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

Posted by on April 15, 2013 Comments Off on Does the US face a shortage of primary care physicians? Part III

We have seen that there is a physician shortage, but it is confined to primary care–the number of specialists relative to the population has expanded.

In addition, there is a geographical factor that is beyond the scope of this blog: are the physicians, primary care and others, distributed to provide coverage of those in need, or are they concentrated geographically so that they are adequate in numbers but inadequate in dispersion? Huang and Finegold believe 44 million Americans will be living in places where the demand for physicians exceeds supply by more than 5 percent, 7 million where the deficit will exceed 10 percent.

The American Association of Medical Colleges (AAMC) advocates lifting the cap on Medicare-financed medical residencies imposed by the Balanced Budget Act of 1997. Senator Charles Schumer (D-NY) has introduced the Resident Physician Shortage Act to increase the number of residencies by 15,000 over the next several years. He is particularly concerned about the absence of physicians in the more rural–and colder–upstate New York. His argument is that the shortage is driven by retirements. Aside: New York appears to have more medical schools (12) than any other state (7 next highest).

However, if the problem is really primary care, will simply increasing residencies address the problem? The following chart from the Washington Post is cause for optimism or pessimism, depending upon how you look at it. The number of residents choosing family practice residencies has declined precipitously since 1998, followed by an upturn, which may be brief or long-lived.

Family Practice Residencies

Consequently, the AAMC, as does Schumer, stresses that retirement will affect specialties as well as primary care.

AAMC Specialty Shortage

The question of adequate numbers of medical residencies is actually a separate, though indirectly related, question than the adequacy of the physician supply. According to Peter Ubel, who supplies the following graph from Karen Sliff of the Washington Post. The source of the data is the AAMC, which is why it is so difficult to get at the truth of an issue in Washington: the providers of information have an interest in actions taken on that information.

Resident Positions

So, let us grant that it is probably reasonable, although not necessarily essential, to increase the number of financed medical residencies; however, it is fair that those residents take responsibility for part of the cost to us of providing them, and that such obligation be forgiven if they are willing to serve rural populations for 5 years? My support for increasing residencies is conditional on them going where the need is, not where specialists find the big bucks.

Next time, we will finish this series by looking at other approaches of providing care to a growing population.

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

Posted by on April 8, 2013 Comments Off on Does the US face a shortage of primary care physicians? Part II

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:

Physicians Per 1000 2004_2012

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.

Physicians Indexed 2004_2012

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:

PCP to US Population 1999_2012

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 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 latest in DME: an umbrella

Posted by on March 25, 2013 Comments Off on The latest in DME: an umbrella

When my wife moved to the States from Singapore, she was amazed to find that the umbrellas sold did not list their UV protection. Singapore is 137 km or 85 miles from the equator, and light skin is valued in Chinese culture. So protection from the aging and darkening effect of the sun’s rays has strong cultural underpinnings–unlike the US where there seems to be a tanning salon in every strip mall.

Normally we don’t think of an umbrella as DME (Durable Medical Equipment). However, if DME is home medical equipment you need for your health, then using an umbrella to prevent melanoma seems to qualify. As reported in JAMA Dermatology The researchers Josette R. McMichael, MD, Emir Veledar, PhD, and Suephy C. Chen, MD, MS of Emory University performed a simple, but well-designed experiment: they invited friends to join them in a parking lot, took 3 ultra-violet radiation (UVR) readings, and then opened umbrellas the friends had brought, taking two UVR readings, 1 cm from the individual, and 1 cm from the edge of the umbrella as shown:

Umbrella_uvr_measurement_20130304

There was wide variety in protection among the 22 umbrellas tested, ranging from a white totes® (77%) to a silver Coolibar® (99%). Fourteen were black in color.

Some of the numbers: Umbrella_findings_20130314

As is apparent in the account, the two readings (close and far) were highly correlated. The following scatterplot shows that as the values of each of the two readings are on the axes. The lowest reading shows the greatest protection, so umbrella 6 is the Coolibar®.

Umbrella_uvr_emory_20130304

As the earth warms, we can expect disturbances in the atmosphere that increase our exposure to UVR. Borrowing the style of the 19th century, carrying umbrellas, especially those designed to screen UVR, may be the best we can do.

How do we know?

Posted by on March 21, 2013 Comments Off on How do we know?

In healthcare, or anything, that is an important question. It comes up in almost every healthcare encounter.

If the number of variables and their combinations were not so huge, it would be an easier question to answer.

We have individual genomes with their own proclivities. We have a dozen different prescription drugs or classes of drugs for the same condition. Then, we also have endoscopic and surgical interventions as well as medical devices, sometimes all for the same condition.

Millennia ago, the answer was easy: ask the shaman. The shaman was a religious leader with access to all hidden knowledge. In the West the first physicians were in Egypt and Babylonia, but still with heavy spiritual overtones. Later medicine seems to have split definitively from religion during the classical Graeco-Roman period, with physicians such as Hippocrates and Galen.

Knowledge began with spirit, continued with logic from the classical period to the medieval, and gave way to empirical methods in the Renaissance, formalized in the science of the modern period.

How we know something is the scope of the epistemology, a branch of philosophy. So, why am I waxing philosophical? Two events within the last month.

First, I went to my primary care physician for a preventive checkup. In discussing my medications to lower cholesterol, and I take more than one, he pointed out that studies had shown that one did not lower LDL and that another did not decrease mortality by raising HDL. And, we discussed our differing views of the matter.

Second, I read a blog discussion today about anti-depressants. A polymath named Irving Kirsch is a recognized expert on the placebo effect and questions the efficacy of antidepressants, most notably in a 2009 book The Emperor’s New Drugs.

During the discussion the name Karl Popper was mentioned. Popper was a 20th century philosopher credited with the concept of “falsification.” In the simplest terms, and not being a philosopher, I may distort his views, propositions cannot be established but only be proved false, or fail to be proved false. Furthermore, to be scientific a proposition must be falsifiable, so saying there is or is not a Deity is not a falsifiable proposition.

Let’s get back to healthcare: if I say that a drug for hypercholesteremia or for depression is no different than a placebo, then it is falsifiable. I can gather data and compare the effect of the medicine to the effect of a placebo. If they diverge by a sufficient amount statistically, then the idea that there is no difference has been falsified.

Even so, questions can always be posed about the methodology of any study, and the ensuing debate begins to resemble the medieval religious debates we thought we left behind.

Furthermore, not every variable that can cloud a conclusion can be eliminated. Two drugs may have negligible effects alone but work powerfully in tandem. A drug that works on one individual may not work on another. A drug may not work on 99 individuals and still be valuable for number 100.

Finally, even if every question of efficacy was answered, the questions of values remain. Those questions are most visible in the public arena with respect to abortion, birth control, end-of-life decisions, and the availability of certain drugs. Less visible but just as important is the following scenario: a patient has a painful condition for which there is an effective intervention. Unfortunately the odds are 60% complete cure, 20% no effect, 15% debilitating injury that is worse than the initial condition, and 5% death. Even if these percentages are accurate and cut in stone with no chance of distinguishing a priori in which basket a given patient will fall, then the clinician can recommend but not decide. The 20% aggregate possibility of a worse outcome than doing nothing has to be left to the patient.

We can produce rules for tests to be made, pharmaceuticals and other interventions to be offered, but for the moment the number of possible interventions and the nearly infinite possibilities of human diversity mean our rules will be imperfect, no matter how well researched, studied, and reviewed.

Having read a bit about Kirsch, I doubt if he is right, but even if he is right, the 25% impact of pharmaceuticals on depression may make them worthwhile even if most of their impact is placebo. I am still taking the same cholesterol medications as I have found through experimentation that removing one raises my cholesterol and retaking it lowers it again, and I am alive 20 plus years beyond the life span of my father and his father.

That is how it should be. The important decisions in life (where to live, who to live with, where to work) are all made based upon imperfect information. So are our health care decisions, but we make them as patients and clinicians with the best knowledge available and hope to look back upon our having been correct.

What’s a woman to do? Or a man? Dairy and weight and bones and stuff.

Posted by on March 18, 2013 Comments Off on What’s a woman to do? Or a man? Dairy and weight and bones and stuff.

In many ways women’s health is more challenging than men’s.

Women over age 50 are much more likely to get breast cancer, or its precursors, such as fibrocystic breast disease.

Women get cervical and ovarian cancer–men don’t need pap smears or the equivalent.

Women are five times more prone to osteoporosis.

Many medical studies have disproportionately targeted men, although that is changing.

But let’s just consider osteoporosis for a moment. Some risk factors are:

  1. Unchangeable
    • Sex
    • Age
    • Race
    • Family History
    • Frame Size
  2. Hormone Levels
    • Sex Hormones
    • Thyroid
    • Other Glands
  3. Dietary
    • Low Calcium Intake
    • Eating Disorders
    • Weight Loss Surgery
  4. Steroid Prescriptions and Others
  5. Lifestyle
    • Sedentary Lifestyle
    • Excessive Alcohol Consumption
    • Tobacco Use
  6. Too little estrogen

This is but one ailment, but threading the needle is difficult. Consider that sedentary lifestyle and inadequate weight are opposites. If someone exercises and loses weight, the risk is increased. If someone does not exercise, the risk is increased. And the task is even more complicated. A recent study found that consumption of high-fat dairy is associated with increased mortality from breast cancer–so your doctor will probably tell you to stick to low-fat dairy to get additional calcium–be sure to ask.

Very often we hear that someone fell and broke their hip; less often we realize that someone’s hip broke, and they fell.

The International Osteoporosis Foundation estimates that 1 in 3 women and 1 in 5 men will experience a fracture from osteoporosis.

Osteoporosis affects more than 10 million Americans, accounting for 1.5 million fractures annually.

Bad News for Boomers: Our Parents Were Healthier

Posted by on March 14, 2013 Comments Off on Bad News for Boomers: Our Parents Were Healthier

As Americans we believe in progress, in a better tomorrow, sometimes with a bump in the road or a hiccough, but always a better tomorrow.

The data are in (March 4,2013 edition of JAMA Internal Medicine), and it ain’t happening for boomers. Blood pressure, cholesterol, diabetes, and obesity–all greater than the previous generation.

Boomer_Parent_Comparison_JAMAinternalmed_20130304
Source: The Status of Baby Boomers’ Health in the United States The Healthiest Generation?
Dana E. King, MD, MS; Eric Matheson, MD, MS; Svetlana Chirina, MPH; Anoop Shankar, MD, PhD, MPH; Jordan Broman-Fulks
JAMA Intern Med. 2013;173(5):385-386

Although longevity has risen during the twenty-year gap between the two groups, every other indicator of health, except smoking, has become less favorable. And the pattern is clear.

At the top of the following chart are general measures of health. Then, we can see that lifestyle factors have declined leading to the trends in the last section: declining indicators of cardiovascular health.

We can’t choose to be healthy or not: what we can do is make healthy choices by changing the lifestyle factors.

We are choosing illness at great expense to ourselves, both financially and in quality of life, while continuing to endure longer and sicker lives instead of enjoying healthier lives.

Boomer_Parent_Extract_Comparison

Salt: Connecting the Dots

Posted by on March 11, 2013 Comments Off on Salt: Connecting the Dots

Some number of millenia ago our evolutionary forebears crawled out of the sea, carrying its salt flowing through their veins to ours. In the right amount, salt is not only good for us but essential to life.

That is not the same, however, as dumping salt on our food before tasting it or eating processed dinners, from the supermarket or from the nearest fast food franchise.

Most of us have long known that salt increases hypertension among salt-sensitive individuals.

Two sets of studies have come out, one widely publicized, the other well below the radar, that add concerns about excess salt consumption.

Researchers publishing in a recent issue of Nature have linked salt consumption to auto-immune disorders such as multiple sclerosis, psoriasis, ankylosing spondylitis, and rheumatoid arthritis. Unless you have a $200 annual subscription to Nature, you may wish to google “salt autoimmune” to read descriptions of the studies. Or, you may wish to simply click on these links to Medical News Today or The Huffington Post.

So, what are the dots to be connected? That’s where the second study comes in, the one with little publicity.

A presentation at the 2013 American Academy of Dermatology annual meeting in March found that individuals with psoriasis were more likely to have metabolic syndrome. They found that 30 percent of the psoriasis children had metabolic syndrome symptoms compared to the non-psoriasis group. There were not significant differences in Body-Mass Index (BMI), c-reactive protein, or endothelial cells

A 2012 study in South India found a higher incidence of metabolic syndrome among those with psoriasis. In this case:

Patients were diagnosed with MetS for having three or more South Asian Modified National Cholesterol Education Program Adult Treatment Panel III criteria: abdominal obesity (waist circumference ≥90 cm for men, ≥80 cm for women); blood pressure, >130/85 mm Hg; fasting blood glucose, ≥100 mg/dL; hypertriglyceridemia, >150 mg/dL; or low HDL (<40 mg/dL for men, <50 mg/dL for women).

Calcium: Friend or foe? Part II

Posted by on March 7, 2013 Comments Off on Calcium: Friend or foe? Part II

Last time we looked at calcium supplements and cardiovascular risk. The indicators are strong that men should not be taking calcium supplements in the absence of a very clear, unambiguous reason to do so. Women at risk for osteoporosis, for example, need to discuss the relative risks and benefits with their physician. No treatment is without potential risks, so we need to make decisions based on likely outcomes and known risks.

Susanna C. Larsson PhD puts the issue of calcium in perspective:

Larsson_JAMA_Calcium_2013

In addition to the cardiovascular risks we have considered, there are elevated risks of kidney stones (renal calculi). Calcium is intimately related to the development of kidney stones, also called “calcium stones.

The U.S.Preventive Services Task Force has issued recommendations.

Annals of Medicine Calcium 2013

Here is what those recommendations ( I Statement and Grade: D) mean:

UPSTF grades

The best, meaning safest, sources of calcium are not supplements but diet. The Office of Dietary Supplements at NIH has issued a helpful Calcium Fact Sheet/a>

The recommended daily allowances for calcium are:

CalciumRDAs

And some of the best sources to attain that level of daily calcium consumption are:
NIHCalciumsources

Calcium: Friend or foe? Part I

Posted by on March 4, 2013 Comments Off on Calcium: Friend or foe? Part I

As I approached a certain age, my doctor said, “Oh, are you taking calcium supplements?” And, I asked him, “Isn’t arterial plaque calcified cholesterol? Is it really a good idea to flood my arteries with calcium?” He is a thoughtful person. “Maybe not,” he said, upon reflection.

The main therapeutic use of calcium supplements is to ward off osteoporosis. We are beginning to live longer than our bones were intended, and we are trying to avoid turning into boneless amoebae before we die. Knowing from childhood that “calcium builds strong bones,” we thought calcium supplements made perfect sense.

Calcium Source: news@Jama

I felt really validated when studies came out showing calcium to be a cardiac risk. The most recent was published online a month ago. The NIH AARP Diet and Health Study found a higher risk of cardiovascular events in men taking supplementary calcium. Why the risk did not appear to be elevated for women is a subject for further study.

Similar findings have been reported in the British Medical Journal: Heart and Education in Heart.
Calcium supplements: bad for the heart?
Heart 2012;98:12 895-896
As well as in other European studies:
2011_BMJ_Heart_Calcium