Will Primary Care Survive?

Last week’s New England Journal of Medicine features an important article by Dr. Thomas Bodenheimer, Primary Care — Will it Survive?  I encourage all of you to read it.

Dr. Bodenheimer starkly presents the looming crisis in primary care.  Patients are waiting increasingly long for shorter appointments, frequently do not understand their doctor’s instructions, and are increasingly dissatisfied.  Primary care doctors are seeing more patients then ever before, for flat or declining reimbursement.  Ironically, this is happening at a time that the number of preventive tests and services that primary care doctors are expected to deliver is increasing.  Not surprisingly, primary care physicians are increasingly dissatisfied, and fewer medical students are choosing primary care.  Just as the baby boomer generation ages and requires more care, there will be even fewer trained primary care doctors.  This is clearly a recipe for a national disaster.

While Dr. Bodenheimer perfectly details the symptoms and the severity of the impending disaster, he never attempts to diagnose the cause, and therefore recommends therapy that is sure to fail.

Why is it that for all other services, from transportation, to housing, to even leisure, Americans are generally satisfied?  Why is it that even those below the median income can typically afford the basics in other services, while the middle class increasingly can not access quality medical care?  The reason is that other services are generally purchased directly while healthcare is usually purchased through a third party.  When we shop for a service ourselves, we find providers who give us great quality at reasonable prices; when we allow middlemen to shop for us we pay them to tell us what services we need and to set the price we’re willing to pay.  Price inflation and decreasing quality is an inevitable consequence of delivering care through third-party payers.  That is why for all other services, insurance is purchased only to cover catastrophes.  You want home-owners insurance in case your house burns down.  You would never want home-owners insurance to cover mowing your lawn.  That would immediately lead to lawn mowers becoming unaffordable, and lawns being neglected.

In any other marketplace customer dissatisfaction would create an irresistible opportunity for a provider to give the customers what they want.  So when Dr. Bodenheimer prescribes

A covenant is needed between those who pay for health care and those who deliver primary care: primary care must promise to improve itself, and in return, payers must invest in primary care.

he misses the point entirely.  Payers investing in healthcare is what brought us to this calamity.  It is patients who must invest.

Like in every other marketplace, informed patients who demand quality and bear the cost of their care will lead us to affordable care for everyone, not just the rich.  You will bear the burden of the coming crisis, and you, not government, not insurance companies, will deliver the solution.

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Chantix is Modestly Helpful for Quitting Smoking

Quitting smoking is probably the hardest thing I ask my patients to do.  Many patients try to quit multiple times before finally being able to quit permanently.  Smoking is a frustrating and profound addiction.

A new medication has recently been approved for smoking cessation.  The medication is varenicline and is being marketed under the brand name Chantix.  Its efficacy was studied in three randomized blinded trials that were all published in the July 5 issue of the Journal of the AMA (Vol 296, No 1) and reviewed by The Medical Letter.

The studies illustrate the potential, and the limitations, of Chantix.  Two of the studies randomized smokers who wanted to quit to receiving either Chantix or bupropion or placebo.  Bupropion (marketed as Wellbutrin and Zyban) has already been proven to have some efficacy for smoking cessation.  After 12 weeks, continuous smoking cessation rates in both studies were about 18% with placebo, 30% with bupropion (Zyban), and 44% with varenicline (Chantix).  So the patients on Chantix did best, but even on Chantix, over half of patients were smoking again at 12 weeks.  Nine months after the end of treatment, the results were even more discouraging.  Continuous smoking cessation rates were about 9% with placebo, 15.5% with bupropion (Zyban), and 22.5% with varenicline (Chantix).  Again, Chantix did best of the three groups, but three quarters of the patients in that group had not successfully quit.  Still, that suggests that for every 8 patients given Chantix instead of placebo, one additional patient was able to quit successfully nine months later.

The medication is generally started a week before the patient’s target smoking quit date and continued for 12 weeks.  Patients who are successful in quitting smoking during the first 12 weeks should continue the medication for another 12 weeks.

So Chantix is not a magic cure, but it’s significantly better than Zyban.  If you know someone who has become discouraged by unsuccessful previous attempts to quit smoking, this might be a good reason to encourage him to try again.

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A Concierge Physician Can Be Handy When Traveling

Last Saturday’s business section of the Los Angeles Times featured an article by James Gilden that discusses the benefits of concierge medicine for frequent travelers.  It tells the very dramatic story of one of my patients, Mr. Andrew Gitkin, who found himself unexpectedly in need of help while abroad.  When you have a chance, please take a few minutes and read the article.

While Mr. Gitkin’s story may be the most spectacular, I receive calls all the time from my patients while they are out of town.  Issues as mundane as forgetting to pack a prescription medication or as scary as an acute illness happen unexpectedly.  Being able to immediately reach a physician who knows you, regardless of the time difference or the day of the week, can help restore peace of mind in a frightening situation.

I appreciate Mr. Gilden highlighting my practice, and I am indebted to Mr. Gitkin for agreeing to tell his harrowing story.

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Horse Chestnut Seed Extract Is Effective for Symptoms of Venous Insufficiency

Chronic venous insufficiency is a very common and very uncomfortable condition. It occurs when the valves in the veins of the legs become leaky, leading to leg swelling, pain and itching. When severe, skin breakdown can occur. The most effective treatment is compression stockings, which can be uncomfortable and difficult to use. An effective oral medication would be a major advance in terms of convenience.

Horse chestnut seed extract (HCSE) is a herbal remedy sometimes used for venous insufficiency. The current issue of the ACP Journal Club [vol 145, no 1, p 20] reviews a comprehensive analysis of randomized trials in the Cochrane Database of Systematic Reviews comparing HCSE either to placebo or to compression stockings.

Many of the studies found HCSE more effective than placebo. Some found HCSE as effective as compression stockings.

The caveats are that the studies were all short term so the long term safety and efficacy of HCSE remains unknown, and up to a third of patients in some of the trials reported side effects such as dizziness or stomach upset with HCSE. Nevertheless, this provides a hint at a possible treatment for a chronic and frustrating condition.

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Lipitor Helps Prevent a Second Stroke

An important study in this week’s New England Journal of Medicine expands what we know about the benefits of cholesterol lowering medications. Statins, a family of cholesterol lowering medications which include Crestor (rosuvastatin), Lescol (fluvastatin), Lipitor (atorvastatin), Mevacor (lovastatin), Pravachol (pravastatin), and Zocor (simvastatin), have already been proven to have many benefits. We already know that they prevent a first heart attack in patients who are at high risk of a heart attack because they have diabetes, or high cholesterol, or atherosclerosis (narrowing of the arteries). They also prevent a second heart attack in patients who have had a first heart attack, and prevent strokes in patients with coronary artery disease (narrowing of the arteries that supply blood to the heart itself).

The current study was designed to test if Lipitor helped prevent a second stroke in patients who had recently had a stroke. The study enrolled 4731 patients who had had a recent stroke or transient ischemic attack (a temporary stroke) and did not have known coronary artery disease. The patients were randomized to 80 mg daily of Lipitor or placebo and followed for about five years. In the group taking Lipitor 11.2% of the patients had another stroke, compared to 13.1% in the group taking placebo. That means that for every 45 patients taking Lipitor over 5 years, one stroke was prevented.

It’s safe to infer that almost all patients who have ever had a stroke or a heart attack or have atherosclerosis should be on a statin, even if their cholesterol by older standards would have been considered normal. The authors of the study conclude:

In conclusion, in patients with a recent stroke or TIA, treatment with 80 mg of atorvastatin per day decreased the risk of stroke… These results support the initiation of atorvastatin treatment soon after a stroke or TIA.

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Saw Palmetto Does Not Help for Prostate Enlargement

Some of my patients ask me if I “believe in” Eastern, or holistic, or homeopathic medication. The truth is I don’t “believe in” any kind of medicine. I need to be convinced. I’m not a Western medicine chauvinist; I’m an evidence-based medicine chauvinist. If there is a good study that supports that a medication is safe and effective I’ll use it. I won’t ask if it comes from the East or West, or if it’s natural or artificial, or if it’s a tablet or a crushed leaf. I just want the evidence.

That’s why I’m delighted when alternative therapies are rigorously tested. That lets me recommend them with confidence if their effectiveness is proven, or recommend against them with confidence otherwise. That’s why I was happy to review the evidence on acupuncture back in May.

The most recent issue of the ACP Journal Club [vol 145, no 1, p 12] reviews the best study yet done on saw palmetto for benign prostate enlargement, which was originally published in The New England Journal of Medicine in February. In the study, men with moderate-to-severe symptoms of prostate enlargement were randomized to receive saw palmetto or placebo. They were followed for one year and had formal measurement of their urinary symptoms as well as measurement of biological markers of prostate enlargement, like prostate volume, urine flow rate, and residual urine volume after voiding.

The men on placebo did as well as the men on saw palmetto. The symptoms and biological markers of men in both groups didn’t get much worse or much better. The reviewer concluded:

Saw palmetto does not improve symptoms or objective measures of benign prostatic hyperplasia. There is also no evidence that saw palmetto maintains prostate health or prevents development of urinary symptoms or prostate cancer. Its use should not currently be recommended.

Flomax is the first line treatment for benign prostate enlargement, because it has been proven to decrease the symptoms associated with that condition and has fewer side effects than other effective medication. For men who didn’t want to take prescription medication, I used to suggest saw palmetto. From now on, I won’t.

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Fighting Jet Lag

Many of my patients are frequent business travelers. Travel presents its own set of health challenges, from the risk of prolonged immobility in small airline seats, to the risk of acquiring respiratory infections on a plane. One painful consequence of travel that we’ve all experienced is jet lag. Especially when crossing several time zones, jet lag can make the first day or two at your destination very unproductive.

In last Saturday’s Los Angeles Times business section, James Gilden has a very helpful article: Shedding Some Light — or Not — on Fighting Jet Lag. He discusses a recent study for British Airlines by Chris Idzikowski, a founder of the British Sleep Society. The study attempted to discover the most important factors that effect jet lag, and how to modify these factors to get the greatest relief.

What really works in influencing the body’s biological clock and consequently combating jet lag, he said, are six factors: exposure to light, sleep, exercise, eating, drinking and social interaction. It is in timing a traveler’s exposure to light that Idzikowski has found the most promise for combating jet lag.

One result of the study is the British Airways Jet Lag Advisor. Take a look at it. It’s very easy to use and gives advice about the hours that you should avoid light and seek light in the first two days of travel to minimize jet lag. Please try it during your next trip and let me know how well it goes.

Now I just need to figure out how to keep you from getting colds when you fly.

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Critically Ill Patients Do Better in Large Hospitals

An interesting study in the July 6 issue of The New England Journal of Medicine confirms what many physicians and patients have suspected: experience leads to quality. The study looked at over 20,000 patients with respiratory failure (inadequate or stopped breathing) in 37 different hospitals. The patients all required mechanical ventilation, meaning they were connected to a machine (a ventilator) that assisted their breathing until their respiratory problem improved. The study compared the number of these patients who survived their hospitalization to each hospital’s patient volume (the number of patients admitted to the hospital). The study took into account differences in illness severity and other differences between patients.

The patients admitted to the largest hospitals survived most frequently. A patient admitted to a hospital that was in the bottom 25% of hospital volume had a 34.2% chance of dying during the hospitalization. In the busiest 25% of hospitals, the average in-hospital mortality was 25.2%. That suggests that for every 11 patients with respiratory failure, one additional in-hospital death will occur in the least busy hospitals compared to in the busiest hospitals. That’s a surprisingly big difference.

Since this wasn’t a randomized study (meaning patients weren’t told which hospital to go to) the results may be potentially biased, so we should be cautious. The authors speculate about why busier hospitals may have better outcomes:

High-volume hospitals may improve outcomes by implementing a broad range of best practices, including higher nurse-to-patient ratios, multidisciplinary care teams. Clinicians at high-volume hospitals may also gain experience in the care of the critically ill, which could translate into improved rates of survival. More experienced as opposed to less experienced clinicians may be better at recognizing and treating the complications of critical illness or may be better at translating evidence into practice.

The bottom line is that experience translates to quality.

The Beverly Hills area is served by several hospitals, and I am frequently asked what I think about specific medical centers. This study further informs my initial opinion. Larger hospitals, like Cedars-Sinai Medical Center, have the care protocols, the information infrastructure, and the experienced specialists to provide better outcomes than small hospitals.

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Seattle TV News Story Gets Worldwide Attention on Inflammatory Breast Cancer

(Thanks to my patient J.R. for pointing me to this story.)

A little over a month ago a Seattle TV station broadcast a news story about inflammatory breast cancer. You can read the story or watch the video on the station’s website. Since then, interested viewers have emailed the story to friends and acquaintances and the video has been viewed over ten million times. This has drawn welcomed attention to inflammatory breast cancer, a very aggressive form of breast cancer.

The Mayo Clinic website has a very comprehensive review of inflammatory breast cancer. What makes inflammatory breast cancer different than other breast cancer, and frequently leads to late diagnosis, is the absence of a lump. Inflammatory breast cancer is frequently misperceived as an irritation or infection of the skin. According to the Mayo Clinic overview, signs and symptoms of inflammatory breast cancer include:

  • A breast that appears red, purple, pink or bruised
  • A tender, firm and enlarged breast
  • A warm feeling in the breast
  • Itching of the breast
  • Pain
  • Ridged or dimpled skin texture, similar to an orange peel
  • Thickened areas of skin
  • Enlarged lymph nodes under the arm, above the collarbone or below the collarbone
  • Flattening or retraction of the nipple
  • Swollen or crusted skin on the nipple
  • Change in color of the skin around the nipple (areola)

Early correct diagnosis can make a big difference in inflammatory breast cancer, so keep this in mind when you do your monthly breast self-exams and pass it along to someone you care about.

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Fighting Prostate Cancer by Doing Nothing

I wrote in March about the controversies regarding prostate cancer screening, and I made the point that, unfortunately, it is still not clear whether or not diagnosing prostate cancer early saves lives.

This week’s Los Angeles Times Health Section features a fascinating article by Susan Brink that highlights the limited scientific evidence, and therefore the many reasonable options, available to prostate cancer patients. She discusses several healthy men diagnosed with early prostate cancer who have researched their options and have chosen active surveillance. Active surveillance involves frequent monitoring of the cancer through blood tests, ultrasound, and even biopsies, but with no intervention to treat the cancer.

Given the lack of evidence that current treatments like surgery or radiation prolong survival in early prostate cancer, the option of active surveillance is entirely rational.

“Most of the time, I tell men that they may need treatment, but they’re not going to die,” says Mark Scholz, a Marina del Rey oncologist, specializing in prostate cancer. “A lot of men with low-grade cancer may not need treatment for five to 10 years.”

Some may never need it.

I recommend reading the article, especially the excellent summary at the end of the different available treatments.

The important thing to remember is that prostate cancer is very common and grows very slowly. A new diagnosis is not an emergency. There is plenty of time to collect opinions from oncologists, urologists, and radiation specialists, collect your thoughts, and then decide what to do. Even if it’s nothing.

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