American family practice: Canada looking better?

I still believe my "generality" of Family Practice makes sense in settings that reflect real-world resource constraints, such as a "free market" libertarian system or a single buyer/payor model or the future mixture thereof. Alas, FP doesn't make sense in the unreal world of today's American health-care marketplace. FP is a weak and wounded beast, and the "minute clinics" are moving in for the kill.

So it's not surprising that this month's issue of FPM was suspiciously thin, and included some grim correspondence:

Letters - May 2007 - Family Practice Management

In response to Dr. James Glazer's editorial "Specialization in Family Medicine Education: Abandoning Our Generalist Roots" [February 2007], I have to ask why are we wasting our time saving generalism? The marketplace has deemed us valueless. Supply and demand has dictated that we are unnecessary. Insurance companies, the government and the public have said we have no worth... mostly I get up in the middle of the night to see patients with minor problems that should have been dealt with in the clinic during daylight hours. I applaud my colleagues who have limited their practices, and I plan to do the same in about five years.

--

... I don't mean the above to sound dark and angry. Part of the paradox of life in family medicine is that it would be hard for me to conceive of a more satisfying career. I would never trade my practice life for that of another specialty. Caring for patients with the spectrum of needs that mine have is immensely rewarding.

Still, I'm not sure that today's medical students are willing to meet the demands of family medicine. The financial rewards are likely to be greater in almost every other specialty, and many young physicians have difficulty seeing beyond that.

--

I am now retired, but having practiced for more than 30 years, developed a family medicine residency program, taught residents for many years and watched the ancillary services once preformed by family doctors disappear, I am disillusioned and afraid for the continued existence of family medicine...

--

The same issue features a somewhat discouraging look at an idealistic (but unpersuasive) attempt to "reengineer" family practice. Ahh, they'll miss us when we're gone. You have to love a group of people who, faced with immense economic pressures, decide to make their board certification five times harder. There's a definite impulse to self-punishment among family physicians ...

Primary care will return to America when we emerge from our delusional health-care mess; the names will change but no-one will really be fooled.

In the meantime, not coincidentally, my wife and I received a recruitment survey from the Canadian Medical Association. They've noticed an unprecedented reversal of the "southwards flow of physicians" in the past two years. It's probably too late for us (I left practice for research and development 10 years ago), but if I were still doing primary care I'd be looking north again ...

Update 5/14/07: I forgot to mention one of the more direct "killers" of family practice. Evaluation and Management coding. It diverted primary care from patient services to documentation services, and biased towards the delivery of suboptimal, but coded, services. Performance measures will have a similar effect, though for primary care that will be a "flogging a dead parrot".

The genetics of weight: why so long to be accepted

Obesity management is one of those marvelous examples of research results that take eons to be incorporated in practice. Gina Kolata documents research published in the mid 80s in the NEJM that showed weight was almost certainly genetically controlled in an environment of plenty. Twenty years later, this is only beginning to be accepted.

Obesity, in an environment of plenty, cannot be controlled by available means...

Genes Take Charge, and Diets Fall by the Wayside - New York Times

... Dr. Stunkard also pointed out the implications: “Current efforts to prevent obesity are directed toward all children (and their parents) almost indiscriminately. Yet if family environment alone has no role in obesity, efforts now directed toward persons with little genetic risk of the disorder could be refocused on the smaller number who are more vulnerable. Such persons can already be identified with some assurance: 80 percent of the offspring of two obese parents become obese, as compared with no more than 14 percent of the offspring of two parents of normal weight.”

A few years later, in 1990, Dr. Stunkard published another study in The New England Journal of Medicine, using another classic method of geneticists: investigating twins...

...The identical twins had nearly identical body mass indexes, whether they had been reared apart or together. There was more variation in the body mass indexes of the fraternal twins, who, like any siblings, share some, but not all, genes.

The researchers concluded that 70 percent of the variation in peoples’ weights may be accounted for by inheritance, a figure that means that weight is more strongly inherited than nearly any other condition, including mental illness, breast cancer or heart disease...

...The findings also provided evidence for a phenomenon that scientists like Dr. Hirsch and Dr. Leibel were certain was true — each person has a comfortable weight range to which the body gravitates. The range might span 10 or 20 pounds: someone might be able to weigh 120 to 140 pounds without too much effort. Going much above or much below the natural weight range is difficult, however; the body resists by increasing or decreasing the appetite and changing the metabolism to push the weight back to the range it seeks...

...“Those who doubt the power of basic drives, however, might note that although one can hold one’s breath, this conscious act is soon overcome by the compulsion to breathe,” Dr. Friedman wrote. “The feeling of hunger is intense and, if not as potent as the drive to breathe, is probably no less powerful than the drive to drink when one is thirsty. This is the feeling the obese must resist after they have lost a significant amount of weight.”

One reason I think this took so long to be accepted is that the results are a direct attack on the concept of responsibility and free will. In the 1960s and 1970s environment was still thought to be a far more important factor in behavior than mere biology. This was the era when menopausal symptoms were imagined, by feminists, to be socially constructed. In the 1970s 1980s sociobiology emerged, to thunderous denunciation. It had to be renamed 'evolutionary biology' to survive. It wasn't until the 1990s that Americans began to accept that biology is often destiny, and our "soul" or our environment may be much less important than our genes.

We're still processing this "retreat from responsibility", it'll take decades to figure out all the implications. This long journey, I think explains why it took 20 years to recognize what now seems obvious ...

BTW, this data supports use of the ADA to prevent workplace discrimination against obesity ...

The limits of the modern military: occupation is no longer an option?

Since the beginning of the Iraq war, I've felt that three things were under-analyzed:

1. The impact of Turkey's withdrawal on the original war plan. Few now remember that the original plan assumed a massive military contribution from Turkey.
   
   
2. The likelihood that Rumsfeld always assumed Iraq would be partitioned into 3 parts (With US clients keeping much of the oil of course. I suspect Bush was not informed of Rumsfeld's opinion, though Cheney would have been.)
   
   
3. The reality that the US never had a large enough military to occupy (vs. invade) Iraq and that the military knew this from the start.

Phil Carter has written quite a bit about the limitations of the volunteer army, now an article in the June Atlantic provides some more detail on the training and recruitment challenge. I was struck by this number (emphases mine)

The Army We Have

... In the prime age group for recruitment (17 to 24 years old), 7 in 10 are ineligible for military service, Army officials say. More than half the members of this youth cohort are disqualified for moral, mental, or medical reasons: They have had too many run-ins with the law, or they have gang-related or extremist tattoos; they have had psychiatric treatment for severe mental problems or antisocial behavior; or they have been diagnosed with one or more of a staggering list of medical conditions, from heart murmurs to obesity. Other potential recruits have too many dependents, scored too low on the Army aptitude test, or lack high-school or general-equivalency diplomas...

It's a telling number, though on reflection one can see the sense of it. Obesity alone would eliminate many today, and an effective requirement of an IQ above 100 would eliminate about 40% of the population.

Modern warfare demands a lot of human "capital".

I think one historic lesson of the invasion of Iraq may be that a modern military power cannot occupy a nation. In other words, military occupation is not an option -- for anyone.

Has that been much discussed? It seems rather a significant change ...

Patents, copyright and Spider Robinson

Spider Robinson wrote Spider Robinson: Melancholy Elephants in 1983. Wow. I haven't given him enough credit; I can see why it won a Hugo.

He's put it online, though he doesn't tell us how he obtained the copyright to do so (most authors lose copyright when they publish). It's a great illustration of the risks of long lived intellectual property protection, though it's a dramatic work of course. In reality I think humans would adjust to the idea that we aren't really doing new art; several human cultures have embraced the "redo" rather than the novel.

Today I think we feel more the pain of patents than of copyright. Anyone looking at a new enterprise is daunted by the thicket of patent battles ahead, particularly the immense collection of process patents that emerged in the 90s. I'm reasonably sure the vast majority of simple solutions to everyday problems I think of have undeserved process patents.

I'm optimistic the patent monster will be tamed. If nothing else the advent of 3D "printers" (assemblers) will allow hackers to route around the patent block, and will force a rebalancing.

Petraeus: the geek's general

Petraeus says no torture. He surrounds himself with military and non-military intellectuals, and no-one would be shocked if he turned out to vote Democrat (or GOP either, for that matter). Phil Carter likes him.

He's been dealt a major losing hand, but he has vastly more believability than Cheney/Bush. Even if he and his team can't pull off a miracle, we have to hope his career survives his current post.

Apple's MacTel transition: why did they do it?

In 2005 I was pretty sure the Intel transition was really about digital rights management. Well, it's been almost two years, and so far the main hardware/software DRM enforcement (Intel Palladium renamed) are all on the Vista side.

Terrible thought -- could I have been wrong?

Well, the iPhone and 10.5 aren't out yet, so there's still a chance of redemption. If they don't show a Palladium-like hardware/software DRM lock I'll have to admit I was wrong!

Eight lousy years for the market - not just your imagination

Measured in dollar terms the S&P has returned to its 1999 peak. Measured in other ways, the bubble is still pretty flat:

The Big Picture | Looking at the S&P500 (Relatively)

... against the Japanese yen, S&P500 is up 18 percent during this decade. But in British pounds, its down 22%. Even worse, in Euros, the SPX lost a third of its value.

The impact of inflation on commodity prices is even more stark: Compare what a unit of S&P500 bought at the end of 1999 versus today. The S&P500 index buys only 58% as much corn, only 57% as much house (based on the Case-Shiller index) as it used to, only 40% as much Oil, and only 32% as much gold as it did in 1999.

Only 40% as much oil. For most index fund investors it's been a lousy 10 years, reminiscent of the crummy stock markets of the 1970s. Remember when financial planners used to assume 6-8% annual returns? Ahh, those were the days ...

iPhone effect: cell phones do really suck

An investor web site shows the pre-launch effect of the iPhone on cellphone sales and carrier subscriptions. It's an unprecendented effect for an unavailable product that is going to take 1-2 iterations to truly succeed.

The only possible explanation is that today's cell phones suck. It's not just the RAZR, they're all bad. The good ones are gone, and the Treo carries the curse of a dead OS (Vista support in 2008?).

Consumers may not be able to articulate what's wrong with their phones, but they know they're bad. Apple is our only hope.

My Sprint contract expires in October, so I'll have a few months to see how bad iPhone 1.0 will be. I expect it will be pretty flaky, but Apple flaky may be good enough ...

Innovations in back pain management: cold and colder packs

[Update: I had a more extensive post on the same topic in 2005, that one's more complete.]

Every bad back is bad in a different way. Mine puts me down fast, but recovers fast. The key for me is cold [1], cane, and motion. Slap the cold pack on within a minute of an outage, whip out the cane, slug back the ibuprofen, and get moving. (I swear by therapeutic inline skating on day 2, but that's a bit extreme.)

My fundamental accessory is the brilliant Tru-Fit neoprene/velcro wrap that holds one of the four cold packs we keep in the freezer. That patent was well deserved.

There's only one problem. Therapeutic cold packs aren't all that cold, and they're only good for about 20 minutes at a time. They're designed to be relatively safe for persons with impaired vasculature and sensation, particularly diabetics. On the other hand, picnic packs are uncomfortably hard and too cold, not to mention absolutely contraindicated for just about everyone.

So my latest innovation is to double 'em up. A small picnic pack goes on the outside of the pocket, a large therapeutic pack goes on the inside (against my back). The results is just right, and it lasts for over an hour (yeah, I know, you're supposed to use cold for 20 minutes -- I have a lot of experience with this).

Use at your own risk. I guarantee you will develop deep tissue freezing, secondary necrosis, massive muscle loss, disseminated infection, toxic shock, and massive stroke due to multisystem organ failure. You will fester in misery for 20 years draining your family's resources. Don't say you weren't warned.

[1]. I suspect cold therapy doesn't work nearly as well when there's a thick lipid layer involved.

Climate change: the optimist's case

Der Spiegel presents the optimists case for global warming. There's a great deal of spin in the dramatic presentation, the underlying data they reference is pretty conventional. Faster than expected arctic melting, considerable Greenland melting, sea level rise @ 20 inches. The primary difference is they claim current models show less African drought and more American drought, and they discount any diversion of major Atlantic temperature flows.

They seem to be arguing against 'An Inconvenient Truth', which was a dramatization of a worst case scenario, but was based on models of several years old. The worst of the Spiegel article is a muddled implication that warming is good for all existing animal species, which is simply whacko.

I think they're arguing that we don't need to slow CO2 production, but I think the models they reference are based on limiting CO2 output ...

Happy 50th, your brain's myelin is toasty

As if 50 wasn't enough fun already, Future Pundit review current research on demyelination in the aging brain. I don't think this is new, but I've of course forgotten about it. After age 50 or so the brain is increasingly crummy at synthesizing myelin and neurons work less well. The Alzheimer's process may be related, but even if we could prevent that we'll still have flaky myelin.

Oh well.

Product excellence: protect the genius

A former apple executive pays slightly reluctant homage to the gifts of Steve Jobs (emphases mine):

Mobile Opportunity: Apple's industrial design: The value of a decisive bastard with good taste: "

... But the issue's more than just decisiveness vs. bureaucracy. I think Steve Jobs also has very good taste in hardware. I watched the Apple industrial design folks up close for almost ten years, under both Brunner and Jonathan Ive. The groups produced a huge variety of product concepts, ranging from sublime to downright ugly. The bureaucracy pre-Jobs (including, alas, myself) generally picked designs that were nice but prudent -- easy to produce, low risk, not too expensive.

Steve Jobs picks the pretty ones. The ones your average risk-averse business manager would look at and say, "gee, that's nice, but..."

Steve sometimes goes overboard (remember the G4 Cube, a triumph of gorgeous shape over practicality; or the magnesium fetish of the NeXT computer?). And I think his taste in software interfaces isn't as good as his taste in hardware, which is why the current Mac interface is (in my opinion) tarted up like a teenage girl just learning to apply makeup...

Jobs has a very strong aesthetic sense (which is far more than merely "pretty", there's a bit of malice in that word). That's credible, but not useful. CEOs are not selected for that ability. Mace translates this into a very challenging recommendation:

...There is another alternative. Hire someone with good taste, and then back their choices vigorously when everyone else tries to compromise them. Go watch the movie Amadeus. If you can't be a Mozart, be a Salieri -- recognize and use the genius in others...

Ahh, now that's really hard. There are so many reasons this doesn't work. Remember -- Mozart died a miserable death and was buried in a pauper's grave...

This is why great products almost always come from startups, usually reflecting the vision of a handful of creative and committed individuals. The products rarely, if ever, survive long in a public company. (Microsoft Excel being the notable exception.)

Apple's continued ability to create great, innovative products on a semi-regular basis, is almost unprecedented. SONY used to be able to do something similar, but they died 10 years ago. 3M used to have the knack, but they seem to have lost it.

It's extremely hard to keep creative types happy and functional in a corporate setting, reward them for being creative, and keep their vision moving forward. I'd like to read Jobs thoughts on that ...

How to buy a physician - first find someone who agrees with you

I dug this post out of the archives of unpublished posts. I wrote it in 3/07, but the NYT has followed up with a 2nd article today. So I've put them together.
--
In the old days, when you wanted to buy a Senator you slipped them a bag full of money. That still happens I'm sure, but we're more sophisticated now. If Philip Morris wants to buy a Senator, they find who agrees with them (preferably someone stupid, but a smart libertarian will do) and they fund their political career. Chances are they'll still be an idiot even if they're elected, and Philip Morris will have purchased a senator.

Not surprisingly, physicians are just as easy to purchase as Senators -- and cheaper. They're equally likely to deny that they've been bought. This is not new, but now, thanks to my home state, we have numbers (emphases mine). Much of this money will come from small CME programs sponsored by drug companies rather than direct payments. I've done those CME programs, though I probably wasn't speaking about meds. So the money trail is probably less precise than the NYT article implies ...

Doctors’ Ties to Drug Makers Are Put on Close View - New York Times
The New York Times
March 21, 2007
By GARDINER HARRIS and JANET ROBERTS

... payments ... appear in an unusual set of records. They come from Minnesota, the first of a handful of states to pass a law requiring drug makers to disclose payments to doctors. The Minnesota records are a window on the widespread financial ties between pharmaceutical companies and the doctors who prescribe and recommend their products.

The Minnesota records begin in 1997. From then through 2005, drug makers paid more than 5,500 doctors, nurses and other health care workers in the state at least $57 million [jf: over 8 years] Another $40 million went to clinics, research centers and other organizations. More than 20 percent of the state’s licensed physicians received money. The median payment per consultant was $1,000; more than 100 people received more than $100,000.

Doctors receive money typically in return for delivering lectures about drugs to other doctors. Some of the doctors receiving the most money sit on committees that prepare guidelines instructing doctors nationwide about when to use medicines. Dr. Collins, who received more money than anyone else in the state, is among a limited number whose payments financed research.

In dozens of interviews, most doctors said that these payments had no effect on their care of patients...

...There is nothing illegal about doctors’ accepting money for marketing talks, and professional organizations have largely ignored the issue.

But research shows that doctors who have close relationships with drug makers tend to prescribe more, newer and pricier drugs — whether or not they are in the best interests of patients.

“When honest human beings have a vested stake in seeing the world in a particular way, they’re incapable of objectivity and independence,” said Max H. Bazerman, a professor at Harvard Business School. “A doctor who represents a pharmaceutical company will tend to see the data in a slightly more positive light and as a result will overprescribe that company’s drugs.”

In an e-mail message, Dr. Collins said he personally received in 2004 less than $10,000 from Amgen for educational presentations. “The contract amount of $1.9 million from Amgen was paid to the Minneapolis Medical Research Foundation (MMRF) for the research contract, on which I am the designated senior researcher,” Dr. Collins wrote. He wrote that he did not work for or serve on the board of directors of the foundation. Dr. Collins discloses on his Web site and research papers that he is a consultant to Amgen, among other companies.

Dan Whelan, an Amgen spokesman, said the company paid the Minneapolis Medical Research Foundation “to conduct sophisticated research and data analyses that have enhanced the understanding of health care delivery” for kidney patients.

But Dr. Daniel Coyne, a kidney specialist at Washington University, said he was troubled by the payments.

“Amgen’s funding for Dr. Collins’s MMRF is another huge financial connection to individuals at the National Kidney Foundation,” Dr. Coyne said. “The foundation’s recent pro-industry anemia guidelines — and the revisions due next month — have to be viewed with great skepticism.”

... More than 250 Minnesota psychiatrists together earned $6.7 million in drug company money — more than any other specialty. Seven of the last eight presidents of the Minnesota Psychiatric Society have served as consultants to drug makers, according to the Times examination.

After psychiatrists, doctors who specialized in internal medicine garnered the most money, followed by cardiologists, endocrinologists and neurologists...

... In addition to Minnesota, legislators in Vermont, Maine, West Virginia, California and the District of Columbia have passed laws requiring some level of disclosure of drug company marketing efforts. In Vermont, the state has collected three years of data on payments to doctors, but drug makers are allowed to keep the records private by declaring them trade secrets....

...Dr. George Realmuto, a psychiatrist from the University of Minnesota, said most of the marketing associated with his lectures was packaged around his talks.

“It’s at a wonderful restaurant, the atmosphere is very conducive to a positive attitude toward the drug, and everyone is having a good time,” said Dr. Realmuto, who compared the experience to that of buying a car in a glitzy showroom. He earned at least $20,000 between 2002 and 2004 from drug makers.

... Jamie Reidy, a drug sales representative for Pfizer Inc. and Eli Lilly & Company who was fired in 2005 after writing a humorous book about his experiences, said drug makers seduced doctors with escalating financial inducements that often start with paid trips to learn about a drug.

... “You’re making him money in several ways,” said Gene Carbona, who left Merck as a regional sales manager in 2001. “You’re paying him for the talk. You’re increasing his referral base so he’s getting more patients. And you’re helping to develop his name. The hope in all this is that a silent quid quo pro is created. I’ve done so much for you, the only thing I need from you is that you write more of my products.”

...The number of drug marketing presentations delivered by doctors across the United States rose nearly threefold between 1998 and 2006, according to Verispan, a company that tracks drug marketing efforts.

In some cases, consulting doctors are so well recognized that they offer drug makers far more than the chance to influence their own prescriptions. For drug makers, among the most prized consultants are those who write guidelines instructing their peers about how to use drugs...

A prior (harshly titled) post of mine has links to an article that details just how an individual is, slowly, corrupted. The great disappointment for me is how completely the drug companies have infiltrated the standards groups.

The NYT followed up in 5/07 with another article using the same data source, this time focusing on pyschiatrists and their prescription patterns:

... A New York Times analysis of records in Minnesota, the only state that requires public reports of all drug company marketing payments to doctors, provides rare documentation of how financial relationships between doctors and drug makers correspond to the growing use of atypicals in children.

From 2000 to 2005, drug maker payments to Minnesota psychiatrists rose more than sixfold, to $1.6 million. During those same years, prescriptions of antipsychotics for children in Minnesota’s Medicaid program rose more than ninefold.

Those who took the most money from makers of atypicals tended to prescribe the drugs to children the most often, the data suggest. On average, Minnesota psychiatrists who received at least $5,000 from atypical makers from 2000 to 2005 appear to have written three times as many atypical prescriptions for children as psychiatrists who received less or no money...

... Ten years ago, Dr. Realmuto helped conduct a study of Concerta, an attention deficit hyperactivity disorder drug marketed by Johnson & Johnson, which also makes Risperdal. When Concerta was approved, the company hired him to lecture about it.

He said he gives marketing lectures for several reasons.

“To the extent that a drug is useful, I want to be seen as a leader in my specialty and that I was involved in a scientific study,” he said.

The money is nice, too, he said. Dr. Realmuto’s university salary is $196,310.

“Academics don’t get paid very much,” he said. “If I was an entertainer, I think I would certainly do a lot better.”...

I wonder if Dr. Realmuto has any idea how bad that sounds? There is, finally, one hero in the entire series ...

Other psychiatrists renewed Anya’s prescriptions for Risperdal until Ms. Bailey took Anya last year to the Mayo Clinic, where a doctor insisted that Ms. Bailey stop the drug. Unlike most universities and hospitals, the Mayo Clinic restricts doctors from giving drug marketing lectures...

Praise be to the Mayo.

Great series NYT, but lord its bad news for physicians. Psychiatrists, in particular, are supposed to know a bit about how the mind works. Be ashamed, be very ashamed.

Health care reform 2007 - the Massachusetts plan

The discussion begins again. Gawande begins with the assumption that we introduce a new plan without removing the existing system. It's a practical approach.

Curing the System - New York Times
By ATUL GAWANDE
Published: May 10, 2007

....Experts have offered half a dozen more rational ways to finance all this than the wretched one we have. But we cannot change everything at once without causing harm....

...Option 1 is a Massachusetts-style reform.... Enacted statewide last year, the law has four key components. It defines a guaranteed health plan that is now open to all legal residents without penalty for pre-existing conditions. Using public dollars, it has made the plan free to the poor and limited the cost to about 6 percent of income for families earning up to $52,000 a year. It requires all individuals to obtain insurance by year end. And it requires businesses with more than 10 employees to help cover insurance or pay into a state fund.

The reform gives everyone a responsibility. But it leaves untouched the majority with secure insurance while getting the rest covered. As a result, it has had strong public approval. Experience with delivering the new plan is accumulating. And best of all, it offers a mechanism that can absorb change. The guaranteed health plan may cover 5 percent of the state at first, but as job-based health care disintegrates, the plan can take in however many necessary...

The Massachusetts plan seems very much like the Clinton plan, or at least something that would evolve to it. The employer burden is interesting, I assume it's there so employers don't ditch health care coverage en masse.

The "shared responsibility" part sounds like a political slogan. In any event this is consistent with my prediction of how it will all turn out.

Slouching towards world government: the police force

Phil Carter joins a call for an international policing mission...

INTEL DUMP - New articles of interest

... The time has come to develop standing constabulary forces at several levels: U.S., NATO, and U.N. Such a building block approach would allow national and regional operations, as well as global U.N. efforts....

...Policing and crime control skills must be integrated into strategic and operational responses to peace operations and related conflicts that challenge transnational stability. A global framework of standing or composite constabulary forces could fill this need...

Global warming management, global standards for food and drug safety, global police forces, a recent 'parliament of the united nations' meeting... world government is in the air again.