availability of portable alcohol-containing gels and foams has made hand cleaning easier than in out-of-the-way sinks in hospitals and offices. Although probably not as good as thorough washing with soap and water, they can cut the chain of infection.

This article first appeared in the March 2008 issue of Consumer Reports On Health.

—Marvin M. Lipman, M.D.

Tracking down migraine triggers

If you can pinpoint exactly what’s causing your migraines, you might be able to better treat them—or even prevent them from occurring in the first place.

Migraines affect 18 percent of women and 6 percent of men in the U.S. and are a leading cause of absenteeism and decreased productivity at work. The overall cost burden of migraines to society exceeds that of other chronic conditions, including asthma, depression, diabetes, and heart disease. Although medications called triptans, such as rizatriptan (Maxalt) or sumatriptan (Imitrex), can often halt a migraine in progress, nearly half of migraine sufferers who take those or other pain-relieving drugs are still dissatisfied with their ability to function or work afterward. And when used on a regular basis, over-the-counter and prescription pain relievers can even cause headaches. Quite a few commonly used preventive medications, such as amitriptyline or divalproex (Depakote), might have unwelcome side effects, including weight gain and/or sedation. That might be why only 12 percent of migraine patients take them.

A better and more satisfying approach to preventing migraines is to find and avoid the triggers that set them off. Surprisingly, research has shown that more than three quarters of sufferers are ultimately able to identify triggers, such as:

• Beer, red wine, chocolate, and cheeses
• Hunger
• Odors, including perfume
• Bright or fluorescent lights, the sun, or glare from TV or computer screens, particularly if flickering
• Insomnia (regular, but not too much, sleep is known to protect against attacks.)
• Tension, irritability, and stress

But it’s not a precise exercise. Not all culprits cause migraines each time, and sometimes migraines result only when factors occur simultaneously—so-called “stacked triggers.” For instance, while perfume alone might not cause a problem, drinking a glass of red wine might change those odds for the worse. To further complicate matters, some sufferers have a delayed response to stimuli, and triggers can even change over time.

Some doctors recommend keeping a headache diary —a log detailing your attacks and the medication responses that can help patients and doctors identify possible triggers and assess treatment effectiveness. You should document each headache episode, describe its connection to meals and beverages, and note situational factors such as fatigue, sleep patterns, or stress. You should also list the medications you took, and write down how you felt afterward. Women should note their menstrual cycle as well.

If a trigger is a food or fragrance, simply avoiding the offending substance will do the trick. For light-related triggers, sunglasses or tinted glasses can be helpful. Behavioral therapies, such as biofeedback and meditation, are recommended when stress is a factor. Keeping to a regular sleep schedule can help with sleep-related headaches. Alas, some triggers, such as weather and time zone changes, can’t be easily manipulated.

Visit our conditions section for more details about migraines, our detailed Treatment Ratings (for subscribers), and our free CR Best Buy Drugs report on triptans.

—Orly Avitzur, M.D., medical adviser to Consumers Union

See Dr. Avitzur talking about migraine triggers and treatments on ABC news.

Heart attack? Get to the ER on time

If you suddenly felt faint and developed shoulder discomfort, would you call 911? You should. Those are two of the five most important heart-attack warning signs. And more than half of cardiac deaths may occur within an hour of developing the first symptom.

But according to an article in the February 22, 2008 issue of Morbidity and Mortality Weekly Report, published by the federal Centers for Disease Control and Prevention, less than a third of adults recognize all five warning signs of a heart attack:

1. Pain and discomfort in the jaw, neck or back
2. Feeling weak, lightheaded or faint
3. Chest pain or discomfort
4. Pain or discomfort in the arms or shoulder
5. Shortness of breath

Even more disturbing, the CDC study found that many people who did suspect a heart attack would delay calling 911. That hesitation can be fatal: Your odds of surviving an attack are much higher if you get to the emergency room within an hour of the onset of symptoms. After you call 911, chew and swallow one 325-mg (regular) aspirin or four 81-mg (baby) aspirins, since that can help prevent artery-clogging blood clots from forming.

The CDC data revealed striking variability across the country.  In Washington, D.C., for example, only 34 percent of respondents recognized pain or discomfort in the jaw, neck, or back as a sign.  Joel Rosenberg, M.D., Clinical Director of Cardiology at the George Washington University Hospital, said, “We’ve done a very poor job of educating people on how heart attacks present.” Rosenberg is not surprised by the poor results in D.C. given a financially devastated healthcare infrastructure, substantial numbers of low income residents, and poor access to care. “We have to start investing more time, money and effort into prevention of disease as opposed to just focusing on treatment” said Rosenberg, adding, “This includes teaching the public about the warning signs of heart attacks.”

Minnesota—which ranked number one in residents’ ability to identify chest pain as a heart-attack symptom and in calling for emergency assistance—may provide some clues as to how to accomplish that goal.  Thomas Behrenbeck, M.D., Ph.D., Associate Professor of Cardiology at the Mayo Clinic in Rochester, Minn., attributes these stats to focused public service campaigns and grass roots efforts, such as CardioVision 2020, dedicated to improving heart health. “As a result, Minnesota folks are probably more in tune with the warning signs and get medical attention faster than most,” Behrenbeck said. And efforts to improve the care chest pain patients receive once they get to the ER has improved the heart-attack survival rate at Mayo’s emergency room to between 94 and 97 percent, proving, said Behrenbeck that “time is life.” 

—Orly Avitzur, M.D., medical adviser to Consumers Union

Put Vytorin back—way back—on the shelf

Last month, Merck/Schering Plough Pharmaceuticals finally released the disappointing results of a clinical trial, completed nearly two years ago, on the hoped-for ability of Vytorin to halt the progression of thickening in the carotid arteries (the two major blood vessels in the neck). In the interim, with the public totally unaware of those results, Vytorin continued to be heavily advertised to the public and widely prescribed by physicians.

That two-year study of 720 volunteers with inherited very high cholesterol levels, showed no significant differences between the carotid artery scans of those patient who took Vytorin (a combination of Zocor and Zetia) and those who took Zocor alone, despite the finding that the Vytorin takers had lower LDL cholesterol levels.

I think this study has two important implications, over and above the money wasted on purchases of Vytorin:

1. There’s no connection between the lowered LDL cholesterol levels and the lack of change in carotid artery thickening (actually the Vytorin group had more plaque formation which was not, however, statistically significant). This is unlikely in view of the overwhelming evidence that ties LDL cholesterol to cardiovascular disease. Perhaps the study was not long enough.

2. There is fallibility in clinical studies that use so-called intermediate end-points (imaging techniques, biochemical changes) instead of real events (heart attack, stroke, death). There are still many unknowns about the causes of heart attacks; fully half of coronary-disease deaths occur in people with no discernable risk factors.

And what about the patients and professionals who believed the TV ads and the hype of the drug reps and spent large sums of money on a drug that was very likely not helping them?
Here’s my advice:

Regard Zetia for what is—excessive and expensive baggage and a relatively weak LDL cholesterol lowerer. It should only be used by those who cannot tolerate statins or by the few patients who are already on high-dose statin therapy and are not achieving desirable LDL cholesterol levels. As for the combination product Vytorin? Put it back—way back—on the shelf and stick to a statin drug, preferably one available as a less-costly generic version. Read our CR Best Buy Drug report on statins to see which ones we recommend.
—Marvin M. Lipman, M.D.

Dr. Lipman has been Consumers Union's chief medical advisor since 1967. He is a diplomate of the American Board of Internal Medicine (certified in endocrinology and metabolism) and is clinical professor of medicine emeritus at New York medical College.

The hook in hookahs

Just last month my 15-year-old son, Daniel, mentioned that some of his friends were smoking hookahs (also known as shisha, narghile, goza, and hubble bubble). Daniel ticked off its advantages: It’s not addictive (like alcohol), not illegal (like pot), and safe from the health hazards of cigarettes. His friends’ parents think that it’s cool, he said, and someone he knew even had her Sweet 16 party at a hookah bar (before they became illegal in New York City).

Daniel and his friends were parroting the myths that are being perpetuated by many other teens and young adults in the U.S. As our reporting of the recent research reveals, 15 percent of freshmen surveyed at my alma mater, Johns Hopkins, admit to smoking water pipes. Although many Hopkins students are future doctors, they’re ignoring the facts. Last year  the American Lung Association reported evidence that hookah smoking carries many of the same health hazards as cigarette smoking—heart disease, clogged arteries, and lung cancer. And because the mouthpieces are shared with others, users are also at risk for infectious diseases, such as TB, hepatitis, and herpes. 

Furthermore, evidence suggests that an average 45-minute hookah session raises levels of nicotine in the blood up to 250 percent. It also delivers the equivalent of 100 times the smoke of a cigarette (with its related toxic agents such as carbon monoxide), contributing to a growing concern in the medical community that the practice may lead to regular cravings and addiction to cigarettes. 

As the February 2008 journal Nicotine & Tobacco Research illustrates, it seems that hookah users don’t have a clue! Data analyzed from 201 hookah smokers revealed that 79 percent felt that cigarettes were more addictive than water pipes, 67 percent felt cigarettes were more harmful, and more than 65 percent believed that cigarettes have more nicotine. 

So far, the part about germs has been enough to deter Daniel. But the battle is far from over. When I told him that I was writing this, he insisted, “They wouldn’t make something legal if it were so unsafe.” —Orly Avitzur, M.D., medical adviser to Consumers Union

Don't gamble with your heart during the Super Bowl

What is it about sporting events like the Super Bowl that turn even the most docile couch potato into a screaming, wildly gesticulating lunatic?  A subject that has long served as comedic fodder for sitcoms and hidden camera exposes has suddenly become deadly serious.  A new study released in the January 31st issue of the New England Journal of Medicine highlights the potential harm to the heart that can be caused by watching an intense and stressful sporting event.

Researchers in Germany analyzed the number of cardiovascular emergencies that occurred among German citizens during the World Cup soccer games in 2006 when their home team was playing and found that the fans experienced twice the number of heart attacks and other cardiac problems, especially within the first two hours of the soccer match.  Men with a history of heart disease were at highest risk.

As if that’s not bad enough, a University of Maryland study presented by Dr. David Jerrard at the American College of Emergency Physicians in 2006, found that there were 50 percent more visits to emergency rooms by men after professional football games than during the games over the three-year period examined.  This came on the heels of a previous study by the same investigator showing that men’s visits to emergency rooms declined during games. 

Not only are men at risk, they delay getting proper medical care so they can finish watching the fourth quarter!

Although triggers were not examined in these studies, Anthony G. Alessi, MD, ringside physician for the Connecticut State Boxing Commission points out that fans who don’t want to give up their seat at a match often skip the diuretic prescribed to control their blood pressure, to avoid having to take a bathroom break. This raises their risk for both heart attack and stroke enough to cause casinos, where boxing events are held, to keep large numbers of defibrillators throughout the house and have three teams of paramedics strategically placed and on alert at all times.

So, whether you’re rooting for the New England Patriots or the New York Giants, take heed:

• Avoid overeating, especially junk food
• Watch the alcohol
• Don’t smoke
• Take your prescribed medication
• Try to relax
• Reduce your stress…don’t bet on the games
• And above all else, don’t bet on your life—if you experience chest pain or shortness of breath, ACT IN TIME!

—Dr. Orly Avitzur, Medical Adviser, Consumer Reports

See how Super Bowl snacks stack up in our chip ratings.

More treatment isn’t always the best option

Our health care system sometimes seems like a runaway train. We all know it’s out of control, but no one can figure out how to stop it.  Here’s one example:

A man in his mid-80s, quite frail, had managed to survive two surgeries for lung cancer but the disease had now spread elsewhere in his body. His oncologist was pressing him to start chemotherapy, and he was seeking a second opinion from me. Now, understand that there was zero chance the chemo would cure him. At best, it had about a 10 percent chance of extending his life for six months beyond what would be expected without it – but he would be sick most of that time with nausea, vomiting, and weakness, and would be unable to travel away from home. After weighing the tradeoffs, he decided to skip the chemo. I have since left my position at the hospital where this conversation took place, but the last time I saw him, about six months later, he was still alive and feeling reasonably well. He had spent quality time with his family and even traveled over the holidays.

Conversations like this don’t take place often enough.  Too few consumers and doctors challenge the belief that “more treatment is always better.”  There are many reasons that we have come to believe this. Medical breakthroughs and heroic treatments are always news, whereas failures and horrible side effects are often not. Drug and device manufacturers spend billions to promote the idea that the shiniest, costliest new treatments are better than the old ones, even when there’s no solid evidence for this. High-tech treatments are moneymakers for doctors and hospitals.

I don’t see the situation getting better without some significant changes in the way we deliver and pay for health care. We need more doctors to do what I did with that man—talk through the risks and benefits of treatments, especially expensive, invasive ones. We need better research comparing old and new treatments. Right now, the incentives are in the wrong direction. Doctors earn very little for sitting down and talking to patients, but a lot for delivering costly interventions, whether they’re needed or not.

If you or someone you care about is facing decisions about treatment for a serious illness, keep the following in mind:

• You don’t have to accept the first recommendations you receive
• Insist on a meaningful conversation with your doctor, spelling out the risks and benefits of tretament
• Make sure you understand the side effects and success rates of the treatments you’re offered
• Balance those side effects and success rates against your own quality of life preferences
• Seek a second or even third opinion if necessary

—John Santa, MD, MPH

We are interested in hearing from you about your experiences. Have you ever received high-tech treatment that you later regretted because of side effects or lack of effectiveness? Have you ever turned down treatments that your doctor recommended? Did you have a tough time navigating the complexities of our system when deciding on treatment options? What and who helped you the most? What information was most useful to you? 

Share your story with us.

When the going gets tough: Constipation causes and treatments

Remember summer camp? Carefree days of new friend-ships, arts and crafts, swimming and boating, noisy mess halls, sing-along campfires, and the quiet time at the end of the day, followed by “Taps” and lights out. But not before the camp nurse, in her starched white uniform, made her appearance, clipboard and pencil in hand, and directed the question of the day to each, in turn: “Soft, medium, hard, or none?”—and she wasn’t taking egg orders for breakfast. A teaspoon of castor oil was the unwary respondent’s reward. Although that barbaric ritual has gone the way of public hangings, America’s obsession with daily bowel movements has persisted, largely due to persistent misconceptions. One myth is that waste products can accumulate and contaminate the rest of the body. Another is the belief that constipation can cause colon cancer. Patients have varying ideas about what constitutes constipation. One survey of nearly 600 constipated patients found that the main complaint of 79 percent was straining to pass the stool. Hard stools were a problem for 71 percent, while 57 percent complained of infrequent bowel movements. (Some had more than one complaint.)

The standard medical definition of constipation includes both of the following: 1. Infrequency (less than three bowel movements per week); and 2. Difficult passage of hard, dry stools. Most everyone agrees that anything between three times a week to three times a day can be considered normal. Constipation, as defined above, affects as many as one of every four Americans at one time or another, occurs more than twice as often in women as in men, and is more frequent among older people. Laxative sales in the U.S. are projected to exceed $850 million annually by 2010.

The cause may vary
Most of the time constipation is transient and related to changes in diet or schedule. Going on vacation, starting the Atkins diet, cutting out your usual exercise routine, or ignoring the morning urge in order to catch a train can play havoc with your bowels. A host of medications can cause constipation, including iron and calcium supplements, antidepressants, painkillers, and some blood-pressure drugs. Constipation can occur in pregnancy or be caused by serious conditions, such as an underactive thyroid, elevated blood-calcium levels, Parkinson’s disease, multiple sclerosis, irritable bowel syndrome, and actual blockages of the intestine by colon cancer. All can cause difficulty in moving one’s bowels.

Loosening up
Although a lack of fiber in the diet and dehydration can cause constipation, treating the problem by increasing dietary fiber and drinking eight glasses of water a day lacks the certainty of evidence-based medicine and often results in bloating, flatulence, abdominal distention, and increased urinary frequency. As long as you’re consuming adequate amounts of fiber (at least 25 grams per day) and drinking enough fluids to keep your urine a pale yellow, increases are not likely to help. Resuming your usual lifestyle after a vacation or switching the medication that was the cause usually does the trick. You won’t suffer permanent harm from a few days of constipation, but there’s nothing wrong with the temporary use of a laxative if you’re truly uncomfortable. But how to choose from the myriad products that line the shelves of your pharmacy?

The trick is to select a single-ingredient product that matches your particular complaint. If your main symptom is straining to pass hard, dry stools, try docusate (Colace and generic), an emollient type of laxative better known as a stool softener. If your problem is infrequency, choose a bulk laxative such as methylcellulose (Citrucel and generic), polycarbophil (Equalactin, FiberCon, and generic), or psyllium (Fiberall, Metamucil, and generic). If you have both complaints, take both kinds. Despite lore to the contrary, both types of laxatives are relatively safe for long-term use, but check with your physician. For more stubborn cases, as can occur in seniors with aging bowels, the occasional use of a stimulant laxative such as bisacodyl (Correctol, Dulcolax, and generic) may be necessary. Drawbacks are painful cramping and diarrhea with urgency. As with any symptom treated with an over-the-counter medication, if constipation persists longer than a week or two or recurs after treatment, it’s time to see your physician to find out if something more serious is going on.—Marvin M. Lipman, M.D.

Dr. Lipman has been Consumers Union's chief medical advisor since 1967. He is a diplomate of the American Board of Internal Medicine (certified in endocrinology and metabolism) and is clinical professor of medicine emeritus at New York medical College.

Pace yourself for better health in 2008

Around this time each year, I see a rush of patients with medical conditions and injuries related to New Year’s resolutions gone awry. Recently enrolled health club members come in with back pain and slipped discs, and crash dieters complain of dizziness and headaches. Simply put, pushing too fast or too hard often causes more harm than good. Just because you’ve made a decision to get healthy and fit, doesn’t mean that you have to try to reach your target by the end of January. To paraphrase a celebrity NFL quarterback, unless you are under the age of 23 or are a professional football player, it probably isn’t going to happen.

As someone who’s tried most diets from Atkins and Cabbage Soup to the Zone, and has been drawn to nearly every exercise craze du jour, I understand the craving to get quick results. But after recurring sprains and rebound weight gain, I’ve had to revise my approach. Contrary to the adage, “no pain, no gain,” good fitness programs start by finding enjoyable exercise that doesn’t hurt, and permanent weight loss begins with a nutritional plan designed for the long run. So, set your goals, make them reasonable, and pace yourself for a healthy 2008!—Dr. Orly Avitzur, Medical Adviser, Consumer Reports

Holiday help for heartburn

It's that time of year when food and wine merchants thrive, tons of hors d'ouevres are consumed at office parties, families convene for feasts, glasses are raised to "Auld Lang Syne," and heartburn remedies fly off pharmacy shelves.

About 20 percent of people in the U.S. suffer at least once a week from symptoms of acid reflux, or heartburn (also known as dyspepsia, indigestion, sour stomach, or agita), and another 20 percent have it less frequently. A smaller but substantial percentage of the population has heartburn often enough (two or more times a week) to have earned the diagnosis of GERD (gastroesophageal reflux disease). No wonder the sales of heartburn remedies add up to billions of dollars a year.

Causes and complications
The food and drink you swallow are transported by strong, involuntary contractions of the muscular esophagus into your stomach through an opening guarded by a powerful muscle called the lower esophageal sphincter. The closure of that sphincter prevents stomach acid from backing up, or refluxing, into the esophagus. Those involuntary mechanisms are so powerful that you can swallow quite well while doing a headstand.

But when the sphincter doesn't close properly, whether because of a genetic weakness, excessive fat ingestion, obesity, or reasons unknown, acid reflux can wreak havoc on the relatively delicate esophageal lining, causing inflammation, irritation, and, sometimes, ulceration. Victims feel it as a distinctive burning sensation located under the breastbone, which may or may not be related to meals and commonly occurs at night.

Long-standing reflux into the lower part of the esophagus can cause changes in the appearance of the lining cells, a condition called Barrett's esophagus that can turn into esophageal cancer in about 1 of every 200 cases. If the reflux reaches the upper portions of the esophagus, it can irritate adjacent structures and cause wheezing, coughing, hoarseness, or chronic sore throat, which often leads to misdiagnoses, especially when the usual reflux symptoms are minimal or absent.

What to take
Since heartburn is an easily recognizable symptom (although at times it can be confused with angina pectoris, or heart pain), it is a natural for self-medication. And there are many over-the-counter products to treat it. Those products can be divided into three categories--antacids, histamine-2 receptor blockers (H2 blockers), and proton-pump inhibitors (PPIs)--that vary in how they work, how quickly they work, how long they work, and how well they work.

If your heartburn occurs occasionally and unexpectedly, as is apt to happen to many of us once or twice this holiday season, your best bet is a simple antacid such as generic or store-brand versions of Maalox, Mylanta, Rolaids, or Tums. They come in various dosage forms--liquid suspensions, tablets that you chew or swallow, effervescent solutions, and chewing gum--from which you can choose. They all work in a few minutes by neutralizing the acidity in the esophagus. Their effect lasts up to a few hours, plenty long enough for reflux symptoms to have ceased.

If you know from bitter experience to expect heartburn in certain situations ("I love pizza, but it always gives me agita"), take an H2 blocker beforehand, which stops histamine from stimulating stomach acid production. There are four available, formerly only by prescription but now over the counter as well as generically: cimetidine (Tagamet HB), famotidine (Pepcid AC), nizatidine (Axid AR), and ranitidine (Zantac 75, Zantac 150). They all start working in 30 minutes to 1 hour and one dose can last up to 12 hours. One product, Pepcid Complete, combines famotidine with an antacid for both immediate and longer-term relief.

When heartburn happens more than once or twice a week, taking antacids several times a day is much too labor-intensive, and even continuous twice-daily use of H2 blockers may not be very effective. At that point, more complete blockage of stomach acid production is called for. Enter PPIs, which actually block the mechanism in the stomach cells that releases acid into the stomach. The first of those to be approved, omeprazole, is available over the counter as Prilosec OTC. It may take days for these medications to provide complete relief, so they are not appropriate for occasional or intermittent heartburn. If there is no improvement from Prilosec OTC or your symptoms recur after a 14-day course, medical evaluation is mandatory.
—Marvin M. Lipman, M.D.

Dr. Lipman has been Consumers Union's chief medical advisor since 1967. He is a diplomate of the American Board of Internal Medicine (certified in endocrinology and metabolism) and is clinical professor of medicine emeritus at New York medical College.

Don't be taken by drug ads

Overheard recently on the radio: The pediatrician was about to conclude 6-year-old Michael's annual checkup and asked if his mother had any further questions. "No," she replied, and then felt a forceful tug on her arm as Michael blurted out, "Yes, we do, Mom. Ask the doctor if Viagra is right for me."

No, Michael was not precocious. He was merely following instructions given by a gray-haired person in a white coat in a TV ad. He might have thought that the drug ad was somehow similar to those for sugared cereals and junk food that interrupt his favorite cartoons on Saturday mornings. After all, they are both aimed at consumers who need an intermediary to get their hands on the advertised product: For one, a parent with the money to buy the "kid-friendly" food, and for the other, a doctor with a prescription pad.

Caveat prescriber

Recently, a 76-year-old retired journalist, a long-term patient, called me about an ad he saw for ropinirole (Requip), a drug previously approved for Parkinson's disease that now had been approved—the first drug ever to be so honored--for the treatment of restless legs syndrome, an uncomfortable urge to move one's legs, which can interfere with sleep. The journalist had been wrestling with that problem for years but had been coping lately with the help of a small dose of diazepam. He had seen the satisfied consumers in the Requip ad and wanted to try it. I resisted. He insisted. Against my better judgment, I gave in. At 3 a.m. I received a call from the emergency room, where he had been taken by ambulance because of a fainting episode due to a drop in his blood pressure just an hour or two after taking his first (and most likely his last) dose.

Truth in advertising?

In one survey, half of the respondents believed that drug ads had to be approved by the government before they were aired or printed, and nearly half thought that only "entirely safe" drugs were allowed to be promoted. Nothing could be further from the truth. The Food and Drug Administration (FDA), the government agency that has jurisdiction over drug promotion, rarely gets a chance to review ad copy before the public sees it. Months can go by before the agency catches up with any misrepresentation, puffery, or inaccuracies. Those months inevitably see burgeoning sales of the drug.

Direct-to-consumer (DTC) drug ads not only permeate the TV screen, but they also fill the radio waves, print media, and, more recently, the Internet. The pharmaceutical industry in 2005 spent the staggering sum of $4.86 billion on consumer advertising—more than the Gross Domestic Product of 53 countries, according to the latest World Bank data. It is a productive investment. As spending on DTC advertising has risen, so have the number of prescriptions written and drugs sold. For each dollar spent on advertising, the pharmaceutical industry recoups $4.25.

Add to that $7 billion spent on advertising to doctors and other professionals, and it's obvious why drug costs are so high in this country. Spending on drugs is only part of the overall increase in health-care costs that have now risen to the point that the U.S. is the world leader at $5,200 per capita per year. Yet we rank lower than several similar industrialized and even some less-developed countries on such public-health benchmarks as life expectancy, infant mortality, and rates of obesity and chronic disease. And people in those countries pay much less for drugs than we do here in the U.S. Is it a coincidence that DTC ads are not allowed anywhere except here and in New Zealand (where a ban is being strongly considered)?

What you can do

To be a savvy consumer, pay little or no attention to prescription drug ads. Those ads usually promote the newest and most expensive drugs. Many older drugs are available in generic form—and they can be every bit as effective as the newer brand-name drugs. Ask your doctor whether there's an older drug that has stood the test of time and can do the job as well as the newer product. Consult a nonbiased source, such as the Consumer Reports Consumer Drug Reference or the National Institutes of Health's Medline Plus, to learn about your alternatives, drug interactions, side effects, warnings, and how to take prescription medicines safely. 

And don't let the ads convince you that every personality quirk, such as shyness, fear of heights, or performance jitters, requires a pill. If you're bothered by such problems, open a discussion about them with your physician. —Marvin M. Lipman, M.D.

Dr. Lipman has been Consumers Union's chief medical advisor since 1967. He is a diplomate of the American Board of Internal Medicine (certified in endocrinology and metabolism) and is clinical professor of medicine emeritus at New York medical College.