questioning everything: CT scans and cancer, coffee and diabetes

Computerized tomography, otherwise known as CT or Cat scanning, has imaged 70% of non-elderly adults in the last 3 years. The use of this technology has been steadily rising, and we now perform a total of over 19,500 CT scans per day in the US.

CT scans use a computer to organize x-ray data in such a way as to produce pictures that resemble cross sections of the human body, complete with bones, brains and soft tissues, tumors and blood vessels. The pictures are truly marvelous and have revolutionized the way we diagnose disease, allowing us to know many things about the insides of a person without actually cutting them open. We can see if a tumor is present, has spread, if an aneurysm is bursting or if the excruciating pain in a person's belly and back is a kidney stone or pancreatitis. We can tell if a victim of trauma is bleeding internally or if a mysterious fever is caused by a well hidden abscess.

In December's issue of the Archives of Internal Medicine, researchers from the National Cancer Institute and other participating institutions published an article looking at the cancer implications of all of these wonderful CT scans we have been doing. Based on risks of cancer predicted by a study of ionizing radiation done by the National Research Council, the CT scans done in the US in the year 2007 will be responsible for 29,000 cases of cancer, and 15,000 excess deaths. One CT scan of the abdomen and pelvis may be equivalent to 450 or more chest x-rays in terms of radiation exposure (though this varies by procedure and institution.)

CT scans, besides being life saving and revolutionary, are also killing us and eating up our health care budget. The trick is moderation. It is clear to me, from seeing my patients return from visits to emergency rooms or specialists, that we do far more CT scans than are truly necessary to diagnose serious disease. Sometimes an elective CT scan is interesting or reassuring, but just as often the tests done for interest or reassurance end up being confusing and anxiety provoking, as they show the benignly quirky internal makeup of individuals who might have cysts or enlargements of organs, duplicated spleens, liver hemangiomas, missing kidneys.

But moderation is not always a good thing. Take coffee, for instance. Another study reported in the month's Archives of Internal Medicine shows that a person who drinks coffee in large amounts has a significantly lower risk of getting diabetes than a person who drinks coffee moderately or not at all. Many studies have shown this, to varying degrees. The meta-analysis, a statistical combination of many small studies to produce a more robust result, suggests that for every additional cup of coffee you drink in a day, you reduce your risk of diabetes by 7%. Although fewer studies have looked at tea and decaf, they appear to carry the same benefits as real hi-test java. The best outcomes were seen in people who drank at least 6 cups of coffee a day.

Once again we see the limitations of science to address the concerns of the individual: if I drank that much coffee I would certainly die.

mammogram screening, take 2

I finally read through the 3 articles in the Annals of Internal Medicine that addressed the new recommendations from the US Preventive Services Task Force (USPSTF) about the recommendations for mammogram screening and breast exams. These have led to angry reactions, mostly based on lack of information and lack of understanding of the science behind the recommendations.

First of all, the USPSTF is far from the only organization to weigh in on screening recommendations. There are organizations such as the American Cancer Society, the American College of Obstetrics and Gynecology and various other official groups from various branches of medicine. The USPSTF is, however, the most evidence based of the groups, the least financially motivated, and the most conservative.

The recommendations of the USPSTF are categorized according to how sure they are that they are right, and changes come after long discussion and detailed evaluation of the research and the opinions of other organizations. In 1996 they were unable to endorse regular mammogram screening for women younger than age 50, but in 2002, based on information from studies done since that time, they extended their recommendations to women starting at age 40. They acknowledged at that time that there were risks associated with mammogram screening and that it was neither sensitive nor specific during that decade.

Yet more studies have become available since that time and the recommendations have gone back to encouraging women to begin mammogram screening at age 50, saying that screening before that time should “take patient context into account, including the patient’s values regarding specific benefits and harms.” They conclude that evidence is insufficient to recommend screening of women 75 years and older, which is solidly in line with recommendations in European countries. They do not, however, recommend against screening in older women.

The decision not to recommend mammograms routinely for women ages 40-49 is based on the fact that mammograms often pick up abnormalities of the breasts which appear suspicious, result in further procedures, and harm women through over treatment and excessive diagnostic testing. Breast cancers are detected in that decade, but the risks of screening all of those unaffected women outweigh the benefits of early detection in the few.

The recommendation that women not be taught breast self examination has engendered the greatest amount of misunderstanding of all. On the face of it, it makes no sense. What harm could self examinations do? Why should a woman not know her own body?

The recommendation is based on two large studies, one in Russia and another in China, evaluating self breast exams in a population that did not get regular mammograms. Women who were taught breast self examination techniques had no benefits in terms of breast cancer survival when compared to women who were not. So this recommendation really addresses the question of whether a physician should spend time specifically teaching women techniques of self breast examination. It does NOT say that doctors should now tell women not to examine their breasts. Perhaps women are just fine at examining their breasts without being harangued by their doctors to do so.

What, you may ask, is the rationale behind getting mammograms every 2 rather than every one year? Studies have shown that as many as 99% of breast cancers are picked up by every other year mammograms, and given known harms of radiation and associated costs of those extra mammograms, were they done every year, 2 year intervals seem like they are the magic number.

But why 2 years? What’s so special about the number 2?

At the Norwegian Institute of Public Health, studies have looked at women who got mammograms every two years for 6 years vs women who got only one mammogram at the end of 6 years. The women who got the mammograms every 2 years had a significantly higher incidence of breast cancer than the ones who got only one mammogram, and this difference persisted in the years that followed. The conclusion that the Norwegian doctors came up with was that the every 2 year screened women had breast cancers discovered which would have gone away if left untreated. American researchers have hotly disputed this interpretation, but their arguments are not compelling.

It is clear to me that the recommendations of the USPSTF to reduce recommended mammogram screening is NOT based on a politically motivated desire to reduce health care spending at the expense of the health of women. It is not yet clear to me what the best recommendations for mammogram screening should be. I intend to continue, as I have, to discuss with patients the pros and cons of mammogram screening and help them make the choices that are best in line with their risks and their values.

missing the safety net

What if you graduated from high school, left home, got a job delivering pizza, and were critically injured in a motor vehicle accident?

What if you had a part time job at a big company, a house, a family and got cancer?

What if you lost your job and your 8 year old daughter got appendicitis?

In the United States there are systems that act as safety nets for situations such as these, but they are not self sufficient and are severely strained in their ability to provide services with the progressive loss in adequate insurance coverage, the floundering economy and the increasingly outrageous costs of various forms of medical care.

If you were the first guy, ejected from your Geo Metro when you were t-boned at an intersection by a drunk driver, you would be taken to an emergency room at any hospital, transported to a trauma center if necessary, and treated until you were on the mend by that hospital. If you were eligible for medicaid or medicare due to the severity of your disability the hospital would eventually be reimbursed for the cost of your care (at least partly), and if you were not eligible, the hospital would attempt to bill you and when you were unable to pay, would eat the cost, part of which would be tax deductible.

If you were the second guy, the doctors who treated you would do so with little hope of being paid, might bill you, and would eventually eat the costs. You might be able to apply for a county emergency payment program to pay for things like surgery and CT scans, but you would eventually be expected to repay these costs. You would apply for public assistance based on disability, but the process of being approved for it would be slow. Your savings would inevitably be used up. You might lose your house.

In the case of the child, we have guaranteed medical insurance available for children through the government, but you do need to apply for it. The child with appendicitis might die or have some other bad outcome due to delay in treatment from lack of insurance. In a perceived emergency, though, treatment through the local emergency room would be assured.

Much of the problem with American health care stems from the escalating costs associated with it. Yet many of these costs, especially those associated with procedures and tests, go to hospitals who are the basis of our safety nets. In cutting costs, it is going to be vital that we pay attention to making sure that hospitals stay solvent. Providing adequate universal insurance will be a project that takes time, probably years. It is this insurance that can support hospitals and allow them to continue to support the communities in which they operate.

An article in the New England Journal of Medicine (http://content.nejm.org/cgi/content/full/361/23/2201) addressed our safety net system, and just how fragile it is. Because some hospitals are located in areas of particularly acute economic and social disaster, they are simultaneously vitally important to a safety net and totally inadequately reimbursed. Allowing hospitals like that to go under threatens the whole fabric of the larger medical system.

How the conference on affordable health care went

There were nearly 30 people there, at a not much more than 40 bed hospital. This is unprecedented for a not-required noon meeting. There was food, but it wasn’t very good, so they were there for the content (or maybe they though the food would be better.)

The radiologist talked about appropriate use of technology and reducing unnecessary testing. Primary care docs talked about ways to make the computerized medical record systems give information about costs. The pharmacist talked about how to find out good information about drug costs, and we discussed ways to educate docs in the hospital on alternatives to the most expensive medications. We discussed other methods for reducing pharmacy costs which will also have other health benefits (changing medications given by vein to ones given by mouth, for instance.) The hospital CEO was willing to commit to putting into practice a system that would promote cost transparency for providers and patients. We talked about shifting responsibilities for record keeping to nurses in our offices so we would have more time to see patients so they wouldn’t have to go to emergency rooms where the costs are higher and the care is less personalized.

What will come of this is unclear, but the very act of discussing it in an open forum is brand new in my experience.

There is a part in the hippocratic oath about sharing the precepts and learning only with those who have taken the sacred oaths and the sons of other doctors. This may partially underlie a tendency of doctors to be circumspect. For whatever reason the workings of the practice of medicine are not shared easily outside of the profession. Discussing and re-evaluating what we do will go against some pretty basic instincts.

Post conference feedback has been interesting too. As might be imagined, not everybody had their say, and not everybody's issue got discussed. One provider mentioned that she would have liked to problem solve some really pressing issues of access to care. A tech guy mentioned that he had lots of ideas on how to make the hospital staff more efficient by making technology more effective. I am sure that the more we talk, the more issues will come up, and there may need to be smaller conversations and groups of people with similar interests will have to do their own work.

Framing a conference on making health care affordable

Tomorrow will be my first attempt at bringing the health care providers from my community together to discuss how we can change our practices to make health care more affordable.

I approach it with some level of trepidation due to the fact that doctors can be pretty defensive about change. Nevertheless in many one on one conversations I’ve noticed that all of us are to some extent disgusted by how much health care costs, and by the fact that this means that many people don’t have access to good care.

So what will I say to a group of internists, nurses, family practitioners, radiologists, orthpedists and surgeons (if they show up)?

I hope that it won’t be me talking at them, since I already know what I think. But I will have to get the whole thing rolling.

I am co-facilitating this with a radiologist who is motivated to change our doctors’ ordering habits for radiological procedures so they are at least ordering the right tests and not repeating tests unnecessarily.

I intend to say:

I’ve talked to many of you over the last months about the costs of health care. I’ve been doing thinking and research on the subject, and I think that, although we do a god job with our patients, the whole process costs way too much. Some of that is because we order too many tests when we are busy or because we are worried about malpractice, and some of it is because there are so many demands on doctors that we have trouble organizing our efforts. Many of us have adopted computerized medical records, and though they improve the quality of followup and documentation, they are sometimes distracting, and slow us down and focus us away from our patients. Technology and pharmaceuticals have exploded since most of us finished our training, and it is hard to keep track of which medications or procedures are really worth the time and expense.

The result of these factors is that our patients end up going to emergency rooms or quick care offices for things that could be better handled by their primary care doctors, and end up with testing that is expensive, and often unnecessary. We spend much of our time keeping track of preventive medicine recommendations and being glorified record keepers and ineffective nags in the service of smoking cessation, weight loss, colonoscopies, mammograms, pap smears and other preventive strategies.

We have very little knowledge of what the things we order cost our patients, and so they end up with huge bills that often profoundly affect their finances and so their overall social health.

There has been much talk about health care reform, and I have paid attention to a good bit of it. What I see is that legislators have lots of ideas for improving access, though they don’t necessarily agree with each other, but they really do not know how to address reducing costs, which is the basis for most of the debate. In some ways this is good. If legislators make rules to reduce medical costs, they are liable to be rules that don’t make sense from our standpoint. I think reducing costs is something that we, as providers, can do best. There are limitations to what we can do as a small community, but this is our community and it is a place to start.

What I would like to do today is sit together and talk about what we do that is effective in our practices, and what things we see happening, or do ourselves, that contribute to the high cost of health care. I would like for us to come up with some concrete ideas for ways to improve our efficiency, our and our patients’ well being and move medicine in the direction we want to see it take.

We the people who love food too much

We the people who love food too much

November 23, 2009 by janiceboughton

Every year we tell the story of pilgrims, coming to a new land to seek religious freedom, nearly wiped out by hunger and disease, and saved due to their resolve and some good advice by native Americans. I will not speculate on how much of that is true, but it is our story. We then tell the story of a meal shared to celebrate and express gratitude for their survival.

The original Thanksgiving feast was probably not much of a spread. We have gone far in the last 200+years to make amends for that. I personally never remember a Thanksgiving celebration when it was possible to fit all of the food I wanted on one plate.

Corn was one of the reasons that our predecessors survived. It grew easily, was forgiving of nasty weather and inadequate soil, and now is our major cash crop. We produce huge amounts of it, and so we make all kinds of stuff out of it, and instead of scrawny pilgrims, we are now round, well fed, and increasingly diabetic.

We continue to be a resolute and industrious people, and have fixed the problem of inadequate food supply, in spades. We make plenty of cheap food, and though starvation is by no means wiped out in the US, more of the poor are injured by access to cheap and abundant corn-based carbohydrates than are from inadequate calories. Like Scarlett O’hara in “Gone with the Wind’, we will “never go hungry again.”

Pap smears and mammograms: what's the story?

If you've been watching the news, you may have seen some historic changes in recommendations about cancer prevention. There have been news releases regarding a change in the recommendations for mammogram screening by the US Preventive Services Task Force (USPSTF). Women in the 40-50 year old age group are now only encouraged to have regular mammograms if they are at increased risk of breast cancer, due to the fact that this test often finds non-existent of unimportant abnormalities in this age group that, on the whole, makes them less, not more, healthy. This will save women thousands of dollars and countless hours of time and energy at a time in their lives when that time and energy is a real gift.

Today I read that the American College of Obstetrics and Gynecology now recommends starting pap smear screening at 21 for most people, and reducing the frequency in that first decade to every 2 years. I have studied evidence based recommendations for pap smears for years, and the formula that makes sense is somewhat more complex than this, but in most cases our standard yearly pap smears are not necessary. This is based on the fact that some of the treatments for abnormal pap smears can make a women less healthy, less fertile, and that the whole process is expensive enough that honing it down to what is truly necessary makes excellent sense.

Cost is certainly not the only issue here, but diversion of significant money from womens' health funding in directions where it does no good hurts all of us. Google tells me that a mammogram costs around $100, and may cost as much as $200, and a pap smear runs about the same price. The cost of these tests in terms of comfort and dignity is not insignificant.

cool things we should all want (not)

Three articles in the most recent New England Journal of Medicine describe more new medical technology, and have made me curl my toes in mental conflict.

1. A pacemaker that goes into both the right and left chambers of the heart, rather than just the right side, preserves heart function better, according to ultrasound tests. It is a much trickier (read inaccessible, expensive, desirable) procedure than the standard one, and the patients don’t actually feel any better or act any healthier than with the standard kind of pacemaker.

2. Giving an intravenous iron supplement that I’ve never heard of before (new) (they didn’t test the ones I have heard of before) can improve heart function and health in patients who have congestive heart failure and are iron deficient. How odd that they didn’t evaluate oral iron supplements which have been generic since before I was born and are the standard treatment for iron deficiency. Is it just possible that the new product will be the only product approved for treating congestive heart failure in patients with iron deficiency? Is it just possible that it will cost some jaw dropping amount of money?

3. In people who have heart failure so bad that they would need a heart transplant to survive, but they are not well enough to survive a heart transplant, use of a mechanical pump can prolong their life, and can be used somewhat indefinitely. Only 1/4 of these people will live a year with this technology, and 17% of those treated will have a major stroke. The cost of the technology wasn’t mentioned, and quality of life was not addressed.

We continue to move towards technology that is more expensive, more resource consuming and does not seem to improve quality of life, at least in clinical research. Frequently practice follows close on the heels of research. A good journal still publishes studies like the intravenous iron one that may influence practice without any evaluation of possibly equivalent less expensive and resource intensive alternatives.

Whence my internal conflict? Clinical science occasionally barks up the right tree, and contributes to the health and happiness of people. It also burns money like it is nothing, as if resources were unlimited.

Sermon to Unitarians on health care reform: Healing America's health care system

(this is really long compared to my usual stuff, but some people may want to read it anyway. It is a compressed synopsis of my many mini-essays that I delivered today at church.)

I love my job. It is possibly the best job that anyone could ever have. I get the chance to meet people of incredible diversity, and participate in decisions that they make about some of the most important aspects of their lives. I hear amazing stories. I get to solve mysteries, or at least try to solve mysteries. I get to interact with other doctors, who are some of the most interesting and committed people I know.

In the years I have practiced medicine I have been impressed often with the compassionate and effective care we can give to people regardless of their ability to pay for it, regardless of their social status, race or nationality.

So when I say that the American health care system is broken, I say it with love, and with the frustration that comes of knowing how good it can be.

The major problem that I see with American health care is that it simply costs too much, which is the reason that we are not providing adequate care for a sizeable proportion of our population. If we can untangle the causes for the high costs of medical care and thus free up resources we can provide care for everyone and start to focus on what is really of value to all of us.

I grew up very close to my two grandmothers who weathered the depression well because they really had very little to lose and were already incredibly thrifty and hard working. Although they were comfortable by the time I knew them, owning their own houses and with plenty of food to eat, they always considered cost and good value in making decisions. So when I began doing my clinical rotations at John’s Hopkins, I sometimes found it difficult to come to grips with testing and treatment that we did that seemed to lead to nothing of value in patients’ lives. I have practiced medicine as if cost matters since I have matured, but certainly not to the extent that my grandmothers would have, if they had been in my place.

As the health care debate has heated up, I began to hear figures related to costs in medicine that were and are increasingly disturbing. Figures like 2.3 trillion dollars spent on health care yearly in the US, and 17% of our GDP going to health care. I looked at a book of facts and figures that came to me by chance a couple of years ago, and saw various health indicators for developed countries that showed us to be merely average, despite our higher per capita spending on health. I asked my friends, other doctors, why they thought we were so expensive, and they all knew. And I knew too. We all know that, for various reasons, we order too many expensive tests, procedures and medications, without considering the costs and the benefits. There are 4 reasons that we do this: we don’t really know what medications and tests cost, we feel that our patients have come to expect this kind of care, we don’t have time to discuss care with our patients, and we think that ordering these medications or tests or procedures will protect us from being sued for malpractice.

One day I sat down and calculated about how much money we might really be wasting on testing and procedures that do nobody any good, and came up with a ballpark figure of 20,000 dollars wasted in a half a day. I’ll tell you the story of a busy doctor on an average morning. The story is entirely fictional, but happens all the time in the US. The costs are approximate, because they vary considerably.

8AM—arrive at the hospital, perform two treadmill tests with nuclear imaging, ordered by physicians for patients at low risk, because of concern about malpractice should they have a heart attack. Each costs $3000, one unnecessary, the other of which could have been done without nuclear imaging at my office for $200.
9AM—see two patients at the hospital. One remains in the hospital because she can no longer live at home and can’t afford to go to any of the extended care facilities that have openings, at a cost of $1000 for the day. The other is there because she wasn’t insured and waited too long to see a doctor for her migraine headache, costing $2500 for her MRI scan of the head and $1200 for her day’s stay at the hospital, and $600 emergency room fees.
9:45—get to the office late because the uninsured patient was news to me, so I didn’t plan on seeing her. See my first patient who has a physical scheduled. She wants “a complete lab workup” even though all of her labs were normal last year and nothing has changed, because her insurance will cover it. She has been having back pain. Since I don’t have time to talk to her about the natural history of back pain I order an MRI scan and physical therapy. Labs: $120, MRI$2500, 8 physical therapy appointments $1000.
10:30—next patient has numbness in his fingers when he is anxious. He can’t afford counseling and I don’t have time to discuss relaxation techniques with him so I refer him to a neurologist. He will see the neurologist 3 times, at a cost of $150 per visit, and she will order a head MRI scan for $2500.
10: 45—next patient has a cough and a stuffy nose for 4 days. I think it is viral, but she is sure she needs antibiotics. I don’t have time to explain the side effects and futility of antibiotics so I prescribe an antibiotic. She says the generic doesn’t work. Cost is $120 for that and $200 for an inhaler which is what I think will work, though if she just waited she wouldn’t need that. Because she smokes and I am worried about being sued if she eventually gets lung cancer, I order a chest x-ray. That is another $200.
11:00—patient comes in for follow-up of his diabetes. It has been in poor control, but since I don’t have time to counsel him on diet and exercise in a way that will probably have an impact, I prescribe a new medication. He is already on generic pills, so I have to prescribe insulin, and because time is an issue, I use the newest insulin delivery system which is easier to explain. This costs $150 and doesn’t make him any happier, plus his risk for complications is just as high because he will continue to gain weight.
11:15—the next patient comes in for follow-up of an abdominal CAT scan I ordered because I didn’t have enough time to counsel the patient on how to avoid constipation which had then given him belly pain. The CAT discovered a cyst on his kidney and a nodule on his adrenal gland. He is beside himself with worry, even though both of these things are usually normal findings. I reassure him that I will get a follow-up CAT scan to make sure they are normal, which will use a better technique and cost $2000 (but I don’t tell him this because I don’t know what it will cost and have no idea what his insurance will pay.) Because he is so worried I don’t have time to see my next patient who has to leave and go to the emergency department with her pneumonia at a cost of $1500.
With over half a million practicing physicians in the US, this may add up to 100s of millions of dollars every day. It has become clear that many of the expensive things we do are the things that don’t make patients healthier or happier, and that costs related to what I think of as stupid care may make up a sizeable portion of our health care budget.

So let’s move away from my personal experience a little bit. Trends in health care spending have changed some, but why have the American people all of a sudden noticed that something is wrong? Our economy took a nosedive about a year ago. Insurance prices finally became too high for individuals and companies to afford them, and the services they provided became inadequate to cover the medical care that people were receiving. People are now commonly bankrupted by paying for medical care, insured or not. We got a new president who started focusing on health care, and began talking about making changes that would allow more people access to it, and about ways to bring the spending on that health care in closer line with most other developed nations. Focus has moved to improving the cost and service provided by the insurance companies, and we have become alarmed by their high profits. But even if their prices come down and profits are reduced, the budget for health care will still be unsupportable.

Because medical care is so expensive now, people who are uninsured have virtually no access to non-emergency care.

So what do we need to do?

We obviously need to allow access to good medical care for everyone. We also need to substantially reduce the cost of that medical care.
If we substantially reduce the cost of medical care, all sorts of options become possible for extending access to everyone. The point that our democratic legislators have failed to emphasize is that if we do not reduce the cost of medical care, extending access to everyone becomes economically unsupportable. The really miraculous thing about this situation is that reducing costs can directly improve the quality of medical care. When we spend money on things that don’t really help people to become healthier, we are also spending time and energy on those things, and that is time and energy that could be spent giving better care.

One way to reduce costs and improve health will be to provide adequate primary care for everyone, so we can take the time that is needed to do what is most valuable to each individual. Patients need to be able to see a provider who knows them and their issues for problems as they arise, rather than having to go to emergency rooms or urgent care offices where costs are much higher and procedures are ordered much less conservatively. When you go in to the emergency room for a condition, the doctor focuses on the many life threatening conditions that you might have, and with no familiarity with you or what makes you tick, will order many blood tests and imaging tests that will be done while you wait. In some situations this is just what should happen, but in most situations you will get way more tests than you actually need.

Allowing everyone access to a primary care doctor will mean changing the way medical care is paid for so that primary care is a more desirable field. When a new doctor finishes medical school, that person is in debt for about $150,000. Going into a medical specialty guarantees a much higher salary than going into primary care, and this has driven a progressive trend away from training physicians in primary care fields. When I graduated from medical school over half of graduates became primary care docs, and now that number is just above 10%. This trend does not allow us to even replace the internists and family doctors who retire, much less increase the work force to take care of the patients who we hope will soon have access to medical care.

Another way to bring down costs is to make them part of the discussion when deciding what should be done to take care of a problem. Procedures are often ordered in place of spending time with a patient. A discussion of costs, risks and benefits would likely reduce the number of procedures done, and make sure that they will actually contribute to a patient’s health. To have such a discussion, doctors and patients need to know what they cost. As odd as it may seem, it is quite difficult to find this information. When I order an antibiotic for a patient or a CAT scan I truly have no idea what the total cost will be or what the patient will end up needing to pay, and that situation is simply unacceptable.

Worries about being sued for malpractice drive doctors to order tests and consultations that are not necessary. We need to have a system of dealing with medical malpractice that is designed to improve quality rather than lead to defensive medicine. The way things are now, very few people who injured due to a medical mishap are compensated, and the process of completing a malpractice case takes years of a patient’s and a doctor’s time, leading to bitterness rather than quality improvement, in most cases.

What can we do, as patients and families of patients? We can look honestly at what we want to get from our medical care. We need to realize that the resources to pay for everything are, in fact, limited. Money we spend for medical care is money we don’t have to spend on food and shelter, education, and having fun with our friends and family. We need to have honest discussions with our health care providers about costs of things and expected benefits. We need to consider ahead of time what we want the end of our lives to look like, whether we want intensive care, and we need to discuss these things with our providers.

Doctors need to look at the way we provide care, and seriously study what procedures and evaluations for common conditions work and which do not, and what methods of treatment give best value. We need to use our substantial clout to open up discussions of costs which are out of line with other countries, such as costs for radiology procedures and medications. We need to take the time with patients to provide the counseling that the patients need, and push for compensation for this that allows them to do this without going broke.

But what about insurance?

Insurance issues dominate much of the discussion of health care reform right now. About 58% of people have private insurance at this time, and about 34% of people have some sort of public plan. We pay insurance companies, by salary deductions, direct billing or through taxes, and they, mostly, pay for our health care. The way they pay for our health care is positively diabolical in its complexity, and separates us from having much direct effect on what things cost. When insurance pays for something, we are usually just relieved, and not very concerned if the cost is outrageous, because the money paid out does not really look like “real money” anymore. So the very fact of being insured contributes to the excessive cost of health care.

Until something can be done to reduce prices for medical care, and this will be a slow process, everyone needs insurance.

I do not have the solution to the proper way to insure everyone. Presently Medicare covers something like 17% of Americans, and in many cases pays half of what private insurance does for many services. It is because there is a mix of public and private insurance that many offices can afford to provide services to everyone. A simple extension of Medicare to cover all of those who can’t afford insurance would strain the ability of offices to provide care, and many of those insured publicly would find themselves without providers. If Medicare were reformed, and payment schedules were changed, this would be a viable option. Health care coops are an interesting idea, and seed money for an expansion of that system would eventually result in improvement in availability of care. Tighter regulation of private insurance companies, requiring that they compete across state lines, be portable from job to job, and cover pre-existing conditions will help, but if medical costs continue to rise, that improvement will be short lived as costs outstrip anyone’s ability to pay.

Many other countries have developed systems that work for them, and if we can be flexible, their ideas could be modified to work for us.

You may notice that I have not yet mentioned evil drug companies. Much like evil insurance companies, evil drug companies do exactly what they were designed to do which is make money. They will continue to make medications that are overpriced and over advertised as long as we continue to pay for them. We will continue to pay for them as long as we are unaware of their costs and alternatives.

So—there is much to think about. In my mind, there is huge balloon of hope at this time in history. Something finally will be done to improve the way health care is delivered, and liberate resources that have gone to buy medical care that makes no one healthier and happier. Doctors are seeing this, and are actively working to improve the way care is delivered, and the rest of us have the power to bring about change we have previously thought of as impossible. A very special thing about this crisis of costs in the US is the opportunity it brings us to focus on what we really want from medical care, rather than continuing with the “business as usual” which has become a very different thing.

Closing Reading: by Rachel Naomi Remen MD

For the past hundred years the goal of health care has been the curing of the body. Restoring the concept of healing to the heart of health care is no small thing. It requires rethinking the assumptions on which medical relationships are based, rethinking the goals of every health care interaction. It will require a revolution.

How Important is Travel Insurance for your next Great Vacation ?

Are you the adventurous kind,  making travel plans almost throughout the year? If your answer is -Yes then along with your trip, you should also plan your insurance. If you have not bought a travel insurance policy yet, consider doing it right now. Always remember to compare travel insurance rates, coverage and plans before you decide on  an  insurance company. Try and look out for the cheap travel insurance plans offered by various  travel insurance companies. After all, a cheap travel insurance is always better than no travel coverage.

Thousands of students, business travelers and vacationers are traveling across the world,  secured via cheap and affordable travel insurance Even the middle class family, that usually takes at least one vacation in a year, can afford cheap travel insurance.  In all of these instances, standard cover won't meet your needs and you should be considering a specialist travel policy. Cheap travel insurance  in such cases is often regarded better than going in for a standard insurance policy and plan including additional coverage.

The insurance company makes sure that no matter how big your travel plans are, you will be in a position to save up as much as possible. Now, if you buy a cheap travel insurance plan, the benefits of extra insurance coverage will be limited . But you are, however, assured of the insurance coverage required to fulfill your future requirements.

Purchasing a cheap travel insurance plan, offered by any leading insurance company today,  is a wise step to manage your finances. You just have to keep in mind that your baggage is insured, you and your family will arrive conveniently, and in case a crisis crops up, you don’t have to fall back on the fact of whether the insurance coverage of the travel company will cover you or not.

Cases of erroneous travel cover have been frequently heard of. The insured believes that he is safely insured with a travel insurance coverage, only to find out later from his travel insurance company, that he was not. To avoid such situations, you can compare and choose a cheap travel insurance policy and be safe.
Invest in a cheap travel insurance and enjoy a better travel experience. An affordable travel insurance plan is a smart decision that you must take, instead of going for an extra insurance coverage.

Get the best quotes of cheap travel insurance online. But it always does not imply that an affordable travel insurance plan will come with less coverage. Choosing the right travel insurance policy is a safeguard against the travel agents, who dupe into believing that travel insurance is inclusive of your travel plan. For more information, please visit www.1travelinsurance.com

unthinkable thoughts about preventive medicine

Of course it’s true that preventing disease is less painful and less costly than treating disease. Or is it?

Take the recent New York Times article (http://www.nytimes.com/2009/10/21/health/21cancer.html) addressing mammogram and prostate cancer screening. Apparently over the last 20+ years of screening with mammograms, we have been able to discover many more breast cancers that are small, and might never have been noticed, and probably never would have progressed to the point of hurting anybody. This has given rise to alarming statistics, such as the one that breast cancer incidence has risen 40%.

We have long known that detecting prostate cancer early, especially in older men, finds many cancers that would never have caused any injury and would never have been noticed had we not screened the men. When we find cancer, we usually remove it, and for women with breast cancer this means amputation of a breast or radiation therapy, and often chemotherapy. For men with prostate cancer this means surgery on their very delicate private parts after which they often have trouble with bladder or sexual function.

But even if mammogram screening did detect cancer early, thus protecting women from getting more serious breast cancer, which honestly it sometimes does, is it really less painful and less costly than treating the disease? Mammogram screening, it is estimated, costs about $105,000 per year of life saved if we screen women yearly starting at age 40. Because mammograms are somewhat difficult to interpret, many of those women have breast cancer scares, and all of those women get their breasts painfully smashed flat once a year. Encouraging them to get those mammograms is the job of doctors and nurses who might use that energy to provide other more life affirming activities. The focus on the breast as the seat of cancer, rather than of, say, love or courage, puts women in the position of being at war with their bodies.

Let’s go back to the $105,000 per year of life saved. I certainly love my women friends and relatives enough to believe that a year of their life would be worth $105,000, but isn’t it possible that if we spent that money on something a little different than mammograms, we might be able to buy more than a year of life? I could support a family, for instance, for a year on $105,000.

I do know and love people who have had screening mammograms, found breast cancer, had it cured, and are now healthy. I think some of them might have died had they not had a mammogram. I am not ready to say that women shouldn’t get screening mammograms. It is, however, not necessarily accurate that preventing disease is less costly and less painful than treating it, at least in the case of breast and prostate cancer.

Vacation Villas in Orlando-Luxury Vacation Rental at Reasonable prices

If you are planning your next vacation in Florida and you want your overall budget costs to remain low then renting an Orlando Vacation Villa is the best choice rather than staying at a five star hotels. And be rest assured you will get all the amenities, luxuries and modern day facilities offered by a 5 star hotels. 

Vacation Villas rentals in the Orlando area have been witnessing a tremendous boom in the last decade or so, fueled by the unprecedented rise in tourism to this wonderful area. Plus families on average are now demanding more space and luxury than hotels can barely provide. Instead of being stuffed into one or two rooms, a vacation villa can allow your whole family to stretch out in an area of two to seven bedrooms.
The advantage of more space is the main factor in the popularity of rental homes. The largest villas have more than 6000 square feet and even the four bedroom homes are more spacious and luxurious than any 5 star hotel suite you will ever stay in.

Although most of the Orlando vacation villas are situated in resort communities within fifteen minutes from Disney World. There are some which you can find in just two to three miles of Disney gates in communities which are full of shopping plazas and restaurants.

Orlando vacation villas are not of ordinary type. They are equipped with all the modern facilities that you could picture in a 5 star hotel. Indoor spas, homing entertainment systems, private swimming pools, big screen plasma TVs, hi-fi wireless internet and full air-conditioning and heating systems etc. are some of the basic amenities which these luxury villas are furnished with. Moreover, there are some added advantages like more privacy, more independence as compared to hotels strict restrictions.

The nearness to the Gulf Coast, Disney World and other Orlando attractions allows you to be more flexible. You can go out to the amusement parks in the morning, return to your villa and relax and then go out again in the afternoon and evening. You can enjoy your spa, have a naked swim in your private pool with your girlfriend or wife, have a barbecue in your own backyard or just relax in your own big garden of the vacation villa. Your whole schedule is all up to you and nobody is gonna bother you and your spouse.

As I highlighted at the top all these unbelievable luxuries and comfort of the Orlando vacation villas is reasonably priced. An Orlando Vacation Rental for a 3-bedroom is available for as little as $115 per night in the down season and no more than $135 in the top season. The peak or top seasons are holiday periods like Christmas, Thanksgiving, Easter and New Year.

At the end please note that it is highly advisable to always book your Orlando Vacation Villas well in advance since their rates and availability vary with regard to the low and peak seasons throughout the year. To get more information please visit this website  http://www.orlandovillas.com/  and enjoy your Disney vacation rental. Happy Vacationing!

 

The Costa Rica Travel and Vacation guide

Costa Rica, officially the Republic of Costa Rica is a country in Central America, bordered by Nicaragua to the north, Panama to the east and south, the Pacific Ocean to the west and south and the Caribbean Sea to the east. Costa Rica comprises of several beautiful islands which attract tourists and vacationers alike. If you are planning to travel to Costa Rica then it is better to first put some efforts in getting to know each and every intricate details about Costa Rica travel and vacation guide such as the best time to go to, the tourist destinations that you will be visiting, local restaurants, hotels Costa Rica accommodations, culture etc. before booking a flight or a Costa Rica travel package because this can save you lots of money and ensure your trip to be one of the best and long remembered.

According to different Costa Rica vacation travel guides, travel brochures and many websites, the prominent feature of the paradise of Costa Rica is the republic's beaches. Most tourists come for the pristine waters that are abundant in Costa Rica along with the white sands where they can sun swim, surf, bathe or fish all day long.

Check out all the different beaches which are available. Some famous beaches are Playa Santa Teresa, Playa Conchal, Playa Grande, Playa Flamingo, Playa Blanca, Playa Zancudo, Playa Ballena, and Montezuma. But amongst all, one beach stands out from the rest. It is located along the coast of the southern Caribbean and considered as the best beach in Costa Rica. It is known as the Gandaco Manzanillo Wildlife Refuge.

Gandaco Manzanillo Wildlife Refuge has been the most popular choice for Costa Rica vacation travel experts. This is known as one of the most stunning areas of Costa Rica which is located only a few kilometers away from Panama. Not only this is a terrific beach, it is also a home for different endangered birds like flora and fauna. This is a tropical rainforest where most mangroves grow. Different wildlife species such as crocodiles, dolphins, pacas, manatees, caimans, tarpons, tapirs, eagles, green sea turtles, parakeets, leatherback sea turtles, toucans, pelicans as well as motmos.

Since there is also a protected coral reef here in Gandaco Manzanillo Wildlife Refuge, you can also see several marine species which are vividly colored including blue sea cucumbers, parrot fish, angel fish sea anemones, venus sea fans, sea urchins and a lot more. But you should only visit this rainforest during the months of March to April and September to October since these are the drier months of Gandaco Manzanillo Wildlife Refuge.

Besides that there are some exceptional opportunities for the saltwater angler in Costa Rica. Where else can you fish from the beaches and hook up with both snook and tarpon in the surf ! However, the offshore fishing opportunities are what draw the most attention by anglers. You can fish the Pacific Ocean for rooster fish and tuna one day and the Caribbean for Marlin and sailfish the next. Finding a charter that will provide all the fishing opportunities is quite easy.

So I would conclude here by saying that doing some research on travel Costa Rica before actually embarking on your vacation trip can guarantee you the most exciting and enjoyable time. Visit this website www.costa-rica-guide.com to know more about all the adventures which this wonderful country is willing to offer to its visitors. Happy Traveling!

Romantic Vacation in the Mysterious City of Las Vegas

Whenever we think of Las Vegas so many things come to our mind like the famous Las Vegas casinos and five star grand luxury hotels etc etc. but one very especial thing is a romantic vacation in this spectacular city of world. This city never sleeps and is known for it glowing beauty. Las Vegas is a city of romance and if you are newly married or just in love with someone then my humble advice to you is never miss this opportunity of a lifetime. There are lots of various shows for all ages especially the adults and lovers. There are fantastic games you can play, rides you can enjoy, parties you can attend, beautiful places you can visit. The planners of this city have taken an extra effort in making this place heaven on earth especially for youth and lovers!


Las Vegas is one extravagant place which attracts the tourists from all over the world. Not only ordinary travelers from all over the world are attracted to this city but for the gamblers this place is awesome. So if you plan to have your romantic vacation in this city then plan it accordingly since this place is special and it can make your stay memorable. You truly deserve the entertainment and refreshment which this city can guarantee you.
In the last two decades or so the impression of Las Vegas has now changed. Earlier it used to be recognized as a city of gamblers and adults who were off to some crazy fun! But now there are so many attractions for children as well like amusement parks, the gondola ride which has now become an inseparable part of Las Vegas travel. So when you are planning to go there, try to enjoy as much as you can.

Today the planners of Las Vegas have realized that to become even more popular among the world’s hottest tourist destinations, they will have to target even more younger people and kids. Though, most of the places are still enjoyable for the adults only, but you can find a few places for your children too. Earlier there was no opportunity for the kids to enjoy these casinos and games but now they can but you must stay in control so that you and your children do not loose more than what you can actually afford. The casino owners are trying to invent newer things to attract gamblers from all over the world so you must ask your agent to arrange everything beforehand so that you do not miss anything of this mysteriously famous and attractive place.

As I mentioned earlier for newly-wed and lovers it can be your dream vacation destination. Ask your travel agent to plan a grand Las Vegas travels and tour. For the newly married couples, the theater can be a great place to spend an evening together. The darkness and aura attracts them and brings them closer. Also various Vegas hotels can offer you some packages which are integrated in their plans for couples only.

Four Seasons and Ritz Carlton are very famous for their packages, but they are very expensive. Ask your agent to arrange something according to your hip pocket. You can also take a tour of Topaz Lake. If you can arrange a bower by the lake you can enjoy many things. Other romantic couples and their intimacy plans can also help you to make your romantic life even more enjoyable.

There are plenty of nightclubs and bars. If you want to explore the city life or just want to avoid hopping to the casinos every night of your stay; the night clubs can be the best place for you and your partner. There are Hoover Dam and some other places that you can visit. The glory never fails to attract people from all over the world, and once you get the opportunity, remember to enjoy every bit of it. Life is short buddy and Las Vegas travel can give you something to cherish for the rest of your life as your memorable romantic vacation. So take your girlfriend there and have lots of crazy fun. Happy vacation!

A Luxury Las Vegas Vacation at the Bellagio Hotel

The Bellagio Hotel is home to the fabulous and famous Cirque du Soleil show “O”. And this is just the start of your Luxury Las Vegas Vacation fun as the Bellagio Hotel has so much more to offer.

The style of this luxury hotel is taken from the theme of a Roman extravaganza. It sits at the edge of a 10-acre man-made lake which provides you with a host of activities. There are also some 20 restaurants and cafes on site, a 65,000 square foot spa and salon and a numerous other attractions.

Just outside the hotel is the Beautiful Bellagio Fountains. Here you can see an incredible water ballet created by a thousand choreographed sprays that burst into the air and blossom like flowers. The display is accompanied by classical music that matches the beat of the water jets. They are so mesmerizing that it is not uncommon for Las Vegas visitors to spend an hour or more gazing at the water show, especially at night.

The Bellagio Hotel lobby alone is a show in itself. Over 2,000 hand-blown glass flowers, each perfectly each hand-crafted, cover the ceiling. In addition multi-colored works of art, called The Fiori di Como, add to the atmosphere

Conservatory and Botanical Gardens are also a part of this amazing city within a city. Here you will find exotic plants from all over the world. It’s a botanical display that rivals the gardens you might find in London or New York City.

At the Bellagio Gallery of Fine Art there is a small but quite impressive display of dozens of works by masters such as Picasso, Monet, van Gogh and others. You tour is aided by an audio presentation. Art lovers will certainly find this to be a must visit spot on their Las Vegas vacation.

A large casino is a central part of the Bellagio Hotel site so guests must be over 18 years of age. If fact the casino is so large that you will pass through it while on your way to most of the other attractions on site. In the casino there is plenty of action ranging from $1 slots to poker tables where you can wager $5,000 per hand.

Because the Bellagio Hotel is a luxury hotel, the rates are not for the budget conscious Las Vegas visitor. But even so, discounts are often available for off-periods. Regardless, they will so to it that you get your money’s worth here. This is a place for elegance and pampering with luxurious Italian provincial-decorated rooms and a high-end spa. At the spa the general ambiance is enhance by the music and the unusual architectural features such as the walls made of water. It’s all designed to completely melt your stress away.

There are over 3,400 rooms at the Bellagio but the staff ensures that every visitor is catered to promptly and in the style expected of a luxury Las Vegas vacation destination. Come visit the Bellagio. You will find out for yourself.

Florida--One of the Best Location for your Romantic Vacations

Whether it is a special day or an ordinary day, it does not hurt to be loving and cozy with your partner. If you have spent several years together, a crazy holiday getaway will remind you just how much you mean to each other. If your relationship is just starting out, a romantic time together will make your bond with your partner stronger. Romantic vacations are among the best ways for you to spend quality time together. With no one else in tow, you will be able to enjoy each others company.

If you have a limited budget for your holiday getaway, there is one possible option for you. You can get to spend a special weekend with your loved one through romantic vacation packages. You will be able to find these through the website of Romantic Vacations 101. This is a site which provides couples information on the greatest places to travel when you want to get cozy in an exotic location. Other than the best vacation deals, the site also offers information on the best spots to go. When you want to experience the most out of your romantic getaway, you should look into the tips that Romantic Vacations 101 has to give.

One of the romantic vacation ideas that the site provides is a weekend at Florida State. When you visit this tropical state, you will benefit greatly. For one, there are a lot of wonderful activities found here. Aside from exciting adventures, you can also get to visit lots of beautiful places. Get romantic by waking up early to watch the sun rise. At the end of the day, you can go to the beach and watch the sunset together. The climate of Florida boasts of long months of sunshine. This is the reason why it is one of the most famous holiday destinations all over the world.

Romantic vacations at Florida offer you with hundreds of engaging activities. You can go to hangout spots and watch the city lights twinkle. Or else, you can take a walk down by the beach. When you and your partner are hopeless romantics, traveling to this state is perfect. You can go to sandy beaches, enjoy an afternoon at a private spa, or take fun rides at theme parks. Since there are a lot of wonderful things to see and do at Florida, you should know beforehand where to go and what to do. This way, you won’t spend much of your vacation trying to decide.

One of the best places to go when you travel Florida is at Lakewood Ranch. This location houses cozy and romantic restaurants, nostalgic theaters, comfortable bed and breakfast accommodations, village arts, and fantastic sceneries. If you want, you can choose from romantic vacation packages which offer cruises for couples. If you have just gotten hitched and you want the best honeymoon idea, St. Augustine is appropriate for you and your spouse. You can ride horse-drawn carriages and spend the entire afternoon looking at beautiful gardens. You can also spend your time at a spa and have a luxurious massage.

Romantic vacation packages provided for couples who want to visit Florida often involves carriage rides, couple massages, dining at oceanfront restaurants, and luxury honeymoon suite accommodations.

Beach Vacations - The Ultimate Way To Have Fun !

We know that a Beach Vacation is different from other types of vacations. But what makes them so special?

White sand, dolphins swimming in blue water and a cabana boy serving you frozen Margaritas. Those are just a few of the things that make a beach vacation stand out from other vacations. The tropical sun seems to melt away all your worries except one… should you turn over to even out your tan or wait five more minutes?

If, however, a laid back, nothing to do vacation isn't for you, there is plenty to do on the beach as well. Vacations on the beach can be leisurely or busy. Maybe you want to go for a swim or learn how to snorkel and check out the reefs. Maybe you want to stay on the beach or are you the more adventurous type and are looking to learn to water ski or surf. The nice thing about vacations is it is all up to you. What ever you want to do, do it!

What should you expect from a vacation package?

That depends on what you want to do and where you want to go. Are you going to the Caribbean? Europe? Are you going to vacation in the Untied States? Mexico? Once you have decided on where you will be vacationing, you have to decide what you want to do when you get there. Because you can get different packages for the same beach, make a list of amenities. One end of the beach may have those cabana boys serving drinks while the other end is open for camping and the middle may be a family atmosphere. So while it would appear that all beaches are the same, they are not. You will want to do your homework before you settle on one.

If a vacation you don't have to 'think' about once you get there sounds like your idea of relaxation, you are in luck. There are so may vacation packages that you will literally have your pick of doing nothing, everything or something in between. The most popular packages for beach vacations will include round trip airfare or cruise to and from the beach. They will have a certain number of days – do you want to stay for three days or the whole week… or longer? Other packages will include tours, meals, attraction tickets and other things as well.

Some ultimate beach vacations:
By doing research, you can find some excellent beach vacation packages. For example, with packages that can be customized to include family amusement parks and miniature golf, Myrtle Beach vacation packages are among the best packages available.

Delta, and some other airlines also offer beach vacations. While you may not think about going through an airline for your beach vacation package, they really allow you to customize your vacation right down to the last detail. And since they will most likely have airports with flights into and out of your designation, you might as well make a package deal with them and save on your airfare.

How to find Beautiful (However Cheap) Cruise Vacation

A cruise vacation may seem very out-of-reach during these strenuous economic times. Luckily for us, cruise companies like Carnival have readjusted many of their fares to really accommodate travelers that are trying to penny-pinch. Because of these price adjustments many and more people are finding incredible deals for cruise vacations all across the seven seas. No matter if you are looking for a cruise to the Caribbean, the Bahamas, Hawaii, or even Alaska many of these pricing adjustments put these destinations completely within reach. If you or your family are looking for an escape from these hard times and want to take a few days to disconnect why not hop onto a Carnival funship and start to clear your head, and have a blast while doing it?

Considering the low cost of ticket prices the main financial preparation will be managing what you spend once you are on board. Cruises offer incredibly lavish free buffets for the entire duration of the cruise, it's included with your initial travel fee. These buffets contain a wide variety of food selections with basically anything you want to drink as accompaniment. Most people who have been on a cruise will tell you that cruise buffets are some of the best quality buffets in the world.

Another popular pastime on cruises are the casinos. Obviously, sitting down at the casino and gaming are not free on the cruise, and before you partake in these fun activities it is in your best interest to have a set budget in mind. When you arrive on the ship, know the amount you are willing to spend at the tables and no matter what happens do not exceed it. Get into the casinos, play for fun, and maybe you'll be leaving your already cheap cruise vacation with all expenses paid.

Your other money management is going to take place on your stops. Depending on the cruise you select you could be stopping at some incredibly fun, or incredibly relaxing locations. These stops will lead you on tours, or let you take your own path to explore the countryside. Along the way you may want to have some spare cash for entertainment, exotic foods, or even souvenirs. You will have an incredibly array of options to venture out and learn about these tropical cultures, or just kick back and enjoy the scenery.

Hopefully now you realize that it is in fact very possible to go on a cruise vacation without breaking the bank. One can enjoy a high quality, relaxing cruise vacation without spending much more than just your initial ticket fare, and even those have been dramatically reduced in price! If you are still struggling for cash for your on board expenses you can always look into free cruise dollar offers. Cruise dollars can help pay for anything from alcohol to souvenirs. If you are interested in spending any money at all cruise dollars may be your best option during your trip. Remember, with some proper planning it is very easy to enjoy a long, relaxing cruise vacation without spending too much of that hard earned money.

Planning A Cruise Vacation For The Perfect Cruise Experience

Cruise vacations are one of the most exciting and fun vacations you and your family will ever have. Planning your cruise vacation is the key to making the most of the cruise experience. So please read the Travel Tips+Vacation Tips carefully.

Cruise ships are floating hotels that sail through ocean while you enjoy all the hotel's amenities provided. They have casinos, swimming pools, theaters, restaurants, shopping centers or boutiques, spas, gyms and more.

As great as taking a vacation on cruise ships may seem, you still need to know how to plan a cruise ship vacation properly so you have the perfect cruise experience. You need to know about the different types of packages the cruise lines offer.

When planning a cruise ship vacation you need to know how to choose one that will meet your expectation or tailor to your needs. Here are some guidelines that you can follow to plan your cruise travel and enjoy the perfect cruise experience:

Think of who you want to take with you on your cruise vacation. There are many different packages offered by cruise lines. There are packages for the whole family and there are packages for single travelers.

Will you be taking the cruise vacation with children? Maybe you will take your significant other for a romantic getaway. There are cruise ships that are tailored for children and there are cruise lines that cater to single cruisers and honeymooners. There are even some ships that offer wedding services. What could be better than to get married on the ship and have your honeymoon built in?

Decide how long you want to cruise. If you just want to try it out, opt for a three day cruise. Normally, cruises start at three nights and can go anywhere from seven to fourteen days. But there are also world cruises that can last as long as three months. My advice is if you are going to cruise in Europe you should pick a fourteen day cruise because of the expense and long plane rides to get to your port of embarkation. If you live near a port and you just want to take a long weekend choose of three or four day cruise. Decide what cruise travel is best for you.

Choose the perfect destination for you and your family. Alaska is beautiful but can only be cruised in the summer months. If you live in the colder climes you may want to take a mid winter cruise to the Caribbean or even South America. If you want your cruise travel to be in the Caribbean and you want to spend two weeks on your cruise vacation, choose a line that alternates between the Eastern and Western Caribbean. This cruise vacation takes you to many different islands.

The cruise lines have a variety of destinations to choose from. Visit your cruise travel agent to go over the different itineraries or check out the individual websites of the cruise lines.

Consider the port of departure. Since 9/11 cruises have been emphasizing home port cruising. Now there are many cruises that depart from Bayonne, New Jersey, Galveston, Texas, or Seattle, Washington, not just Miami and Fort Lauderdale.. Depart from the one closest to you and you will save money on expensive airfare.

Speak to a knowledgeable cruise travel agent. Make sure they have personally sailed on many different cruise ships so they can give you an honest opinion on what each cruise line has to offer and which would give you the perfect cruise experience.
A cruise travel agent will also be able to supply you with cruise tips. Scour the cruise reviews for additional cruise tips.

Large cruise lines have a variety of activities and facilities that you can use on the ship. If you like to gamble then choosing a cruise ship with casinos is probably right for you. Or if you are taking your kids with you, a cruise ship that offers activities and facilities for children would be the best choice for your cruise travel. For instance, Disney is, of course, geared toward children but they do not have casinos. So if you are taking the family but you want to gamble steer away from Disney and choose one of the other major cruise lines. Almost all of them have children's programs. If you don't want to be on a ship with children sail on one of the fancier lines that don't cater to children. Here, again, it pays to read as many cruise reviews as you can to pick up additional cruise tips.

Cruise vacations do not necessarily mean that you have to spend all your vacation time onboard. All the cruise ships offer land and shore excursions. The cruise lines offer pre and post cruise land vacations usually for two or three days.

Land excursions are a great way to explore different cultures and destinations when taking a cruise vacation. You can choose from many activities once you reach a port of call. You can go kayaking, scuba diving or go shopping in the markets of the ports of call.

Following these guidelines will give you some ideas on planning your cruise vacation properly. Proper planning will give you a more exciting cruise experience. Happy Cruising!