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Title: Blog by Novelist William S. Frankl, MD

Archive for April, 2009

Disappearing Doctors

Tuesday, April 28th, 2009

Here is an important article I want to share with you. It also dovetails with my post of April 20th: MEDICARE FOR ALL. UH, OH.
WSF

SHORTAGE OF DOCTORS AN OBSTACLE TO OBAMA GOALS
by Robert Pear
NEW YORK TIMES, April 26, 2009

WASHINGTON — Obama administration officials, alarmed at doctor shortages, are looking for ways to increase the supply of physicians to meet the needs of an aging population and millions of uninsured people who would gain coverage under legislation championed by the president.

The officials said they were particularly concerned about shortages of primary care providers who are the main source of health care for most Americans.

One proposal — to increase Medicare payments to general practitioners, at the expense of high-paid specialists — has touched off a lobbying fight.

Family doctors and internists are pressing Congress for an increase in their Medicare payments. But medical specialists are lobbying against any change that would cut their reimbursements. Congress, the specialists say, should find additional money to pay for primary care and should not redistribute dollars among doctors — a difficult argument at a time of huge budget deficits.

Some of the proposed solutions, while advancing one of President Obama’s goals, could frustrate others. Increasing the supply of doctors, for example, would increase access to care but could make it more difficult to rein in costs.

The need for more doctors comes up at almost every Congressional hearing and White House forum on health care. “We’re not producing enough primary care physicians,” Mr. Obama said at one forum. “The costs of medical education are so high that people feel that they’ve got to specialize.” New doctors typically owe more than $140,000 in loans when they graduate.

Lawmakers from both parties say the shortage of health care professionals is already having serious consequences. “We don’t have enough doctors in primary care or in any specialty,” said Representative Shelley Berkley, Democrat of Nevada.

Senator Orrin G. Hatch, Republican of Utah, said, “The work force shortage is reaching crisis proportions.”

Even people with insurance have problems finding doctors.

Miriam Harmatz, a lawyer in Miami, said: “My longtime primary care doctor left the practice of medicine five years ago because she could not make ends meet. The same thing happened a year later. Since then, many of the doctors I tried to see would not take my insurance because the payments were so low.”

To cope with the growing shortage, federal officials are considering several proposals. One would increase enrollment in medical schools and residency training programs. Another would encourage greater use of nurse practitioners and physician assistants. A third would expand the National Health Service Corps, which deploys doctors and nurses in rural areas and poor neighborhoods.

Senator Max Baucus, a Montana Democrat and chairman of the Finance Committee, said Medicare payments were skewed against primary care doctors — the very ones needed to coordinate the care of older people with chronic conditions like congestive heart failure, diabetes and Alzheimer’s disease.

“Primary care physicians are grossly underpaid compared with many specialists,” said Mr. Baucus, who vowed to increase primary care payments as part of legislation to overhaul the health care system.

The Medicare Payment Advisory Commission, an independent federal panel, has recommended an increase of up to 10 percent in the payment for many primary care services, including office visits. To offset the cost, it said, Congress should reduce payments for other services, an idea that riles many specialists.

Dr. Peter J. Mandell, a spokesman for the American Association of Orthopaedic Surgeons, said: “We have no problem with financial incentives for primary care. We do have a problem with doing it in a budget-neutral way.

“If there’s less money for hip and knee replacements, fewer of them will be done for people who need them.”

The Association of American Medical Colleges is advocating a 30 percent increase in medical school enrollment, which would produce 5,000 additional doctors each year.

“If we expand coverage, we need to make sure we have physicians to take care of a population that is growing and becoming older,” said Dr. Atul Grover, the chief lobbyist for the association. “Let’s say we insure everyone. What next? We won’t be able to take care of all those people overnight.”

The experience of Massachusetts is instructive. Under a far-reaching 2006 law, the state succeeded in reducing the number of uninsured. But many who gained coverage have been struggling to find primary care doctors, and the average waiting time for routine office visits has increased.

“Some of the newly insured patients still rely on hospital emergency rooms for nonemergency care,” said Erica L. Drazen, a health policy analyst at Computer Sciences Corporation.

The ratio of primary care doctors to population is higher in Massachusetts than in other states.

Increasing the supply of doctors could have major implications for health costs.

“It’s completely reasonable to say that adding more physicians to the work force is likely to increase health spending,” Dr. Grover said.

But he said: “We have to increase spending to save money. If you give people better access to preventive and routine care for chronic illnesses, some acute treatments will be less necessary.”

In many parts of the country, specialists are also in short supply.

Linde A. Schuster, 55, of Raton, N.M., said she, her daughter and her mother had all had medical problems that required them to visit doctors in Albuquerque.

“It’s a long, exhausting drive, three hours down and three hours back,” Ms. Schuster said.

The situation is even worse in some rural areas. Dr. Richard F. Paris, a family doctor in Hailey, Idaho, said neighboring Custer County had no doctors, even though it is larger than the state of Rhode Island. So he flies in three times a month, over the Sawtooth Mountains, to see patients.

The Obama administration is pouring hundreds of millions of dollars into community health centers.

But Mary K. Wakefield, the new administrator of the Health Resources and Services Administration, said many clinics were having difficulty finding doctors and nurses to fill vacancies.

Doctors trained in internal medicine have historically been seen as a major source of frontline primary care. But many of them are now going into subspecialties of internal medicine, like cardiology and oncology.

Stephen Hawking

Tuesday, April 21st, 2009

A terrible bit of news:

Stephen Hawking, the physicist who brought cosmology to the non-scientific public with his best-seller, A Brief History of Time, is “very ill,” according to a hospital spokesperson in Cambridge, England. Hawking is a professor in Cambridge university’s department of applied mathematics and theoretical physics.

Professor Hawking is 67 and has amyotrophic lateral sclerosis (ALS), a progressive  degenerative disease that has left him wheelchair-bound and almost totally paralyzed. The disease is often fatal in about three to five years, but it’s been more than 45 years since the diagnosis was made in Hawking.

Hawking’s research in theoretical physics led to a theorized form of radiation from the perimeter of a black hole called Hawking radiation.  This theory states that black holes gradually lose mass because of this process and eventually evaporate,despite  the fact that the process might take longer than our universe has existed.

Hawking’s research has included the study of: string theory, supergravity, Euclidean quantum gravity, quantum entanglement and entropy, quantum cosmology, cosmic inflation, helium production in anisotropic Big Bang universes, large N cosmology, the density matrix of the universe, topology and structure of the universe, baby universes, Yang-Mills instantons and the S matrix, anti de Sitter space, the nature of space and time, including the arrow of time, spacetime foam, Brans-Dicke and Hoyle-Narlikar theories of gravitation, gravitational radiation, and wormholes.

At a NASA’s 50th anniversary celebration at George Washington University  in a lecture in honour of him, Professor Hawking theorised about the existence of extraterrestrial life in a lecture entitled, “Primitive Life Likely Elsewhere”

We can only hope that Professor Hawking survives this acute illness and returns to continue his enormously important work.

FDA Woes

Tuesday, April 21st, 2009

Here’s a significant essay by an expert on the FDA. It’s worth posting.

––––––––WSF

FDA’s Woes Will Grow Under New Leadership
By Dr. Henry I. Miller

The FDA, which regulates products worth more than $1 trillion — a quarter of every consumer dollar — has over the past two decades become a dangerous impediment to patients’ getting the medicines they need. Drug development costs are up, approvals are down. Reforming a demoralized and chaotic FDA will require leadership that manages competently, is science-driven, is untainted by ideology, and is sufficiently strong to deflect congressional brickbats.

That’s why the Obama administration’s selections for the leadership at the FDA are especially disappointing. Although Dr. Margaret Hamburg, the nominee for commissioner (as the agency head is called), boasts significant experience in government and is highly thought of in the public health community, her new deputy, Dr. Joshua Sharfstein, is an inconceivably poor choice.

The selection of Dr. Sharfstein — who is acting agency head while Dr. Hamburg awaits Senate confirmation — is particularly bad, given that he will reportedly be entrusted with oversight of the most important sector of FDA-regulated products, and is apparently being groomed to head the agency.

FDA commissioner has long been one of the most difficult jobs to fill in the federal government. On most high-profile issues, the incumbent is subject to intense criticism from a number of quarters, and the position has never been a stepping stone to fame or fortune. He or she needs to be equal parts scientist, technocrat, and Lord High Executioner (the latter, in order to keep balky bureaucrats in line).

The new leadership will face the added challenge of addressing the legacy of recent incumbents who imposed excessive and expensive burdens on those trying to bring new medicines to consumers, pushed drug development costs into the stratosphere, damaged agency morale, permitted the drug approval process to become politicized, and allowed drug-safety zealots to dominate agency policymaking and decisions.

The new FDA leadership must also confront a trend — especially among members of Congress and the media — toward vilifying drug companies, and even alleging that regulators have become too cozy with industry. In response, the FDA has battered the pharmaceutical industry with overly risk-averse, burdensome new policies, as well as erratic and dubious decisions on individual products. As a result, Sharfstein will need to establish credibility and rebuild trust with a variety of stakeholders — including drug companies and their investors, patient groups, consumer activists, and members of Congress from both parties.

The probability of that happening approaches zero. Sharfstein has a long history of dubious associations and hostility toward the pharmaceutical industry. While a medical student at Harvard, he led a campaign urging classmates to return textbooks donated by a pharmaceutical company (the project failed — apparently, most of Sharfstein’s classmates were less radical than he). Also, while in medical school, he was an intern for FDA Commissioner David Kessler, whom many consider to be the most disliked and disreputable leader of the FDA within memory. (Kessler, who was unceremoniously fired last year as Dean of the medical school at the University of California, San Francisco, has bragged lately about his close ties to the new FDA leadership.)

Of course, it wouldn’t be fair to predict an official’s future approach to issues based only on his youthful activism, but Sharfstein’s early “us versus them” view of the pharmaceutical industry has persisted throughout his career. He went on to work for anti-drug and anti-industry zealot Sidney Wolfe, and as health policy advisor to Rep. Henry Waxman (D-Calif.), who personifies the divisive approach that castigates and persecutes innovative pharmaceutical companies.

These are difficult times for both the drug industry and its regulators. Leadership at the FDA will demand nuance and the ability to weigh benefits and risks — including the risks of excessive regulation that inhibits innovation and investment in R&D. Federal regulators should not be collaborators with industry, to be sure, but they must cooperate with drug manufacturers in order to get new drugs to patients in a timely and cost-effective way. Sharfstein has shown no willingness to do so, nor does he have any experience with the arcane and high-risk business of developing and regulating prescription drugs.

The aging American population is literally dying for regulatory reform at the FDA — but not the kind that is in store.
Henry I. Miller, a physician and fellow at the Hoover Institution and the Competitive Enterprise Institute, was an official at the FDA from 1979 to 1994. He is the author of To America’s Health: A Proposal to Reform the FDA.

************************************************
Henry I. Miller, M.D.
The Hoover Institution
Stanford University
434 Galvez Mall
Stanford, CA 94305-6010
U.S.A.

Medicare for All. Uh, Oh!

Monday, April 20th, 2009

With the federal deficit rising to astronomical levels, even Congress and Obama realize that all of their plans to “ change” America can’t be done in 100 days or even in 1 year. So, they’re zeroing in on what they think will be the easiest aspect of our lives to “change”–– the establishment of “universal” health care, with a new government insurance plan as the center– piece. What they fail to recognize is that Medicare and Medicaid have forced many physicians to leave these programs because of falling reimbursements, delays in payments, and the paperwork involved, thus reducing a patient’s access to medical care. The Administration will propose ” Medicare for All ” insurance to compete at a lower cost with private insurance plans. As a result, employers will drop medical benefits for their employees, and private insurance companies will flee the medical field, causing large numbers of people (130 million?) to enroll in that government program with all its problems. The effect on the quality of care will be disastrous ––– more and more physicians will opt out and many less doctors will be forced to take care of increasing numbers of patients, young and old, exacerbating an already deteriorating situation.
Today, the quality of our medical care from the scientific and technological standpoint is the best in the world. The problems with our medical care are systemic, not medical ––– the way the system functions economically, structurally, and bureaucratically. Address these first with the major input from physicians and nurses. You don’t ask an economist to design a spaceship, do you?

Jefferson

Wednesday, April 8th, 2009

In light of the present financial crisis, it’s interesting to read what Thomas Jefferson said in 1802. Here are some of his most interesting and incisive quotes:

“When we get piled upon one another in large cities, as in Europe, we shall become as corrupt as Europe. ”
––Thomas Jefferson

“The democracy will cease to exist when you take away from those who are willing to work and give to those who would not.”
––Thomas Jefferson

“It is incumbent on every generation to pay its own debts as it goes. A principle which if acted on would save one-half the wars of the world.”
––Thomas Jefferson

“I predict future happiness for Americans if they can prevent the government from wasting the labors of the people under the pretense of taking care of them.”
––Thomas Jefferson

“My reading of history convinces me that most bad government results from too much government. ”
––Thomas Jefferson

“No free man shall ever be debarred the use of arms.”
––Thomas Jefferson

“The strongest reason for the people to retain the right to keep and bear arms is, as a last resort, to protect themselves against tyranny in government.”
––Thomas Jefferson

“The tree of liberty must be refreshed from time to time with the blood of patriots and tyrants”.
––Thomas Jefferson


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