Category Archives: Sources

Addiction: Twenty-first Century Style

Posted by Sam on November 19, 2013 Comments Off

Technology is wonderful, ever moving forward. Now that cigarettes and other tobacco products have been thoroughly discredited as nothing more than a dirty 20th Century addiction, the purveyors of nicotine addiction have developed the e-cigarette for the 21st.

None of that harmful tar. None of that distasteful, annoying smoke. Just pure pleasure, as innocent as sucking a straw.

The Food and Drug Administration (FDA) is not convinced and is expected to issue regulations shortly.

E-cigarettes are a battery-powered device, about the size of a cigarette, that heats a nicotine-laced liquid into a vapor to be inhaled.

First, the FDA will not be able to regulate e-cigarettes as medical devices. That was decided by the DC Court of Appeals in Sottera, Inc v. FDA at the end of 2010. That means that restrictions will be similar to tobacco products rather than to nicotine patches.

Second, there will be considerable debate about the relative safety of e-cigarettes. While it is true that the tar and smoke is missing, it is unclear what the effects of the vapor components are both or the “vaper” and those around him.

A 2012 study at the University of Perugia (Italy) concluded:

The e-cigarette seems to give some advantages when used instead of the conventional cigarette, but studies are still scanty: it could help smokers to cope with some of the rituals associated with smoking gestures and to reduce or eliminate tobacco consumption avoiding passive smoking. However, the e-cigarette causes exposure to different chemicals compared with conventional cigarettes and thus there is a need for risk evaluation for both e-cigarettes and passive steam exposure in smokers and non smokers.

In August, 2013 respected researcher Igor Burstyn of the Drexel University School of Public Health issued a study financed by The Consumer Advocates for Smoke-free Alternatives Association (CASAA), an advocacy organization of the e-cigarette industry. Burstyn’s work and presentation is rigorous, but it is a technical study, not the peer-reviewed journal article considered the gold standard among researchers. While finding that the contaminants are generally safe, Burstyn:

does not evaluate the risk of nicotine exposure to the person “vaping.”
notes the difference in standards between exposure to a willing user and more stringent standards for an unwilling bystander.

This approach to secondhand vapors provides a legal and philosophical foundation for applying existing tobacco regulation to the newer nicotine delivery systems.

Third, the e-cigarette industry is following the lead of the tobacco industry in its advertising. Note the remarkable parallels in Cigarette Flashbacks, a presentation by three Democratic members of the House Energy and Commerce Committee.

Fourth, there is widespread concern about the marketing and increased consumption of e-cigarettes by teenagers. Ninety percent of adult smokers had begun smoking in their teen years. The issue is well summarized by Health.Howstuffworks.com Flavoring the vapor with chocolate, caramel, strawberry, and bubble gum suggests a conscious attempt to lure youth into early addiction for later profits. Similar concerns have been expressed about the flavorings in hookah smoking as well. The Centers for Disease Control and Prevention recently issued a report on the percentages of teenagers using flavored tobacco products, nearly half of the consumption is flavored.

In the Jewish tradition, consumption of dairy and meat products together is forbidden. Technically, it would be permitted to have soy cheese on a hamburger, but the rabbis have forbidden that as well, because the appearance of violation by believers might encourage others to violate the prohibition.

It is clear that the appearance of smoking cigarettes should be treated no differently than the consumption of cigarettes. The difference between suggesting “Reach for a Lucky instead of a sweet,” and “E-cigarettes have no tar or smoke,” is minimal.

The FDA should treat e-cigarettes as tobacco products, and the several states should follow the examples of Utah, North Dakota, New Jersey, Arkansas, and the District of Columbia in banning indoor use in public places. Additionally, sales to minors should be banned as well as Internet sales since age-verification is not possible on line. In short, we need to bring these products under the same regulations as their tobacco cousins–NOW.

Learning about fat people

Posted by Sam on September 16, 2013 Comments Off

When I was growing up, I had a first cousin who was morbidly obese, long before the efforts of the rest of the country to catch up with her. Her failure, and it was considered a failure, to lose weight was seen as evidence of a moral failing, a lack of willpower, only slightly less pejorative than the sin of gluttony in earlier times. There was some vague talk that she might have some hormonal imbalance, but it was clear that all around her considered her problem to be predominantly one of willpower.

Both alternative and scientific medicine have taken a recent interest in gastro-intestinal (GI) flora, or “gut bacteria.” The alternative medicine folks have favored “probiotic” supplements and yogurts fortified with bacteria. The probiotic movement began with Nobel laureate Elie Metchnikoff, known as the “father of probiotics,” who believed that longevity of rural Bulgarians and Georgians could be attributed to their consumption of fermented milk products.

Consideration of the impact of GI flora on diarrhea is not really new–a half century ago I can recall being given lacto-bacillus pills to counter the gastric distress resulting from penicillin. It is the potential impact of bacteria on obesity that is notable in the current focus. Recently National Public Radio (NPR) interviewed Jeffrey Gordon, a microbiologist and director of the Center of Genome Science and Systems Biology at the Washington University School of Medicine in St. Louis.

While I hope you will either listen to the embedded audio clip (about 12 minutes) or read the interview transcript, the short version is that there the research shows a recursive feedback loop between how the bacteria impact our appetite and how what we eat impacts the bacteria that are in our intestines. By eating the right or “lean” foods, we encourage the bacteria that help us maintain our weights at a healthy level. Now, there has been some experimentation with fecal transplants, having a similar aim, but that does not seem to be for everyone–particularly those of us who would be grossed out by the very idea. Eventually, we will probably have probiotics, which, combined with proper diet (they need to be fed or cultivated in our gut), can be delivered to our intestines in pill form, or at least a suppository rather than a fecal transplant.

Over time my cousin became estranged from nearly everyone in the family and died a few years ago, not having been seen by any family members in decades. Waxing philosophically, I cannot help but wonder how different my cousin’s life might have been had she been born a half-century or better a century later. And, I wonder how different my father’s life might have been had he survived his first heart attack and lived to see statin drugs.

It seems that much of our survival depends upon living just long enough for technology to address a mortal weakness in our genome. Nonetheless, it is encouraging to note that promising approaches to obesity may make it seem like nothing more interesting than a historical healthcare statistical blip rather than the crisis it appears to be as we live with it and address it.

Three research pieces with a lot of heart

Posted by Sam on September 10, 2013 Comments Off

Often the most heartening news comes from health research. The past couple of weeks have revealed three worthy of note. All three involve prevention measures, two before a heart attack, and one after.

First, the US Centers for Disease Control and Prevention estimate that 200,000 deaths from heart attacks can be avoided annually. The preventable deaths are concentrated in three areas.

The first area is age, where preventable deaths are concentrated in the 45-64 age cohort.

The second area is race, where African-American men are at the highest risk of preventable death, 143 out of 100,000.

Finally, the deaths are concentrated geographically in the South-Central Region.

Second, a study from Britain and India, published in the Journal of the American Medical Association (JAMA) found that a single pill or “polypill” with fixed doses of aspirin, anti-hypertensive, and cholesterol-lowering drugs was statistically more effective than offering separate prescriptions. While physicians point out that this approach limits flexibility, greater variation of dosage combinations in polypills is a promising approach.

Third, a study in JAMA Internal Medicine found that even after a heart attack, better diet, as measured with Alternative Healthy Eating Index (AHEI 2010), resulted in lowered mortality.

The good news is that either before, or failing that, after a heart attack, the good practices of medication adherence and reduction of risk factors such as poor diet, can improve our survival as individuals. Furthermore, we can move the needle in a better direction by focusing our educational and interventional efforts on those under 65, African-American, residing in the South-Central United States.

Herd Immunity — How vaccines avoid thinning the herd

Posted by Sam on September 3, 2013 Comments Off

Part of the difficulty in making a case for universal vaccination against dangerous disease is a lack of understanding of probability. Since there are few certainties in life, except its eventual end for individuals, we are constantly calculating probabilities. What is the probability that I will get to the other side of the street before that oncoming car arrives? What is the probability that the wheel stop on my number or that I will draw the card needed to complete my hand? What is the probability that the game I am going to attend will occur or get rained out? And, of course, what is the probability that the suggested intervention will cure my disease rather than kill me or leave me permanently debilitated?

Some probabilities are more difficult to calculate than others: what are the odds that I will die from prostate cancer, and what are the odds that the operation will leave me impotent? how do I calculate the best course when my choices are an operation with an 80 percent success rate that leaves another 15 percent paraplegic and 5 percent dead? How about the same operation with 93 percent success, 5 percent paraplegic, and 2 percent dead?

The more complex the alternatives, particularly when they are being balanced against complex outcomes from non-intervention, the more difficult it is for us to make a rational decision.

That leads to a discussion of vaccination. Let’s consider a disease such as smallpox, which has killed 100s of millions of people. Not everyone got smallpox. Not everyone who got smallpox died from it–estimates are that about 30 percent, or 3 out of every 10 died. Now, consider that not everyone who gets a vaccination gets 100 percent immunity. Some people get partial immunity. Some very small percentage may not produce antibodies in reaction to the vaccine. Some people actually die of the side effects of the vaccination.

As an individual, you might think, well, it’s not great but 70 percent odds of surviving are better than none, and maybe it will miss me altogether, so why should I vaccinate? Of course, smallpox has been eradicated, and we don’t have to make that kind of determination any more since the dangers of side effects from the vaccination exceed the danger of contracting smallpox, particularly in the United States where the last documented case appeared in 1949.

If you were a free individual, not part of a society, not part of the possible transmission stream of a disease, then no one is likely to care too much what you decide? However, if you are reading this, you are part of a society providing this message to you via a societal mechanism. As part of that society, you have obligations to others in the society, including children, yours and others, who once were considered private property but are now considered individuals with rights, albeit limited compared to adult rights.

The concept of “herd immunity” goes directly to the questions posed and to your obligations within the society.

Those who are vaccinated provide a barrier to illness for those who are not:

Consider:

Assume you have 5 friends who do not know one another, and that everyone has 5 such friends.

Assume that vaccinations give almost 100% immunity and that the corresponding disease gives almost 100% probability of infection if you come in contact with a person who has it.

Now, if 80 percent of people are immunized against the disease, it is quite possible that one of your friends is not immunized. However, if 80 percent of that person’s friends are immunized, there is now only 1/5 times 1/5 or 1/25 = 4 percent chance of the disease vector reaching you. It may be that you friend’s friend has friends with 100 percent immunity, all five of them immunized, and the further you are socially from the source of infection, the lower your odds of becoming infected–even if you are not immunized. You are protected by herd immunity.

However, consider if only 60 percent of people are immunized, then 2/5 times 2/5 is 4/25 or 16 percent chance of becoming infected. That is 4 times your chance of infection from a secondary friend, as in the first example. The degree of herd immunity is a complicated calculation depending upon the percent immunized and the way the disease is transmitted. Your chance of infection depends on those factors as well as your social distance from the source of the infection.

For an animated look at the concept, click on “Play Animation” in the three scenarios of The History of Vaccines: Herd Immunity.

Here are the thresholds for different diseases as estimated by the Centers for Disease Control (CDC):

Think about flu shots for a moment:

The vaccine is based upon recent mutations of the virus, so you might catch a virus that is not part of the vaccine.
Not everyone gets 100 percent protection from a vaccine–it may be sufficient to protect against some strains and give partial protection against others
In part, because of herd immunity, not everyone exposed to influenza is infected

So, we have friends and relatives drawing the wrong conclusions (e.g. the vaccine caused me to get influenza), based on an association of factors that are coincidental or subject to an alternative explanation, such as a new strain or partial immunity. For most young people, the flu is an occasional inconvenience rather than life-threatening; however, their failure to vaccinate exposes others whom they could be protecting by a simple annual injection. Let’s spread the word–it might not save those young individuals–just an older person, or an asthmatic standing close to them.

Vaccination–Now and Then

Posted by Sam on August 26, 2013 Comments Off

Smallpox was long one of the scourges of humanity, killing millions throughout history. Early attempts were made to combat it through “variolation,”inoculation with the scabs of the disease. Such efforts began at least a thousand years ago in China.

Without images to guide us, it is easy to think of smallpox as chickenpox that kills. Not exactly. Besides the fact that smallpox does not concentrate on the torso, the number of pustules seems much more severe to my eye. Here is a child in Bangladesh in 1973 with smallpox. This is what we no longer fear because of vaccination:

Vaccination is relatively new in human history–the United States of America is older. Just before and after 1800 Edward Jenner, noticing the apparent immunity to smallpox of milk maids, experimented with inoculation using the relatively benign disease cowpox to which they had been exposed. It was not until 1840 that the British government routinely provided the means for inoculation, as the medical establishment had been slow to accept Jenner’s findings.

Nonetheless, the disease that killed an estimated 400,000 Europeans annually at the time of Jenner’s discovery, was still able to kill several hundred million in the 20th century.

The last documented case of smallpox occurred in Somalia in 1977. By 1980 the World Health Organisation (WHO) was able to declare smallpox eradicated. Consequently, routine smallpox vaccination was discontinued in the 1980’s as the statistical danger from the vaccination (14 to 52 per million per the CDC) exceeded the danger of the disease.

I would prefer to be able to present a time series of smallpox cases, but have been unable to locate one this week. Failing that, here is the impact of vaccination in the US on numerous diseases during the 20th Century, worth considering when someone questions the value of vaccination.

The things we already know–but don’t often do

Posted by Sam on July 15, 2013 Comments Off

There is the old Middle Eastern story of the one who journeyed East in search of wisdom. He came upon a stone where he read, “Turn me over.”
He picked up the stone and read on the underside: Why do you seek new knowledge when you do not use that which you already have?

A recently reported Swedish study that followed 71,000 individuals over a 13-year period found that consuming less than five daily servings of fruits and vegetables was associated with higher mortality and shorter survival periods. Those eating one serving of fruit daily lived 19 months longer on average, while those eating 3 servings of vegetables lived 32 months longer.

Now by itself, this is not very surprising. We know that heavy meat consumption is linked to colorectal cancer, particularly in combination with genetic mutations, as described in a recent issue of Smithsonian Magazine. So, the possibility that a different diet would be protective, even by contrast, makes some sense.

Fornaciari subsequently analyzed bone collagen of King Ferrante and other Aragonese nobles, revealing a diet extremely reliant on red meat; this finding may correlate with Ferrante’s cancer. Red meat is widely recognized as an agent that increases risk for mutation of the K-ras gene and subsequent colorectal cancer. (As an example of Ferrante’s carnivorous preferences, a wedding banquet held at his court in 1487 featured, among 15 courses, beef and veal heads covered in their skins, roast ram in a sour cherry broth, roast piglet in vinegar broth and a range of salami, hams, livers, giblets and offal.)

In a similar vein, one out of three Americans suffers from hypertension (high blood pressure), a major risk factor for serious cardiovascular events such as stroke and heart attack. A recent study in JAMA showed that 18 months after the beginning of a study in which the experimental group did home blood pressure monitoring along with pharmacist case management, 71.8 percent had controlled blood pressure compared to the control group with usual care at 57.1 percent.

It would be easier if we had pills that would lower our body weight or a vaccination against high blood pressure. We don’t. But we have knowledge that we are not using: walk more, eat less processed foods and more whole grains, vegetables, and fruits, monitor blood pressure and pulse regularly. No, it is not magic–just the best that we can do.

PTSD: Military and Civilians

Posted by Sam on July 1, 2013 Comments Off

As I was surfing my car’s radio dial for some music–not much luck at the time–I heard a DJ defending his decision to discuss PTSD in the military. I guess some other listeners had been unsuccessful in finding music but found a serious discussion of trauma and war on a music show unacceptable.

What used to be called “shell shock” or “battle fatigue,” has the medical diagnosis of Post Traumatic Stress Disorder (PTSD). It is the kind of thing that got General George Patton in trouble, when he slapped a soldier suffering from it.

In many areas of brain disorder (ADHD, bi-polar, OCD, and PTSD), we can now provide a medical diagnosis rather than a moral diagnosis. Suffering from one of these disorders is no more evidence of moral shortcomings than diabetes, heart disease, or cancer–just different organs involved.

PTSD results from a shock or trauma–perhaps war is the most common and severe emotional trauma. I regret to note that having a volunteer army has resulted in the unintended consequence of making troops expendable to the civilian population. Now, we think nothing of sending them into combat with minimal reason or provocation, as they are volunteers, while we are in no way inconvenienced by doing so–no rationing, no higher war taxes, zilch.

As a result, we have decade-long wars (2 at last count in recent years) that cannot help but create PTSD along with other casualties of confict. And, of course, we need to make sure those needs are met along with the amputations and prostheses that the civilian population associates with war. The Veterans Administration (VA) maintains a National PTSD Center, and I have no idea how good the programs are, but they can be found by consulting the VA PTSD Locator

A related point, however, is that civilians as well as military are subject to the traumas that trigger PTSD. As the National Institute for Mental Health notes:

PTSD was first brought to public attention in relation to war veterans, but it can result from a variety of traumatic incidents, such as mugging, rape, torture, being kidnapped or held captive, child abuse, car accidents, train wrecks, plane crashes, bombings, or natural disasters such as floods or earthquakes.

While our primary concern may be with the direct effects (psychological and emotional) of PTSD, just this week an Emory University study of identical twin Vietnam War veterans found that risk of heart attacks was more than doubled in those with a history of PTSD.

Mental illness or brain disorders of any type require considerable investment of resources, professional and financial, to address. As a society we have dragged behind on this–mental health parity laws at the state level commonly had loopholes for high financial impact. There is a federal law in place, but it is not clear how effective it is. Change is occurring, but slowly.

Just within the past week, we learned that the California Department of Managed Health Care had imposed the second largest fine ever on Kaiser Permanente for failure to provide long term mental health care.

This country was founded by emptying Europe’s jails, and has been populated by escapees from prisons and hospitals around the world, along with other immigrants. As a nation, we have our share of people with “issues.” Some of the benefit has come from their creativity and willingness to challenge frontiers; however, in the 21st Century we need to help those folks adjust to what passes for civilization. Our veterans deserve it, but so do a lot of civilians, too. Let’s work to see they receive the necessary services–having mentally stable neighbors and colleagues improves life for all of us.

Are we doing ourselves in faster than we think?

Posted by Sam on May 6, 2013 Comments Off

We know that our health is adversely affected by obesity, a sedentary lifestyle and fat consumption, not to mention tobacco and lack of access to healthcare. These factors are holding down what should otherwise be continued gains in life expectancy. They also adversely affect those who survive: the strains of obesity on the skeletal structure, emphysema from tobacco consumption, chronic heart disease, cancer that takes over lives, etc.

Recent studies indicate that not only are we experiencing indirect and long-term impacts on our lives and health, but the rate of suicide is increasing, surpassing deaths by motor vehicles in 2009. What adverse lifestyles are not doing to us in the long-term, we are doing directly to ourselves in the now.

The recent CDC study Suicide Among Adults Aged 35–64 Years — United States, 1999–2010 showed that the largest increase in the suicide rate was among whites between ages 45 and 64, in contrast to the common concern about teen and geriatric suicide.

In general, the suicide rate is related to stressors and the availability of means. The following chart, with data from the National Vital Statistics system, is from that CDC study:

Noteworthy are the increased use of firearms, which account for about half of all suicides among men, and suffocation (euphemism for hanging). The study lists the rates of suicide by state as well as the rate of increase from 1999 to 2010. I wondered about the ownership of firearms in those states.

I found that the study, “Association of suicide rates, gun ownership, conservatism and individual suicide risk,” was published online in the journal Social Psychiatry & Psychiatric Epidemiology in February.

The title a bit provocative, but if the availability of firearms reflects the political views of a population, and if the availability of firearms is related to the suicide rate, then it is possible to find statistical correlations among the three, without implying that a particular political view is suicidal or causes suicide any more than suicide causes a political view.

The study by researchers at the University of California, Riverside presented the following map of suicide rates by state:

The map seems to show higher rates in states where one might expect more gun ownership, but, being a data person, I did a little experiment of my own.

I ran a couple of regressions, down and dirty, not up to publishable, academic standards. I used MS Excel, probably acceptable for this purpose but not a tool I would use for a publishable regression analysis.

My data sets were gun ownership from the Behavioral Risk Factor Surveillance System for 2001 and Median Income from the US Census Bureau for 2006. First, regressing gun ownership by state on income found that income was a significant factor, inversely related to gun ownership, and explaining 35 percent of the unexplained variation. This is not surprising as rural states are generally poorer and are more likely to have traditions of gun ownership for protection as well as for hunting.

It also meant that the cross correlation of income and firearms ownership might cloud the findings when I looked at the suicide rate from the latest CDC report and its separate relationships to the two factors. Those figures were for only 39 states, so that is how I handled it. My informal findings were that gun ownership rates were strongly correlated with the suicide rate, p=.00025 with R squared =.308, accounting for 30.8% of the unexplained variation. Income was inversely related to suicide and was much weaker, with p=.045 and R squared = .104.

Now, you might say, “Oh, suicide is related to economic factors. With recent economic challenges, of course suicide is rising.” You would be correct. Researchers from Rutgers have provided a graph of the relationship between suicide and unemployment.

Source: Social Fact: The Great Depressions?

That is not, however, the public health issue, as there will always be stressors causing suicide. We need to find a way to block access to guns in the same way that we block access to bridges for suicidal people. Of course, there are a lot more guns than bridges. In the United States we ban automatic weapons from private ownership, so the issue is not whether the right to bear arms can be restricted: the entire debate is how extensive those restrictions should or should not be. The data on suicide suggests that greater restrictions on access would have a positive public health impact.

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

Posted by Sam on April 8, 2013 Comments Off

In the first act I left a gun on the wall. I questioned whether there was a physician shortage in the US.

The rule of drama is that a gun on the wall in the first act has to be used later in the play. Let’s look at the US physician shortage.

We want to determine: is there really a shortage? what is the nature of the shortage? if there is a shortage, do the measures proposed address that shortage?

The AAMC claims that the shortage has resulted from the cap on Medicare-funded residencies implemented under the Balanced Budget Act of 1997.

I wanted to find a time series on the number of physicians from 1997 to the present. It may be that the AAMC and AMA have such a series but it would be time-consuming, even if possible, to get hold of those figures.

Consequently I went to the Bureau of Labor Statistics (BLS) for physician employment and to the US Census Bureau for population figures. Also, the BLS changed the way it classified and calculated numbers of health care practitioners. The BLS has confirmed to me that the physician totals for 1999-2003 do not exist, although some sub-totals do.

First, I compared the number of physicians to the US population. I simply divided the number of physicians by the population and multiplied by 1000 to get physicians per 1000 population, yielding this graph:

Now that does not look like a physician shortage–indeed, it looks like we may have a physician surplus with the growth in the number of physicians outstripping population growth.

So, I looked a bit further. I grouped pediatricians, general internists, and family practice physicians, calling them “Primary Care.” Then, I produced this graph, indexing them to 2004 being 100 so we could see the relative growth.

It is clear that while the total number of physicians has grown faster than the population, the number of primary care physicians has trailed.

Since we have the sub-categories going back to 1999, just after the Balanced Budget Amendment of 1997 was passed, here is the indexed comparison:

While the number of Primary Care Physicians kept pace with the population from 2004 through 2007, it has generally fallen short of population growth.

The challenge then is: how do we allocate resources to increase the number of physicians in primary care without those funds being diverted to creation of even more specialists?

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

Posted by Sam on April 1, 2013 Comments Off

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.

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:

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:

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)

There was a man with tongue of wood

Who essayed to sing . . .

Category Archives: Sources

Addiction: Twenty-first Century Style

Learning about fat people

Three research pieces with a lot of heart

Herd Immunity — How vaccines avoid thinning the herd

Vaccination–Now and Then

The things we already know–but don’t often do

PTSD: Military and Civilians

Are we doing ourselves in faster than we think?

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

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

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