American College of Physicians: Internal Medicine — Doctors for Adults ®

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Tuesday, August 31, 2010

To medical students considering primary care

Dear Student:

Thank you for your consideration of my profession for your career. I am a primary care physician and have practiced for the past 16 years in a privately owned practice. (At some point I intend to stop practicing and start doing the real thing. It amazes me at how many patients let me practice on them.)

Anyhow, I thought I'd give you some advice as you go through what is perhaps your biggest decision regarding your career. Like me, you probably once thought that choosing to become a doctor was the biggest decision, but within medicine there are many options, giving a very wide range of career choices. It is the final choice that is, well, final. What are you going to do with your life? "Being a doctor" covers so much range, that it really has little meaning. Dr. Oz is a doctor, and he has a very different life from mine (for one, he's not the target of Oprah's contempt like I am, but that's a whole other story).

Here are the things to consider when thinking about primary care:

1. Do you like talking to people who are not like you?

Primary care doctors (PCPs) spend time with humans, normal humans. This is both good and bad, as you see all sides of people, the good, bad, crazy, annoying, funny, and vulnerable sides. If you see mental challenge as the main reason to do something, and would simply put up with the human interaction in primary care, don't do it. The single most important thing I have with my patients that most non-PCP's don't have is a relationship. I see people over their lifetime, and that gives me a unique perspective.

2. Do you prefer variety over predictability?

Every room I walk into is different--often vastly different--from the last. I could be walking in on a crisis or a stable recheck. The person could be elated or crying. They could be 90 years, or two days old. They could have something wrong with any system, and it could range from mild to life-threatening. I'd go nuts doing the same thing every day, be it looking just at skin or just dealing with the kidney. But some folks do better with routine and a lack of surprise; they don't want their days to be unpredictable.

3. Do you need to be in control?

Primary care is not about control. Those primary care doctors who try to maintain control of their patients are both unsuccessful and unhappy. Relationships are not always predictable, and much of what PCPs do depends heavily on the patient's "cooperation." I put the word in quotes, because the word implies that the doctor's agenda is more important, an implication that I reject strongly. PCPs are part of "team patient." Our job is to help them, not direct them. We give them our expertise and they make the final choice. Surgeons, on the other hand, don't consult the patient when operating; they don't depend on patient compliance as they cut a person open.

4. Are you a people-pleaser?

The flip side to #3 is that a PCP must always practice good medicine, even if it makes people mad. You have to learn to say "no" to people who seek drugs, who want an antibiotic, to drug reps who want you to prescribe their products, and to insurance companies that want you to work for free. We are not co-dependents. We don't base what we do on the reaction we get from patients. Often we are the only ones with the opportunity to tell them the hard truth about lifestyle choices or about their future health. I deal daily with the consequences of people-pleasing PCPs, who addict their patients to drugs, who create antibiotic resistance, or who give in to drug reps and give expensive prescriptions where cheaper ones are better. Please don't choose primary care if you are a people-pleaser.

5. How important is social status?

PCP's have an interesting paradox in their social status. In the eyes of the public, we are the ones who earn less money and so must have gotten worse grades than the cardiologists and dermatologists. In the eyes of those same specialists, however, good primary care doctors have a very large amount of respect. We are actually the ones who run the medical show, using specialists when we think it is needed. We need to know 90% of all specialties, and also know when we are in the 10% we don't know for each of them. I often get "I could never do your job" from my colleagues. So if outward social status matters (like what kind of car you drive or how big a house you own), then don't choose primary care. I am not saying that PCPs don't have a good income (98% of my patients would like my income), just that my outward status is not nearly that of the surgeon who operates only on left ring-fingers.

6. Do you like puzzles?

The term "gatekeeper" got applied to primary care via our friends in the HMOs, and that term has haunted our profession since. Good primary care is not simply triaging people and sending them to those who can offer real care. Some PCPs do that, but they are both lazy and unambitious. I do whatever I can to keep people from the specialists and out of the hospital. I need to know when to send them, but I also need to know what to do before I send them. This endears me to my consultants, as I am sending only patients who needtheir expertise. I know orthopedists will give an anti-inflammatory and probably order physical therapy for shoulder problems, so I do this before I refer the patient. 80% of my patients avoid orthopedists this way, and the ortho docs know my consults are not usually fluff.

But the real challenge of primary care is the fact that I am usually the first to see a problem. Specialists get sifted problems. I have already thought the situation through and so they get the leftovers. I don't usually send people to specialists for a diagnosis, I send them for a specialized treatment for the problem I have diagnosed or strongly suspect. I am the quarterback, the manager, the lead singer, the director of the symphony orchestra.

7. How patient are you?

I have to confess that I was not a beacon of patience when I started practice. That being said, I have learned that one of the most powerful tools in medicine is waiting. We get to see the big picture. We see people over months, years, and decades, and watch the progression or deterioration of conditions. I find this most satisfying. People who were suicidal ten years ago are now cracking jokes and are productive citizens. One of the biggest mistakes a PCP can do is to value intervention over waiting. We are caretakers of the big picture. Surgeons do their job in a few hours, radiologists in a few minutes, and oncologists in a few months or years. But PCPs do their job over the lifetime of the patient. To me, that's a plus, not a minus.

8. Are you compassionate?

Again, this is something that has developed over time for me, but the seed of it was there early in training. Primary care is about "care" in all of the definitions of the word. We care for people because we care. It does matter to us that people are hurting. There is a degree to which primary care is a calling or ministry, not just a job. There will always be a necessary detachment we have from our patients (for our own sanity), but a PCP who is simply punching the clock is both sad and dangerous. You need to be able to listen and see things from people's perspective. You are their doctor, and they are your patients. The possession is emotional, it is one of caring. People judge PCP's on how much they like them and how well they feel listened to.

There is much more to say (read the rest of my blog, as well as other primary care blogs such as Kevin MD, Musings of a Dinosaur, Jill of All Trades, and DB's Medical Rants for a more complete picture. Sorry to those I left off; there are many other good ones). Any specialist would tell you that a very good PCP is incredibly valuable. I love my job, as do many of my colleagues. I want more PCPs, but I only want you in my field if you'd raise the average. We need good PCPs.

Come join the fun.

This post appeared at Musings of a Distractible Mind. Rob Lamberts, ACP Member, writes the blog and is on Twitter. His podcast, House Call Doctor, is available online and on iTunes). He is board certified in Internal Medicine and Pediatrics and was an early adopter of electronic medical records.

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QD: News Every Day--Patients prefer doctors, deserve to know who's treating them

Patients in the emergency room would rather wait for a doctor than be treated by a nurse practitioner or physician assistant, a survey found. Patients would even rather see a resident.

Researchers administered surveys to a random sample of patients in three emergency departments and another survey to emergency department residents and physician assistants. They reported results in the American Journal of Bioethics Almost 80% of patients preferred to wait for the doctor.

Even for a cold, only 57% would want a nurse practitioner and 53% a physician assistant. Patients deserve to know who is treating them, the bioethicists said, and what level of training each type of provider has. Some nonphysicians may not properly identify themselves when busy, and patients may not understand the differences even when they do. (American Journal of Bioethics, American Medical News)

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Monday, August 30, 2010

QD: News Every Day--Charitable hospitals to act like for-profits to stay open

More than one-fifth of hospitals are government-owned, but states and counties are out of cash to keep them open. So, charitable hospitals are being sold to for-profit groups or facing closures. Rising costs and more uninsured patients run smack into falling Medicare and Medicaid reimbursement. When bonds come due, there's little chance of states and counties paying them back. And the facilities are often standalones, and they can't fall back on corporate backing. This year, 53 hospitals have been sold in 25 arrangements. While the deals often stipulate that care for the poor continues, so one is certain exactly how or even whether such services will continue.

That said, other charitable hospitals are making big profits. What are they doing differently? First, they're competing for patients, so they're increasing room sizes, offering amenities and even investing in high-end procedures such as robotic surgery. They continue to offer community care, but they're acting more like for-profit institutions to cover their charitable missions. But this conflicts with an old-fashioned view of what charitable care is supposed to be.

Stepping into the breach is the Centers for Medicare and Medicaid Services, which is offering one solution, by increasing reimbursement for inpatient services in rural areas. The agency is expanding a pilot program by increasing reimbursement for inpatient services. Facilities are eligible if they offer care to rural areas in the 20 states with the lowest population densities, have fewer than 51 beds, provide emergency-care services and are not a critical-access hospital. (Wall Street Journal, Washington Post, Modern Healthcare)

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Friday, August 27, 2010

QD: News Every Day--Millions in fraud makes Medicare crack down

Honest physicians report fraud and are ignored. Dishonest physicians bill millions in procedural claims (one totaled more than 24 hours of billing per day for years) and don't even hide it. While both are rare examples, fraud is constantly occurring, and it's bankrupting the system, according to Medicare officials. So the U.S. Justice Department and Centers for Medicare and Medicaid Services are continuing the crackdown with more enforcement (580 convictions and $2.5 billion recovered since May 2009) and new regulations to tighten oversight of durable medical goods such as prosthetics. (Los Angeles Times, New York Times)

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Thursday, August 26, 2010

QD: News Every Day--Trimming costs by splitting pills

Patients are pill-splitting more to trim back health care costs, according to a poll by Consumer Reports. In the past year, 39% took some action cut costs.

The poll of more than 1,100 people found that 45% of people take at least one prescription drug, and average four. But, 27% said they didn't always comply with a prescription, and 38% of those younger than 65 without drug coverage didn't fill prescriptions at all.

Just over half of patients felt that doctors didn't consider their ability to pay when prescribing a drug, while nearly half blamed drugmaker's influence for physicians' prescribing habits. (HealthLeaders Media)

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Wednesday, August 25, 2010

QD: News Every Day--What smartphone are you using?

An eye-popping statistic shows that 94% of doctors have adopted smartphones, in part to keep up with an information glut. A consulting group released results of 100 in-depth interviews with physicians working in acute and ambulatory care environments in numerous specialties nationwide. The physicians used the phones to communicate, manage personal/business workflows, and access information, including medical reference materials. (In case you're curious about what your peers are using, 44% use an iPhone and 25% use a Blackberry.)

This growth in adoption--a 60% increase since 2006--isn't surprising, since the same survey reported that doctors' biggest challenges are communicating with colleagues in a timely manner, the volume of communications with patients and the entire care team, and the different platforms (e-mail, voice mail, pager, etc.) needed to keep up with it all.

But one early adopter, Rob Lamberts, ACP Member, cautions that while the new technology can help, it isn't yet.

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Tuesday, August 24, 2010

QD: News Every Day--radiation risk in breast cancer tests

Certain diagnostic tests for breast cancer may put patients at risk for additional disease, the New York Times reports. A study published today in Radiology found that nuclear-based breast scans such as positron-emission mammography can increase risk for other cancers. The point of the study, the lead author told the Times, was to show that all tests are not created equal where radiation is concerned. Manufacturers of the nuclear-based tests agreed that they expose patients to more radiation than mammography but pointed out that they're not intended for routine screening. Concerned physicians, meanwhile, could follow the approach of Deborah J. Rhodes, FACP, who told the Times she considers herself a "radiation phobe": Don't order tests blindly--look up the amount of radiation involved and balance the risks and benefits in the context of a patient's past radiation, as well as available alternatives, before proceeding. (New York Times)

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Monday, August 23, 2010

QD: News Every Day--rectal cancer rates rising in younger people

Rates of rectal cancer in those younger than 40 have been increasing, the LA Times reported today. Researchers studied data from the Surveillance, Epidemiology and End Results (SEER) Registry and looked at the change in rectal and colon cancer incidence in those under 40 from 1973 to 2005. Overall rates were low, but while colon cancer incidence remained constant, rectal cancer incidence increased by an average of 3.8% annually, the authors reported Sunday in the journal Cancer. The authors didn’t advocate routine screening in those under 40, but did recommend that physicians be more alert to the possibility of rectal cancer in those presenting with symptoms such as rectal bleeding, according to the Times. (LA Times)

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Friday, August 20, 2010

QD: News Every Day--CDC warns of heat dangers in young athletes

With back-to-school time around the corner, the Centers for Disease Control and Prevention has issued a warning about the risk for heat-related illness in young athletes, especially football players, the Los Angeles Times reports. Coaches and parents should be aware of the signs and symptoms of heat stroke, dehydration and other problems, and fluid replacement formulas should be used during practices and workouts, among other precautions, the Times said.

Meanwhile, a British meta-analysis published in BMJ offers another possible reason to eat your vegetables: Enough of the green leafy kind might cut risk for type 2 diabetes. Researchers analyzed six studies involving 223,512 people and found that those who ate 1.35 daily servings of green leafy vegetables (such as lettuce, kale and, somewhat surprisingly, cauliflower) had a 14% decrease in risk compared with those who ate only 0.2 serving daily, MedPage Today reported. (LA Times, MedPage Today)

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Thursday, August 19, 2010

QD: News Every Day--preeclampsia and vitamin D

A new study in the American Journal of Obstetrics & Gynecology reports that low levels of vitamin D may be linked to early-onset preeclampsia in pregnant women. The trial found that the average vitamin D level in 50 pregnant women with preeclampsia was 18 ng/mL, compared with 32 ng/mL in 100 women with healthy pregnancies. No causal relationship was proven, and the study's lead author told Reuters Health that the recommended vitamin D intake in pregnant women hasn't changed, but the study results raise yet more questions about this much-discussed nutrient. ACP Internist covered the pros and cons of vitamin D in its November 2009 issue. (Reuters, ACP Internist)

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Social mission and primary care

This post by ACP Member Kevin Pho, MD, originally appeared on MedPage Today's KevinMD.com.

Medical schools are traditionally ranked on criteria like research funding and technological innovation. These rankings are highly significant. A place on the US News' annual Best Medical School list is a coveted spot indeed.

So that's why there was some media attention paid to a recent study from the Annals of Internal Medicine, which ranked medical schools according to their "social mission" — a phrase that defines a school's commitment to primary care, underserved populations and workforce diversity.

Using this new criterion, some of the traditionally high ranking schools fell significantly.

In other words, schools that received a lot of grant money — thus propping their rankings in US News — did not allocate as many resources to primary care, sullying their social mission score.

As the New York Times' Pauline Chen writes, "Grant money and the security it affords individuals and institutions drive institutions to emphasize research, sometimes at the expense of other urgent but less lucrative endeavors."

With the primary care shortage at the forefront, and surely to get worse as health reform covers millions more Americans, it’s time to give schools the incentive to churn out more primary care doctors.

Maybe US News can incorporate a variation of the "social mission" into their rankings, for instance. Knowing how important these lists are to schools, it could be an impetus to divert more money to primary care training programs.

Furthermore, the ACP’s Bob Doherty suggests that politicians take notice if schools don't: "If medical schools won't re-examine their priorities on their own, aren't they inviting politicians to force change – by shifting funds to schools that have a better primary care track record?"

This post originally appeared on MedPage Today's KevinMD.com, social media's leading physician voice. Voted best medical blog in 2008, and with over 33,000 subscribers and 23,000 Twitter followers, KevinMD.com is the Web's definitive site for influential health commentary.

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Wednesday, August 18, 2010

Doctor/patient communication could use a boost

In a surprising report from the Archives of Internal Medicine, we learn that most hospitalized patients (82%) could not accurately name the physician responsible for their care and almost half of the patients did not even know their diagnosis or why they were admitted. If that isn't enough, when the researchers queried the physicians, 67% thought the patients knew their name and 77% of doctors thought the patients "understood their diagnoses at least somewhat well." I would call that a pretty significant communication gap!

Ninety percent of the patients said they received a new medication and didn't know the side effects. Although 98% of physicians thought they discussed their patient's fears and anxieties with them, only 54% of patients thought they did.

The researchers from Yale University School of Medicine and Waterbury Hospital concluded: "Significant differences exist between patients' and physicians' impressions about patient knowledge and inpatient care received." Moreover, responses didn't significantly differ by sex, age, race, language or payment source, for the patients, or level and type of training, for the doctors.

A great deal of evidence exists that shows patients who understand their condition, are educated about medication and have good rapport with their physician have better outcomes. It is just common sense. I know that medical schools teach interpersonal relationships and the fact that so many physicians think they are doing it right makes me wonder how they can be perceived so differently by the patients.

Some possible explanations are:
--Patients are stressed while hospitalized and do not remember what is said;
--Many patients are heavily medicated and that affects ability to learn and remember;
-- Doctors are too rushed and deliver information too quickly to be understood;
--Hospitalized patients have too many consultants and no one is identified as the "responsible physician;"
--The trend to get patients out of the hospital quickly short changes communication time; and
--Nurses, consultants and hospitalists don't communicate well together and the patient gets a different message from each visit.

There may be many other potential reasons. Everyone in medicine should take a pause to look at this study very carefully because it shows so much room for improvement.

This post originally appeared at Everything Health. Toni Brayer, FACP, is an ACP Internist editorial board member who blogs at EverythingHealth, designed to address the rapid changes in science, medicine, health and healing in the 21st Century.

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QD: News Every Day--Nation's largest tele-health network launches

California launched the nation's largest tele-health network, a $30 million public/private project to bring broadband access designed to reduce the cost of follow-up care by 40% and overall costs by 6%. The network seeks to connect more than 800 California healthcare facilities, including rural, underserved and Indian health facilities, to a statewide network of healthcare and emergency services. (Healthcare IT News)

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Tuesday, August 17, 2010

Early detection of Alzheimer's disease? Not yet, thanks.

Alzheimer's disease made headlines this week, first with news about a new biomarker test that is able to diagnose the disease with increased accuracy, then with a follow-up story detailing the collaborative model of data-sharing that contributed to the success of recent research.

As I read the news with interest I couldn't help but feel that in our current climate, the manner in which it was reported was somewhat ironic. Just nine months ago experts on the United States Preventive Services Task Force argued that harm, in the form of anxiety related to the detection of breast abnormalities, was too excessive to warrant screening mammograms in forty-year-old women. Just think of the anxiety that will occur if we begin screening asymptomatic adults for Alzheimer's disease.

The unfortunate reality is that despite recent gains in our ability to accurately diagnose Alzheimer's disease, there is still no therapy that has proven effective in preventing its progression. On August 3, 2010 the Annals of Internal Medicine published a summary of this year's National Institute of Health Preventing Alzheimer's Disease and Cognitive Decline Conference.

Alzheimer's disease, the most common form of dementia, is a critical field of study, given the impact that this condition will have on our aging population. In my view, at this point the main benefit of earlier and more accurate diagnosis of cognitive impairment and dementia is that it will promote more research on therapeutics on a population level. However, practically thinking, what about the burden that this type of diagnosis could have individuals who go through testing? Is it worthwhile to detect a condition early for which there is currently no definite effective therapy? What would have happened to Ronald Reagan had he had this spinal fluid test when he was sixty years old? Would he have run for president? Would we have elected him? The test may accurately predict Alzheimer's, but does it tell us when? And will happen to health insurance or long-term care insurance coverage for patients after this test is performed?

MRIs are an also an effective means for detecting changes related to Alzheimer's disease, demonstrating amyloid plaque accumulation in patients with Alzheimer's, and distinguishing these patients from those who have other types of dementia, such as vascular dementia, which might be managed differently. However, what about all of our talk of comparative efficacy? Has performing an MRI been shown to alter the outcome of patients with a cognitive impairment or dementia diagnosis? I doubt that it has. I hate to be a cynic, but who will pay for the spinal fluid test, and the MRI, and the neuropsychological testing? And then, the repeat MRIs, and biomarker tests, and neuropsychological tests when the results of the first tests are inconclusive? How frequently will these tests need to be done? These questions are at the heart of the reality that our country faces with respect to the role of medical progress, cost, and health care. But as a physician I advocate mainly for my patient, not for the health care system, so I make these diagnostic decisions collaboratively with my patients, not necessarily with the population-level questions in mind.

The Alzheimer's progress is a perfect example of how our country will have to grapple with balancing exciting innovation with the appropriate use of "evidence-based" diagnostics in the coming decade. But how will diagnostics ever become evidence-based if health plans refuse to pay for them? If industry finances expensive clinical trials, should we really be attempting to regulate the cost of their drugs?

In the wonderful book by Audrey Niffenegger, The Time Traveler's Wife, the time traveler witnesses his future death. His fate is unalterable and torments him. Until there is more effective therapy, I, for one, will not be doing the Alzheimer's test. Instead, I will do my best to remain mentally and physically active, control my cardiovascular risk factors, eat my vegetables, consider taking fish oil, take an 81 mg aspirin when I am 65, and wait to see what the next decade of Alzheimer's research will bring in terms of therapeutics. Hopefully innovation will not be stifled by policy change within our country.

Juliet K. Mavromatis, FACP, is a primary care physician in Atlanta, Ga. Previous to her primary care practice, she served on the general internal medicine faculty of Emory University, where she practiced clinical medicine and taught internal medicine residents for 12 years, and led initiatives to improve the quality of care for patients with diabetes. This work fostered an interest in innovative models of primary care delivery. Her blog, DrDialogue, acts as a conversation about health topics for patients and health professionals. This post originally appeared there.

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QD: News Every Day--How much is enough? The cost of fighting cancer

Cancer is the world's costliest disease, sapping the equivalent of 1.5% of the global gross domestic product through disability and loss of life, according to the American Cancer Society. Cancer cost $895 billion in 2008, and that's before factoring in the cost of treating cancer.

Cancer and other chronic diseases cost more than infectious diseases and even AIDS, according to a report the society will present later this week. While chronic diseases are 60% of all deaths globally, they receive only 3% of private and public research funding. The organization is calling for a new look at priorities by the United Nations and the World Health Organization. (AP)

And, one cancer drug is being questioned in a debate of efficacy vs. cost. The FDA is still examining whether to revoke Avastin's breast cancer indication following studies that it delivers marginal benefits compared to potential side effects. Studies show the drug slows tumor growth for as little as a few months while leading to potential cardiovascular complications. While the agency doesn't include cost in its deliberations, they've become part of the political debate. An FDA advisory committee voted 12 to 1 in July to withdraw the breast cancer indication, but even a modest effect is enough, said advocates at the breast cancer organization Susan B. Komen for the Cure. (Washington Post, The Fiscal Times)

In other news, the global recession cut overall health care use in America the most, since its citizens pay the most out-of-pocket, according to the National Bureau of Economic Research, a nonprofit organization based in New York City.

More than one in four Americans cut back on routine health care use between 2007 and 2009, while 12% of French, 10.3% of Germans, 7.6% of British and 5.3% of Canadians did. They cited a lack of universal coverage and the highest out-of-pocket amounts for care for the difference. (New York Times)

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Monday, August 16, 2010

QD: News Every Day--Novel approaches to fill primary care needs

New primary care arrangements show how primary care is evolving--or splitting apart, depending upon one's perspective.

Retainer fees let one practice handle more patients by phone or e-mail. But, points out Richard Baron, FACP, affluent communities can take advantage of such arrangements, and not every community is. And Sam Fink, FACP, of southern California says tele-visits are no substitute for hands-on care. In another model, nurse-led facilities service the poor in north Philadelphia, and more states are expanding the power of the pen to cover shortages.

Another trend is the shared medical appointment. Led by physicians and conducted by "behaviorists," the sessions cover a half-dozen or more patients at a time for both primary and specialty care.

Even pharmacists are getting in on primary care. Blue Shield of California is trying a pilot project of pharmacists, believing they have the clinical and patient-communication skills to be as effective as doctors, but for less cost. But primary care doctors aren't completely ceding their profession. There are also pilot projects in California to train more doctors and steer them into communities facing a shortage of primary care services. (USA Today, Fox News, ACP Internist, New York Times, Whittier Daily News)

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Friday, August 13, 2010

QD: News Every Day--Ready for re-entry, physicians return to practice medicine

Physicians who've left medicine are returning to medical practice. They're not coming back in droves, but it's a way for those who'd left medicine for another field to finish their careers pursuing what had driven them into medicine to begin with.

Programs to help doctors return to practice medicine are scarce, but they exist. Participants in Denver's Center for Personalized Education for Physicians (CPEP) or the Drexel Medicine Physician Refresher/Re-Entry Course of Drexel University College of Medicine create an education plan, receive mentoring and even follow a fellow physician during the re-education process.

The programs help the doctors evaluate gaps in knowledge, closely monitor progress and procedures, and provide a hospital or other program an assessment when the physician is ready to return to independent practice. The programs also help physicians get up to speed with electronic health records and other administrative hassles that go along with medical practice. And, finally, they even help physicians ready to practice navigate the tangles of regulations required to return to practice.

Drexel's program director, Nielufar Varjavand, MD, writes that it's one way to ease has the primary care shortage, since it's faster than training a new doctor. Elizabeth Bower, FACP, oversees the Oregon Health & Science University's re-entry program, adds that it's also much less expensive.

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Thursday, August 12, 2010

Texting+driving=crashing

This post by ACP Member Kevin Pho, MD, originally appeared on MedPage Today's KevinMD.com.


It's time to ask patients whether they text and drive.

An important perspective piece from the New England Journal of Medicine urges doctors to include that question during preventive health exams. The data surrounding texting and driving is grim:

Texting while at the wheel by the Oregon department of transportation via FlickrAlthough there are many possible distractions for drivers, more than 275 million Americans own cell phones, and 81% of them talk on those phones while driving. The adverse consequences have reached epidemic proportions. Current data suggest that each year, at least 1.6 million traffic accidents (28% of all crashes) in the United States are caused by drivers talking on cell phones or texting. Talking on the phone causes many more accidents than texting, simply because millions more drivers talk than text; moreover, using a hands-free device does not make talking on the phone any safer.

The author of the piece, Amy Ship from Boston's Beth Israel Deaconess Hospital, says that doctors should update traditional preventive questions to keep up with the times. The simple question, "Do you text while you drive?" is a way to start this important conversation.

But how can we deal with skeptical patients? Dr. Ship provides good advice when responding to patients who downplay the risk: [Patients] ask why talking on the phone, even with a hands-free device, is more dangerous than talking to a passenger in their car. There are several reasons: first is the obvious risk associated with trying to maneuver a phone, but cognitive studies have also shown that we are unable to multitask and that neurons are diverted differently depending on whether we are talking on the phone or talking to a passenger. When patients aren't convinced, I ask them, "How would you feel if the surgeon removing your appendix talked on the phone--hands free, of course--while operating?" This hypothetical captures the essence of the problem--the challenge of concentrating fully on the task at hand while engaged in a phone conversation.

I've started to incorporate this question during my routine health exams, and it's something all primary care doctors should consider as well.

This post originally appeared on MedPage Today's KevinMD.com, social media's leading physician voice. Voted best medical blog in 2008, and with over 33,000 subscribers and 23,000 Twitter followers, KevinMD.com is the web's definitive site for influential health commentary.

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QD: News Every Day--Internal medicine seeks to delay duty hour restrictions

Internal medicine groups including ACP are asking to delay implementing new duty hour restrictions for residents. The Alliance for Academic Internal Medicine (AAIM) urged the Accreditation Council for Graduate Medical Education (ACGME) to delay duty hour restrictions until July 2012 to allow programs and institutions time to develop compliance plans. AAIM also urged ACGME to continue allowing first-year residents to work extended shifts of 24 hours during at least the second half of the internship. In addition to ACP, the VA, American Hospital Association and American Association of Medical Colleges also called for a delay.

Of concern to the internal medicine groups:
--programs might comply by moving residents from outpatient to inpatient services,
--program might cut subspecialty and research experiences (29% of program directors anticipated doing exactly that), and
--programs cannot complete the 2011 residency recruitment process because they cannot answer questions about rotations, inpatient schedules and night float.

ACGME proposed its restrictions in July. Most programs will have to hire more help to cover work shifts, but it will take time to find the money to pay for that, which will be especially tough for institutions that have already set their fiscal budgets for the year.

Previously, it's been found that duty hour restrictions have little effect on mortality.

Pain medicine abuse
Massachusetts regulators approved an online database of pain medication prescriptions designed to prevent addicts from doctor shopping. For the first time, physicians and pharmacists will be able to look up information directly, instead of the current system, in which the state health department detects patterns and notifies doctors. It will also expand the drug categories tracked. Addiction medicine specialist Daniel Alford, FACP, told The Boston Globe, "The more tools we have to help us to know whether we’re benefiting or harming the patient, the better off we are."

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Improbable, unsinkable glucosamine

This post by Harriet Hall, MD, appeared at Get Better Health.


Glucosamine is widely used for osteoarthritis pain. It's not as impossible as homeopathy, but its rationale is improbable. As I explained in a previous post:

Wallace Sampson, one of the other authors of Science Based Medicine, has pointed out that the amount of glucosamine in the typical supplement dose is on the order of 1/1,000th to 1/10,000th of the available glucosamine in the body, most of which is produced by the body itself. He says, "Glucosamine is not an essential nutrient like a vitamin or an essential amino acid, for which small amounts make a large difference. How much difference could that small additional amount make? If glucosamine or chondroitin worked, this would be a medical first and worthy of a Nobel. It probably cannot work."

Alpha-D-glucosamine via Wikipedia CommonsNevertheless, glucosamine (alone or with chondroitin) is widely used, and there are some supporting studies. But they are trumped by a number of well-designed studies that show it works no better than placebo, as well as a study showing that patients who had allegedly responded to glucosamine couldn't tell the difference when their pills were replaced with placebos.

The GAIT trial was a large, well-designed, multicenter study published in The New England Journal of Medicine that showed no effect in knee osteoarthritis. A subsequent study of hip osteoarthritis also showed it worked no better than placebo.

A new study shows that glucosamine works no better than placebo for osteoarthritis pain in the low back. It was published in the Journal of the American Medical Association: Effect of Glucosamine on Pain-Related Disability in Patients with Chronic Low Back Pain and Degenerative Lumbar Osteoarthritis: A Randomized Controlled Trial, by Wilkens et al.

It is well-designed, randomized and double blind, with 250 subjects, a low drop-out rate, a six-month duration with a one year follow-up, appropriate clinical criteria for improvement (disability, pain, quality of life, use of rescue medications), intention-to-treat analysis, and even an "exit poll" to insure that blinding had been effective, that patients couldn't guess which group they were in. It used the doses of glucosamine sulfate that had been called for by critics of previous studies. It was done in Norway, where glucosamine is a prescription drug (in the U.S. it is marketed as a diet supplement under DSHEA regulations so there is a greater possibility of dosage variations and impurities); it was independently funded, with no involvement of industry.

Although no one study can be definitive, this one is pretty convincing when viewed in the context of all the other published data. The authors rightly conclude that glucosamine doesn't work any better than placebo, but they go on to say some rather strange things. They say it should not be recommended for "all" patients with osteoarthritic low back pain, implying that it might still be recommended for "some" patients. But if so, which patients and according to what criteria? They seem strangely defensive. They stress that glucosamine caused no side effects and could be used safely. They suggest that glucosamine might work for a subset of patients or for joints other than the spine. For instance, the knee. But another new study has confirmed that it is ineffective for the knee.

I don't understand this. If they had found that a new antibiotic worked no better than a placebo for pneumococcal pneumonia, would they say it should not be recommended for "all" patients with pneumococcal pneumonia or would they simply say it should not be used for pneumococcal pneumonia? Would they speculate that it might work for a small subset of pneumonia patients or for infections in other parts of the body? Probably not. They thought glucosamine worked; they tested it; it didn't. Why not just say so? Are they letting a prior belief in glucosamine influence their thinking? Unbiased science-based researchers are not usually so hesitant to give up on a treatment that repeatedly fails to pass tests.

I must be psychic, because I had predicted this in a post I wrote two and a half years ago (about the study showing that glucosamine didn't work for hip pain). I said:

They can always complain that maybe it works for knees but not for hips, or that a different dosage might have worked better, or that it works for some small sub-set of patients. There will always be "one more study" to do.

This new study confirms my opinion that we shouldn't spend any more research dollars doing "one more study" on glucosamine.

This post originally appeared on Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

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Wednesday, August 11, 2010

Checkmarks for check-ups, the mandatory annual exam

My car was making a chirping noise when I drove forward and a high-pitched whine when I went in reverse, so I took it into the mechanic and, while he's under the hood, for some long-deferred routine maintenance (an oil change).

So when the phone rang, I was expecting him to tell me I need new brakes. Nope, it's the pharmacy, which can't refill a prescription. I have to see the doctor in person. I'm not sick, but I'd deferred my routine maintenance for too long. In this case, because I'm on a maintenance drug, he needs to check my blood pressure (which by this point was rising).

Past due for an oil change by Chovee via FlickrThe insurance company audits the doctor, and publishes physician ratings based on his charts. I'm a checkmark against him if don't get check-ups while on a maintenance drug. I asked him how he felt about my being there for the insurance company.

"I'm not a doctor, I'm a provider of medical services."

Don't take this the wrong way. My doct ... er, medical service provider wants to see me more often than I come in. But working in the background are the insurance companies who give him an annual exam, or in the case of one, a check-up three times a year. They pull his charts to make sure that patients are getting the care that the insurance company wants them to get. Women need to have proof of an annual OB/GYN exam, and the OB/GYNs rarely copy him on the visits. That's a checkmark against my doct ... er, medical service provider. If too many people on his panel are obese, it's a checkmark against him

In my case, a routine physical exam for a 40-year-old man meant getting weight, blood pressure, an EKG (baseline only, in case there's ever a problem) and a blood exam (the works). Then, I could get my prescription filled.

The hero of the story is actually Ron, my mechanic. I needed new front brakes and that long-deferred maintenance. I wonder how long before my car insurance starts to enforce oil changes?

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QD: News Every Day--More Medicaid funding on the books

Medicaid funding is on the books. It will extend care for the poor through the first half of 2011, but the same economic downturn that left states high and dry for Medicaid funding is also forcing states to cut mental health programs and close facilities. The result is that patients who'd relied on publically funded programs to address mental health issues, or just not get so frustrated at a lack of resources, sometimes turn violent in the ER. (The Washington Post, AP)

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Tuesday, August 10, 2010

Saving primary care: Is anyone home?

The Patient Protection and Affordable Care Act (aka "Health Care Reform") signed by President Obama in March will revolutionize primary care in the United States. By 2014 tens of millions of uninsured people will "enter" the system by being granted insurance, either through expansion of the Medicaid program or through mandated purchasing of insurance via state pools or the private market.

This alone will have a profound impact, straining the capacity of our already frayed system. Therefore, embedded in the law are funds to encourage growth and improvement in primary care: Incentives to encourage graduates to enter primary care fields (family medicine, internal medicine, and pediatrics) and practice in underserved areas (through scholarships and loan forgiveness), and money to re-format the way that primary care is practiced and paid for.

love Don't live here anymore... by Robb North via FlickrThe most prominent example of primary care restructuring is something called the patient-centered medical home (PCMH). Currently a national "demonstration" project is underway to show us that the PCMH model is a sustainable way forward. The PCMH promises nothing less than greater access to primary care, delivered with improved quality and safety, better data capture and analysis, all with lower per capita costs. Devotees of the PCMH are surging ahead to tie together the twin strands of incentives for transitioning to electronic medical records and improving on the delivery and payment models of primary care.

They have support from their major societies, all of which have wholeheartedly signed on to the PCMH model: The American Association of Family Physicians, the American College of Physicians, the American Association of Pediatrics and the American Osteopathic Association. These four groups total 330,000 members, more than a third of the practicing doctors in the United States. Even the venerable American Medical Association has joined the chorus, lending its endorsement to the concept.

[The idea of a PCMH has actually been around for decades. You can see a timeline of its evolution on page S4 here.] Early data from some of the demonstration projects show promising results, reinforcing the idea that paying for quality in health care doesn't necessarily mean delivering more care.

Yet while the PCMH sounds good conceptually, individual doctors and patients are finding it less lofty than its rhetoric. For one thing, the model presupposes the doctor as the center of a "care team," consisting of nurses and "mid-levels" (i.e. nurse practitioners and physician assistants). Under the PCMH model, doctors would only see the "complex" patients, leaving the "simpler" issues (like sore throats, colds, sprains, and urinary tract infections) to the rest of the team.

In theory, the doctor (really the doctor's team) has the ability to handle many more patients, improving both practice revenue and efficiency (attributable to the new informatics tools and data pooling). The obvious problem with this is that the patient has to buy in to the model. Some folks are fine seeing the nurse practitioner for their acute complaint, but how does the medical home model improve the doctor-patient relationship, especially if you already have trouble seeing your actual doctor?

Worse yet, with all of this restructuring, the PCMH has yet to be shown to be cost effective. Reorganization costs money, as do the startup costs of the electronic tools. Integrated systems like Group Health in Seattle and Geisinger in Pennsylvania have shown cost savings when doctors are salaried, networked, and have a captive audience of insureds to analyze. Unfortunately, the vast majority of practicing doctors still operate outside of these networks. Encouraging them to transition their practices into "homes" will be disruptive to say the least; the real question is whether the disruption will be transformative toward the ideal or cause the destruction of individualized doctor-patient relationships.

Feel free to chime in with your thoughts.

John Henning Schumann is a general internist in Chicago's south side, and an educator at the University of Chicago, where he trains residents and medical students in both internal medicine and medical ethics. He is also faculty co-chair of the university’s human rights program. His blog, GlassHospital, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people that inhabit them.

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QD: News Every Day--Baby boomers dominating ambulatory care, but bypassing primary care

Office-based practices are focusing increasingly on patients 45 and older, reports the Centers for Disease Control and Prevention.

In 2008, those 45 and older accounted for 57% of all office visits, compared to 49% in 1998. Prescriptions, scans and time spent with the doctor also became increasingly concentrated on those middle aged and older, according to data from the CDC's National Center for Health Statistics.

Also, physician visits increasingly concentrated on medical and surgical specialists and less on care provided by primary care practitioners for those ages 45 and older. Furthermore, for patients ages 65 and older, the percentage of visits to primary care specialists decreased from 62% to 45% from 1978 to 2008, while the percentage of visits to physicians with a medical or surgical specialty increased from 37% to 55%.

These trends will increase as the baby boomers age, the CDC says, and as physicians increasingly focus on managing chronic conditions such as hypertension, coronary atherosclerosis and diabetes.

Meanwhile, the CDC also reported that one in five Americans visited an emergency room. They derived data from the 2007 National Hospital Ambulatory Medical Care Survey, which uses a national probability sample of visits to emergency departments of nonfederal general and short-stay hospitals in the United States. Sample data were weighted to produce annual national estimates.

There were nearly 117 million emergency room visits in 2007, or an increase of 23% from the previous decade. About 25% of visits were covered by Medicaid or the State Children’s Health Insurance Program (SCHIP).

States may see $16 billion in Medicaid funds after the U.S. House votes this morning. More than three-fifths of the states have already budgeted the federal funds to keep their Medicaid programs solvent this year. President Obama will sign it and is expected to make remarks on the bill's importance. The legislation also funds public schools and border security, but has drawn fire from opponents. (CDC, AP)

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Monday, August 9, 2010

QD: News Every Day--Costs dissuade patients from seeking care

One in five Americans didn't seek medical care for a recent illness or injury, often because of the cost, according to a survey of adults polled by a health care consulting firm, and the number of people who saw a doctor fell as well.

Four out of 10 adults said the cost was the main reason not to seek care, a trend that be driven by unemployment and health insurance costs, said a survey by the Deloitte Center for Health Solutions. They surveyed more than 4,000 adults. Also, 79% of respondents sought medical attention from a doctor or other health care professional in 2010, down from 85% in 2009.

Other findings include:
--15% of consumers reported visiting a retail clinic and 34% said they would do so if it cost half as much as a doctor.
--17% sought alternative medicine in 2010 before seeing a physician, up from 12% the previous year. More consumers use alternative remedies now, 20% in 2010 compared to 16% in 2009.
--While consumers are receptive to medical tourism, only 7% sought health care services outside their local community in the past year.

Meanwhile, the U.S. House will likely vote tomorrow on a funding package to provide an additional $16 billion to bolster cash-strapped state Medicaid programs. (CNN)

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Friday, August 6, 2010

The uninsured

The following post appeared in March 2009 on Musings of a Distractible Mind.


Have we made any progress?

There's lots of discussion among politicians and "experts" on TV about the uninsured. The number is growing, and the push among some is to make sure there is "universal" coverage (which I assume covers people in the Horsehead Nebula and Andromeda Galaxy). The idea that some people would have no coverage for health problems frankly baffles people from other countries. How could we as a "civilized" country allow people to be without coverage?

Andromeda Galaxy image by NASA/JPL-CaltechI'm not going there. The social responsibility crowd can fight it out with the social Darwinists. I'll wait for the fight to be on pay-per-view as the Mega-Healthcare Social Responsibility Smack-Down. It's probably the sanest way to solve the problem.

No, for me the issue of the uninsured is very different. We talked about it this morning in our office management meeting. How do we deal with the ever increasing number of people coming in without insurance? The issue is very complex and really gives us physicians significant inner conflict.

On one side, we are wanting to do whatever we can for the health of these people. Many of them have been our patients for a long time, and we have taken care of many generations, neighbors, friends, and coworkers. Some have been huge advocates, sending anyone who asks to our office. As a physician, I don't really care if I make lots of money off of these people. In truth, because we don't have to deal with insurance billing, they actually cost us less than insured patients. If I could, I would just charge them enough to remind them they are getting a service from me that does take my time, training and skill to give.

But it's not that simple. Even if I do discount my uninsured to minimal levels, the real problem for me comes when they need labs done, tests run, visits to consultants, or hospitalization. My charge is nothing compared to the amount they can accrue in these other venues. This ties my hands as to what I can do for them. They don't get the care they need because it is too expensive.

One such patient that visited our office recently had a catastrophic eye problem that needed immediate attention. If immediate help was not given, blindness was likely. Despite strong warnings of risk and a direct call to ophthalmology, the patient refused to get the care required to save their vision. Most cases aren't this extreme, but the likelihood of us running labs or referring for consults is much lower in the uninsured. Another problem that happens is that money gets between us and our patients. We see them, do what we can to discount their bill, and try to collect a payment. Some don't have full payment on them at the time of the visit, while others can barely afford it at all. We bill them the balance; some pay in full, but most pay either in part or not at all. The next time they come to the office we not only have to charge them for the care they are getting today, but also for past charges.

This is when one of my billing staff comes to me with the "what do you want to do?" question regarding them. Most of these are people I know. I don't think of them as customers, I think of their kids and parents. I think about the medical struggles they have faced or the tragedies they have endured. I like my patients. Playing "hardball" is not that easy when you have an emotional attachment to your "customer."

The issue of the uninsured will be on the lips of many pundits. Some will say "they pay for cable TV, so why can't they pay for medical care?" In some ways, they are right. I have worked hard for my degree and work very hard every day for my patients. I do deserve to be paid. But my job is to take care of people. I want them to view me as a person, not a commodity. The Hippocratic Oath says, "First, do no harm." Not doing harm is getting harder and harder these days.

It probably would be less complicated if they were from Andromeda.

Rob Lamberts, ACP Member, writes the blog Musings of a Distractible Mind and is on Twitter. His podcast, House Call Doctor, is available online and on iTunes). He is board certified in Internal Medicine and Pediatrics and was an early adopter of electronic medical records.

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QD: News Every Day--CMS: One step forward, one step back

The Senate passed $16.1 billion in Medicaid funding for states and the House will return next week to vote on it. That's a good thing, right? Nope. No good deed goes unpunished.

Hopscotch by daveparker via FlickrWe'd reported that Medicare will be solvent for 12 more years due to health care reform. Medicare's top actuary warns that:
--financial projections aren't reasonable for the Medicare Hospital trust fund
--Social Security trust funds are expected to be exhausted in 2037, just as predicted already, and there's be no cost of living increase again this year, and
--in 2050, Medicare's costs will be 8%, not the 6% estimate used to predict savings.

Such factors cast the expected savings into doubt. (Politico, Los Angeles Times, ACP Internist, AP)

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Thursday, August 5, 2010

False positives can cause real negatives

This post by ACP Member Kevin Pho, MD, originally appeared on MedPage Today's KevinMD.com.

An "incidentaloma" is a finding on a diagnostic test that's found, well, incidentally while looking for something else. In many cases, these findings are benign but may necessitate more invasive tests to prove so.

Writing in the New York Times, cardiologist Peter Libby notes the problems of the incidentaloma. When a patient undergoes a screening exam--a CT scan for lung cancer, for instance--findings on the study may require further tests. More imaging studies, for example. Or worse, a biopsy.

These tests can expose patients to complications that can "make an otherwise healthy person ill."

Dr. Libby rightly notes that, "It's important to think rigorously about the benefits versus the risks and costs of medical procedures, rather than relying on impressions or remarkable individual cases. The medical literature indicates that incidental findings leading to follow-up medical procedures occur in more than 8% of cardiovascular imaging studies."

When you consider the number of imaging studies performed daily, 8% is a lot. And when it comes to the heart, further tests like a cardiac catheterization, are often the next step.

The consequences of these "false positives" are often under-publicized and don't resonate with patients. Although it's encouraging that recent stories in the Times and Associated Press have provided a balanced take on screening tests, they often don't have the emotional impact that, say, an inspirational, life saving story from early cancer detection has. The best that we can do is continue to publicize balanced takes on the issue, and better inform patients of the real risks of promiscuous screening.

This post originally appeared on MedPage Today's KevinMD.com, social media's leading physician voice. Voted best medical blog in 2008, and with over 33,000 subscribers and 23,000 Twitter followers, KevinMD.com is the web's definitive site for influential health commentary.

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QD: News Every Day--Did internists see a big pay raise?

Full-time internists average $191,864 in income, according to one recruiter's annual salary survey. LocumTenens.com conducted its survey in the early spring of 2010 among locum tenens and permanently employed physicians. That's up from $179,958 in 2009, the company reported. Specific breakdowns by gender, years in practice and owner/employee status are here.

That's a 6.6% pay raise. We're going to do our own salary survey right here. Let us know if you saw such an increase in the past year.

Medicaid funding
The Senate will likely pass $16.1 billion in Medicaid funding for states this morning, after two Senators from Maine crossed party lines to end debate and bring the subject to a vote. Now, the U.S. House is likely to call its members back from recess next week to take up the measure. (Politico, The Hill)

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Wednesday, August 4, 2010

QD: News Every Day--Giving it up for obesity

Obesity rates ticked up 1% in the past two years, according to the Centers for Disease Control and Prevention. Adults reached a 26.7% nationwide average in 2009, up from 25.6% in 2007, the agency said.

That's 72 million adults. The CDC made its announcement after parsing out data from the national Behavioral Risk Factor Surveillance System, a survey of 400,000 people. (One hypothesis behind the rising rate is, due to increasing education about its importance, more people are becoming aware of their body-mass index and are reporting it more accurately.)

That said, no state had a 30% obesity rate a decade ago. And it's not picking on the South to point out that they've always led the trend, and continue to do so with an obesity rate of 28.4% and nine states showing advances, up from three just three years ago. (Midwesterners are close behind with a rate of 28.2%).

The CDC's map shows that obesity rates above 30% (dark orange) are concentrated in the Southern and Midwestern states. Only Colorado and Washington, D.C., (light yellow) have an obesity rate less than 20%.

Obese people cost $1,429 per person more than people of normal weight, adding $147 billion in health care costs in 2008. Federal officials want to increase comprehensive education about better diet and activity.

Encouragement at a federal level only does so much. It takes personal motivation to go from obese to normal. For Banks Lee, it was his inability to fit on an amusement park ride that motivated him to lose enough weight to eventually ride it. Maybe if the feds parcel out some free tickets with their information packets, they'd attract more interest. It's done for other public health campaigns. (CDC Vital Signs, Philadelphia Inquirer, Reuters, MSNBC, Camden Courier-Post)

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Tuesday, August 3, 2010

QD: News Every Day--IMGs, iPads and medical education

A report in Health Affairs found no significant difference in mortality between patients treated by a U.S.-educated doctor or an international medical graduate (IMG), a group that makes up one-fourth of all doctors practicing in the U.S. The study looked at 244,153 hospitalizations of patients with congestive heart failure or acute heart attack in Pennsylvania.

Patients of IMGs had the lowest mortality rate, while patients of U.S.-born, foreign-trained doctors had the highest. U.S.-born and trained doctors fell in between. The lead author is president and chief executive officer of the Foundation for Advancement of International Medical Education and Research in Philadelphia. (Health Affairs, Reuters)

Stanford plans to provide all first-year medical students with a 32 GB WiFi iPad. The students are already familiar with them, the tablet enhances how they view course content and take notes, it allows better access to textbooks and it's environmentally friendly.

Good thing they'll becomes doctors, because one blogger says the iPad is an ergonomic nightmare. It's too heavy to use for long stretches, and even Steve Jobs has to be a contortionist to balance it while reading. (Scope-Stanford School of Medicine, Suite101.com)

Medicaid funding
The U.S. Senate rejected adding $16 billion more to states to help them cover Medicaid funding over concerns of adding to the federal deficit. The measure will be resubmitted for voting this morning, broken down in a way that is offset by cuts elsewhere. (The Hill)

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Monday, August 2, 2010

Regulating salt

On Wednesdays I like to go to McDonald's for lunch. This Wednesday, as usual, I ordered a double cheeseburger meal. With medium fries and a Diet Coke this is a good value at $2.99, and it keeps me filled up until dinner. For kicks, today I flipped the place mat and read the nutritional content: 440 calories in my double cheeseburger, 23 g of fat, 11 g of saturated fat, 80 mg of cholesterol and 1,150 mg of sodium. In my medium fries I consumed 380 calories, 19 g of fat, 2.5 g of saturated fat and 270 mg of sodium. Generally, I don't worry too much about this tasty weekly bargain, given my relatively healthy diet, daily exercise and normal body mass index. However, some may not agree with my lack of alarm.

Increasingly we're hearing about government regulation of food. Recently I read the May edition of Atlantic Monthly. Its article, "Beating Obesity," was about the obesity epidemic, comparing and contrasting excess food as a social ill, with tobacco. Much like the tobacco industry, the food industry has been under recent attack for formulating and marketing the addictive processed foods that our children snack on. As we all know, these foods are rich in sodium, sugar and fat, and contribute to obesity and chronic health problems including, hypertension, diabetes and cardiovascular disease, among others. Salt is the most recent of these nutritional poisons to come into the limelight.

Sea Salt for Tonight's Surf & Turf by D Sharon Pruitt via FlickrThere is epidemiological evidence from the NHANES Trial and others that high salt intake is linked with hypertension and an increased risk of cardiovascular disease. A recent meta-analysis published in the BMJ demonstrated worse outcomes in those who consumed a high salt diet. The recommended daily allowance of sodium for people at low risk is 2,300 mg. For those at high risk, which I am sorry to say includes healthy me, the recommended daily allowance is less than 1,500 mg. "High risk" is defined as: over age 40, people who have high blood pressure or slightly elevated blood pressure, people who have diabetes and African Americans. This constitutes 70% of Americans. Perhaps I should think twice about my weekly meal.

On April 20, 2010 the Institute of Medicine released the report, "Strategies to Reduce Sodium Intake," recommending that the FDA work with the food and restaurant industry to set new standards for reducing the sodium content of marketed foods. The argument goes that if we all get used to a low sodium diet (less than 1,500 mg) at a young age we will change our palates and reduce our cardiovascular risk. OK fine, I'll give up the double cheeseburger, but not my Kalamata olives, those are Mediterranean, they must be healthy.

A recent New York Times article noted the challenge to the food industry. Salt works synergistically with sugar and fat to mask the taste of foods that without enough salt have the consistency of "damp dog hair." That doesn't sound good.

It seems to me that the food industry is in trouble. Regulation of food has become increasingly popular. In 2006 the New York City Board of Health made New York City the first to ban trans fat from restaurant food. Bill Clinton has campaigned to get sugary soft drinks out of schools, which has been demonstrated to be an effective means of combating childhood obesity, Michelle Obama's current agenda. The movie Food, Inc. certainly showed the ugliness of food industrialization in our country, portraying the big business aspect, with its primary focus on mass production. The implication was that the FDA and USDA have been negligent.

In my neighborhood of Decatur, Ga., located less than two miles from the CDC and Emory University, a new restaurant, Farm Burger, is a big hit, featuring locally-produced hormone-free hamburgers. Farm Burger has very good burgers, but I am a personal fan of burgers at the Brick Store Pub, though admittedly it could be could be its extensive beer list and English pub atmosphere that flavors my preference. I wonder how the sodium content of burgers in these restaurants compares. Should governmental regulatory agencies be getting more involved?

Juliet K. Mavromatis, FACP, is a primary care physician in Atlanta, Ga. Previous to her primary care practice, she served on the general internal medicine faculty of Emory University, where she practiced clinical medicine and taught internal medicine residents for 12 years, and led initiatives to improve the quality of care for patients with diabetes. This work fostered an interest in innovative models of primary care delivery. Her blog, DrDialogue, acts as a conversation about health topics for patients and health professionals.This post by Juliet K. Mavromatis, FACP, appeared at DrDialogue.

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QD: News Every Day--Belt-tightening inside the Beltway

The U.S. Senate may vote tonight to extend $16 billion more to states to help them cover Medicaid funding. Governors across the country have been asking for months for more help to pay the bills, since their budgets have suffered the double-setbacks of more people needing coverage with less tax revenue to pay for it. The recession had driven both of those causes. (Politico)

In other news, the Centers for Medicare and Medicaid Services will cut hospital reimbursement by 2.9%. the move affects 3,500 acute care hospitals, which will see a .4% decline, about $440 million, in the next year. The American Hospital Association says this will hurt not only clinical care, but it will affect hospitals as employers, too. (Modern Healthcare, Health Leaders Media)

But, the silver lining is that cuts and other aspects of health care reform will save $8 billion in Medicare expenditures this year and $575 billion over the next decade. That's enough to run the program for 12 more years, pushing off the program's expected insolvency from 2017 to 2029. (San Francisco Chronicle)

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Career counselor? Thoughts on becoming a doctor

This post by Steve Simmons, ACP Member, appeared at Better Health.


As a physician, I've had several people ask my "honest" opinion of their plans to become a doctor. I know what my response is to this question, but I wonder what others in my profession would answer. Would your response depend, in large part, on who's doing the asking? Could you answer your own child as you would someone you just met? Be careful, your answer to this question, if honestly given, might shine an unsettling light on your own feelings about your current career choice.

Last week I spoke with a college junior working to fulfill her lifelong plans to become a physician. She told me about a recent conversation with her own doctor where she shared her plans to go to medical school and he'd tried to dissuade her. She couldn't recall a single cogent reason given for avoiding the medical profession, yet it appeared to me that his odium had negatively imprinted her image of the medical profession, which is a shame. At this time more than ever, we, doctors and patients alike, need to encourage the most talented of our youth to join the medical profession.

I fear that conversations like the one described above take place on a daily basis given the angry climate in medicine today. Almost 30 years ago, I shared my plans to become a physician with my family doctor and received a surprising rebuttal of the value of my dreams as well. I wish that I could say her story had brought this memory up from a repressed corner within my mind, but the truth is that I have often thought of his response since completing my residency.

The Marine Corps Silent Drill Team by Sister72 via FlickrI recall sitting on the edge of his examination table, my visit nearing its end, when I surprised myself by blurting out: "I want to be a doctor, too." The paper crinkled loudly beneath me as I shifted my weight nervously under his now penetrating and dubious gaze. I doubt he could have looked upon me with more revulsion than if I had suddenly grown a third eye. "You don't want to do that," he scoffed. "There's no money in it, anymore. What you should do is join the Marines. That'll toughen you up."

The older I get the more confusing I find his response, and I will never forget the hypocrisy I observed on seeing his Mercedes parked in a spot marked "Doctor" as I walked out of his office that day. I expect, like me, that you will be asked by some aspiring student for your thoughts on becoming a doctor. Would you be able to recommend a career in medicine? If not, then I hope you can find a way to answer this question that will educate a potential student on the problems they will face from outside influences without discouraging them from fulfilling their dreams.

I have to believe that we in the medical profession, today, still have the opportunity to improve modern medicine and make it a rewarding career choice for following generations. Although we as primary care providers may have given up control of the purse strings to government and the insurance industry, I know that none of us can be forced to surrender our creativity or passion for medicine, at least without a fight.

I will continue to recruit our future colleagues and recommend medicine as a career choice. Furthermore, after thinking about this question I see a deeper lesson in all of this that I intend to share with my children. If you're doing something you're not proud of, then either get out or try to change it.

Until next week, I remain yours in primary care,
Steve Simmons, M.D.

This post originally appeared on Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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