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

Posted by on July 15, 2013 Comments Off on The things we already know–but don’t often do

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 on July 1, 2013 Comments Off on PTSD: Military and Civilians

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.

Illusion and Health

Posted by on June 24, 2013 Comments Off on Illusion and Health

A recent University of Texas study about the gap between perception of adequate exercise and optimal diet and the reality of an individual’s regime sent me googling.

I remembered a similar meme about body image. My memory was that men do not see how fat they are, and women imagine themselves fat when they are not, leading to anorexia.

Here are a few of them, and there are no doubt more:

Those studies raised an important question: how do reality and perception diverge when it comes to health?

So, let’s look at the University of Texas study from the Journal of Women’s Health, entitled Lifestyle and Cancer Prevention in Women: Knowledge, Perceptions, and Compliance with Recommended Guidelines.

Among those who believed that good diet and physical activity prevented cancer, the study found discrepancies (I have color-coded them) between what they believed they were doing and were actually doing as shown in the following table:

Women's Perceptions JWH 20130610

It can be seen that while 85 percent believe they are consuming a healthy diet, only 8.5 percent are eating an adequate amount of fruits and vegetables. While 73.1 percent reported engaging in physical activity to prevent cancer, only 31.5 percent were active enough to have a positive impact.

The study found that the significant predictors of the discrepancy were education, and to a lesser extent race-ethnicity independent of education. While the authors speculate about the reasons for those findings, they are clear and unambiguous about the implications, which I quote at length with the footnotes removed:

This finding has important public health implications. The first implication is that women in the current study reported understanding that engaging in regular physical activity and eating a healthy diet are important behaviors for cancer prevention. Thus, media campaigns and targeted public health messages should focus on the importance of specific frequencies and durations of recommended behaviors (i.e., 5 a Day for Better Health), and place less emphasis on the general importance of health behaviors. This may help attenuate the “underdosing” observed in the current study. Current public health efforts are focusing on making community-wide changes to reduce obesity and improve health.19 These efforts may be enhanced by promoting awareness of potential discrepancies between perceptions of behavior and actual behavior and by highlighting practical ways to integrate specific cancer prevention behaviors into daily life at adequate levels. Furthermore, they should consider the imbalance between educational resources for healthy eating and physical activity and barriers to these behaviors (i.e., society encourages the overconsumption of unhealthy food; low access to fresh produce and places to exercise safely sometimes exists). Given that women often serve as “gatekeepers” of health behavior within their families, efforts to address these discrepancies among women may ultimately have a positive downstream effect on men and children. Because dietary habits are often solidified in childhood, the discrepancies observed in this study could potentially set children up for a lifetime of poor health behaviors. These findings add to the body of existing literature indicating that although health-relevant knowledge and attitudes are generally positively associated with the practice health behaviors, the associations are only modest.

Results further indicated that the observed discrepancies for diet and physical activity were significantly more common among women with less education and among members of racial/ethnic minority groups. This is consistent with a large body of research supporting a social gradient in health (i.e., lower socioeconomic position and minority status are associated with poorer health behaviors and poorer health outcomes). One explanation for this is differential exposure to obesogenic environments. That is, individuals with low socioeconomic status and racial/ethnic minorities have less access to healthier foods such as fruits and vegetables due to higher cost and lower access to grocery stores that carry fresh produce. They also have fewer safe places to engage in physical activity. These women may be particularly vulnerable to perceiving that they are engaging in specific diet and physical activity behaviors to help prevent cancer. However, they may lack the opportunity to fully engage in preventive behaviors, thus failing to engage in such behaviors with sufficient frequency and duration to reduce their cancer risk. Such women may need to be specifically targeted for intervention and may benefit from tailored messages and interventions regarding diet and physical activity.

Do we not all know friends and family and clients who believe they are eating well and exercising adequately, but do not understand why their weight keeps rising, with the attendant complications? Our challenge as a society is not only to find ways of addressing the health problems that are undermining our economy and personal functioning that underpin our nation, but to communicate those findings in a way that is unambiguous and specific. The challenge of communicating the findings of a solution to the public health issues may be even more daunting than isolating those causes.

Doing the porcelain dance

Posted by on June 17, 2013 Comments Off on Doing the porcelain dance

As a general rule, food-borne illness, commonly called “food poisoning,” has remained fairly constant over the years. Indeed, since 1996 only one pathogen has shown considerable increase.

Based on 19,531 cases from Foodborne Diseases Active Surveillance Network (FoodNet) the CDC found:

Food Illness Trends 1996_2012

If Vibrio were a stock instead of a pathogen, you would have wanted to buy in around 1996 as it has enjoyed a considerable rise. Perhaps, like me, you wondered what Vibrio was. Most of the others have been in the news media or are simply well-known.

The trend continued in the period 2006 to 2012:

Foodborne Illness 2012

Vibrio is a genus of bacteria–one species causes cholera. This species Vibrio parahaemolyticus, however, likes sea water so much that it hangs out with oysters. If you get this infection, antibiotics do not help, so you drink liquids and wait it out.

Vibrio

By contrast, another species Vibrio Vulnificus can respond to anti-biotics. Among healthy people, the experience is likely to be the same as for Vibrio parahaemolyticus, but for those with compromised immune systems, immediate medical attention is indicated. Fortunately, this seems to be the more rare form of non-cholera Vibrio, and the incidence is much less frequent, generally occurring in the Gulf States.

One mystery in the data: incidence of Vibrio is higher among adults over 65 years old. While it can be contracted by an open wound in the wrong sea water, most Vibrio results from consumption of raw oysters or other uncooked seafood. I have not been aware of any trend to gulping raw oysters among seniors, but as the boomers enter old age, maybe they are going for anything that might keep the Sexy Sixties going. It would be of interest to see the geographic distribution of these cases–are there a lot of them in South Florida, for example?

Be careful out there.

Fast food and slow death

Posted by on June 3, 2013 Comments Off on Fast food and slow death

My father returned from a business trip with great enthusiasm for a new food product he had experienced. A company had found the best meat available and mass produced hamburgers, with the mustard, ketchup, and pickle already on the bun. Dad had eaten his first McDonald’s hamburger, more than a half century ago.

He died at age 45 of a massive heart attack, a product not only of McDonald’s and other fast food, but of a sedentary lifestyle, poor heredity, and a 1950’s diet, in which it wasn’t a meal without meat.

He and others who lived through the Second World War had experienced the deprivation of rationing following not long after the Great Depression. Having enough to eat, enough protein to eat, and then seeing opulent food as a sign of material success were all very real to that generation.

The success of feminism led to changes in America’s eating habits. Instead of one partner packing the lunch pail and preparing dinner, both were in the work force, too hurried and harried to spend as much time on meals. Quick meals, whether processed from the grocery store or from a fast food chain, became the norm. In the not too distant future we will learn what the impact has been on gut bacteria that process nutrients and play a role in regulating our weight.

In October 2011 researchers from the University of Michigan, Warsaw School of Social Science and Humanities, and the University of Texas published a study showing significant correlation between national rates of obesity and the density of Subway restaurants in 28 developed nations. Their study ‘Globesization’:
ecological evidence on the relationship between fast food outlets and obesity among 26 advanced
economies found high rates of obesity in countries such as the United States and Canada with high density of Subway restaurants compared to low rates of obesity in countries such as Japan and Norway with low rates.

We can safely assume that it is not Subway alone, but a propensity to support fast food restaurants that is related to obesity. In the study graphic below, the clustering of values along a rising trend line from lower right to upper left, demonstrates the correlation between obesity on the vertical and subways on the horizontal:

Subway_Obesity

Source: Roberto De Vogli , Anne Kouvonen & David Gimeno (2011): ‘Globesization’: ecological evidence on the relationship between fast food outlets and obesity among 26 advanced economies, Critical Public Health, 21:4, 395-402

My father’s generation died sooner, from fatty diets, cigarettes, and a sedentary lifestyle. If anything, computers have made our lifestyles more sedentary, but we know the dangers of cigarettes and saturated fats. We have statin drugs to stave off early death. Now we live longer, die slower, and endure chronic illnesses, such as cardiovascular disease and diabetes.

One of the singular distinctions between children and adults is the ability of adults to postpone pleasure and even endure discomfort in pursuit of a greater good. That may mean planning healthier meals, lighter meals, walking more and driving less. It means, in short, all the things we know we should do but sometimes do not. A long life need not be accompanied by a slow death–if we are willing to act on the knowledge we already have.

Are we making progress or falling behind?

Posted by on May 27, 2013 Comments Off on Are we making progress or falling behind?

In health care we don’t need to look far for bad news. In the past week, I have read:

  1. The prevalence of diabetes has increases 75 percent from the early nineties to the late naughts. A more extensive discussion (may require free Medscape subscription registration) is at New Statistics Shed Light on ‘Worrisome’ Diabetes Epidemic
  2. Leapfrog Hospital Safety Scores ‘Depressing’
  3. Study finds jump in ER-related admissions

And certainly we could include partisan bickering in Washington among politicians more focused on the next election than any meaningful policy debate or measures.

However, the simple fact is that none of this matters. We have no choice. If we do not adequately address our health care needs, then we will no survive as individuals or as a society.

If that premise, the premise of this blog, is correct, then we must assure access to healthcare for everyone. We must get the public health epidemics of obesity, diabetes, and gun violence, among others, under control.

On this Memorial Day, as we reflect on how many Americans have given up their lives at a young age to protect the American experiment, let us consider our debt to them: we owe it to them to insure that our society does not fail and that individuals not on battlefields do not give up their lives at a young age because they ate too much or someone bought a gun out of fear.

We are Americans: we do not accept failure in ourselves. The rest is trivial distraction.

How researchers confuse the public

Posted by on May 20, 2013 Comments Off on How researchers confuse the public

A nursing professor once told me how a graduate student came to her all excited. There was a population cohort dying from an epidemic of cardiac disease that had been ignored in the literature: women above age 85.

Now, while we can chuckle together about the naivete of the observation, consider it for a moment from the graduate student’s perspective:

1. Clearly the phenomenon was real as a high percentage of women over age 85 may well be dying of cardiac disease.
2. The red flag of gender bias stood out–it was women who were being victimized by this scourge.
3. A literature search turned up no one acknowledging the problem.

What was missing was the larger context: the twin facts that no one lives forever, and everyone eventually dies of something.

Sometimes more experienced researchers fail to provide the needed context. The following study came to my attention this week. Truth be known, I have not read the entire study, just the abstract and the accounts of those who have, so I will admit up front that this discussion may be unfair to the researchers.

The Canadian study is The long arm of parental addictions: The association with adult children’s depression in a population-based study.

It came to my attention in Trouble Coping with Parental Addiction

I am going to quote the abstract in full:

Parental addictions have been associated with adult children’s depression in several clinical and population-based studies. However, these studies have not examined if gender differences exist nor have they controlled for a range of potential explanatory factors. Using a regionally representative sample of 6268 adults from the 2005 Canadian Community Health Survey (response rate=83%), we investigated the association between parental addictions and adulthood depression controlling for four clusters of variables: adverse childhood experiences, adult health behaviors, adult socioeconomic status and other stressors. After controlling for all factors, adults exposed to parental addiction had 69% higher odds of depression compared to their peers with non-addicted parents (OR=1.69; 95% CI, 1.25–2.28). The relationship between parental addictions and depression did not vary by gender. These findings underscore the intergenerational consequences of drug and alcohol addiction and reinforce the need to develop interventions that support healthy childhood development.

The authors suggest that previous studies have not directly looked at gender differences of children of addicted parents. If so, then that is a clear contribution to the literature. But, the abstract and the descriptive article that I cited above go further: there is the clear implication that beyond a correlation or “relationship,” depression is the consequence of parental addiction.

Let’s consider two scenarios:

First, parents engage in substance abuse. The substance abuse causes them to act out, to neglect their children’s physical and emotional needs. The children grow up insecure and prone to depression. That is the clear implication of the abstract.

Second, a small but measurable percentage of the population inherit a tendency to mental illnesses (bi-polar, uni-polar depression, anxiety disorder, etc.) They self-medicate with both legal and illegal substances. They have children, whom they raise while self-medicating. A high percentage of their children inherit the tendency to mental illness, including uni-polar depression, and depressive cycles of bi-polar, showing a higher tendency toward those illnesses in the general population.

I find the second scenario more compelling. Indeed, attributing the problems of children to their parents because children follow their parents temporally is to my mind a classic case of the post hoc, ergo propter hoc logical fallacy in which one concludes that events following another event were caused by the previous event due to their proximity.

Runny noses do not cause colds, nor does “catching a chill,” whatever that means. Scientific studies are confusing enough to the general public, particularly through the filter of news media that do not look past the headline. We need researchers to be more cautious and guarded in their conclusions.

When we read that President Harry Truman wanted some “one-handed economists,” we can be sure that the economists were doing their job in informing him. We need the same of healthcare researchers.

Are we doing ourselves in faster than we think?

Posted by on May 6, 2013 Comments Off on Are we doing ourselves in faster than we think?

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:

Suicide by Sex and Means 1999-2010

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:

Suicide_2000_2006

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.

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.

How Do We Implement What Works?

Posted by on April 29, 2013 Comments Off on How Do We Implement What Works?

Medicare is abandoning the one experimental program that works. So claims Ezra Klein of the Washington Post in “If this was a pill, you’d do anything to get it.”

Klein describes a program by Healthy Quality Partners (HQP) where nurses make home visits to geriatric patients with chronic illnesses. It has been subsidized by Medicare as an experiment, in which some randomly chosen patients receive the intervention while some do not. The results have been better outcomes at lower cost to Medicare per the article as well as a study published last July.

Let’s assume that the claims are true: better outcomes and lower costs. How do we take an experiment, and by definition experiments have a beginning and an end, and generalize it into practice?

There are numerous possibilities:

First, we could do what the article implies: provide more government funds to Healthy Quality Partners, instructing them to expand the experiment operationally beyond the 1,736 members in Pennsylvania. I am assuming that maintaining indefinitely a small-scale experiment that works makes no sense–onward and upward.

Second, we could change the reimbursement scheme at Medicare to provide reimbursement for such services so that anyone in the country could create a similar program with the financial incentive of knowing that Medicare would reimburse the services.

Here is how that second possibility has developed:

The Clinical Procedure Terminology (CPT) codes were created and are owned by the American Medical Association. Recently Medicare adopted additional CPTs for coding reimbursement for coordination of care services.

Care Coordination CPTs

A statement by the American Nurses Association (ANA) is enthusiastic about the addition of the codes. Note: the ANA participates on the AMA CPT and RVU Update Committee.

ANA Care Coordination

Eileen Shannon Carlson RN, JD of the ANA points out that it is rare for CPTs to be adopted that only apply to nurses, as do two of chronic care coordination additions.

To be fair, the new codes only reimburse care coordination after a hospitalization and for a short period of time, why the HQP initiative addressed the needs of the elderly with chronic conditions. Nonetheless, I can imagine the next step being a protocol to target care coordination for the elderly independent of a hospitalization. Contrary to much in the popular press, government programs are very aware of spending dollars and getting value in return, so they limit risk by taking baby steps in developing programs.

Ezra Klein may well be correct, or he might be underestimating the challenge of turning a large ship, particularly when the upfront costs of such a turn may be prohibitive. What do you think?

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

Posted by on April 22, 2013 Comments Off on Does the US face a shortage of primary care physicians? Part IV

We showed it exists. We show that one proposed solution probably won’t help without extensive micro-managing: conditioning receipt of new residencies on service in under-served areas, e.g. service in the National Health Service Corps.

What else can be done?

First, we can make alterations in the practice of primary care by physicians in the United States.

Peter Ubel makes this argument, suggesting that primary care physicians adopt the model of anesthesiologists supervising nurse anesthetists. He argues that the advantages of having more non-physicians offering care under the supervision of a physician are:

  1. More non-physicians doing routine primary care frees physicians from routine.
  2. Such a practice could see more patients per hour, improving physician compensation in primary care
  3. The model would improve primary care, as it is not physicians but primary care that is in shortage.

A recent article in Health Affairs adds the element of telemedicine to changes in primary care, long distance diagnosis and supervision of non-physicians through the use of technology.

Second, we can move more of primary care to non-physicians.

The second proposal takes the first one step further: allow nurse practitioners and physician assistants to practice independently of physicians. Peter Ubel is a physician, so his proposal in part reflects his background.

Consider this: we allow paramedics operating in a moving vehicle to make life-saving decisions but do not permit nurse practitioners to prescribe or refuse to prescribe an antibiotic with a supervising physician.

Paramedics and emergency medical technicians have a scope of practice that they know. There is no reason for nurse practitioners and physician assistants not to have a similar scope of practice clearly defined for when they are operating independently of a physician–such a scope might be slightly different than when a physician is involved.

The scope of practice of health care professionals is at the state level. In Texas bills are under consideration to make it easier for nurse practitioners to locate supervising physicians. In Connecticut bills have proposed permitting nurse practitioners to operate independently.

Third, we can make it easier for foreign physicians to practice primary care in this country.

A study at the University of Virginia is skeptical of the additional residency requirements for foreign-trained physicians.

All physicians must pass the three sections of the US Medical Licensing exam. It is a good test: there are no statistical differences in patient outcomes or complaints to medical boards between foreign and domestic-trained physicians. The proposal is to permit those passing the exam to compete for residencies on an equal footing, regardless of the location of their medical school.

If the problem is as dire as the AAMC and US Senators have suggested, then we should use all of these approaches to be sure the problem is addressed. At the worst we will have too many primary care providers, improving our health and lowering costs through an abundance of supply.