A Country Doctor Writes:

Archive Page 216

A Cobbler’s Mistake

Published May 10, 2008 Progress Notes Leave a Comment

I saw Billy G. yesterday afternoon on his way home from work. He was thrilled to be back to work again. A cobbler’s mistake cost Billy two weeks’ pay, and it could have cost him his foot.

Billy has had diabetes since he was a teenager, and he has such severe diabetic neuropathy (nerve damage) that he has no feeling at all in his feet. He needs special diabetic shoes, which his insurance company will only replace every several years. They will help him pay to have his work boots re-soled, however, and this got done a month or so ago. Our local cobbler did the job for him while he waited. Billy didn’t notice that a week after he got the boots back, the nails used to attach the new soles started to work their way through the sole of his left work boot and the sole of his left foot.

Billy’s wife, Theresa, checks his feet for him every night because he isn’t quite limber enough to see the bottoms of his feet; some people use a mirror in order to see their feet better, but Billy’s diabetes has affected his eyesight too much for him to do the job himself. If Theresa hadn’t spotted the wound the first day, who knows what could have happened to Billy’s foot. It took two weeks to heal the damage, two weeks without a paycheck, and two weeks of worrying.

Billy went back to the cobbler and told him what happened. Theresa had told me “I suppose we could have sued him, but we just wanted him to know so nobody else got hurt like Billy”.

Theresa does one more thing for Billy every day now: Every morning, she checks the inside of his work boots for nails before he puts them on. Then, as she has had to since he started to lose the feeling in his fingertips, she ties his boots for him, and she makes sure they’re not tied too tight.

Billy can’t feel pain in his feet, but I know he can feel the love in the countless little things Theresa does so that the two of them can carry on day after day.

New Doctors: Too Few, Too Many or Too Late?

Published May 3, 2008 News & Reviews 2 Comments
Tags: Add new tag, Health Care Costs, Medical Education, Medical Specialists, Physician Supply, Primary Care

There are too many doctors in the U.S according to Dartmouth’s Goodman and Fisher‘s commentary of the Association of American Medical Colleges’ Center for Workforce Studies report. The AAMC recently made the proud announcement that 85% of medical schools have or are in the process of increasing first year medical school student enrollment by a total of 30% by 2015. In my view, the real issue here isn’t quantity at all.

This country already has just about the world’s highest ratio of doctors per capita. As a group, U.S. physicians deliver more expensive care with no better outcomes than our colleagues in other countries. American patients are not going overseas for elective surgery because they don’t have access to surgeons here – they fly halfway around the world at their insurance companies’ expense to save money. Now, if the strategy behind increasing physician supply is to drive health care costs (read: doctor salaries) down, it might make more sense, but I believe that even if physician reimbursement is ratcheted down even more, prices will have a way of staying up there anyway because of the tremendous overhead in health care.

There are enough studies showing that greater physician supply, particularly at the specialist level, correlates more with increased cost than improved quality. And where do most medical school graduates today end up? They choose specialties with higher incomes and better life styles than Primary Care offers in today’s climate. Right now our little community is trying to recruit one or two new Family Physicians, so I know first hand how few new graduates want my kind of job. At the same time, I read advertisements in the City paper, where Family Doctors are offering laser skin jobs (for cash) instead of accepting new Primary Care patients – and they certainly don’t do house calls. Yes, house calls are good medicine and they can save health care dollars! We have plenty of examples in our community of elderly, homebound people we have kept out of the hospital with the help of weekly or biweekly home visits. One Emergency Room visit via ambulance costs more than a dozen house calls!

One of the hot topics in medicine, Primary Care and Health Care Policy these days is “The (Advanced) Medical Home”, which basically means having a technologically astute old-fashioned Family Doctor, who keeps track of your whole medical situation, actually reads your different specialists’ reports, and makes everything happen. If all of us working in primary care don’t claim the authority that goes with this concept, health care will continue to fragment and become more and more inefficient. In my practice I see patients every week who have been discharged after a very brief hospitalization, with lots of loose ends that I have to pull together in order to keep the patient safe. Only if I have the time and resources to do this well will the hospitalization have been worth the time and money it cost.

What will the first year medical students of 2015 have to look forward to when they graduate from their residencies in 2022 or 2023, especially if nothing is done to strengthen Primary Care? They may have hopped on the band wagon too late to find the destination they expected, particularly in the shortage area of Primary care. By then we may have a lot more clinics within drug stores staffed by Nurse Practitioners and Physician Assistants, pharmacists may be prescribing for common ailments, psychologists will be doling out Prozac®, and RN’s will deliver telemedicine services backed by off-shore corporations with Medical Directors in other time zones.

We must learn from the Europeans and not prioritize specialty care over primary care so heavily. Only then can we provide enough preventive and basic health care to affect the ultimate cost of treating the chronic diseases that now drain so many of our healthcare dollars.

So, don’t give us more specialists! Give us well trained generalists, and pay them enough to make it worth their effort to work in the small towns and Community Health Centers where the underserved patients can get their health care needs met!

Cholesterol Guidelines and the Bachelor with Platform Shoes

Published April 28, 2008 News & Reviews 5 Comments
Tags: Cholesterol, Clinical Guidelines, Evidence Based Medicine, Vytorin, Zetia

I have read that tall bachelors have more dates than short ones, and until recently it seemed obvious that men with low LDL cholesterol would have fewer heart attacks than men with higher levels. So what happens when a vertically challenged young man dons a pair of ABBA style platform shoes? And what does this really have to do with cholesterol?

Let me start from the beginning.

In medicine today, there are two mantras, even buzzwords: Evidence Based Medicine and Clinical Guidelines.

To practice Evidence Based Medicine is to do precisely those things that are proven by rigorous research to help the patient. Examples include giving heart attack survivors certain medications (Beta Blockers) or to give aspirin to patients with TIA’s (often called “Ministrokes”).

Clinical Guidelines often involve reaching numerical targets, and this is the first tip-off that we’re on much shakier ground. Keeping a diabetic’s blood pressure under 130/80 may be a good thing to do, but not if the person has a history of fainting from low blood pressure when standing up too quickly.

A dramatic example of failed guidelines came with the recent publication of the ENHANCE study (New England Journal of Medicine, April 3, 2008). The National Cholesterol Education Program has long recommended keeping the bad LDL Cholesterol under 70 in high risk patients, like those who have had a heart attack or a bypass procedure. The problem with this guideline was that it created a situation where doctors faced with an LDL slightly above “target” would abandon high doses of, for example the proven drug Lipitor, and switch patients to moderate doses of Vytorin, which contains a less powerful “statin” drug and an until now unproven new drug, called ezetimibe (Zetia).

The new drug, introduced in 2002, lowers cholesterol by blocking intestinal recycling of old cholesterol from the body’s different cholesterol-based hormones etc. In the beginning, there was no proof that ezetimibe lowered heart attack rates or limited cholesterol buildup in our arteries, but there was something very promising about the drug; it not only helped lower cholesterol, but it also reduced levels of CRP, or C-reactive protein, an inflammation marker that closely follows heart attack risk.

So the number crunchers started to put pressure on doctors to reach numerical targets, and television ads promoted the dual action of Vytorin.

Fast forward to a couple of months ago when, after a billion dollars in sales, the new drug looks no better than platform shoes; better measurements, but same number of dates (in this case meeting our maker…), so to speak. The ENHANCE study didn’t count deaths or heart attacks, but it did measure thickness of cholesterol buildup in arteries, and there was no difference between plain Zocor (simvastatin) and the combination drug (Vytorin). Factor in that you can buy simvastatin for $4/month at some supermarket pharmacies, while Vytorin costs 2,500% more (yes, do the math; $100 divided by $4 times 100%!).

The lesson here is that the guideline writers failed to think about what evidence we had about how patients achieved their goal numbers, just like the guy in the ridiculous shoes only thought he was closer to eye level with the girl he was trying to impress.