Wanted - Primary Care Doctors ASAP.

In a few years, every American will be required to have health insurance. As a result, the 32 million people currently uninsured will seek out a personal physician. This role typically is filled by a primary care doctor, like an internist or a family physician.

While passage of the health insurance reform bill affirmed the belief that having health insurance is a right rather than a privilege, the legislation falls short on building a healthcare system capable of absorbing the newly insured. Universal healthcare coverage is not the same as providing universal access to medical care. Having an insurance card doesn't guarantee that individuals can actually get care.

One doesn't need to look any further than the Commonwealth of Massachusetts to see what problems lay ahead. In 2006, the state required everyone to have health insurance. It was believed that having universal coverage would have slowed healthcare costs. Expensive emergency room visits would be averted as newly insured individuals would have a personal doctor who could address the problems sooner and at less cost.

Unfortunately, that scenario never occurred. According to the state medical society over half of internists and about 40 percent of family physicians were not accepting new patients. So the newly insured still didn't have a personal doctor to call upon even though Massachusetts has the most primary care doctors per capita than any other state. Insurance coverage does not mean access to medical care.

If a manageable patient panel per full time primary care doctor is about 2000 patients, then the nation would need an additional 16,000 doctors to care for the newly insured. With some evidence that the nation is expected to be short about 40,000 primary care doctors over the next decade, one should wonder if we are training enough doctors to fill the gap.

The answer is no. With the 2010 residency match, US trained medical students have indicated that primary care is not what they want to do. Of the roughly 2300 positions in family medicine residency programs, only 45 percent were filled by students attending American medical schools. While the American Academy of Family Physicians proclaimed the 2010 Match as the most successful ever with 91% of residency positions filled, the sad reality is obtaining this rate required eliminating 600 positions over a decade. In 1999, there were over 3200 family medicine positions available for medical students to match into.

Internal medicine numbers are better, but won't address the primary care crisis either. Though nearly 5000 students are training in internal medicine, the trend has been to use the three year residency program as a prerequisite for more lucrative medical subspecialties like cardiology, pulmonary, or oncology, to name a few. While in 1998, 54 percent of internal medicine residents planned on becoming primary care doctors after training, by 2003, the number fell to only 27 percent.

Solving the primary care crisis can't be done with ancillary clinicians. As Americans are paying more for healthcare, I don't believe that they would willingly choose to have primary care done by nurse practitioners or physician assistants. That is not to say that there are not plenty of excellent clinicians out there, but adding these physician extenders won't bend the healthcare cost curve. Their costs often are comparable even as their knowledge base is less.

Though the healthcare reform legislation tries to maintain the primary care workforce via increased income for primary care doctors providing Medicaid services as well as increase the numbers with grants for more primary care training and loan repayment for doctors working in underserved communities, the reality is medical students won't be signing up. The specialty's relatively low pay, absence of work-life balance, and low prestige compared to other medical fields doesn't resonate with today's students.

That's too bad because the nation and the public needs more primary care doctors than ever. Not only can primary care doctors decrease costs, but also the amount of time wasted getting to the right specialists. One health plan that focused on using primary care physicians to coordinate care discovered use of specialists fell by 14 percent, emergency room use decreased by 16 percent, and prescriptions declined by 11 percent. When patients self-referred to specialists, about 60 percent went to the wrong specialist. More troubling is that on average $1500 was spent on various tests and diagnostic services over an 11 month period before patients were told that the specialist could not help them.

So having a personal doctor is important and can save you time and money, but more importantly get you feeling better sooner. Too bad the nation won't have enough to go around. Hurry and find a primary care doctor you like and trust because it is possible later on you might find yourself without this indispensable advisor and guide for many years to come. Result to you and implications for the nation? Spending more time and money and not getting any healthier.

Want a crystal ball on how this legislation will affect the country? See what Massachusetts does next.

Coronary Calcium Scans Can Raise Cancer Risks

Interesting articles from the Annals of Internal Medicine and reported in HealthDay courtesy of Yahoo.

In summary, there is risk of radiation with using CT scan to determine if there are blockages in the coronary arteries. Note that from the article, "having such a screening test every five years would cause 42 additional cases of cancer among 100,000 men and 62 additional cases among 100,000 women."

Yet as one of the doctor notes it isn't proven that this screening test saves lives or is better at predicting who is at risk for heart disease than the usual measures of cholesterol, blood pressure, smoking status, age, and gender. (You can calculate your risk of having a heart attack or dying of a heart attack using the calculator provided by the National Cholesterol Education Program).

Interestingly, when hormone replacement therapy (HRT) for women in menopause was found to increase risk of cancer by 8 in 10,000 or 80 in 100,000, which is a little more than the increased cancer risk by this CT scanning, doctors and women essentially stopped using HRT. It was probably easier to do because there were alternatives to HRT.

Currently the US Preventive Services Task Force doesn't recommend it. The American Heart Association only suggests it for certain cases. Yet, unfortunately the state of Texas requires that the procedure be covered for all despite no evidence it works. Perhaps that is why a city in Texas was singled out as spending the most for medical care in a recent piece by physician author Atul Gawande in the New Yorker.

There are alternatives to using a CT scan to check the arteries to determine risk factor for heart disease. Until proven, it is best to stay away. Also, more importantly, quit smoking, stay active, maintain a healthy weight, control your blood pressure (ideally less than 120/80, but see your doctor if greater than 140/90), and control your cholesterol.

The entire article is here.


Coronary Calcium Scans Can Raise Cancer Risks
HealthDay Reporter by Ed Edelson

Mon Jul 13, 11:48 pm ETMONDAY, July 13 (HealthDay News) -- When weighing whether a coronary calcium scan is worth the risk, a new study suggests that arriving at an answer won't be clear-cut or easy.

A team of researchers from the U.S. National Cancer Institute and Columbia University found that the average range of radiation exposure from having such a screening test every five years would cause 42 additional cases of cancer among 100,000 men and 62 additional cases among 100,000 women. However, given the wide range of radiation doses seen in the study, the increase could be as low as 14 cases and as high as 200 cases among 100,000 men, and as low as 21 cases or as high as 300 cases among 100,000 women.

This is an issue of growing importance on the American medical scene, said Dr. Andrew J. Einstein, director of cardiac computed tomography research at Columbia University, and a member of a team that reports its findings in the July 13 issue of the Archives of Internal Medicine.

"There has been great interest recently in computed tomography, owing to the fact that the number of CAT scans has grown tremendously in the United States," Einstein said. "The National Council on Radiation Protection & Measurement estimates that 70 million are done per year."

The study in which Epstein took part looked at a form of computed tomography that scans for calcium deposits in heart arteries. CAC scanning, as it is called, is one of the lesser-done forms of computed tomography, but a private organization, Screening for Heart Attack, Prevention and Education, has proposed that it be done annually on 50 million Americans, and a new Texas law mandates health insurance coverage of the procedure.

The new study looked at what a dose of radiation in a single CAC scan would be, and found an enormous variation. There is no single protocol -- set of rules -- for such a scan, which can be done on a variety of equipment, Einstein said. "This was first proposed in 1990, and CT scanner technology has changed, so it is not clear what the protocol might be," he noted.
The study found roughly a 14-fold difference in radiation dosage among the various CAC scan protocols. Eliminate two or three "outlying" readings, and the difference is still threefold, Einstein said.

But those estimates are suspect, said Dr. Thomas G. Gerber, an associate professor of medicine and radiology at the Mayo Clinic, and co-author of an accompanying editorial, because it is based on extrapolation of the damage done to people exposed to high doses of atomic bomb radiation at Hiroshima and Nagasaki.

"At the very low doses used in medical imaging, there is a huge controversy about whether there is an increased risk of anything," Gerber said. "Estimates of increased risk are based on a linear no-threshold hypothesis. There is even a theory that chronic exposure to low doses of radiation might be beneficial."

There is equal cloudiness on the benefit side of the equation, said Gerber. "I am not a strong proponent of screening," he added.

"The risk of cardiac events increases if calcium is present in the arteries," Gerber said. "But you can't pick up blockages before they are 70 percent or more. There is some debate about whether the risk predicted by coronary calcium screening is incremental [adds to] the risk predicted by conventional risk factors. It stands to reason that it might be, but that is not proven."
The U.S. Preventive Services Task Force recommends against using CT scans in screening programs, and the American Heart Association says they should be used for "selected individuals" at intermediate risk.

So what do physicians do about CAC scanning in the real world?

"I like using it for patients at intermediate risk of coronary disease, when I do not know how aggressive therapy should be," Einstein said. "For such patients, it is a fantastic test."

"In my practice I use it for patients with no symptoms but an unfavorable risk factor profile," Gerber said. "If there are risk factors but they are adamant about not changing their lifestyle or taking coronary medication, I think it sometimes helps patients realize their coronary atherosclerosis [hardening of the arteries] has begun."

A definitive study of the risk-benefit ratio of CAC scanning is unlikely, Einstein said. The people in question are not at high risk of heart disease, and "the rarer an event is, the larger the sample size that is needed," he said. "A randomized controlled trial would require hundreds of thousands or millions of patients, with adequate follow-up."

More information
For more on coronary calcium scans, go to the U.S. National Heart, Lung, and Blood Institute.

Multivitamins Not Worth the Money - Except...

Interesting, yet hardly surprising story that in most cases multivitamins are NOT worth the money.

The source is from an article from the Annals of Internal Medicine specifically:

• the 161,808 postmenopausal women enrolled in the Women's Health Initiative Study that took multivitamins there was no protective effect from common forms of cancer, heart attacks, or strokes.
• during the eight years of observation, the numbers of deaths were the same between women who took and did not take vitamins.

There were situations, however, which are still every important vitamins are taken. These are:
* Folic acid supplements in women who are pregnant or plan to become pregnant can help to prevent serious neural-tube defects that affect the baby's brain and spine.
* Supplements that contain more vitamin D and calcium than is present in regular multivitamin pills can help older men, and especially women, avoid osteoporosis and bone fractures.
* Supplements of vitamins C and E, beta-carotene, zinc, and copper may slow the progression of vision loss in people with early macular degeneration.

Check with your doctor to see if multivitamins are necessary or a waste of your money and time.