Before we gather with loved ones to give thanks for our abundant blessings and eat until we lose consciousness, I wanted to take this opportunity to express my gratitude to you.

To all my readers, thanks for all the medical news articles, the feedback and the encouragement.  The weekly writing would get very dull if I thought I was talking to myself.

To all my patients, thanks for granting me the greatest thing anyone can expect from a career – getting paid to do what you love.  I appreciate your loyalty.

I wish you and yours a happy Thanksgiving.  I hereby grant all of my patients a one day reprieve from the dietary restrictions I harangue you about during the rest of the year.  You may eat what you like provided that instead of counting calories, you’re counting blessings.

Early in life we all have to choose which of the seven dwarfs we want to be.  Most of us physicians, for mostly altruistic reasons, chose to be Doc.  But it turns out that many of us instead ended up being Grumpy.

A survey of twelve thousand U.S. physicians released this week by the Physician’s Foundation paints a grim picture of our morale, and it received a lot of press.  78% of physicians believe that there is a shortage of primary care doctors today.  49% of doctors said that they were planning to shrink their practice or retire entirely in the next few years.  60% of doctors would not recommend medicine as a career to students.  94% said they were spending more time with non-clinical paperwork than a few years ago and 63% said this caused them to spend less time with patients.  (You can read more of the results by following the link below.)

Now, we should keep in mind that the Physician’s Foundation is basically a doctors’ grievance group which exists to get more money out of insurers, so they’re as likely to publish a study saying doctors are happy as an oil industry lobby is to declare that we have enough energy.  So we should take these results with a big grain of salt.  But, still, the overall picture isn’t encouraging.

My advice to patients is to make sure you have a primary care doctor now.  If you wait until you’re sick, the doctor you were hoping to see may be out of practice or may be full.

My advice to physicians is to reclaim your autonomy.  If you’re working too hard, work less.  If you’re making too little, drop your contract with the insurer paying you least.  If you’ve reached the point that you hate what you do or are losing money doing it, do yourself and your patients a favor and retire or change careers.  Physician unity isn’t going to help us.  (Note well the fate of the UAW.)  Our only hope lies in physician independence, excellence, and love of our work.

We have to demonstrate to today’s students that we can be Doc and also be Happy.

Learn more:

USA Today article: Primary care doctors in short supply

LA Times Booster Shots: Docs aren’t happy, and if docs aren’t happy …

Survey results from The Physician’s Foundation

My post about the coming primary care shortage: Will Primary Care Survive?

“If you think health care is expensive now, wait until you see what it costs when it’s free.”
– P.J. O’Rourke

I’ve written several times about the proven benefits of a family of cholesterol-lowering medicines called statins.  Statins include the medications Crestor, Zocor, Lipitor, Mevacor, Pravachol and others.  The group has a solid base of evidence showing that they prevent strokes and heart attacks in patients with high cholesterol and in patients who have had a stroke or heart attack.

This week, a study published in the New England Journal of Medicine brought us more good news about statins, and potentially broadened their usefulness.  The study has received a lot of attention in the mainstream press.  The study randomized over 17,000 patients who:

• were men over 50 or women over 60
• did not have a history of heart disease, stroke or diabetes
• had normal cholesterol (LDL < 130)
• and had an elevated C-reactive protein ( > 2)

C-reactive protein (CRP) is a blood test that is a general marker for inflammation.  CRP has long been known to be elevated in people at higher risk for heart attack, but until now, there’s never been anything known to decrease that risk.

The patients were randomized to Crestor 20 mg daily or placebo and were followed for an average of almost two years.  The patients on Crestor had fewer heart attacks, fewer strokes and fewer deaths from any cause – a pretty remarkable finding in a group of patients who are not at high risk of cardiovascular illness.

These results strongly support checking a CRP in older men and women and considering statin therapy in those with an elevated CRP regardless of their cholesterol levels.  There are some caveats, though.  This group of patients had a fairly low risk of adverse events and it took a very large number of patients to show a difference between Crestor and placebo.  Extrapolating from the results of the study, it would take treating about 277 patients for two years with Crestor to prevent one heart attack, and 346 patients to prevent one stroke.  Using the current price of Crestor, the cost of Crestor needed to prevent one adverse event is over $170,000.  The price would be less with a generic statin, but it’s still a big expense and a lot of patients taking a statin who don’t benefit.  But we don’t know ahead of time who is the one patient who will have the stroke or heart attack.

So will I recommend checking a CRP to my older patients?  Yes.  Will I recommend statins to patients with an elevated CRP?  Probably, but with the explanation that the benefit may be quite small.

Economists call this the law of diminishing returns.  The more resources you spend on a problem (in this case, stroke and heart attack prevention) the less benefit you get from each incremental increase in spending.  At some point the possible benefit is so vanishingly small that costs aren’t worth it, but that point is different for every patient.  Each one of us has different preferences, different attitudes about risk, and different ways to spend our finite resources.  In a free market each patient would balance the risks and benefits herself, but in our current system in which we all indirectly pay for each other’s medicines the decisions will likely be made by insurance companies and by national expert groups.

(I’m grateful to my colleague Dr. Roy Artal and to the several patients who emailed me about this story.)

Learn more:

New England Journal of Medicine article: Rosuvastatin to Prevent Vascular Events in Men and Women with Elevated C-Reactive Protein

New York Times article: Cholesterol-Fighting Drugs Show Wider Benefit

USA Today article: Crestor would save lives at $500,000 each

“I can’t get no satisfaction”
– The Rolling Stones

Many women after menopause experience decreased interest in sex and decreased satisfaction with sex.  Some women accept this as a natural part of the aging process, but other women are quite distressed by these symptoms.  The Diagnostic and Statistical Manual of Mental Disorders, the authoritative text on defining psychological illness, even lists “hypoactive sexual desire disorder” as a disorder marked by a lack of sexual interest which causes personal distress or interpersonal difficulties.

This week’s issue of the New England Journal of Medicine published a study attempting to treat these symptoms.  Not surprisingly, the study was widely covered in the general press.  In the study, post-menopausal women who reported a decreased interest in sex and significant distress related to this were randomized to either a patch that released a small amount of testosterone or placebo.

Twenty-four weeks later, women using the testosterone patch reported significantly greater interest in sex and more frequent satisfying sexual episodes than women using the placebo patch.  Women using the testosterone patch also reported significantly less distress about their sexual health than women using the placebo patch.

The women were followed for a year to monitor side effects.  The most common side effect was unwanted facial hair, reported by 20% of women on the testosterone patch and 10% of women on placebo.  (There was no note of how this side effect impacted their partners’ interest in sex.)  There was also some skin irritation at the site of the patch.

This study was too short to find any long-term risks of testosterone.  As with any hormone, the most serious concern is that it may increase the risk of breast cancer.  So while this study may offer a possible helpful advance for post-menopausal women, safety concerns will have to be answered before women can use it with confidence.

Learn more:

New England Journal of Medicine article: Testosterone for Low Libido in Postmenopausal Women Not Taking Estrogen

Wall Street Journal article: Patch Boosts Libido for Some Older Women

Los Angeles Times article: Testosterone makes women friskier — but should it be prescribed?