Citation Impact

Share The US scientific community as ranked by the number of citations for our scientific articles falls behind Italy for 1012.

Our global ranking in the burden of disease studies(GBD) -- ranking us near the bottom -- may be only the tip of the iceberg. As for widely cited scientific papers, we were once far ahead of all other countries, but Switzerland surpassed us in the relative citation impact sometime prior to 2002. The UK followed suit in 2006 and now Italy in 2012. SciVal Analytics of Elsevier did the calculations. We do, however, remain ahead in the share in the top 1% of publications according to a notation in Nature News[1]

Can you doubt that our academic standing has slipped as a result of the exorbitant cost of higher education, or is there something more? Has medical education slipped as well; do physician extenders now practicing on their own, or does alternative medicine have an impact? Osteopathic schools are a growth industry. Hopkins advises medical student applicants seeking family practice to apply to schools of osteopathy. Many schools are back to a curriculum before Flexner paying for community preceptors and in a new wrinkle, standardized patients and semi robotic manikins.

Absent the academic rigorous of scientific education and of the ethical discipline of professional societies, entropy prevails. Has science given way to humanity, or has it given way to expedience?

 [1] |Nature 12 Dec 2013, 504, p192

Protocol-Based Treatment of Hypertension

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Protocol-Based Treatment of Hypertension: A Critical Step on the Pathway to Progress 
Thomas R. Frieden, MD, MPH, Sallyann M. Coleman King, MD, MSc, Janet S. Wright, MD.
JAMA. 2014;311(1):21 doi:10.1001/jama.2013.282615

The undiagnosed and untreated incidence of Diabetes in this country far exceeds that of the rest of the modern World. If the article is to be believed half of us are walking around with BP in excess of 140/90. Are treatment protocols the solution to correcting this burden?

I think not. The problem is not treatment protocols or any treatment, but diagnosis of the hypertension in the first place. Judging by my experience with students, hospitals clinics and offices, the BP cuff is the most neglected and misused instrument in the clinic. The best you can hope for is a very expensive automated BP machine that may or may not be reliable, never mind calibrated. The operator of the auto BP machine likely has minimal training in its use and little or none in the anatomy, physiology and principal of BP readings.

The only reliable BPs readings come from the physician him or herself, the least likely person to waste time on such a mundane thing as vital signs, and even then a cavalier attitude can negate abnormal findings. A good RN will get you good BPs if you give her a good cuff and a mercury manometer, but there too, administrators do not want to waste RN time taking vital signs when it can be done at the lowest cost denominator by an assistant. If a number gets duly recorded. that satisfies the administrator and any auditor that might review the chart.

Can you say why, for instance, you might want to take the BP in both arms or at least in the right arm? Was the patient standing, sitting or recumbent when the reading was taken? Was the cuff the right size; was the stethoscope turned the right way, or was one earpiece of the stethoscope behind the ear of the assistant, or did she bother to take the patient's sweater off?

If any of us, psychiatrists included, profess to practice by the Hippocratic method -- by that I mean total focus on the patient observing every detail -- then the physician must surely examine the pulse, the appearance and the blood pressure. I submit that if half of us are running around with undiagnosed hypertension or pre-hypertension, then half or more of the BP recordings in the patient record are wrong. How long does it take to take a BP and note the patient's pulse? How often do you suppose the assistant fails to note an arrhythmia? There are BP machines outside almost every pharmacy. I have yet to try one that I found believable. The point is that diagnosis of HT will emerge as epidemic if we bother to sit down with our patient, look them in the eye -- not the computer -- and take the pulse and BP ourselves. (Left arm BP may be normal in Coarctation while the Right arm and cerebral circulation reaches high levels.) Protocols are worthless in the absence of the right diagnosis.|

Informed debate over free-market ideas for health reform.

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Academicians and planners often miss the simple fact that health care by any measure is not a free market. Arguably, there is room for debate. There are no winners or losers in this debate except the American people. They are losing. The Global Burden of Disease shows the US some 26^th out of 33 industrialized countries, close to the bottom in nearly every category.

The concept of competition has merit, but a blank check from insurance companies promotes only competition for the dollar return and not for patient care. The intentions are great, but the planners do not see the forest for the trees. Nearly everything they have done has made matters worse. There is no competition between insurance companies, either now or back before the ACA. There is no competition between providers or between institutions either. With insurance company blank checks each provider and each institution is free to charge whatever they like promoting the most profitable services as would any corporate business. There is no incentive for insurance companies to restrict charges because increased charges result in approved increases in policy pricing and thus revenue. All of these players in health care: insurance, institutions, providers and drug companies are, in effect, monopolies. I submit that efforts to enlist the magic of free enterprise merely codify the monopoly and greed from all players including patients.

Competition with cooperation between states is good. There are vast regional differences in health risk and disease. Competition with cooperation between universities is good; it leads to academic excellence and progress. Open competition with cooperation between providers is good because medicine is a science and diversity of effort, inductive reasoning and sharing of data are the scientific method.

Competition for the dollar in a vital public infrastructure is not helpful. Public health is practically dead on the vine in the US due to the favoring of personal liberties over the intrinsic mandate for the public good – health.

The best competition of all would be between the private sector and traditional insurance company medicine. Competing public systems, run state by state, would increase the diversity, the science and the advancement of medicine -- with patient outcome the reward. Medical schools and city or county hospitals once fulfilled some of that role but not now given the Siren call of pre paid insurance and deregulation. These two competing systems are vastly different. Let free enterprise work for the two systems and let the market determine which system dominates. Let both sides give it their best.

This dichotomy is the real debate in Washington. Let the debate play out in the real world as a competition between belief systems with cooperation between both.

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Medical Education

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In reading The Law, it sounds like a formula for today, a Flexner Report[1] from 25 centuries ago, and it would not hurt to reread the Flexner Report either.

          1. Medicine is of all the arts the most noble; but, owing to the ignorance of those who practice it, and of those who, inconsiderately, form a judgment of them, medicine is at present far behind all the other arts. Their mistake appears to arise principally from this, that in the cities, there is no punishment connected with the mal practice of medicine except disgrace, and that does not hurt those who are familiar with disgrace. Such persons are like the figures in tragedies, for as they have the shape, and dress, and personal appearance of an actor, they are only stage dressing, so also physicians are many in title but very few in reality. [They wear the stethoscope around their neck and pretend to the knowledge]
          2. Whoever is to acquire a competent knowledge of medicine, ought to be possessed of the following advantages: a natural disposition; excellent instruction; a favorable position for the study; early tuition; love of labor and leisure. First, a natural talent is required; for, when Nature leads the way to what is most excellent, instruction in the art takes place, which the student must try to appropriate to himself by reflection, becoming an early pupil in a place well adapted for instruction. He must also bring to the task a love of labor and perseverance, so that the instruction, taking root, may bring forth proper and abundant fruit.
           3. Instruction in medicine is like the cultivation of the products of the earth. For our natural disposition is, as it were, the soil. The tenets of our teacher are, as it were, the seed. Instruction in youth is like the planting of the seed in the ground at the proper season. The place where the instruction is communicated is like the air imparted to vegetables by the atmosphere. Diligent study is like the cultivation of the fields. It is time, which imparts strength to all things and brings them to maturity.
           4.  Having brought all these requisites to the study of medicine, and having acquired a true knowledge of the art, we shall thus, in travelling through the cities, be esteemed physicians not only in name but in reality. However, inexperience is a bad treasure, and an empty purse to those who possess it. Whether in opinion or reality, being devoid of self-reliance and competence, fosters both timidity and audacity. For timidity betrays a want of powers, and audacity a lack of skill. There are, indeed, two things, knowledge and opinion, of which the one makes its possessor truly to know, the other to be ignorant.
           5. Those things, which are sacred, we must impart only to sacred persons, and thus it is not lawful to impart them to the profane until they have been initiated in the mysteries of the science.

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[1] Flexner Report is a book-length study of medical education in the United States and Canada. , written by the educator Abraham Flexner and published in 1910, sponsored by the Carnegie Foundation. Flexner lived 1866-1959. Flexner reformed medical education in the United States; he also helped found the Institute for Advanced Study in Princeton. Many aspects of the present-day American medical profession and educational system stem from the Flexner Report.

 

Dianostic Error

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The clinic dutifully followed the instructions for "E" codes, workman compensation codes. It was a simple fracture of a finger. When the response, with payment, came back, the diagnosis listed was gonorrhea resulting from a fall from aircraft.

Who is to say how this error occurred. Was it the insurance clerk exercising humor, a mistaken entry, a change in code numbers by the commission or an error in theirs or our computer.

Unfortunately, the above is not the only source of spurious diagnosis. In many cases the insurance clerk faced with, looking up the proper ICDA code from the clinician's notes, picks the one that justifies the laboratory and treatment ordered. She does so in  order to receive remuneration -- her responsibility. Even when the clinician lists the appropriate ICDA, the clerk may likely change it in order to met the criteria for payment. This manipulation of diagnostic code might be considered fraud. On the other hand, the clinic provided an honest service, rendered a diagnosis that may not exactly fit the codes and criteria. The clerk is fulfilling her duty to the clinic, the coding system and the patient. The clinic is therefore resolving ambiguities in good faith. However, the coded diagnosis may not accurately reflect the diagnosis for the patient.

Moreover, many clinicians are reluctant to record any diagnosis that the insurance company can call a preexisting condition. A noble concern, but one that erodes the acknowledgement of  early risk or the identification of incipient disease.

When one adds to these sources of erroneous diagnosis and the all to frequent missed or wrong diagnosis, there results a database of demographics and diagnosis that is corrupt from the start. A system of confirmed diagnosis might help.

Will the ACA or the EHR eliminate these sources of error? Probably not, the patient confidentiality issue remains. Even though the insurance company may no longer be able to deny preexisting conditions, the patient information is none the less in their database. The draconian rules limiting access to patient data makes it difficult for clinicians to coordinate care or the patient to access his or her information; whereas the system makes the information readily available to insurance companies and government. If Equifax wants to know if you have HIV, they are going to find out.

Lastly, how do you know that the diagnosis is correct even at best. Autopsy results find as much as 60% missed or wrong diagnosis. That is not to say that missed or wrong diagnosis occurs 60% of the time, but among patients who die, the missed or wrong diagnosis may be critical information. Shamefully, autopsy is a thing of the past. Blame it on families, fears of litigation, cost or hospital inconvenience, a revenue issue.  Autopsy is the final analysis, but who will pay for it?

Undiagnosed Hypertension

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|With 36 million estimated cases of uncontrolled hypertension, 14 million of whom are unaware and undiagnosed, there exists a target rich environment for the life saving diagnosis of hypertension.

Why should this be when most of these people visit clinics and doctor's offices, but remain unaware? A small number suffer the rather high threshold some doctors set for the diagnostic criteria for hypertension. The majority, however, represent a negligence in both the taking of blood pressures and the recording of the results stemming largely from cost cutting and sheer boredom.

Very few assistants know how to take a blood pressure. Rather than teaching them the right way and training them to a level of competency, accuracy and consistency, they are turned loose either with superficial knowledge or with an automated blood pressure cuff and recording instrument that may or may not be accurate and is still dependent on the assistant's ability to use the instrument correctly. If a clinician wants to treat more patients that are appreciative and save lives, the clinician would be well advised to take blood pressures his or herself.

Mechanized BP apparatuses notoriously give spurious results even the most expensive in the wrong hands. Moreover, what good is an automated cuff in the hands of a physician; he or she might rather use a mercury manometer and be certain. Today's hurried schedules with highly discounted reimbursements lead to a focus on a single problem. Ancillary abnormal findings get overlooked or discounted as probably in error. Sad but true, this happens and what more relevant condition can there be than the early diagnosis of hypertension along with the appropriate workup for underlying causes.

A proper BP reading requires an appropriate size cuff, a mercury manometer, and a stethoscope. The cuff should go first to the right arm in order not to miss Coarctation of the Aorta. The patient must fully extended the arm and raise it to chest level. The assistant must palpate a strong pulse placing the bowel of the stethoscope over the pulse while pumping the pressure to a safe level above the audible pulse, approximately 200 mm. Open the valve only a little so that the pressure drops slowly. Record the pressure for the first audible pulse, a rather distinct and abrupt point, easy to determine. Continue listening as the pressure falls. Record the first abrupt weakening change in sound and continue listening until no sound is heard recording that number as well. In some patients, there will be only one clear disappearance of sound while in others there are two changes to consider for the diastolic pressure, record them both. With only borderline BP, take another reading and do so for both arms. Record all readings such as 120/80-70 RA sitting. Include the position of the patient as well as the arm or leg. Always take multiple readings if pressure is above 120/70 and if above 140/90 take BP in one of the legs using a large cuff. Relegate BPs to only well known and trusted nurses and check even that during your physical exam. Take the patient’s pulse yourself as well; both make interesting conversation during your exam and lead to relevant system review questions.

The JAMA article below speaks of treatment protocols, but the diagnosis and workup come first. A treatment protocol may unerringly select the right treatment for the statistically average American patient but miss completely the appropriate treatment for the patient sitting before you. Many other conditions influence the choice of medications for treatment.

http://jama.jamanetwork.com/article.aspx?articleID=1778410&utm_source=Silverchair%20Information%20Systems&utm_medium=email&utm_campaign=JAMA%3AOnlineFirst11%2F14%2F2013

 

What Diagnosis?

Share | In the early nineteen sixties Larry Weed promoted the problem oriented medical record (POMR) in order to focus physicians on all of a patient's problems rather than focusing mainly on the chief complaint. No doubt the problem oriented approach was a systems improvement resulting in an improvement in medical care. Indexing all of the problems on a list with dates and resolutions made better sense of the patient record. The POMR was widely accepted but usually implemented in a mixture of the traditional source oriented medical record and the system promoted by Larry Weed. A medical school may title the teaching as POMR and then proceed to teach source oriented history taking with a chief complaint and a problem list.

Some complain that the POMR tends to focus on treating problems whilst ignoring diagnosis. Indeed, medical records and reimbursement documents force a qualifying diagnosis, but anyone wrestling with the ICDA diagnostic codes knows that a diagnosis can be written at various levels, four digits or five digits. For example are we treating cough, community acquired pneumonia or pneumonia due to a specific organism? The list is  long and reflects historical diagnoses based on gross findings. A physical diagnosis without regard to the bio-molecular underpinnings may be based on the problem list. For example: gastritis, hypertension, pneumonia, colitis, arthritis, arrhythmia, etc. 

The qualifying diagnosis for the guidelines may not accurately reflect the true underlying condition.

GBD omissions

Share | What about TB and Malaria? Christopher Dye and Mario Raviglione point out that GBD did not include TB. They call for a broader range of disease determinants for future studies.[1] One might also point out the omission of Malaria. TB and Malaria are the two most widespread and lethal diseases. TB especially could once again take hold in the US due to the concurrence of HIV and the emergence of TDR-TB, totally drug resistant organisms.

"This proposal goes beyond TB: for many causes of ill health, an unidentified risk is a missed opportunity."
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Nature 502, 10 Oct 2013 Perspective, Weigh all TB Risks, Tuberculosis Outlook, S 13

Lim, s. s. et al Lancet 380, 2224-2260 (2012)

Global Burden of Disease (GBD) ranking

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JAMA published a seminal investigation documenting the Health of America compared to other developed countries broken down by disease, risk factors, morbidity and mortality. The massive undertaking involved hundreds of collaborators in thirty-four countries and some highly sophisticated statistics comparing the burden of disease. The report here includes the developed countries participating in the Organization for Economic Co-operation and Development.  The State of US Health, 1990-2010, Burden of Disease, Injuries and Risk Factors appears in the August 14 issue of JAMA.[1] If you have any interest in the shortcomings of our health care system or the health of our own human resource, you should read this landmark study.

Harvey Fienberg’s editorial on page 585 observes the decline in the US standing among developed nations.  Herein, “results for the United States are presented in detail for the first time.”  The statistics utilized in the study were extremely complex and all inclusive. However, Fienberg points out the fact that socioeconomic s was not included as a risk factor in this study.  The collaborators agree. The difficulty was in equating socioeconomics across the many cultures in the thirty-four nations that took part in this study. The editorial further reminds us of the well-established fact that socioeconomic status relates strongly with mortality[2] Fienberg further observes that the assessment for the US as a whole does not account for significant regional differences. On the plus side, the editorial suggests that the framework for assessing the burden of disease is scalable and applicable to states, counties and municipalities.[3]
The statistical terms used in this study include:  Years of Life Lost due to premature mortality (YLL), Years Lived with Disability (YLD), Disability Adjusted Life Years (DALY), which combines YLL and YLD and, Healthy Life Expectancy (HALE). The article compares these attributes in the thirty-four countries between 1990 and 2010. This monumental study goes beyond all previous reports by including risk factors for disease. In 2010 in the US the big eight YLL were in order: Ischemic heart disease, lung cancer, stroke, COPD, road injury, self-harm, diabetes and cirrhosis. The first eight YLD, however, were:  Low back pain, major depression, other musculo-skeletal, neck pain, anxiety disorder, COPD, disorders resulting from drug use, and diabetes.

The diseases causing premature mortality, YLL, differed dramatically from those causing morbidity and disability, YLD. However, the risk factors underlying the leading causes for both YLL and YLD diseases were almost the same. The list of risk factors included: Dietary, tobacco, HBP, high BMI, physical inactivity, high serum glucose, ambient particulate pollution, alcohol, drug use and high cholesterol.

The figure 4 illustration on page 604 reflects the US’s low YLL ranking compared with the thirty three other countries. The US is 7th from the bottom following the Check Republic and Chile in overall ranking. Our ranking by the raw longevity score, infant mortality and perinatal mortality reported elsewhere[4] are even worse.[5] The US comes in 38th in both longevity and infant mortality. The perinatal mortality rates are even worse.[6]

Figure 4.

Rank of Age-Standardized YLL Rates Relative to the 34 OECD Countries in 2010
Numbers in cells indicate the ranks of each country for each cause, with 1 representing the best-performing country. Countries are sorted on the basis of age-standardized all-cause years of life lost (YLLs) for 2010. Diseases and injuries contributing to YLLs are ordered by the difference between the US rate and the lowest rate in the Organization for Economic Co-operation and Development (OECD) countries for each cause. Colors indicate whether the age-standardized YLL rate for the country is significantly lower (green), indistinguishable (yellow), or higher (red) from the mean age-standardized YLL rate across the OECD countries. HIV indicates human immunodeficiency virus.[7]

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[1] JAMA,2013;310(6):591-608. Doi:10.1001/jama.2013.13805
     Lim, S. S. et al Lancet 380, 2224-2260 (2012)
[2] National Research Council; Institute of Medicine. US Health in International Perspective: Shorter Lives Poorer Health. National Academies Press; 2013
[3] Katz B. Bradley J. the Metropolitan Revolution. Brookings Institution; 2013
[4]  http://www.enagic.com/enagic_life.php
[5] http://data.worldbank.org/indicator/SP.DYN.IMRT.IN
[6] http://whqlibdoc.who.int/publications/2006/9241563206_eng.pdf
[7] Figure 4 reproduced with permission JAMA RightsLink and Copyright Clearance Center Aug 14 JAMA, Christopher Murray et al; Copyright © 2013, American Medical Association

 

Virus vs Bacterial Respiratory Infection

Share |Science Translational Medicine reports an RT-PCR that can distinguish a viral pneumonia from a bacterial pneumonia. Christopher Woods and Geoffrey Ginsburg at Duke claim that the assay monitors  human genes that react differently to viral disease than to a bacterial infection. 
Based on a trial of 102 patients with fever and respiratory symptoms, the test showed 94 percent sensitivity and 89 percent specificity.
PCR might be an expensive test at the clinical level. It would be nice to run such tests as a routine if the small clinical lab can have the technology without involving big pharma patents.
With the new terminology for basilar rales, namely "crackles," one might expect the new physician to be confused over the identification of the subtle left lower lobe sounds which sound nothing like crackles. The PCR might help and more so for upper respiratory infections. Professor Kemp once told me as a resident on pediatric rotation that I was treating an upper lobe pneumonia with a lower lobe antibiotic. It won't hurt to look at the gram stain either.
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Sci. Transl. Med. 5 203ra126 (2013)

Malaria Vaccine

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Science, Aug 8, 2013, DOI: 10.1126/science.124800, reports a new highly successful Malaria vaccine. Stephen Hoffman's intravenous (IV) vaccine consists of live attenuated plasmodium falciparum sporozoites -- labeled pfspz.

In a group of volunteers given four or five intravenous injections of the vaccine: 0/6 of the volunteers receiving five injections contracted malaria when later inoculated (p=0.018); 3/9 of the volunteers given only four injections (p=0.028); and 5/6 of the untreated volunteers contracted malaria. Despite the small population, the results were significant.

Prior experiments had shown that multiple mosquito bites by infected but radiated Mosquitos induced immunity. Hoffman took the process forward in employing numbers of radiated sporozoites. Sub-cutaneous injections did not work well, but the intravenous injections did.

Logistics in Africa may pose a problem in that the vaccine requires delivery in liquid Nitrogen containers. The IV dosing may not be so difficult because the volume is quite small, but getting patients back for four more injections likely will be. The authors suggest including the malaria vaccine along with other routinely delivered frozen veterinary products as a feasible avenue. Go.nature/mae5tu has a helpful summary on the background development of the vaccine.

Prior malaria vaccination attempts proved only slightly effective. Malaria remains, despite slow improvement, the number one killer worldwide with deaths estimated by WHO to be between 490,000 and 836,000 in 2010 and cases worldwide between 154 million and 289 million.

Global warming may once again result in Malaria's spread to northern regions, as p. vivax did in the first half of the twentieth century as far north as Archangel, Russia. (Lat: 64.5333)

The emergence of an effective vaccine comes at a good time. It remains to be seen if the vaccine works on other than the p. falciparum variety and on young children.

Under Diagnosis

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Even when we have the right diagnosis, the underlying cause is often ignored. This is a trend in part driven by economic expediency and the over simplification of practice guidelines. Better to just call it congestive heart failure, CHF, and forget the meriode of complex causes. The same can be said of valvular disease, arrhythmias, chronic kidney failure etc. How many times do we change the acronyms and theories of pathophysiology?  As we discredit each theory, we replace it with another one on equally shaky ground. Does obesity cause diabetes or does diabetes cause obesity? Does sleep apnea cause cardiovascular disease or does cardiovascular disease cause sleep apnea? When you cannot find anything wrong with the complaining patient, is it in her head, or is she suffering from environmental and genetic factors that are pulling her apart? Who is to say that the controlled study today is any better than the one done in the fifties?

Medicine is on the cusp of a breakthrough in knowledge. Genomics and proteinomics offer new understanding of etiology that will change much of what we think we know.  Even then, the theories will be a moving target. No wonder, faced with these vagaries, those who would presume to write standards of best evidence look for the four-digit diagnosis.

Disease is a mal adaptation to the environment. If you look at it that way you open a Pandora’s Box of considerations, but that is the art of medicine. If we continue to promote simplified guidelines for diagnosis and treatment, we reduce the physician to a technician. There are those who consider such standardization a good thing from the viewpoint of highly efficient industrial practices. One has to ask one’s self, can medicine be privatized and run like IBM with industrial standards of efficiency and performance, or does the patient suffer from an over simplification?

I want my doctor to open Pandora’s box looking for all the underlying causes.

Adult Onset Diabetes and Obesity

Share |Until legislators put the common good ahead of their fast food lobbyests and get sugars out of the packaged food supply, our only defence against the out of control epidemic of diabetes and obesity stems from early detection and agressive treatment. 

Unfortunately the current standard limits detection of diabetes to fasting blood sugar tests, and initial treatment to oral hypoglycemics. Juvenile diabetes is another matter, but protocals call for adult diabetes that does not respond to first line hypoglycemics to be treated by adding more powerful oral hypoglycemics. This polocy based on so called best evidence codifies the too little too late axium of treatment.

Early detection and early treatment will greatly reduce the mortality and morbidity of adult diabetes, but fasting blood sugars detect the disease long after the disease has damaged other organ systems. The damage results from the high osmotic pressure acompaning higher glusecose levels, like a storm front moving throughout the vascular system and extracellular fluid compartment damaging basement membranes and connective tissue.

In order to get a handle on the control of adult diabetes and obesity too, one needs the concept of pre-diabetes to catch the disease before it mets the current criteria for diagnosis. A hemaglobin A1c will help with an earlier detection. HbA1c measures the glucose on red blood cells. Red blood cells have an average life of 120 days in circulation; therefore, testing today measures the average high points of circulating glucose over that time span. The follow up diagnosis of pre diabetes might beter be with a 5 hour glucose tolerence test.

Interestingly, the first signs of diabetes seen in the clinic often include arcus senilis, A-V nicking, obesity or polyuria. Such is a testimony to our lack of rational preventive medicine guidelines.

The patient can often reverse pre-diabetes with diet and exercise. Failing that one might better turn to small doses of regular insulin before meals rather than oral hypoglycemics. Patients want a pill in order to perpetuate a denial of the disease or a denial of their obesity. The only way to overcome that resistance is by education. Here again the advertising by the drug companies for mor powerful and more toxic oral hyperglycemic medications works against us. If the physician believes in tight control and is passionent about it, that entheusiasm and passion can be transmited to the patient. 

Most endocrinologists and many internists urge treatment of adult onset diabetes with regular insulin or equivalent. Not the long acting kind but fast acting physiological insulin before meals.

I learned this technique and philosophy over fifty years ago in medical school. Why is knowledge forgotten? That may be another question. To the point, my clinic diagnosed pre diabetes and treated it aggressively with diet and exercise. HbA1c at frequent intervals identified early advances in the disease. We were very successful with the pediatric subcutaneous fine needle attached to thin tubing and a push button fountain pen like measured delivery device.

Patient compliance depends on patient education and an agreed upon strategy to protect vital organs and extend life expectancy. Life style changes come  easy when you have a needle in place as a reminder. It works.

With regard to the oral hypoglycemics, some have a use, but most are the promotion and advertising product of drug companies valorized by lobbying and tainted publications -- and yes the protocols of best evidence as well. Again early diagnosis is the key. Modern medicine lacks sufficient emphasis on diagnosis.

Diagnosis and the Physician’s Laboratory

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The curriculum renewal committee of the University Of Washington School Of Medicine[1] offers suggestions for curriculum changes that would enhance the numbers of graduates choosing a primary care specialty. Notably the report did not mention the issues of prestige nor the availability and training in the use of diagnostic tools for a primary care setting.

From a clinical viewpoint primary care is more of a science not less of one than the other more limited specialties. The training and clinical tools should match the challenge and they do not. Medical students need both the tools and the training to do serious diagnostic studies. Contrary to the image of a doctor making a snap diagnosis wherein the only problem is the treatment protocol, diagnosis is multifaceted and no simple matter. Multiple conditions, individual patient constitution, and multiple layers of symptoms compound the challenge. Many studies suggest a high percentage of missed and wrong diagnoses, 35.8% in this study.[2] We use to have the autopsy as a final arbitrator of diagnosis but no more. Autopsy has gone out of style; it is not profitable enough. Some medical schools have abandoned the microscope in favor of digital images in training. The microscope, however, remains one of the most essential diagnostic instruments. Today’s microscope should provide polarized light, dark field and fluoroscopy. This is realtime microbiology.

Historically, medical science advanced through the evolution of diagnostic tools and techniques. First, there was the autopsy, then the stethoscope, and the microscope, then statistics, the x-ray machine, ultrasound and more recently bio-molecular science. Today, hospitals excuse the autopsy with reliance on the CT scan. Largely the CT scan replaces the plain old x-ray. This is not progress. Today the stethoscope hangs around the neck unused. Offices send out most lab work, either to a reference lab or to the hospital. It should be obvious that the primary care doctor needs a small clinic version of all of the basic diagnostic tools and some that exist only in research labs. Basic equipment should include ultrasound, microscope, x-ray, and the skills to go with them. Looking to the future, the primary care physician needs to link current clinical research with his or her practice, especially in statistics and genomics. Polymerase Chain Reaction (PCR)[3] should find common use in the clinic; students should have enough undergraduate experience in proteinomics to manage it.

Many frustrations to the practice of good medicine come from outside the profession. These distortions, accepted as the way things are, limit both the role of the physician and his or her ability to diagnose conditions at hand. For instance, EPA limits a physician from conducting many laboratory tests in the doctor’s office, or requires burdensome licensing and exemptions.[4] While well intended to improve quality and control costs, it does the opposite. One fear suggests that physicians do laboratory studies because they produce more revenue. Perhaps some do, but the unintended consequence denies access to simple inexpensive tests. These tests done in realtime, while the patient is present, save time, save money and improve outcome. A trip to the hospital, results in delay and a much more expensive procedure. I cannot imagine a physician doing a gram stain, a peripheral blood smear, stool, a urine sediment, a sedimentation-rate or a culture and sensitivity for the money; although, payment for these services must cover the cost of time and equipment. Some of the tests are time and space sensitive with unstable chemicals and fragile structures. These further limitations also argue for on site availability in rural clinics.

The same argument can apply to office x-ray. The office machine requires the same inspections and calibrations as in the hospital. The machine may be identical. One does not have to use much imagination to see a political undercurrent persuading legislators that everything must be done in the hospital. Unfortunately, hospital profit motivates the lobbying.

In 1998 while on the Board of Directors of the South Peninsula Hospital, I attended a dinner seminar set up by the network of Alaska hospitals including legislators presumably for educational purposes. It had only begun when it became evident that this meeting had the primary agenda of promoting a bill prohibiting office x-ray machines. The program presented undocumented evidence that office x-ray machines were sub substandard and hazardous while hospital machines were new and operated by licensed technicians. Presenters built a case for eliminating office x-ray machines in favor of securing all x-ray business for hospital radiology units. I was sitting at a table next to Senator Murkowski. He turned with a questioning look. I simply compared the cost of flying a patient from a native village to an Anchorage hospital for an x-ray of the chest in order to assess a clinical pneumonia. The unfavorable cost and the poor medical treatment of a time sensitive illness delayed by a trip to the hospital were obvious. The bill did not pass. In today’s environment, a hospital x-ray becomes a CAT scan. The cost is a hundred fold greater and the information only marginally better. The accumulated CT radiation expositor falls into the danger zone.[5] Students should learn the physics of radiology, quantum physics and participate in research for the newer less toxic photonics.

In short, the primary care doctor should be educated as a scientist in the tradition of the great physicians, past and present. He or she needs the tools of science and of diagnosis and be expert in their use. One wonders, just what is the character we strive towards in a primary care physician? Do we want a doc who is indeed a scientist with the humanity of Hippocrates? Or, do we want a Feldsher with an unused stethoscope hanging indolently around the neck?

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[1] http://www.uwmedicine.org/Education/MD-Program/curriculum-renewal/Working-Groups/Documents/Report-Primary-Care-April-2013.pdf

[2] http://archinte.jamanetwork.com/article.aspx?articleid=1656540

[3] http://en.wikipedia.org/wiki/Polymerase_chain_reaction

^[4]  Clinical Laboratory Improvement Act (CLIA) 1988 http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c16.pdf

^[5] http://radiology.rsna.org/content/251/1/175.abstract

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Anthracimycin

Share |found in deep ocean sediment from streptomyces. Bacteria, anthracimycin appears to be effective against MRSA and Anthrax. Watch for more.

Rural General Practice

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Conventional wisdom states that we have a shortage of physicians and more is better. A more careful look suggests that the problem is more of a mal distribution of physicians. We suffer a scarcity of primary care physicians. We need more of them in rural communities. Medical educators face both of these problems. The solutions are difficult without better insight into the challenges of both primary care and rural practice. The first problem is lumping pediatrics, internal medicine and family practice into the same category with family practice. Even OB/GYN wants to be considered primary care for women which adds to the confusion. General practice is still general practice. Calling it family practice as a specialty does not make it a specialty and therein lies a problem with identity, prestige and self image. Medical students soon sense this disparity. Thinking of it, however they may, students choose the specialties, and that perpetuates the problem with both distribution of health care and the competence level of those who do choose general practice or family practice. The intellectual filter works against both distribution and competence in rural areas.

Then what is the solution? Sadly, the one that prevails is the formation of a sub prime provider who acts as more of a technician following protocols and algorithms. He or she is glad for the opportunity, and works semi supervised in structured, mostly in public health or native corporation clinics in a team setting. On the surface this sounds good. The problem is in recognizing critical problems that do not fit the protocols and the distance to a center that handles the more difficult case. In reality practicing in any kind of isolation without multi specialty support requires more of a supper physician, rather than a lesser one.

The steps towards motivating the better talented physicians to undertake a rural practice from a clinical viewpoint are several. First, there must be prestige and assured remuneration sufficient to attract the best physicians and their families to live in a rural community. Forgiveness of medical school debt and tuition will not cut it. The only way I see to accomplish these two things is to extend the residency program to four or five years with extensive time spent in the various specialties to the extent of gaining a core competency in each and with extensive clinical experience in each. In addition these young doctors need the basic tools of genomic and proteomic research, biotechnology, computational biology, epidemiology, public health and bioinformatics leading to a PhD. In other words a supper physician. 

Having created a physician for all seasons, the rural practice clinic must match the capabilities of this now highly trained generalist. Here is where government in partnership with the university and the clinician can achieve what the one cannot. The university can focus its considerable computational, statistical, bioengineering, business and law capacities to create a state of the art network of rural clinics in not just a few but all of the underserved areas of the state. The university can additionally provide nursing, student, intern and resident support. The government presumably the state government must provide adequate funding for construction and implementation with the expectation of a payback from Medicaid and Workman's Compensation services more adequately and affordably provided. The physicians would be salaried giving their families an assurance of income and additionally receive a percentage of the fee for service clinic income. 

Such would be a partnership in which each participant contributes and gains more than any one of them acting alone. Underserved communities and all parties benefit.

Diagnosis and the Physician’s Laboratory

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The curriculum renewal committee of the University Of Washington School Of Medicine[1] offers suggestions for curriculum changes that would enhance the numbers of graduates choosing a primary care specialty. Notably the report did not mention the issues of prestige nor the availability and training in the use of diagnostic tools for a primary care setting.

From a clinical viewpoint primary care is more of a science not less of one than the other more limited specialties. The training and clinical tools should match the challenge and they do not. Medical students need both the tools and the training to do serious diagnostic studies. Contrary to the image of a doctor making a snap diagnosis wherein the only problem is the treatment protocol, diagnosis is multifaceted and no simple matter. Multiple conditions, individual patient constitution, and multiple layers of symptoms compound the challenge. Many studies suggest a high percentage of missed and wrong diagnoses, 35.8% in this study.[2] We use to have the autopsy as a final arbitrator of diagnosis but no more. Autopsy has gone out of style; it is not profitable enough. Some medical schools have abandoned the microscope in favor of digital images in training. The microscope, however, remains one of the most essential diagnostic instruments. Today’s microscope should provide polarized light, dark field and fluoroscopy. This is real-time microbiology.

Historically, medical science advanced through the evolution of diagnostic tools and techniques. First, there was the autopsy, then the stethoscope, and the microscope, then statistics, the x-ray machine, ultrasound and more recently bio-molecular science. Today, hospitals excuse the autopsy with reliance on the CT scan. Largely the CT scan replaces the plain old x-ray. This is not progress. Today the stethoscope hangs around the neck unused. Offices send out most lab work, either to a reference lab or to the hospital. It should be obvious that the primary care doctor needs a small clinic version of all of the basic diagnostic tools and some that exist only in research labs. Basic equipment should include ultrasound, microscope, x-ray, and the skills to go with them. Looking to the future, the primary care physician needs to link current clinical research with his or her practice, especially in statistics and genomics. Polymerase Chain Reaction (PCR)[3] should find common use in the clinic; students should have enough undergraduate experience in proteinomics to manage it.

Many frustrations to the practice of good medicine come from outside the profession. These distortions, accepted as the way things are, limit both the role of the physician and his or her ability to diagnose conditions at hand. For instance, EPA limits a physician from conducting many laboratory tests in the doctor’s office, or requires burdensome licensing and exemptions.[4] While well intended to improve quality and control costs, it does the opposite. One fear suggests that physicians do laboratory studies because they produce more revenue. Perhaps some do, but the unintended consequence denies access to simple inexpensive tests. These tests done in real-time, while the patient is present, save time, save money and improve outcome. A trip to the hospital, results in delay and a much more expensive procedure. I cannot imagine a physician doing a gram stain, a peripheral blood smear, stool, a urine sediment, a sedimentation-rate or a culture and sensitivity for the money; although, payment for these services must cover the cost of time and equipment. Some of the tests are time and space sensitive with unstable chemicals and fragile structures, so inaccuracies accrue when the specimen is sent out.

The same argument can apply to office x-ray. The office machine requires the same inspections and calibrations as in the hospital. The machine may be identical. One does not have to use much imagination to see a political undercurrent persuading legislators that everything must be done in the hospital. Unfortunately, hospital profit motivates the lobbying.

In 1998 while on the Board of Directors of the South Peninsula Hospital, I attended a dinner seminar set up by the network of Alaska hospitals including legislators presumably for educational purposes. It had only begun when it became evident that this meeting had the primary agenda of promoting a bill prohibiting office x-ray machines. The program presented undocumented evidence that office x-ray machines were sub substandard and hazardous while hospital machines were new and operated by licensed technicians. Presenters built a case for eliminating office x-ray machines in favor of securing all x-ray business for hospital radiology units. I was sitting at a table next to Senator Murkowski. He turned with a questioning look. I simply compared the cost of flying a patient from a native village to an Anchorage hospital for an x-ray of the chest in order to assess a clinical pneumonia. The unfavorable cost and the poor medical treatment of a time sensitive illness delayed by a trip to the hospital were obvious. The bill did not pass. In today’s environment, a hospital x-ray becomes a CAT scan. The cost is a hundred fold greater and the information only marginally better. The accumulated CT radiation expositor falls into the danger zone.[5] Students should learn the physics of radiology, quantum physics and participate in research for the newer less toxic photonics.

In short, the primary care doctor should be educated as a scientist in the tradition of the great physicians, past and present. He or she needs the tools of science and of diagnosis and be expert in their use. One wonders, just what is the character we strive towards in a primary care physician? Do we want a doc who is indeed a scientist with the humanity of Hippocrates? Or, do we want a Feldsher with an unused stethoscope hanging indolently around the neck?

---

[1] http://www.uwmedicine.org/Education/MD-Program/curriculum-renewal/Working-Groups/Documents/Report-Primary-Care-April-2013.pdf
[2] http://archinte.jamanetwork.com/article.aspx?articleid=1656540
[3] http://en.wikipedia.org/wiki/Polymerase_chain_reaction
[4] Clinical Laboratory Improvement Act(CLIA) 1988 http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c16.pdf
[5] http://radiology.rsna.org/content/251/1/175.abstract