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Monthly Archives: September 2010
Doctor and Patient: Paying Doctors for Patient Performance
Not long ago, a fellow doctor told me that his local health care insurers, in an effort to improve care and rein in costs, had been evaluating physicians and paying them according to their “quality ranking.” With “pay for performance” reimbursement, doctors who had, for example, managed more timely follow-up and achieved better test results with their diabetic or hypertensive patients would rank more highly and earn more in financial bonuses than physicians whose patients failed to meet the insurers’ guidelines.
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Despite his own solid “ranking,” my colleague found himself growing more and more disenchanted with these types of reimbursement programs. “It sounds like a great idea,” he said, “but it assumes that what I do or say always has a direct effect on my patients’ health.” He described a long-term patient he had seen earlier in the week; she had poorly controlled diabetes yet failed to come into his office regularly in spite of his numerous requests.
“She just can’t afford to take that much time off from work,” he said, adding with a sigh, “Does that make me a worse doctor?”
For a little over a decade, amid calls for improved quality and greater transparency, insurance companies across the country have been “incentivizing quality” — shifting away from traditional fee-for-service reimbursement and turning to pay-for-performance programs. Based on the experiences of health maintenance organizations in the mid-1990s with assessing quality, public and private third-party payers started applying many of the same evaluation criteria to individual physicians and linking reimbursement bonuses to similar, if not identical, clinical goals. The hope was that these well-established goals, such as regular mammograms and Pap smears and screening for colon cancer and high cholesterol, would not only improve care and cut costs over the long run but also provide payers and the public a standardized way to compare doctors and the care they deliver.
Health care experts applauded these early initiatives and the new focus on patient outcomes. But over time, many of the same experts began tempering their earlier enthusiasm. In opinion pieces published in medical journals, they have voiced concerns about pay-for-performance ranging from the onerous administrative burden of collecting such large amounts of patient data to the potential worsening of clinician morale and widening disparities in health care access.
But there has been no research to date that has directly studied the one concern driving all of these criticisms — that the premise of the evaluation criteria is flawed. Patient outcomes may not be as inextricably linked to doctors as many pay-for-performance programs presume.
Now a study published this month in The Journal of the American Medical Association has confirmed these experts’ suspicions. Researchers from the Massachusetts General Hospital in Boston and Harvard Medical School have found that whom doctors care for can have as much of an influence on pay-for-performance rankings as what those doctors do.
Drawing on the experiences of more than 125,000 patients, the researchers first ranked the doctors based on criteria commonly used in pay-for-performance reimbursement plans. While they found that doctors who took care of older or sicker patients tended to rank higher, presumably because of more frequent patient follow-up, the researchers also discovered that primary care practitioners who cared for underinsured, minority and non-English-speaking patients tended to have lower quality rankings than their counterparts.
Using statistical modeling, the researchers then attempted to rerank all the doctors after adjusting for differences in patient characteristics. When they factored patient race, ethnicity, primary language and insurance status into their physician evaluations, many of the original rankings changed, with doctors who worked in community centers — and therefore with more minority and non-English-speaking patients — being more likely to improve in ranking, often by more than 10 percentile points.
“Pay-for-performance can work,” said Dr. Clemens S. Hong, lead author and a general internist at the Massachusetts General Hospital, “but we need more sophisticated measures to make sure we are actually measuring physician quality.”
Addressing the discrepancies highlighted in the study will be challenging. Some health care experts, for example, have suggested paying for improvement rather than performance. Under this model, if over the course of a year doctors are able to increase the numbers of patients who obtain screening tests according to a standardized schedule, their reimbursement would increase.
But such a payment model comes with its own set of issues. “If your patient mammogram rate is 100 percent, there’s no way to improve,” Dr. Hong said. “And do we really want to pay doctors who have only half of their patients getting their mammograms done on time?”
Nevertheless, Dr. Hong and his co-investigators believe that their study only confirms the importance of research efforts focused on developing more sophisticated pay-for-performance measures. “It’s human nature to go to where the incentives are,” Dr. Hong said. Without specific assessment criteria, attributes that are currently measured indirectly or bypassed altogether, like the ability to communicate, build rapport and work with more vulnerable and challenging patients, risk being devalued or ignored.
“When you shine a light on certain measures, you take away from others that are also important,” Dr. Hong said. “Fee-for-service has already driven physicians away from primary care. If we don’t address patient differences, we may do the same thing with pay-for-performance.”
Mammogram Benefit Seen for Women in Their 40s
A radiologist reviewing mammogram images in May at the Elizabeth Center for Cancer Detection in Los Angeles. Most health officials recommend the screenings, but experts disagree over their value.
Researchers reported Wednesday that mammograms can cut the breast cancer death rate by 26 percent for women in their 40s. But their results were greeted with skepticism by some experts who say they may have overestimated the benefit.
The study’s authors include Dr. Stephen Duffy, an epidemiologist at the University of London, and Dr. Laszlo Tabar, professor of radiology at the University of Uppsala School of Medicine in Sweden, who have long been advocates of mammography screening. Their paper is published online in the journal Cancer and will be presented on Friday at a meeting sponsored by the American Society for Clinical Oncology and five other organizations.
The study’s conclusions contrast with those of a report last year by the United States Preventive Services Task Force, an independent group that issues guidelines on cancer screening, questioning the benefit of screening women younger than 50.
The new study took advantage of circumstances in Sweden, where, since 1986, some counties have offered mammograms to women in their 40s and others have not, according to the lead author, Hakan Jonsson, professor of cancer epidemiology at Umea University in Sweden.
The researchers compared breast cancer deaths in women who had a breast cancer diagnosis in counties that had screening with deaths in counties that did not. The rate was 26 percent lower in counties with screening.
The study, said Dr. Jennifer C. Obel of the oncology society, “captured the real-world experience of mammograms in this age group.” She suggested that all women, starting at age 40, should “speak to their doctors about mammograms.”
Other experts were not convinced. One problem, said Dr. Peter C. Gotzsche of the Nordic Cochrane Center in Copenhagen, a nonprofit group that reviews health care research, is that the investigators counted the number of women who received a diagnosis of breast cancer and also died of it. They did not compare the broader breast cancer death rates in the counties.
It is an important distinction, Dr. Gotzsche said, because screening finds many cancers that do not need to be treated or found early. With more harmless cancers being found in the screened group, it will look like the chance of surviving breast cancer is greater in that group.
Dr. Jonsson said the aim of screening “is to find breast cancers early and to reduce mortality from breast cancer.” He and his colleagues plan to look at the overdiagnosis later, he said.
But Donald Berry, a statistician at MD Anderson Cancer Center, said the overdiagnosis problem was a serious one. “We are finding cancers that would never be found if we didn’t look,” he said. “Small wonder people think screening is great — some of the cancers it finds were not lethal in the first place.”
Shorter Work Hours Approved for Medical Residents
Filed at 5:55 p.m. ET
CHICAGO (AP) — Rookie doctors will be getting shorter work shifts, along with stricter supervision, but a medical student group said Wednesday that the changes don’t do enough to protect sleep-deprived residents and their patients.
The Accreditation Council for Graduate Medical Education’s board of directors approved new rules on Tuesday for more than 110,000 new doctors being trained at U.S. hospitals. The idea is to improve patient safety and reduce medical errors caused by junior doctors working extremely long hours.
The biggest change affects interns — new doctors in their first year of medical residency. Their work shift limit is being cut from 24 hours to 16 hours, and “strategic napping” is strongly recommended. The maximum shift length remains 24 hours for residents in their second year of training and beyond.
Also, medical residents are to tell patients they’re being supervised by more experienced physicians, and the hierarchy should be spelled out to patients, the rules say.
The revisions “will require small change in some programs and large changes in others, all with the goals of ensuring patient safety, that the next generations of physicians are well-trained to serve the public and that residents receive their training in a humanistic learning environment,” Dr. Thomas Nasca, CEO of the accrediting group, said in a statement.
The American Medical Student Association had sought substantial across-the-board work-hour reductions and argues that there’s no reason to give first-year residents a break but not others. The medical student group, joined by other advocacy groups, earlier this month asked the government’s Occupational Safety & Health Administration to look into work hours for doctors-in-training.
“We’re going to keep pushing” for stronger limits “because it involves both patient safety and our safety and well-being,” Sonia Lazreg, the group’s health justice fellow, told The Associated Press. “The fight for safer work hours is not over.”
The new rules also strengthen supervisory requirements and include an entire page about the types of close supervision first-year residents should receive. The rules also explain that residents must demonstrate specific skills before being given more responsibilities.
The previous rules had only one sentence about supervision standards, Nasca said.
Lazreg said the rules mostly mirror a draft proposal outlined in June, but with one important change. The draft said second-year residents and beyond could be on call only one in every three nights. The final rules say that can be averaged over four weeks, which she said weakens the provision.
“It means you could be on call every other night, developing chronic sleep deprivation, as long as it averages out,” Lazreg said.
OSHA head David Michaels said the agency is considering the groups’ petition. He stressed that hospitals and medical training programs are not exempt from laws ensuring that employees’ health and safety are protected.
In a statement to the AP, he said the agency “is very concerned about long work hours, fatigue and safety, not just for medical residents, but for all workers. It is clear that long work hours can lead to tragic mistakes, endangering workers and the public.”
“With respect to medical residents, we know of evidence linking sleep deprivation with an increased risk of needle sticks, lacerations, medical errors and motor vehicle accidents,” Michaels said.
John Nylen, the accrediting council’s chief operating officer, said the new rules are based on thorough research, with input from residents and the medical community. The revisions protect patients, residents and medical educational opportunities, he said.
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Accrediting council: http://www.acgme.org
Medical students group: http://www.amsa.org
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Shortage of Widely Used Anesthetics Is Delaying Executions in Some States
A nationwide shortage of several widely used anesthetics, which has been exasperating doctors and veterinarians for months, has now spread to the country’s death rows.
Production difficulties have made the widely-used propofol difficult to obtain driving demand for out-of-favor anesthetics like thiopental sodium.
Dr. J. P. Abenstein of the Mayo Clinic School of Medicine in Minnesota said drug supplies were driving anesthetic choices.
Several states have postponed executions and others may soon do so because of the scarcity of thiopental sodium, a barbiturate that is central to the lethal injection process in most of the 35 states with the death penalty.
Some states face the looming expiration of their only doses and are scrambling to obtain usable vials from other states as execution dates approach. Others, by proposing alternate drugs that are not part of standard protocols, have given defendants new grounds to seek delays in court.
In California on Wednesday, the attorney general’s office said it was abandoning what would have been the state’s first execution in more than four years. A federal district judge had stayed the execution on Tuesday; and the decision to examine the constitutionality of new lethal injection procedures would have pushed any execution date well past Friday’s expiration of the state’s only supply of thiopental sodium.
It is not uncommon for manufacturing problems to cause intermittent shortages of critical medications, particularly intravenous anesthetics that yield low profits once their patents expire. But several leading anesthesiologists said this year’s shortages had been severe.
“I’ve been practicing for 25 years and have never seen anything like the frequency and variety of drugs that are in short supply,” said Dr. Alexander A. Hannenberg of Newton, Mass., the president of American Society of Anesthesiologists.
Two executions in Kentucky were delayed this year because the commonwealth had but one dose of thiopental sodium for the three murderers who have exhausted their appeals. Officials decided last month to assign the dose to Gregory L. Wilson because his 1988 conviction for rape, kidnapping and murder was the oldest of the three. Two weeks ago, a state court judge stayed Mr. Wilson’s execution indefinitely; the dose — with a shelf life of up to two years — expires on Friday
An execution scheduled in Arizona for Oct. 26, two decades after the killer’s conviction, may be at risk unless the state obtains thiopental sodium in time. And an Oklahoma inmate, Jeffrey D. Matthews, succeeded in delaying his death last month by challenging the state’s intent to substitute the sedative Brevital for thiopental sodium in its lethal three-drug sequence.
Oklahoma’s Department of Corrections has since obtained a single dose of thiopental sodium from another state — it will not say which — and plans to use it to kill Donald R. Wackerly II on Oct. 14. A hearing the next day will determine whether Mr. Matthews can be executed using a substitute. “Now we’re thinking about phenobarbital,” said Jerry Massie, a Corrections Department spokesman. “Apparently it has been used or approved for use in assisted suicides in a couple of states. It’s also used by veterinarians to put down large mammals.”
Several anesthesiologists, including Dr. Hannenberg, said they had not yet heard about medical procedures being delayed because of the shortages. But he said it was nearly universal that anesthesiologists were being forced to use less familiar medications that leave patients groggier and with a higher risk of nausea and headaches.
“I have a huge concern,” said Dr. J. P. Abenstein, an associate professor of anesthesiology at the Mayo Clinic School of Medicine in Rochester, Minn., “because we’re having to alter the anesthetics not for the needs of the patient but because of what’s available in the marketplace.”
Hospira Inc., the only domestic manufacturer of thiopental sodium, suspended production of the drug almost a year ago because of problems obtaining its active ingredient, which is supplied by another company, according to Daniel M. Rosenberg, a company spokesman. The firm, which is based in Lake Forest, Ill., hopes to resume production in the first quarter of 2011, he said.
Infant Sleep Positioners Pose Suffocation Risk, F.D.A. Says
Infant sleep positioners that are used to keep babies on their backs and protect them from sudden infant death syndrome have led 12 children to suffocate in the past 13 years and should no longer be used, federal officials said Wednesday.
Most of the infants suffocated after rolling from a side position to a stomach position. In addition to the reported deaths, the government has received dozens of reports of infants who were placed on their backs or sides in sleep positioners, only to be found later in potentially hazardous positions within or next to the sleep positioners.
The two main types of infant sleep positioners are flat mats with side bolsters or inclined mats with side bolsters.
Both types of sleep positioners typically claim to help keep infants on their backs and reduce the risk of sudden infant death syndrome, or SIDS, but the Food and Drug Administration has never approved these products as safe. And the government said it was unaware of any scientific studies demonstrating that infant positioners prevented death or were proven to prevent suffocation or other life-threatening harm.
“To date, there is no scientifically sound evidence that infant sleep positioners prevent SIDS,” said Dr. Joshua Sharfstein, the F.D.A.’s principal deputy commissioner.
Rivalry Among DNA Sleuths Comes Alive in Letters
A long-lost trove of letters written by and to Francis Crick, co-discoverer of the structure of DNA, has resurfaced, highlighting the tensions between the members of two English laboratories as they vied with each other and in alliance against a formidable American rival, the great chemist Linus Pauling.
The letters were written during a 26-year period when Dr. Crick informally guided the progress of molecular biologists around the world in establishing how DNA operates in living cells. An article on the letters was published Wednesday in the journal Nature, focusing on those related to the discovery of DNA’s double helix structure in 1953.
“We are really between forces that may grind all of us to pieces,” the physicist Maurice Wilkins wrote after a disastrous attempt by Dr. Crick and his colleague James D. Watson to build a model of DNA based in part on data gathered by Rosalind Franklin.
Ignoring the intimations of doom, Dr. Crick responded to Dr. Wilkins in flippant style, referring to his poaching another lab’s problem and to his friend’s inability to get along with his colleague Dr. Franklin. “So cheer up and take it from us that even if we kicked you in the pants it was between friends,” Dr. Crick wrote in December 1951. “We hope our burglary will at least produce a united front in your group!”
Dr. Crick’s scientific career was delayed by wartime work designing mines, and at the time he was studying for his Ph.D. at Cambridge University and was not supposed to be working on DNA at all. The problem belonged to Dr. Wilkins at the University of London. But he, too, was sidelined because the head of his laboratory, John Randall, had made him give up his DNA material and graduate student to a new hire, Dr. Franklin.
The debacle of the wrong structure was set up by Dr. Watson, who had attended a lecture Dr. Franklin gave about her work on DNA but misremembered a critical measurement. Based on it, he and Dr. Crick built a model of DNA’s structure and proudly invited the London group up to Cambridge to inspect it.
Dr. Franklin saw immediately that it was mistaken and pointed out the error. Worse consequences were to follow. Hearing of the failed attempt, Dr. Randall complained to Lawrence Bragg, the head of Dr. Crick’s laboratory. Dr. Wilkins’s fear of “forces that may grind all of us to pieces” was not misplaced: Dr. Bragg told Dr. Crick to get back to his thesis work and stop building models of DNA. The ban was reversed a year later only when Dr. Bragg learned that Dr. Pauling, his longtime rival, was also hot on the trail of the DNA structure.
Dr. Crick’s correspondence during the formative years of molecular biology was long thought to have been destroyed. Dr. Crick told others in 1976 that an overly tidy secretary had thrown all his early letters away. His colleague Sydney Brenner, with whom he shared an office in Cambridge for 21 years, believed the same. Dr. Brenner once showed the author Horace Judson boxes of his unsorted correspondence, explaining it had survived, unlike Dr. Crick’s, only because he had been too lazy to file it. “And that’s why the girl never destroyed it,” he said, Mr. Judson reports in his book “The Eighth Day of Creation.”
But it turned out the secretary did not destroy Dr. Crick’s correspondence. Dr. Brenner, who is now at the Salk Institute in La Jolla, Calif., recently donated all his files to the Cold Spring Harbor Laboratory on Long Island, where Dr. Watson still works. Looking through Dr. Brenner’s archives, Alex Gann, director of the laboratory’s publishing unit, recognized that they included Dr. Crick’s missing correspondence, which evidently had not been discarded but merely was commingled with Dr. Brenner’s papers.
Dr. Gann and Jan Witkowski, director of the Banbury Center at Cold Spring Harbor, write in their article in Nature that the recovered correspondence “gives us a more nuanced sense of the interactions between the principal players in this most famous of scientific stories.”
Robert Olby, a historian of science at the University of Pittsburgh and Dr. Crick’s authorized biographer, called the rediscovered trove “a rich source of passages that are the live words of the actors at the time, spoken in the heat of the moment.” Dr. Olby’s biography, “Francis Crick, Hunter of Life’s Secrets,” was published last year, its subject having forbade its appearance during his lifetime.
App Smart: Healthful Reminders for Medications, Beyond an Apple a Day
It’s probably not wise to boast about how many pills you can take at once, but I just scored a personal record of 10. I forgot to take one morning’s worth of supplements prescribed by my doctor (and my wife), and my lunchtime reward was a mouthful of badness.
The MedsLog iPhone app, showing a summary page for medications.
The Dosecast iPhone app shows when you took medication.
I suspect it was not the most healthful thing to do. Wishing to avoid repeating the incident, I tried some apps that remind users to take their medications, including MedsLog, Medsy, MotionPHR Health Record Manager and others. Appropriately enough, the experience was like ingesting medicine — an unpleasant chore, but good for you.
MedsLog ($4, with a free Lite version, only for the iPhone) was the most full-featured app I tried, but it was harder to use than many others. Still, if you have complex medication needs, and you spend enough time with the software to understand its foibles, it’s worth the work.
If you do not already take heartburn medication, you may occasionally need it as you navigate MedsLog. At first, it was easy to use; I opened the app and started typing in “Glucosamine,” and MedsLog sweetly finished the task after just a few letters.
Then came the “Consumed by” box. I expected to type my name, but instead the app presented me with a screen that read “No person” and a blank blue box, with no place to add information. I searched around for a button to push, then gave up.
Later, on the home page of the app, I found the “People” tab, where I could type in my name. Only then did my name appear beneath the “No person” tab I’d seen earlier.
I complain about this at the risk of obscuring one of the app’s best qualities; it lets you track medications of more than one person. (The free version works for two people; the paid tracks unlimited people.) For parents, adult children or other caretakers, this can be extremely useful.
After you enter the medications, you set the alarm down to the minute. MedsLog requires you to connect the app with your iPhone’s calendar, which is a hassle other apps avoid. But because my iPhone’s calendar is linked to my Google calendar, that step allowed me to receive alerts at any computer.
As a medicine tracker, the app brimmed with useful features. You can customize the medication page to include information about peak air flow for asthmatics, for instance, or blood sugar for those with diabetes. MedsLog will also predict when you’ll run out of medication, and you can record where you bought the medication, among other things. Finally, you can set a passcode and keep a medication log that you can e-mail or download to your computer.
MotionPHR Health Record Manager ($10 for full version on Android and iPhone, $2 for a Lite version on iPhone) is a similar app that received good reviews from iPhone users until recent weeks, when users began complaining about flaws in the reminder system and a service that backs up user data.
The company acknowledged those problems and said it was working on fixes.
Medsy ($2, only on the iPhone), meanwhile, was more user-friendly than MedsLog or MotionPHR Health Record Manager, but had many fewer features. Touch the “plus” symbol and tap in the name of your medication. (The auto-fill feature from MedsLog is, sadly, missing here.) Next, choose the quantity and frequency of dosages.
It’s a nice touch, but what sets Medsy apart from MedsLog and others is that it will — with no added steps — push alerts even when the iPhone is locked, when other apps are running and when you have no cellular or data connection. If the ringer is off, the phone vibrates until you respond.
Medsy is, however, limited in one important respect. Most of my medications are supposed to be taken with meals three times daily, which is a common enough prescription. I could not set the alerts accordingly.
Dosecast, a new app, is perhaps the best of the iPhone-only offerings. The application is free for the first month, and $4 after that, but it will be worth the price for most users. It lets you set reminders according to your own schedule, or, if specific intervals are paramount, it will set a schedule for you. You can turn off the interval reminders during bedtime, if you wish.
You may also e-mail a list of your medications and your compliance history to anyone you wish. One drawback is that users will miss a reminder if they do not have a 3G or Wi-Fi connection.
BlackBerry users have fewer options, as usual. MediRemind ($3, for both BlackBerry and Android devices) is the most highly rated medication tracker in BlackBerry’s App World, but those ratings are based on just a few reviews.
As with Medsy, the app allows for “push” notifications when other programs are running, or when the device is locked. The software has a longer list of features than Medsy, however. Among other things, it can store all of your medical contacts and make a phone call with a single push of a button.
It’s a highly useful feature when you’re on your last pill and you want to call for a refill before you forget. Or, perhaps, when you have a fistful of pills and a nagging suspicion that swallowing them all at once may not be such a great idea.
Quick Calls
Suddath, a relocation specialist, recently released “Moving Guru,” a free BlackBerry and iPhone app that includes a task list that begins eight weeks before the move date, packing tips and a “We’ve moved” notification feature. …“Swing By Swing,” a free iPhone rangefinder for golfers, recently updated the app to include zooming and panning capabilities, so you can spot obstacles on the course with faster loading and less battery drain. …TripIt is a (free) must-have travel planning app for iPhones, BlackBerrys and Android devices. Forward your travel confirmation e-mail to plans@tripit.com and it creates a master itinerary in a private TripIt.com account. The service recently added a new feature for Gmail users, in which travel-related e-mail is automatically forwarded to your TripIt account.
Oops! F.D.A. Error Is Talk of Henhouse
Don’t park too close to the henhouse!
A delay in sending safety inspectors to egg farms after this summer’s salmonella outbreak and egg recall can be traced in part to a parking mistake outside a pair of Pennsylvania henhouses, according to industry executives and state government officials.
Marilyn F. Balmer, a top egg expert for the Food and Drug Administration, was training inspectors in July to enforce the agency’s new egg safety rule when she parked the van she was driving near a henhouse at a farm in Manheim, Pa. She did it again during another session at a farm in Lancaster.
Ms. Balmer was in Pennsylvania to teach inspectors about how to keep germs away from poultry flocks, known as biosecurity. But the industry executives and state officials said she was breaking a basic biosecurity rule: keep vehicles, which may have driven through manure on rural roads or other farms, as far from the hens as possible.
At the Manheim farm, although the biosecurity breach was mentioned to Ms. Balmer, the van stayed where it was, according to a Pennsylvania state egg official, Kim Kennedy Barnham, who attended the training. In Lancaster, when Ms. Balmer was asked by the farm owner there, James Charles, to move the van, she refused. Finally, after Ms. Kennedy Barnham and an F.D.A. employee intervened, Ms. Balmer allowed the van to be moved.
But that was not all. Later in the day, Ms. Balmer and another instructor got into a heated argument in front of the trainees, according to egg industry executives briefed on the matter.
Ms. Balmer declined to comment.
All of that prompted the F.D.A. to re-evaluate the training program, contributing to a delay in preparing the inspectors to enforce the new safety rule. The rule went into effect July 12, but inspections began only last week at farms not involved in the recall.
The F.D.A. sent letters apologizing to Mr. Charles and the other Pennsylvania farmer (neither of whom were connected to the recall, which involved only eggs from Iowa). “Our employees’ disrespectful behavior was unprofessional and is a breach of good manners and our expectations,” the letters said.
Jeff Farrar, the head of food protection at the F.D.A., said the inspections were on track. “We are ready, we’re inspecting farms, we’re fully trained,” Mr. Farrar said. He would not identify Ms. Balmer by name, but said the person involved in the parking incident had been removed from the training program.
The first stop for the new round of inspections was Maine, where inspectors last week visited farms owned by Austin J. DeCoster, according to the farmer, who owns most of the Iowa farms that produced the recalled eggs.
Ms. Balmer’s parking problems were the talk of egg farmers across the country, many of them skittish over damage to the industry caused by the recall and anxious about F.D.A. inspectors coming onto their farms.
Dr. Nan Hanshaw, the chief of animal and poultry health for the Pennsylvania agriculture department, said the dust-up might have an upside.
“It’s a good training tool,” she said, “to actually show someone what not to do.”
Recipes for Health: Rice Stick Salad With Shredded Vegetables
Rice stick salad is a terrific vehicle for vegetables. Play around with the ingredients here — if you have different vegetables than those called for, try them. You might shred lettuce in addition to the cabbage, add some bean sprouts, add a minced chili or some cayenne if you want a little spice.
Martha Rose Shulman presents food that is vibrant and light, full of nutrients but by no means ascetic, fun to cook and to eat.
1 1/2 cups purple cabbage, finely shredded
7 to 8 ounces thin rice sticks
1 tablespoon shredded pickled ginger (optional)
1 cup shredded or julienne carrot
1/2 cup julienne cucumber
1/2 cup julienne red pepper
2 tablespoons chopped or slivered fresh mint
1/4 cup chopped cilantro
2 tablespoons fresh lime juice
2 tablespoons seasoned rice vinegar
1/2 teaspoon sugar
2 teaspoons minced ginger
1 tablespoon low-sodium soy sauce
2 tablespoons Asian sesame oil
2 tablespoons canola oil
optional: 1 cup shredded chicken, cooked
1. Place the cabbage in a bowl, salt generously and cover with cold water. Let sit for 15 minutes, then drain and dry on paper towels.
2. Meanwhile, place the rice sticks in another bowl and cover with hot water. Let sit for 20 minutes, until pliable, while you prepare the vegetables. Drain, and cut the noodles in half, into roughly 6- to 8-inch lengths, with kitchen scissors.
3. In a large bowl, toss the noodles with the pickled ginger, all of the vegetables, chicken (if using), mint and cilantro.
4. Whisk together the lime juice, rice vinegar, sugar, ginger, soy sauce, sesame oil and canola oil. Toss with the noodle mixture, transfer to a platter or salad bowl, and serve.
Yield: Serves six.
Advance preparation: This will keep for a few hours in the refrigerator.
Nutritional information per serving: 236 calories; 9 grams fat; 1 gram saturated fat; 0 milligrams cholesterol; 34 grams carbohydrates; 3 grams dietary fiber (6 grams if using brown rice noodles); 185 milligrams sodium (does not include salt added during preparation); 4 grams protein
Martha Rose Shulman can be reached at martha-rose-shulman.com. Her new book, “The Very Best of Recipes for Health,” was published in August by Rodale Books.
