Category Archives: Access - Page 2

Does the US face a shortage of primary care physicians? Part I

Posted by on April 1, 2013 Comments Off on Does the US face a shortage of primary care physicians? Part I

Several recent studies and news stories suggest that the US faces a physician shortage, particularly in primary care. Access to health care requires not only insurance but adequate numbers of health care providers such as physicians and nurses, among others. Theoretically, we could imagine everyone in the country with adequate insurance but an insufficient number of practitioners to meet their needs.

Pauline W. Chen M.D., for example, asks Where Have All the Primary Care Doctors Gone?

The obvious solution is to graduate more doctors, but three years ago the Wall Street Journal stated that Medical Schools Can’t Keep Up with the expanding number of insureds. A graphic based on data from the Kaiser Family Foundation shows the geographic nature of the problem.

Doctor Shortage_Kaiser_from WSJ

What the map does not tell us is what the optimal number of physicians per 1000 in the population is, nor does it tell us whether that number varies with the degree of urbanization.   For example, does a geographically dispersed population require more physicians per thousand because the expanse is too great for coverage by one person?

The American Association of Medical Colleges (AAMC) provides the figures quoted in almost all of the stories.

From their website:

AAMC Doc Shortage

But, the AAMC does not suggest that increasing the number of medical students will solve the problem. They point out that medical schools planned a 30 percent increase in medical students by 2016 and were on target to meet that goal.

The problem, according to the lobbying group for medical schools, is the number of residencies, which have not kept pace because of the cap on Medicare-funded residencies in the 1997 Balanced Budget Act. They are calling for removal of the cap by the funding of an additional 4,000 residencies annually.

Not at all coincidentally, the AAMC praises introduction of a bill to create 3,000-4,000 new residencies:

20130315_AAMC_pressrelease

If that would solve the physician shortage that has been alleged, then we could all applaud. However, even if we accept that there is a shortage, that it is related to residencies, and that this proposal increases the necessary residencies, there is another possibility.

What if US medical students will not choose primary care residencies over specialties no matter how many there are. Jacob Goldstein noted in a 2009 WSJ blog that residents in internal medicine often go on to do residencies in more lucrative sub-specialties while

In family medicine, another key supplier of primary-care docs, there isn’t even enough interest among qualified young docs to fill existing residency slots. Hundreds of slots went unfilled this year, and graduates of foreign med schools filled many of the available positions.

Goldstein’s point was validated by a study published in the December 2012 JAMA. The accompanying editorial notes that only 21.5 percent of third-year residents plan to practice in primary care. (to be continued)

The Casualties Do Not End With The War

Posted by on February 7, 2013 Comments Off on The Casualties Do Not End With The War

We know that casualties do not end with a war, but we don’t often think about it. Unless we are directly affected, the symptoms are invisible to us.

Among the casualties are those who suffer from CMI (Chronic Multisymptom Illness). During the 1991 Gulf War there were 700,000 military personnel in the war theater. About 25-35 percent of them have reported symptoms consistent with CMI.

CMI_IOM_20130201

A Congressionally-mandated, consensus report by the Institute of Medicine Committee on Gulf War and Health lists some of the symptoms, based upon the following working definition:

CMI_Definition_IOM_20130201

Reported symptoms are:

CMI_symptons 20130201

As treatments, the reporting committee considered:

  1. Pharmacological interventions (medications)
  2. Other Biological Interventions (such as electrical brain stimulation)
  3. Cognitive Behavioral Therapy (Individual and Group)
  4. Brief Psychodynamic Therapy (Individual and Group)
  5. Biofeedback
  6. Cognitive Rehabilitation Therapy
  7. Complementary and Alternative Therapies
  8. Exercise

My observation is that the Committee recommendations are guarded and limited because of the absence of unbiased, unambiguous research studies. Use of antidepressants along with cognitive behavioral therapy, as well as symptomatic treatment, such as NSAIDs for pain.

Many of the report recommendations deals with programmatic approaches to the problem by the Veterans Administration as well as teaching clinicians how to deal with patients who have a chronic illness, to be managed not fixed.

As citizens we are obligated to pay the full costs of the wars that we support, not just the military hardware and the salaries of military personnel, but the care of those with casualties. Those casualties may be invisible to us, may be difficult to treat, but the distress they cause is real, and the risks their victims have taken on our behalf are just as real. We are without honor as a people if we do not provide them with treatment for all their wounds, visible and invisible.

The Safety of Our Children: Vaccinations

Posted by on January 28, 2013 Comments Off on The Safety of Our Children: Vaccinations

If there is one aspect of health we care most about, it is that of our children.

We are afraid to do the wrong thing, which might be doing something and might be doing nothing.

Vaccinations are the first major encounter our children have with the health care system.

By major I mean:

Under the recommended plan from the Centers for Disease Control and Prevention, children today are vaccinated against 14 infectious diseases, receiving up to 24 vaccines by their second birthday, and up to five in one office visit.

There has been controversy about the frequency of vaccinations, about the content of vaccines, and about the necessity of the vaccines at all in the absence of the diseases they protect against.

The last reported case of diphtheria in the US occurred in 2003.

The last reported case of polio in the US occurred in 1986.

I do not claim to know the incidence and severity of side effects and reaction to these and other vaccines.

Here is what I know:

  1. When a disease like smallpox was eradicated, the routine vaccination was halted.
  2. The diseases that we are vaccinated against have not been eradicated. We live in a small world: we travel to other countries, and others travel here. HIV/AIDS was brought here on a plane. We do not want to be like the Native Americans, wiped out by diseases from Europe because we were not vaccinated.
  3. The risk and incidence of reactions are minimal compared to the severity of an infectious outbreak.
  4. Science brought us the life-saving vaccines, not hunch or intuition.
  5. The Institute of Medicine of the National Academies has issued a report on childhood immunizations and found:
    1. the childhood immunization schedule is considered one of the most effective and safest public health interventions available to prevent serious disease and death. Furthermore, the committee’s review of the literature did not find high quality evidence supporting safety concerns about the immunization schedule.
    2. The committee’s efforts to identify priorities for recommended research studies did not reveal an evidence base suggesting that the childhood immunization schedule is linked to autoimmune diseases, asthma, hypersensitivity, seizures, child developmental disorders, learning disorders or developmental disorders, or attention deficit or disruptive behavior disorders.
    3. The committee found no significant evidence to imply that the recommended immunization schedule is not safe.

The bottom line: in all of our health care decisions we are playing the odds–life never affords us certainty. The odds favor vaccination according to schedule. Listen to your pediatrician–vaccinate your children.

ED use drops when medical practices extend office hours – amednews.com

Posted by on January 17, 2013 Comments Off on ED use drops when medical practices extend office hours – amednews.com

This article from the American Medical Association news service caught my eye because it discusses an issue central to the challenge of providing quality health care at the lowest feasible cost, to individuals and the society: ED use drops when medical practices extend office hours – amednews.com.

With the recent US Presidential election following the passage of the Patient Protection and Affordable Care Act (PPACA) aka “Obamacare,” the issue of access to health care has been prominent.

Access, however, does not merely mean having health insurance, although that is certainly important.

Access also means that the health care provider needs to be open and available. Those of us beyond a certain age can remember when the family doctor made house calls, even in urban and suburban areas.

All of us know that those times are gone, except perhaps in some small, rural communities. Attempts to revive house calls in some areas have not always endured or proved worthwhile.

A study in Health Affairs, 31:12, December 2012 finds that emergency department usage declined 20 percent and unmet medical needs declined over 40 percent when physicians stayed open extended hours.

In the absence of such access, patients go to the nearest hospital emergency room for non-emergency care. The result is a burden on emergency facilities treating more urgent cases as well as an added, and unnecessary burden, on health care insurers. Those costs through higher premiums are passed to the consumer: businesses and individuals.

This study points to a very important lesson: we can improve health care AND lower costs. One important detail is that the practice staying open might mean the availability of a nurse practitioner rather than a physician.

Improving access to health care in a time of fiscal restraint is going to require more innovative use of health care providers, especially nurses, physician assistants, and urgent care facilities. Not only does this study make that clear, but as James King, MD, a family physician in Selmer, TN suggests that practices partner with urgent care facilities in the community that supply after-hours care if the doctors can’t offer these services themselves. “Your patients know to go there, and then the urgent care center knows to get information back to their primary care physician when they’re seen” by their regular office.