Saturday, July 25, 2009

Thoughts re the Future of Single-Payer Medicine

I thought it might be useful to write down my observations and thoughts about the financial side of the practice of medicine, based upon 25 years of private and academic practice of internal medicine, 15 years with a partner, and the last 10 years solo.

First, I have been solo for the past 10 years, because no recent medical school graduate wants to practice (and I have a big-city practice and attend at a medical school) pure internal medicine without an enormous salary guarantee that only a large group can afford to offer (which includes fronting their malpractice insurance). The reason is that HMO's and MCR both pay much more for doing than for thinking and diagnosing, since the powers that pay can measure doing, but not thinking. It is ridiculous that MCR pays me more for a 5-minute rigid sigmoidoscopy than for a 15-minute intake interview. This is why dermatology is the most popular residency. Getting paid $500 for a Botox injection every 3 months is an annuity! And since no insurance pays for it, the physicians can charge whatever they wish. Man is an economic animal, and often will respond to economic stimuli. So when Massachusetts established state-wide health care, there were not enough primary care doctors, and the average wait for a new doctor was 60 days. Just imagine the shortage when the 45 million currently uninsured patients look for a new primary care doctor. We will need at least 10,000 new primary care doctors, and where will they come from? Actually, every doctor should do Botox and Restalen injections and skin biopsies one day a week, so he/she can practice the medicine they like the other four days. And since MCR pays psychiatrists less than they pay me for the same amount of office time, why would any psychiatrist ever want to see a new MCR patient?

Second, we have socialized medicine now, and it's called Medicare. Few MCR patients want to give it up. There are many advantages to the patient, and the main advantage to the physician is that we spend less time on paperwork, and time is our least fungible resource. For a MCR patient, unlike an HMO patient, I don't have to call anyone for permission to get an MRI,and I don't have to worry that the best shoulder surgeon I know is a Cigna MD, and my patient is an Oxford patient, so my patient can't get to see the physician I prefer. I don't have to ask the patient to fax me a list of the HMO ophthalmologists so I can see if I know anyone on the list.
Also, MCR patients get back 5 to 10 times the dollar amount in medical services of the MCR premiums they paid.The tobacco companies showed (but dropped the argument because it made for poor PR) that the government saves money on every patient who dies before reaching MCR age. I also (I hope) will not have to spend time asking someone for permission to prescribe a brand name rather than a generic drug, or to prescribe a brand name drug that is not on their formulary.

Third, if everyone has a private MD, they will "crash" in the ER less often with diabetes out of control, unstable angina, end stage renal disease, etc. If you look at ER visits in Canada vs. here, there are fewer (percentage-wise) visits for acute medical conditions. Having a private physician who you can visit regularly puts a basic floor under your medical condition, even if nothing more is done than blood pressure check, PAP smear, and stool for blood. Overall, since ER visits are extremely expensive because ER doctors do every test they can think of, since they don't want to miss anything (viz. the recent article in the July, 2009 issue of "Archives of Internal Medicine" on the ER workup of syncope in the elderly) we will save a lot of money.

Fourth, technology is expensive, but it works. No patient walks up to an orthopedic surgeon and says "I want a new hip". Instead, the doctor is told "I can't move without agonizing hip pain". No patient says "I need cardiac bypass surgery", or "I need cataract surgery".

Fifth point has to do with malpractice. The most common suit against a family MD is for failure to diagnose a condition. As far as I am aware, no physician ever got sued for doing a test, but only for not doing one. When I started practice,I used to spend 30 minutes to explain to a 40 year old man with no risk factors and atypical chest pain and a normal EKG why he did not need a stress test, and the problems that can result from false positive tests. Now I suggest a stress-echo, stress-thallium and consultation with a cardiologist to the same patient. Why risk being sued even if I know I will win the case? Why spend the time and stress?
As long as we have contingency fees, we will have malpractice cases, and doctors will do extra tests to minimize their exposure, as well as make any referrals any family member of the patient suggests.

Sixth, unless you have a boutique practice, the average MD has to see one patient every 10 minutes, which involves putting 4 patients into 4 rooms, and having the NP or PA take the interval history, do the vital signs, etc. No one can get proper medical care under these conditions. I was trained to spend 15-45 minutes in the office with my patient to take a history and discuss any family stresses, then examine the patient in the exam room, and then bring the patient back into my office to discuss the results. I don't know of any doctor under 60 who practices medicine in this way, and most patients don't know what they are missing.

Seventh, there is something very wrong with the practice of medicine when the majority of doctors advise their children not to go into medicine.

Eighth, every medical system in every country rations by money, time, or availability, since the demand for medical care is almost infinite. England NHS does not transplant kidneys over a certain age, so those who can afford it fly to India to buy a kidney. Some drugs are not allowed in England because the NHS pays for all drugs, and this is how the country caps pharmacy expenses. Canada rations hospitals as to how many open-heart surgeries they can do in a given month. Germany reduces the physicians state-paid salary if their patients' prescriptions cost too much. MCR pays for only so many physical therapy visits or hospital days a year.

Ninth, I still love the practice of medicine, and intend to see my patients as long as I am able.

P.S.: About 10 years ago, there was an article published in NEJM that showed that New Haven had 5 times as many cholecystectomies per capita as did Boston, while Boston had 5 times as many CABG's per capita as did New Haven. Did one city have too many operations, or did the other have too few? No one could determine the answer.

P.P.S. The best review of the current state of internal medicine was published by David. D. Norenberg, M.D., in the Annals of Internal Medicine(Ann. Int. Med. 2009; 150:725-726) accessible at "The Demise or Primary Care". Please read it and share it with everyone you know, physicians, patients, and politicians.

Saturday, July 11, 2009

Vaccines and Immunizations for Adults

This blog is a general (search the archives of Morbidity and Mortality Weekly Report, or the CDC travel page, or for more detailed info) review of the vaccinations/immunizations available for adults. I will be reviewing them in the order of the fatality rate for the infected but unvaccinated immunocompetent adults. WARNING: if you are pregnant, or immunosuppressed--e.g. on steroids, on cancer chemotherapy, have AIDS,etc., do NOT take any live virus vaccine without checking with your doctor, and avoid anyone who has had a live virus vaccine for 8 weeks after they have been vaccinated.

RABIES: Except for one fortunate female in Wisconsin, this disease has been 100% fatal once symptoms are evinced. The virus is carried in the salivary glands of infected meat-eating animals: bats, raccoons, skunks, foxes, dogs, cats,---.The vaccine is available from your state board of health, or vetinarians. You should seek vaccination for any bite or scratch from ANY unknown animal, as well as if you have been in the same room with a bat, since their needle-like teeth often can bite without your feeling it. It is also recommended for pre-exposure prophylaxis if you are traveling to a region where there is a high incidence of rabies in stray dogs, such as certain parts of Asia, including Katmandu, and India, Mexico, and other countries (check with CDC). Chloroquine, and possibly mefloquine, both used for malaria prophylaxis, may blunt your immune response to the vaccine, so be sure to notify the treating physician if you are taking either of these drugs, and ask for deep IM rather than SQ vaccination. Raccoons are nocturnal animals, so any raccoon seen in the daytime should be presumed to be rabid.

TETANUS: Last year there were over 50 fatalities from tetanus in the U.S., and there should be none.It is 100% preventable by an antitoxin shot (no longer made from horse serum, so there is little likelihood of a strong reaction). It is a paralysis caused by a toxin generated by an anaerobic bacterium that inhabits the soil, especially where there is horse manure. You should be vaccinated every 10 years, but there is no harm done if the ER vaccinates you whenever you come in with a laceration. More women than men die each year (often from a non-remembered puncture wound from a garden rose thorn, etc.): Since men get injured more often than women, they are more likely to have been in the ER and been re-vaccinated. If you don't remember when you received your last tetanus shot, please ask your doctor for one at your next visit. I should also mention that the only vaccine currently available in the USA is dT, so you are also re-vaccinated against diphtheria at the same time. It would take up too much space here to explain why, but the reason is not medical.

YELLOW FEVER: This is a LIVE vaccine, and the vaccination is good for 10 years. It is only available from physicians or centers certified by the US gov't. Yellow fever is endemic in many areas of countries in South America, Central America, and Africa. It is spread by mosquitoes both in jungles and cities and one infection confers lifetime immnunity. The case fatality rate can be as high as 50%, and there is no treatment, since we have no drugs that reliably attack flaviviruses. Therefore, when in doubt, take the vaccine. (As a historical point, at one time it was endemic in the United States, from New Orleans to Philadelphia.)

POLIOMYELITIS: The oral vaccine (OPV) is live, and the injected vaccine (IPV) contains inactivated virus. One dose if IPV is recommended for travelers to underdeveloped countries or those with poor sanitation (check with the CDC).

HEPATITIS B: This vaccine is recommended not only because Hepatitis B can progress to cirrhosis of the liver even with treatment, but also because infection with Hepatitis B (or C) is a proven risk factor for cancer of the liver. It can be spread by unprotected sex, exposure to blood, including transfusions, or sharing of needles by drug users. Because it is considered a STD, vaccination for all children has been recommended before they reach the age of sexual activity. As an adult, vaccination is recommended for those exposed to blood (ER workers, dental hygienists and dentists, etc.) and those with compromised immune systems, including those on renal dialysis. You should specifically ask your physician if you should have the vaccine. If you are immuno-incompetent, then it is recommended that you be tested for protective antibodies one month after vaccination. Unless you are tested annually for antibodies, it is unknown how long your protection will last.

N.B.: If you want to help your country, then please donate a unit of blood. The blood bank will test your blood, at no charge to you, for Hepatitis B and C, syphilis, AIDS, and a few other diseases. You will not be permitted to donate blood if you have been in a country where malaria is endemic (including Mexico, even if in a non-malarious area) within the previous 12 months.

SMALLPOX: A LIVE vaccine. No longer given routinely, except to U.S. military personnel. Cidofovir has shown some success in animal models of this disease. Case fatality rate at least 20%.

HPV: Vaccine against Human Papilloma Virus. This is considered to be permissive, if not an inducer for cancer of the cervix. There are many strains of HPV, and the vaccine does not protect against all of them, so women should still have pap smears, even if vaccinated. Recommended for all females before first menses, and any woman who has not received the vaccination.

INFLUENZA: Everyone should have annual vaccination with the regular flu vaccine.
Since the antibody levels decline after 4 to 6 months, I recommend biannual vaccinations to my all my patients. In the past, the vaccine was recommended only for those over 65, as well as health care workers and teachers, etc., because there was not enough to give everyone in the U.S. It is especially important to get this vaccine because Tamiflu is no longer effective against it.
AVIAN FLU: The government hopes to have a vaccine against this available by October, 2009. Fortunately, this flu virus is generally susceptible to Tamiflu. We are all sincerely worried about this flu strain developing resistance to Tamiflu so I(we) are not prescribing it to patients to have "just in case". Patients born after 1956 have no natural antibodies to this H1N1 strain, and so are at risk for death. Patients born before this date were probably infected with a strain somewhat homologous to avian flu, and therefore become less ill.

PNEUMOCOCCAL PNEUMONIA: Patients over 65, those without a spleen (either at birth or after surgery), patients with TB,diabetes and a host of other chronically ill patients are at risk of death from pneumococcal pneumonia. However, it was found that patients younger than 65 develop a stronger immune response than older patients, Most physicians now will give the vaccine to their (normal) patients when they reach age 60, and a booster is recommended 5 years later.

MENINGOCOCCAL MENINGITIS: Recommended for those traveling to areas where this is endemic. The antibody levels decline after 2 years. Saudi Arabia requires this vaccination for those traveling to Mecca.

JAPANESE B ENCEPHALITIS: May to September in Asia. Low risk of infection, and high rate of side effects and reactions. Discuss with your doctor.

PLAGUE: Recommended only for travelers in regions where it is endemic (but this does include the U.S. Southwest). Booster every 1 to 2 years.

TYPHOID: Oral vaccine. Spread by contaminated food and water. Suggested if you are going to be in underdeveloped country for 3 or more months, but you should still be careful what you eat and drink.

HEPATITIS A: Virtually never fatal, but it can ruin your vacation. Spread by contaminated food and water. can be combined with Hepatitis B vaccine.

SHINGLES/HERPES ZOSTER:LIVE virus. This is reactivation of the virus that gave you chicken pox. It lives in your body forever, and can be reactivated along pain nerves as you get older and your immune surveillance competence drops. Classically, it causes redness and blisters along the path of a pain nerve, but you can get non-eruptive zoster, wherein the virus re-activates WITHOUT the rash. The problem is extreme residual pain along the path of the inflamed nerve, and it seems that older patients get more severe pain. We recommend it for all patients, because the pain can be disabling. However, vaccination is not 100% protective. Also, a prior zoster attack does not prevent a second attack.

Wednesday, July 1, 2009

Aspirin, Lipoprotein A, CRP, Anti-oxidants, Heart disease

There have been a number of articles published recently in Lancet, Journal of the AMA, and newspapers about primary prevention of heart disease. By primary prevention, we mean the reduction of risk of a heart attack in patients who have not had a heart attack. Since the greatest risk for having a heart attack is having had one, the number of patients in a study of primary prevention has to be larger and last for a longer time than a study of secondary prevention, where aspirin, beta-blockers, statins, etc., have been shown to be of help.

I should also mention that the over-riding problem in prevention of any disease is not lack of communication between doctors and patients,or lack of information on the part of patients, but the unwillingness of patients to change their behavior (and no, I am not blaming the victim). Most patients know that they should exercise, lose weight, and stop smoking to reduce their primary heart attack risk, but how many do, even if, as in NYC, the amount of calories per dish is published in the menu of every chain restaurant?

1) C-reactive protein, or CRP. Numerous studies have shown a correlation between elevated CRP and heart attacks. This correlation is about as strong as that between elevated homocysteine and heart attacks. However, just as pulling down on the metal elevator arrow in the lobby of a skyscraper does not bring the elevator down, lowering the homocysteine has not been shown to lower heart attack risk. Whether the CRP as a marker for inflammation means that inflammation is a primary risk factor remains to be seen. A recent published genetic analysis (similar to the Lp(A) analysis) seem to show that lowering CRP does NOT lower the risk for heart disease.

2) Aspirin. First we have to decide if we mean 81mg/day, 325 mg/day, or 325 mg twice a day. Since aspirin blocks platelet clumping for 7 days, it is not clear why the studies involved daily aspirin, rather than once or twice a week. In addition, none of the studies to date controlled for aspirin resistance, where aspirin at the suggested dose does not prevent platelet clumping. It has been a "consensus" that absent any other risk factors (smoking, diabetes,etc.) that aspirin prevention should start at age 45 for men and 55 for women. However, a recent article Lancet cast severe doubt on this recommendation, so your guess is as good as mine.

3) Lp(A), or lipoprotein A. A recent article used genetic analysis to suggest that elevated Lp(A) is an independent risk factor for heart attacks. However, no one has shown that lowering Lp(A), prevents heart attacks, nor do we have a good drug to lower Lp(A). The same could be said in reverse about low HDL, the "good" cholesterol.

4) Anti-oxidants. The prophylactic use of anti-oxidants should be approached with caution. Prospective studies have shown that extra daily Vitamin E increases the primary risk for heart attacks, and prophylactic beta carotene increases the risk for lung cancer in cigarette smokers. A recent study at Memorial Sloan-Kettering showed in vitro that vitamin C inhibited the killing effect of chemicals on cancer cells. Selenium and vitamin E have been shown to have no protective effect against prostate cancer.

The conceptual problem is, of course, that correlation does not imply causation. Just recall how coffee drinking was "shown" to be a risk factor for heart attacks until it was realized that more coffee drinkers than non-drinkers smoke cigarettes. We always have to beware of confounding factors, as well as a common cause that elevates both the risk of disease and the marker. Does anyone really understand why female Pima Indians of the American Southwest have such a high incidence of cholecystitis, or the female Parsees of India (Zoroastrians transplanted from the Mideast) have such a high incidence of breast cancer?