Will the primary care doctors of the future be practicing in hospital-controlled practices?

The March 28 issue of American Medical News reported that the number of residents choosing primary care residencies has increased. This is a good thing but one wonders how many of them will remain in primary care and how many will choose a specialty. There is another concern also. See below.



March 29, 2011
Amednews


Carolyne Krupa, in her article titled “Primary care residencies up again on match day” posted on March 28, explained how the number of medical students entering primary care residencies had increased. This is a good thing.

But since it is almost impossible financially for primary care residents to start their own practices, many of them will probably end up working in hospital- controlled health systems or some other large systems where their productivity and adherence to guidelines will be closely scrutinized and used to determine their salaries, making it difficult for them if not impossible to maintain the idealism they learned during residency as it clashes with the economic realities imposed by insurers.

Can true primary care be practiced in a setting that is controlled by a hospital or by a large multispecialty group?

Edward J. Volpintesta MD

"N-of-1" or RCT?

In the JAMA of February 9 (305:604) Marya Zilberberg notes how much physicians need to read to keep up with published research. She goes on to point out that "the data generated in an RCT are frequently irrelevant precisely because of their limited generalizability.." She comments that an “n-of -1” trial can "generate high-quality evidence for treating individual patients in appropriate circumstances."

I translate this statement as suggesting that prudent clinicians, eager to prove nothing but to help their patients-and well-read in the field- may use their own judgment in deciding how to treat a patient rather than depending on ukases from above. I may misinterpret her, but I have long wondered whether a group of 5 or 10 physicians -- charged with evaluating a new agent -- could decide upon its problems as well as its virtues. I understand that larger groups would be statically more virtuous, but as I read all the caveats that accompany reports of RCTs and the criticisms which follow from other statisticians, I wonder whether some studies by experienced clinicians would bring common sense ,and even academic enthusiasm, back to clinical research.

Howard Spiro, M.D.

Are RCT’s our future or our past?

In 1943, I was an orderly at Chelsea Naval Hospital when penicillin won praise for how quickly it cured pneumonia. Later, training at Boston’s old Brigham Hospital, my colleagues and I enthusiastically took up steroids for rheumatoid arthritis before any controlled trials. A movie of patients dancing wildly after taking “Compound E,” supplied confirmation enough.

More recently, an academic I much admire sent me a report of his randomized control trial (RCT) proving that – and here I depart from fact- considerate and supportive doctors have happier patients than others. What might have seemed common-sense needed numbers from a necessarily expensive RCT for support? Does everything need statistical proof? Old-fashioned intuition has been replaced by hard numbers, ideas by “facts.” Is no one a pragmatist any more?

As evidence-based medicine (EBM) grows ever more commanding, physicians might consider whether it is changing clinical practice only for the good. Original commentaries wisely advised that statistical comparisons, considered “evidence,” were meant to supply a basis for intuitive choices by clinicians and their patients. “In making decisions about the course of individual patients…” David .Sackett et al, wrote (BMJ 1996:312: 71-72) “External clinical evidence can inform, but can never replace, individual clinical expertise, and it is this expertise that decides whether the external evidence applies to the individual patient at all and, if so, how it should be integrated into a clinical decision.”

Somewhat later in that same essay, the experts back-tracked, “Because the randomized trial, and especially the systematic review of several randomized trials, is so much more likely to inform us and so much less likely to mislead us, it has become the ‘gold standard’ for judging whether a treatment does more good than harm.” That assertion caught the wind, praise for clinical decisions blown away by the breeze.
Clinical journals, repository of evidence-based truth, report randomized controlled trials with pages of statistical proof and editorials, not yet red-lettered, admonishing clinicians to follow along. Later, some of these declamations are contested by ripostes from statisticians. The tsunami that followed the elimination of Avastatin, for example, suggests some residual disagreement

An old and now retired clinician, I am emboldened to express my bewilderment because others have raised some worrisome questions. At the Harveian Oration at the Royal College of physicians on October 16, 2008 Sir Michael Rawlins is recorded as suggesting that RCTs "have been put on an undeserved pedestal." He listed the limitations of RCTs as 1) impossible, for a very rare diseases; 2) unnecessary, when a treatment like imatinib works so well for chronic myeloid leukemia; 3) stopping trials too early when a benefit seems apparent from too early an analysis; he said that 30% of oncology trials fell into this category; 4) he deplored the cost in money but also in time and energy; 5) generalisability, by which he meant that RCTs are carried out on specific types of patients for short periods on the presumption that an RCT can be extrapolated to wider populations. He added "there is abundant evidence to show that the harmfulness of an intervention is often missed in RCTs."
Finally, he warned that clinical trials "attempt to replace judgment with over-simplistic, pseudo-quantitative, assessment of the quality of the available evidence."

Randomized Trials and Clinical Judgment
The twisting path to seeming certainty is strewn with rocks, some more like roadside bombs. How firm is the evidence we clinicians are asked to accept? Feuerabend suggested that science has replaced religion as a concept that cannot be denied, but must physicians all turn true believers? Have RCTs replaced the imprimatur once required for theological publication? “This book is research-oriented and evidence-based.” wrote one recent reviewer in approbation certifying its qualities.

Unquestioning acceptance of RCTs forbids acting on what has not yet been proven statistically. A good example comes in the report of fractures incurred by some patients who have taken Fosamax.

That Fosamax, intended to increase the density of thinned bones, could lead to multiple unusual fractures of the long bones (“frozen bones”) was recorded first in a series of nine patients by Clarita Odvina et al, (Journal of Clinical Endocrinology & Metabolism 2005; 90:1294-1301.) What clinicians might have judged the report of a real phenomenon, however, was not accepted by the FDA as reality because it lacked statistical analysis of an RCT.

Equally to the point , P Scheel et al (Annals of Internal Medicine2011;154:31-36) reported 26 patients with retroperitoneal fibrosis whose improvement after prednisone and mycophenolate mofetil would have been convincing to me at least, if not hedged about with the requisite apology for not yet having done a double-blind trial.

In JAMA 2010; 304:a study tested the original assertion by “retrospective correlative analysis of metastatic colorectal cancer trials” that KRAS—mutated tumors did not respond to drugs like cetuximab. Nevertheless, the authors went on to report overall benefit in such patients, suggesting that even careful statistical trials may come up with the wrong conclusions. Soon after that, a “systematic review” (Ann Intern Med 2011 154: 37-49,). concluded that KRAS mutations were consistently associated with reduced overall and progression free survival despite treatment with those same agents. What is a clinician to think?

Such results might have been expected had we thought more clearly about “personalized medicine,” adjusting therapy to genetic endowment of patient and tumor. Yet RCT’s aim at generic persons with specific qualifications.

A cost of $100-800 million dollars for each RCT has been suggested, but cost-benefit analyses are not easy to find. Regardless of who pays up front, these costs go into setting prices.Does society get its money’s worth?

Potential harm to study patient/subjects deserves the most stringent evaluation, but does it take stratification and regressions studies to add meaning to what careful clinicians can observe? Years ago when the chief of the laboratories at Yale boasted that his lab gave answers to several decimal points, it was suggested that clinicians did not require that degree of accuracy.

I pass over the many critiques of methodology and applicability, outliers and the mystical 5% cutoff rule as beyond my ken.. Still, after reading about the different forms of bias, about confounding factors, and regressions, and how carefully one must judge events statistically, it may not be unreasonable to ask whether statisticians focus fuzzy borders by the certainty of a single number. Clinicians treat single patients worried about what will happen to them, and who search the Internet like mad. Statisticians and researchers treat populations, like the generals who send “troops” rather than soldiers into battle. The more I read criticisms of published statistical methods, I wonder whether clinicians need certainty or only probability?

The illusion of certainty
Ashcroft accepts RCT’s as the best that can be done, but advises humility, in agreement with physicist Nancy Cartwright, "We may be better off expecting medicine to produce a patchwork of phenomenal laws of relatively low generality, rather than a complete and consistent system of universal, metaphysically founded, laws… Methodological modesty is the order of the day."

Pragmatist Richard Rorty warned that there is no eternal truth that we will agree upon. In arguing our opinions, he wants us to decide what terms are the most useful, not the most “truthful.” Adherents might still remain humble in their pronouncements about RCT’s and EBM.

Everywhere human uncertainty breaks through conclusions/advice currently hedged about with caveats and exclusions, so tentatively phrased as to belie their mathematical basis.

Tacit Knowledge
Yet intuition, which many older folk take as useful knowledge that comes unbidden, may well arise from the brain’s mysterious distillation of experience. Every action finds a probable reaction, and so it is not surprising that increasing numbers of authorities remind doctors of tacit knowledge, that comes suddenly and without conscious thought. Yet “Intuition” that comes from experience gets little respect from the doyens of EBM despite the centuries of attention from philosophers and physicians attention. As someone said, “We know more than we can tell.”

What we old clinicians take to be knowledge may be only our opinion, but it comes in human form , even without the assurance of mathematical certainty. Human interchange is what patients need to make decisions to find, comfortable alternatives, advice from empathic advisors. The human aspects of medicine is getting quite lost. Reading about robots who will do triage and physician-assistants made of metal, I wonder how much empathy these robots will be able to engender in the patients/clients

Old clinicians know when to leave out some details. An old pathologist told me that his students often have no idea what is important and what to look for in a slide and what to ignore.Artifacts prove a stumbling stone to the neophyte. In the same way, in a young person with acute right lower belly pain, an experienced surgeon will examine the right lower quadrant, to find out what is going on. Straight leg raising is in the books, but more “ to be complete” than to gain additional information when the whole picture is considered.

My Conclusions
The individual patient has disappeared from discussion. The single patient carefully studied has been replaced by crowds of investigators and their statisticians. Should we test whether patients would be better off if the average conscientious physician, aided by consultants, could decide what is the best to do for most patients. After all, nobody lives forever, and maybe we should trim the sails of certainty. What about an RCT vs clinicians?

Physicians are being led to think like computers.:nobody chooses a probable working diagnosis any longer, but like the computer young clinicians exclude everything, and that takes time and money. Seeing a patient with sudden right lower quadrant abdominal pain, most physician will think first of acute appendicitis and -in a woman- consider an ovarian problem, but will be unlikely to consider amebiasis or schistosomiasis or some other unlikely possibility until the working diagnosis of acute appendicitis is disproven.

Intuitive knowledge is ignored: only when after everything however unlikely, has been ruled out, as computers can do in a flash – will the diagosis be considered secure. A clinician looking at a sick patient first thinks of the most usual causes and in a flash finds secondary aspects that support that idea. Other remote possibilities might come to mind, but are quickly discarded as clinician’s search builds on the history and physical examination for confirmation. Inexperienced physicians treat every possibility as something that needs to be excluded

Earnest and honest research rs . enthusiasm of others looking for certainty is what is wrong. We must keep a place for clinical judgment, mysterious as it is.

Defensive medicine has many faces

In a recent issue of the American Journal of Medicine, the editor Dr. Joseph Alpert wrote a timely essay on the need for reforming the malpractice system. He pointed out how the threat of malpractice suits forces physicians to practice defensive medicine, a strategy that is both costly and can subject patients to complications. He suggests that “no-fault insurance” may minimize this problem. Indeed, a panel of legal and medical experts addressing medical disputes would be a good alternative to the adversarial process in place now.
But there are reasons for defensive medicine other than the threat of malpractice suits that are equally important in tort reform. Technology has made talking to patients a secondary function. Compared to ordering CAT scans and a battery of lab tests, talking to patients may seem like a waste of time.
And health insurers’ pressure to discharge patients quickly, sometimes contrary to physicians’ judgment also contribute to “defensive medicine”. Here is my response:

March 25, 2011
The American Journal of Medicine
Letter to the Editor

In his recent editorial, Dr. Joseph Alpert (1) discussed his dissatisfaction with the way the legal system deals with medical malpractice; and how the threat of malpractice suits pressure doctors to order unnecessary tests so to have a good defense in case a suit is filed. Even if doctors entangled with a lawsuit are eventually exonerated, the harshness of the experience will leave them forever questioning the noble goals of medicine and the justice of the legal system.
But there are other reasons for defensive medicine besides the threat of malpractice suits.
The refinement of imaging studies and lab tests and their quick turnaround time can seduce doctors into thinking that talking to patients and examining them is of secondary importance. What’s more, ordering lots of tests and consultations can give patients the false impression that their doctors are exceptionally capable and thorough. Also, the data from scans and lab tests are more objective and reproducible than that obtained by a history and physical examination. And, they may withstand better scrutiny in a malpractice action.
Additionally, economic pressures drive doctors to order scans and tests in order to speed up diagnosis and discharge from the hospital.
Ideally, the no-fault system that Dr. Alpert recommends has great promise. But studies published in the New England Journal of Medicine in 1991(2, 3) showed that sometimes no suits were filed even though malpractice had occurred. Thus, there is a risk that more injured parties may file claims and the system’s funds may go bankrupt or doctors’ premiums may raise to unsupportable levels.
Clearly, the problem is a difficult one without a single or a simple answer. Perhaps, access, cost, and physician demoralization have to worsen before sufficient dissatisfaction with the system compels medical educators, insurers, and lawmakers to bring about beneficial change.
It is hoped that doctors will lead that change.

1. Alpert JS. The 800-Pound Gorilla in the Healthcare Living Room. Am J Med 2011; 124:187-188.
2. Brennan TA, Lucian LL, Laird NM, Liesi H, Localio JD, Lawthers AG,Newhouse JP,
Weiler PC, Hiatt HH. Incidence of Adverse Events And Negligence In Hospitalized Patients. N Eng J Med 1991; 324:370-376.
3.Localio AR, Lawthers AG, Brennan TA, Laird NM, Herbert LE, Peterson LM, Newhouse JP, Weiler PC, Hiatt HH. Relation between Malpractice Claims and Adverse Events Due To Negligence. N Eng J Med 1991; 325:245-251.

The Physician Assistant: What's in a Name?

The Physician Assistant: What’s in a name?
By
Brian T. Maurer

While perusing articles on health care in the medical literature as well as in the lay press, I frequently run across the misnomer “physician's assistant.” (Reader, take note of that terminal “apostrophe s.”) What the editor really means, of course, is “physician assistant,” the designated title for the PA profession.

The original proposal for the establishment of the physician assistant profession dates back to the mid 1960s. At that time there was a growing consensus for the need to expand the numbers of primary care doctors in the country. Medical school graduates had begun to pursue careers in specialty care, leaving a dearth of general practitioners. Moreover, many physicians chose to practice in heavily populated areas, leaving residents in rural regions with limited access to medical care.

Dr. Eugene Stead recognized a potential resource in previously trained medical personnel such as registered nurses and prior service military corpsmen. Dr. Stead proposed that experienced individuals selected from these ranks be provided additional training to allow them to function as primary care clinicians, who would then practice under the auspices of supervising physicians.

The nursing profession wanted no part of a new profession which perpetuated what was perceived to be a subordinate role in the medical hierarchy. (Eventually, nursing would develop the concept of the advanced practice registered nurse or nurse practitioner, clinicians legally permitted to practice independently from the physician.) Dr. Stead opted to target military corpsmen and medics as candidates for advanced clinical training. Thus the profession of “assistant to the primary care physician” was created.

With the explosion of knowledge gleaned through medical research over the second half of the 20th century, medical training became more and more rigorous. Today’s medical school graduates receive an exponentially greater fund of knowledge and training than their counterparts of sixty or seventy years ago. I would argue that the same learning curve applies to contemporary physician assistant graduates, who digest a substantially meatier curriculum than their counterparts of forty-five years ago.

In “Handing One Another Along,” a compilation of his lectures to Harvard students, Emeritus Professor and physician Robert Coles muses about his early encounters as an undergraduate with Dr. William Carlos Williams, the pediatrician poet from Paterson, New Jersey. Dr. Coles writes:

“Dr. Williams prompted me to think differently about what I wanted to do with my life. When I started taking premed courses, I complained to him, but he didn’t have much sympathy, since he had never taken them; they weren’t part of a doctor’s education when he was a student.” (William Carlos Williams didn’t attend college or sit for the MCAT exam; at that time neither was required for medical school, which he entered at eighteen years of age.) “He found such courses utterly unnecessary for what he thought being a good doctor was about.”

I imagine Dr. Stead would have voiced a similar opinion. I also imagine that any graduate of a modern physician assistant program has received a superior medical education in comparison to the medical school graduate of Dr. Williams’ day.

Specific to the nomenclature of the physician assistant profession, the issue has become that, in this day and age, PAs no longer “assist” primary care physicians; rather, they practice with them as associates. Physician assistants have been integrated into not only primary care but practically every medical subspecialty in existence. Professional PA societies thrive in dermatology, emergency medicine, obstetrics-gynecology, neonatology, psychiatry, pediatrics, and general surgery, as well as several of the surgical subspecialties, such as cardiothoracic and plastic surgery. Indeed, for the first time in the history of the profession, nearly half of all graduate PAs elect to practice outside the realm of primary care medicine.

PAs are granted prescriptive privilege; many states allow them to enter into partnership or practice ownership agreements with physicians. As such, PAs have come a long way toward receiving recognition as bona fide clinicians by their medical colleagues.

For these reasons many in the PA profession have come to view the title “physician assistant” as somewhat outdated, erroneous—even demeaning. If the title “physician assistant” is demeaning, how much more so that of “physician’s assistant.” (There’s that terminal “apostrophe s” again.) The latter label connotes that the PA is completely beholden to the physician as the physician’s personal assistant—an implication which falls just short of suggesting a master-servant relationship.

There has been a movement afoot for two decades to alter the name of the profession to “Physician Associate.” Indeed, the Yale PA program confers this title upon its graduates. Such a change would allow the “PA” designation to remain in effect. But if the physician assistant profession were to undergo a name change, all of the legislation that governs PA practice would have to be revised and edited, state by state—a rather daunting, if not impossible, task.

At the very least, perhaps we could agree to put to rest the nagging issue of that terminal “apostrophe s.”

by Brian T Maurer (posted for author by blog moderator, Ed Volpintesta)

Nurse practitioners and physician assistants as locum tenens for doctors

March 19, 2011
Amednews

Regarding “More hospitals reaching out to locum tenens doctors (Amednews, March 14):Older doctors who are nearing retirement may see locum tenens work as way of continuing in practice at a pace that is more attuned to their age. And those who are overwhelmed with the administrative hassles of modern medicine may find relief in aligning themselves with hospitals or large groups who can do it for them.

But, with the national shortage of primary care physicians that exists, it’s hard to understand how some can act as locum tenens doctors. By taking away time from their own patients these physicians lessen their availability to them. For strengthening the primary care workforce in one area weakens it in another.

Clearly, there are not enough primary care doctors around to supply the services needed; and although locum tenens primary care doctors may provide some help it is not a permanent solution.

One part of the solution would be to use nurse practitioners and physician assistants to fill the vacancies opened when doctors are on vacation or out for prolonged illnesses.

Nurse practitioners may also be used to do house calls, to see patients in nursing homes, and to follow up on patients discharged from the hospital who may find it difficult to come to the office.

Edward J. Volpintesta MD

If medicine had listened to Sir William Osler would there be a primary care shortage today?

In the Dec. 20, 2010 issue of American Medical News I had written a letter suggesting that one way of increasing the primary care workforce would be to shorten the primary care track by making it more practical. I suggested customizing the basic science courses to reflect more realistically what primary care doctors need in practice. The doctor who responded said that even though many physicians would agree that they have little practical use for the basic sciences in practice, they are necessary because the basic sciences are the main factors that distinguish doctors from nurse practitioners and physician assistants.

Here is my response:
Amednew.com
March 10,2011 yjhm blog


I appreciate the author’s worries about shortening primary care education to make it more practical (letters, Feb 28). He implies that length of training is what differentiates doctors form nurse practitioners and physician assistants.
That’s true but length of training is not the issue. The issue is appropriate training. Appropriate for the demands of real-life practice.

If the letter writer truly believes, as he wrote, that “ all doctors are aware that calculus and organic chemistry have little to do with practicing medicine”, then why not change the system instead of accepting the contradiction?

Training practical doctors is not a new idea. Almost a hundred years ago, Sir William Osler a respected physician and one of the founding fathers of the medical service at Johns Hopkins medical school believed that physicians should be trained along two paths. One that concentrated on research and one that concentrated on producing, as he put it, “practical” doctors.

His chief opponent was Abraham Flexner the author of the famous Flexner Report sponsored by the Carnegie Institute in 1910. Flexner wanted medical education to be based on the basic sciences and research as opposed to Osler’s practical approach.

But medical educators today are re-examining the wisdom of Osler’s approach.

In fact, the Carnegie Institute is undertaking a second look at how Flexner’s ideas have resulted in the disproportionately low number of primary care physicians compared to specialists. For,some medical educators believe that single biggest unintended consequence of Flexner’s approach was the neglect primary care.

I agree with Osler’s original ideas. Making medical education more practical makes good sense. And if tailoring the basic sciences can be done safely, and I think it can, then what is the profession waiting for?

Edward J. Volpintesta MD

Primary care's swan song

This is a letter that didn't qualify for submission to the N Engl J Med because their policy is that letters in response to an article must be sent in no later than three weeks after the article's publication date.

In the February 10 issue Stephen R. Smith discussed some changes that might be made to make primary care more attractive. In addition to curricular changes, he mentioned having students study in community settings including doctors’ offices.

But the author overlooked the single biggest problem with primary care which is that they are being asked to do too much. No amount of fee increases will make up for the physical and mental strain of the responsibilities placed upon them.

Much of the primary workers’ time is spent coordinating patients’ care, which by itself takes considerable time and energy, and it increases almost daily. Combining it with actual hands-on medical care, makes their professional and personal lives unmanageable and joyless, leading for many, to burnout

Increasing their income won’t change any of this very much. But putting some “guidelines” (they seem to solve everything) on running a primary care practice will. The single most important one would be to limit the number of patients seen to about 14-16 a day. Also, the care of hospital patients and nursing home patients should be delegated to other physicians.

Finally, because many primary care doctors practice alone or in small groups they are hard- pressed to find free time for vacation and CME. Thus locum tenens need to be made available to them.

Ideally, these changes will make primary care attractive to more students. The problem is how can this be done and at the same time provide these physicians with a reasonable income?

Do guidelines guide, goad, or beguile?

In the March 2 issue of the NEJM Sean Palfrey (“Daring to practice low-cost medicine in a high –tech era”) makes a good case for using common sense and clinical skills in place of technology. Although he mentions practice guidelines as providing some guidance in achieving those goals, the guidelines can be more of a hindrance than a help.

Guidelines do not take into account one of the most valuable tools that physicians have—intuition. Particularly for doctors who have known their patients for years and are well acquainted with their histories, guidelines can be obstacles to physicians’ exercising their clinical judgment.

Chest pain for example is more often than not, non-cardiac. Yet, physicians, even when, for good reasons, they have a very low index of suspicion, are almost forced to embark on expensive cardiac workups “just to be sure" that they are following the guidelines.

Are guidelines, because they are disconnected from the individual patient, over-rated? Do they guide or goad or beguile?

Ed Volpintesta MD

Interlude at Smilow

Interlude at Smilow
At the end of a long day M. was pushing me in a wheelchair to the valet parking when we realized we were lost. It was vexing and tiring, when a young couple, neither volunteers nor employees appeared and asked if they could be helpful. When told where we wanted to go, he pushed the chair and she preceded with a little dance,


Then she stopped and faced us with a big smile boasting "I know every inch of this hospital-I've just had a kidney transplant." For someone with a recent transplant she looked smashing.


They led us to our departure, shook hands, wished us well, and disappeared.


Young transplant girl: You probably will never see these words and we will probably never see you again, but know I have several wishes for you.


I wish you bluebirds in the spring.


I wish your new nephrons are doing what they must.


I wish your creatinine stay down.


I wish your new glomeruli filter day and night.


I wish your borrowed tubules wash all the bad stuff out to sea.


I thank a young couple for brightening the day of an old couple.

Ari Goldberg MD


--

Can we talk?

In the March 6 issue of the New York Times, an article, “Talk Doesn’t Pay, So Psychiatry Turns Instead to Drug Therapy” described how insurers do not pay adequately for psychiatrists’ “talk” time, thereby forcing them to curtail their conversations with patients and to rely more on drug therapy. Many of my psychiatrist friends have told me this as well.

Primary care doctors, like psychiatrists rely on “talk” in their work. Patients come to them often with a confusing hodgepodge of complaints. Finding the right diagnosis requires time. Talking and listening are often the most important things that primary care doctors, like psychiatrists, can do for their patients.

Insurers do not compensate doctors for “talk” because it lacks the physicality of an electrocardiogram or a CAT scan. Thus, in order to survive some doctors reduce the talk time drastically. Patients assume that their doctors are not interested in them and the doctor-patient relationship withers and patients become frustrated.

Clearly, medicine’s humanitarian foundations are being shaken. If the noble goals of the profession are to be regained, perhaps the payment structure should be reversed. Pay less for the scans, and laboratory tests, and more for “talk”.

Edward J. Volpintesta MD

From Goat Testicles to hCG shots

Nearly a hundred years ago, John R. Brinkley, otherwise known as The Goat Gland doctor, became a national sensation. For a hefty fee, he would surgically implant goat testicles into men. “Dr.” Brinkley (he purchased a medical degree in Europe—let’s just say times were different then) claimed his treatment would enhance the sexual prowess among the aging. His wealthy clientele—including Harry Chandler, the owner of The Los Angeles Times—could fly to Kansas and pick out their very own goat that Brinkley would then castrate. Presumably, Chandler and others on a similar quest hunted for the manliest-manly goat.

What were people thinking back then? Grandiose testimonials skyrocketed sales, particularly among the celebrity set. You have to assume that in the days before randomized controlled clinical trials, clients or other doctors, for that matter, were not investigating the findings. What’s more, we are talking about a time when Americans were gung-ho about all things science and also had faith in their doctors. The upshot, it seems, is that they were willing to try anything. Or maybe people were just more gullible back then.

Or maybe not. According to a front page article in the March 8 New York Times, patients today are flocking to society diet doctors for injections of human chorionic gonadotropin (hCG)—the very same hormone released during pregnancy. Unlike Dr. Brinkley, the doctor-salesmen quoted in the New York Times are really doctors. That makes today’s situation even more appalling. Dr. Lionel Bissoon told that New York Times that “from an anecdotal point of view, physicians all around the country have seen people losing tremendous amount of weight with this stuff and you cannot afford to ignore that.”

You may choose not to ignore it, but you definitely cannot rely on anecdotal information either. Isn’t that something taught in all U.S. medical schools before Christmas break?

The patients, in addition to the hormone injections, must stick to a 500-calorie-a-day diet. I’m not a nutritionist, but I would think that the starvation diet may have something to do with the weight loss. One of the clients, who calls herself a former anorexic, said she likes the shots and strict regime because it makes her feel in control (the way anorexics like to feel, I think she means). She said she no longer obsesses about food. (That’s because 500 calories leave little to obsess over).

It’s funny because I thought the public, these days, was worried about hormones seeping into the water and our meat. And yet, at the same time (and maybe the same people) are paying upwards of hundreds of dollars a month for hormones injections. Are they eating hormone-free beef?

The real lesson is not about evidence-based medicine or whether doctors should be prescribing drugs for off-label uses. What I learned is that if you want to make money in the charlatan business, you should peddle remedies that promise men virility and women weight loss.

When people desperately want results (whether it be ridding themselves of a grave illness or feeling younger or whatever), they will minimize the risks of treatment and dwell on the possibilities. Alternatively, when the goals of treatment are perceived as insignificant, they will maximize the risks. (Look at the anti-vaccine crusades.) Isn’t it the role of doctors to de-mystify the science of it all and put all the confusing bombardment of information in perspective for their patients. If we want to gain the public’s trust, I think we really need to be trustworthy.

Fortunately, the article includes a quote from Dr. Pieter Cohen, assistant professor at Harvard Medical School who researches weight-loss supplements. Besides the potential side effects, said Dr. Cohen, using hCG for weight loss is “manipulating people to give them the sense that they’re receiving something that’s powerful and potent and effective, and in fact they’re receiving something that’s nothing better than a placebo.” Isn’t that what the goat gland doctor was doing?

Talking about Talk-Therapy, A Doctor May Have Mangled His Own Words

A March 5^th front page story in the New York Times was headlined: “Talk Doesn’t Pay, So Psychiatrist Turns Instead to Drug Therapy.” My first reaction was: why is this front page news, or news at all? The article focused not so much on the changing nature of psychiatry and the long-standing scientific debates between the merits of psychotherapy versus psychopharmacology, but about the economics of it all. That isn’t news either. Anyone who has read anything about reimbursement in the past few years, knows that it is much easier to get reimbursed for using a sophisticated imaging device than for spending time trying to diagnose a patient through physical exam or conversation.

When the article said that psychiatry has suffered more than any other specialty when it comes to reimbursement, I felt their pain. I feel sorry for doctors who are not compensated for what they were trained to do. I understand why they must be depressed. And I feel badly for their patients who may no longer be able to afford the psychotherapy they need.

And yet, by the time I finished this rambling piece, I was thinking less about the state of psychiatry and more about the one doctor profiled, and hoped that he isn’t the norm, but an outlier. The piece focused on Dr. Donald Levin, a psychiatrist, and his wife, Dr. Laura Levin, a social worker, who are so disgruntled by the state of affairs, they no longer seem to care about their patients the way we wished doctors would. Dr. Levin spends 15 minutes with each patient, juggling their medications. He no longer offers psychotherapy. Ms. Levin manages the business and provides the talk therapy, if needed.

Here’s a sampler of a few of the Levins’ comments:

· He said he could have accepted less money but “I want to retire with the lifestyle that my wife and I have been living for past 40 years.”

· His wife said that when patients arrive, the first thing she asks is for the co-payment. “This is about volume,” she added, “and if we spend two minutes extra or five minutes extra with every one of the 40 patients a day, that means we’re here two hours longer every day.”

· Dr. Levin does not have time for patients to tell their story, but rather he fires questions at them. “And people want to tell me about what’s going on in their lives as far as stress and I’m forced to keep saying: ‘I’m not your therapist. I’m not here to help you figure out how to get along with your boss, what you do that’s self-defeating, and what alternative choices you have.”

· In response to hearing that a lot of his patients truly appreciate his brief sessions to keep them up on their medications, he said: “The sad thing is that I’m very important to them, but I barely know them, I feel shame about that, but that’s probably because I trained in a different era.”

It is shameful, indeed. I understand that the Levins are upset with the system and they have good reason to be. But I would have hoped that a physician talking to a New York Times reporter would be savvier and more careful with his words that are going to interpreted by a huge lay readership. Dr. Levin, on the front page, became an ambassador of sorts, for all of medicine. And anyone outside the system would think that all doctors want is a way to make a quick buck and get the patients out the door so they can get home by dinner.

The trick is going to be how to shape the future of medicine when so many of our burgeoning young doctors are graduating from medical schools that offer electives (some are even mandatory courses) in the humanities, ethics, and doctor-patient communication. Let’s hope that the new breed of caring physicians, entering into difficult economic times, will not lose sight of the most vital element of every single medical specialty: the patient. And while listening takes time, and yes time is money. I hope that most doctors continue to think it’s worth it. And I hope our insurers will too.

New ways are needed to increase the primary care workforce

In the April 12, 2010 issue of the Wall Street Journal, an article “Medical Schools Can’t Keep Up” warned that about 45,000 more primary care doctors will be needed by 2020. The article points out that although medical schools are increasing their class size, federal funding to residency programs has dropped. This has created a bottleneck whereby even if the schools turn out more students there are not enough residency programs to train them.

One wonders why educators have not considered modifying the way primary care doctors are trained. For example instead of going through the customary three years of hospital-based residency, why not train primary care doctors for at least two of those years in community health centers. This would take pressure off of hospitals to increase residency slots.

The college and med school curricula could also be shortened for primary care doctors. Coursework in the basic sciences could be tailored to what they actually need in practice. Do primary care doctors really need the in-depth study of organic chemistry, calculus, and biochemistry that most med schools require?

Almost a hundred years ago, when medical education was in the throes of great changes, Sir William Osler, one of the founders of the medical service at Johns Hopkins Medical School believed that a two-tier medical education system the best way to train physicians. One tier dedicated to training laboratory researchers and another dedicated to training “practical” doctors.

His ideas were ignored and today the medical system for training doctors is mostly focused on specialization and research. No one would want to halt medical research or the training of specialists, but adding balance to the medical workforce by training more “practical” doctors has great merit and should be re-considered.
Edward J Volpintesta MD

Writing skills valuable for all professions

In a March 3 issue of the Wall Street Journal ,“Students Struggle for Words" an MBA student confessed that his presentations included slides that were supersaturated with data and graphs.

He referred to them as data dumps whose main purpose was to demonstrate that he was knowledgeable and on top of his stuff. He met with a writing coach who stressed brevity and clarity. On a presentation that he was working on he dropped the word count from 113 to 64 and achieved the effectiveness that had been lacking.

Clearly, the single most important issue in communication is brevity. But the problem of fuzzy communication that is too wordy is not limited to MBA students.

Physicians who make teaching presentations called “grand rounds” often, for fear of appearing unprepared, flood the audience with data over-kill. Such presentations may have value for physicians endowed with superior powers of concentration,or for those who already have a deep understanding of the subject matter.

For those of average intelligence, however, like myself, these soporific sessions have little value.

Teaching brevity and clarity should be central to any professional training.

Edward J. Volpintesta, M.D.

More days in the life of Ari Goldberg, pseudonym of an old internist with nonsmallcells

A respite of about 2 weeks from the cancer center, but not from layman's advice. A friend in Israel e-mailed that she was just watching Bernie Siegal MD on TV and I should get in touch with him. A cousin of my wife's suggested I take acais berries and read motivational papers.

Skipping those well-meant suggestions and keeping an appointment at Smilow: First an interview with a hematology Fellow rotating through oncology. She was pleasant and smart and then did what passes for a quick physical exam these days -- taking blood pressure without rolling up the sleeve and listening to heart and lungs through the shirt. I remember when candidates for internal medicine boards were flunked for that, but with my PET Scan on the monitor, it probably made no difference.

Then questioned by my oncologist and reviewing the scan with him and his deciding to do a thoracentesis right then. Pulmonary physician now in the room, and and then brief appearance of a thoracic surgeon who wrote something on a form and quietly left the room. I was glad they did it right then, because it saved me from an extra trip to New Haven.

Lots of talent in the room as my wife chose to wait outside. A cheerful Physician's Assistant set me up and began to prep my chest. I closed my eyes and waited. It seemed quite a long time for the prep to be ready, but I was patient. Finally, I opened my eyes and peaked. To my surprise the PA had already aspirated enough bloody exudate to fill four giant test tubes and a large plastic container. Then coughing and referred shoulder pain briefly, as the pleural layers approached each other. The PA did the procedure as well as I ever did and proves how well, non-physicians can be trained to do these things. Tubes sent to lab for genetic evaluation.

Then a visit from a medical social worker to go over plans for home health care and help for M., who needs it, probably more that I do at this time. Smilow covers all the bases with their evaluations and referrals.

M. is wearing down some, but I can still make her laugh sometimes. These times of shared laughter are precious.