MSNBC has this take on the suit - a bit more and different information AARP sues over drug prices

You get your first clue when they call it "boutique" medicine. You get your second clue when you note that a journalist and economist are writing. As you read their letters, you understand that they are clueless. These letters miss the point completely. The esteemed Dr. Uwe Reinhardt states

Boutique medicine in the United States can be interpreted as a desperate attempt by some doctors to keep the income ratio at 5.5 or above; it is unlikely to be a genuine attempt to provide patients with health care of a higher quality. If quality of care was doctors' main concern there is so much they could do.

Interesting article on the prediction of soccer injuries. Expanding this research to a variety of sports might help us understand sports injury prevention. I hope someone combines golf swing videos with a tool like this - Computer predicts sports injuries

The charges for prescriptions remain outrageous, and get worse every year. Internsits and family physicians have to spend time figuring out which combination of drugs the patient can afford, or fill out drug assistance plans (if the patient is poor enough). I understand capitalism; I understand the need for research; I don't understand the audacity of the pharmaceutical companies. Now they have AARP after them, that might be the ticket - AARP Joins Three Lawsuits Against Large Drug Companies

Beans without flatulence - what will they think of next? Researcher looks to take the bad out of bean eating

Medpundit has a link to an article on specialist shortage which echoes a piece that I featured recently. Medpundit today - Like Coals to Newcastle: and my piece from last week Not enough cardiologists?

The Washington Post runs an interesting series call The Lean Plate Club. This article summarizes factors leading to success. Having lost 25 pounds a couple of years ago (and still losing more slowly), I find that I'm doing all the things discussed here. Now I have to learn to translate this to patients. The Lean Plate Club: Losers Have a Lot in Common

Yesterday's Washington Post has a very practical, patient centered view of depression screening - Depressed? What Makes You Ask?

Most physicians have a tortured relationship with the pharmaceutical industry. We do appreciate their occasional advances which have help many patients, however we are wary of their marketing and "me too" drugs. The New York Times captures the problem nicely today. The gist:

Considering those statistics, the institute found that highly innovative new medicines — those with new chemical ingredients that offer significant improvements over existing drugs — made up only 15 percent of those approved in the period. These medicines included Fosamax, for osteoporosis; Avandia and Actos, for diabetes; and Viagra, for erectile dysfunction.

The study said that drug companies were increasingly relying on the me-too products as patents on top-selling drugs expired, and they could not discover enough truly new medicines to increase revenue as fast as investors expected.

The modified drugs also provide a high return on investment, the study stated, since developing them is much less expensive and also less time-consuming than trying to find a new medicine.

"This is more evidence that the pharmaceutical companies are turning more into marketing companies," Ms. Chockley said. By using advertising to sell drugs that are essentially line extensions of existing medicines, she said, the companies have learned to be like Procter & Gamble, the maker of Tide.

Thanks to RangelMD for another important link - The Best Health Care Money Can Buy . He links to one of two Washington Post articles on the subject. Quoting from the first article

Steven Flier and Busch set off a "moral earthquake" in Massachusetts medical circles with their decision to leave Beth Israel Deaconess Medical Center last month to create the Personal Physicians practice, said Joel Roselin, the ethics educator who organized the forum.

"Doctors who work hard at giving time and attention to patients find it is harder and harder to give," Flier said explaining his decision. "My aim was to provide a higher level of satisfaction and quality for me and my patients."

To achieve their goal of delivering the best care they can, the pair jettisoned about 3,300 patients to focus on the 300 who pay $4,000 a year ($7,500 per family) for round-the-clock access to the two men. Because the fee is for services not covered by insurance -- such as e-mail consultation and preventive tests -- Flier and Busch note they are bringing more money into the overall health system.

Busch describes himself as a modern-day medical Robin Hood -- the money he makes from wealthy clients frees up time to volunteer at an urban clinic. He and Flier also teach and serve on medical boards. Similarly, owners of the upscale Park Nicollet Clinic in the Twin Cities say its $3,000 "concierge care" program offsets losses at two community clinics the company runs.

The Lancet prereleased an article today which shows that increasing fruit and vegetable intact increased plasma antioxidant concentrations and lowered blood pressure - Effects of fruit and vegetable consumption on plasma antioxidant concentrations and blood pressure: a randomised controlled trial. Another possibility for prevention, if we only had the time.

Adult onset diabetes mellitus takes a huge toll on health. Should we look for impending diabetes? Can we prevent diabetes in the susceptible?

"Diabetes doesn't just spring forth," Dr. Nathan said. "People develop diabetes over a number of years, along with several metabolic abnormalities that are also cardiovascular disease risk factors. That might explain why patients are at such high risk for heart disease once they develop diabetes. The risk factors have been there for years."

Consider the results of the NIH's large Diabetes Prevention Program clinical trial, which were published in the Feb. 7, 2002, New England Journal of Medicine. By losing just 7% of their body weight and walking a half-hour a day five times a week, volunteers with impaired glucose intolerance were able within three years to cut their risk of developing diabetes in half, compared to the control group.

The Body for Life phenomenon resembles the Energizer Bunny. This balanced piece from the LA Times presents the phenomenon, and seems to understand it. The author, Bill Phillips makes some interesting ponts, even if not his entire plan hasn't undergone rigorous testing - Going Strong

Once again Jane Brody of the New York Times has written an interesting and worthwhile article. This time she attacks anger and early death - Why Angry People Can't Control the Short Fuse

I'm enjoyed the repartee with medpundit. Her exposition on depression today - A Melancholy Screen actually makes my point. That is we are not very far apart. I ask patients regularly What do you do for fun? When they respond that they have no fun, I explore further. I agree that making a diagnosis does not equal prescribing medications. We obviously both abhor "cook book medicine". One must individualize management decisions. A positive screen suggests further questioning to determine if the patient has major depression. Sometimes, further questioning suggests no treatment is necessary. However, I have been surprised many times. Maybe I tend towards cluelessness, but I have found depression when I least expected it. And sometimes asking the questions and understanding the patient's predicament was therapeutic.

I agree with much of medpundit's post, although two doctors can't ever totally agree. Perhaps the main point of the new guidelines is that when screening is desirable, one can use two questions rather than a long questionnaire.

Thanks to RangelMD for alerting me to this AMAnews article - Physicians are working more, enjoying it less: Morale is getting worse, says a Kaiser Family Foundation survey, and managed care is often blamed.. This is exactly the point I tried to make earlier today. Thanks again to RangelMD!!

Now that I've framed the problem, it's time to examine the movement. I'll assert that, ignoring the money, patients will prefer retainer medicine. Under this system, patients have greater access and more attention from their physician. This system meets patient desires.

Most internists would relish a retainer practice. The system removes our concerns about time. We can provide comprehensive care, both inpatient and outpatient. We have time to talk to patients, in the office and on the phone. When a consult is needed, we can discuss the patient with the consultant both before and after the consultation visit. One can view the X-rays and discuss them with the radiologist. In short, one need not take short cuts to providing complete care.

If not for the money, this would seem perfect. Even without the money though, we would have problems. The numbers don't work. We don't have enough primary care physicians for all the patients. If I decrease my practice from 2000 or even 3000 patients, to only 600 or perhaps 1000 patients, who will care for the remaining patients?

The pros of retainer medicine are obvious. Patients love the attention, and may even get better care (although we have no data to support that claim). Doctors also love the pace and comprehensiveness. Most internists would prefer a mix of inpatient and outpatient medicine, and retainer medicine allows for that mix. Caring for 600 (or even 1000 patients) allows a better quality of life for the physician. The doctor-patient relationship strengthens which gladdens both doctor and patient. Finally, if we adopted a more widespread retainer model, more physicians would choose general internal medicine and family medicine. The retainer model makes the finances work. This model pays for the time and effort to think through each patient, rewarding the physician's intellectual tasks. Seems wonderful.

Opponents raise several interesting points. First, if I downsize from 2000 patients to 600 patients, what happens to the 1400 patients. Have I abandoned those patients? And do they have another physician to choose .. probably not in today's financial climate. Second, will we create a multi-tiered system. They argue that health care is a fundamental right, and no one should be able to pay for First Class care different from any other patient's care. Third, following that argument, increased adoption of retainer medicine would leave increasing numbers of patients without access to good primary care.

I'll take the side of the retainer movement, admittedly understanding the objections. However, when I chose internal medicine, I didn't chose financial suicide, I chose good patient care. I argue that the system, insurers and the government have forced this movement. If I want to practice ideal medicine, Marcus Whelby medicine, then this may be my only option. If health care is a fundamental right, then the insurers and government (Medicare) especially should reimburse general internists and family physicians a reasonable fee, while limiting costly bureaucratic rules. Individual physicians can't just act altruistically, they have responsibilities to their own health and quality of life. The current system is brutalizing those physicians. Growth of the retainer model will help focus the debate to the true antecedants. We have a health care reimbursement system that is tragically flawed. Critique retainer medicine, deride "concierge medicine", but please think. We need good internists and family physicians. If we don't address the root causes, then we will have less access. You cannot force physicians to choose to practice in the current system. And you shouldn't.

Whenever a new idea arises, whenever a new movement starts, one benefits from a clear understanding of the root antecedents. What atmosphere in the medical climate led to the idea and the growing adoption of that idea? Those that blindly criticize the concept miss the point. This idea couldn't arise in a vacuum. As Steven Covey says, 'Seek first to understand, then be understood'.

Let me first define my understanding of retainer medicine (I choose to use this term rather than the term concierge medicine which, in my opinion, immediately labels the concept). The patient contracts with a physician for comprehensive care, and 24 hour access. If the patient needs to see the doctor that day, the doctor can and will comply. The doctor cares for the patient in the hospital, in the office, at the patient's house or on the phone.

Patients want continuity, comprehensiveness, and access. None of my golf buddies are physicians. They want access at their convenience. Often they'll call me in the morning and want a problem addressed that day. I try to help them, when I can, but the current system generally lacks that responsiveness. Last year my 25 year old daughter called me on a Sunday night complaining of an acute illness. I was fairly certain that she had influenza and would benefit from medication. I told her to call her internist the next morning to either get a prescription called in or be seen. Her internist's office said she couldn't be seen until Tuesday. My understanding of the anti-influenza medications says that those 24 hours were very important - she remained ill for approximately a week.

Patients want time with their physician. One physician that works in my division has a great clinical reputation. Her patients commonly tell me that she spends enough time with them and 'really listens'. Unfortunately, you don't often hear physicians described like that.

So we have the first phase of understanding. Patients have difficulty satisfying their needs of continuity, comprehensiveness and access. From the patient viewpoint, I believe that the current system has worsened all these needs over that past 10 years.

General internists are the less satisfied physicians in the United States. When asked they complain about many things, but most complaints center on time and money. Let's address the time issue first. In order to achieve adequate gross income, an internist must see approximately 3 patients an hour, an average of 20 minutes per patient. While some visits really require 10 or 15 minutes, some visits should take 30 or 45 minutes. And the physician doesn't know until the visit starts. What is the internist trying to do? First, one must address any new complaints. Sometimes these come in a long list, often handwritten or typed. Often, the patient has read something on the internet, and wants you to comment. Second, one must address ongoing problems. Each medical problem requires some thought as to how treatment is going, or whether new tests are indicated. One should reconsider each medication, is the dose correct, are there any potential side-effects, could any combination of medications cause an interaction. Third, one considers prevention. Are all prevent issues on schedule? Is it time for new testing? Fourth, one screens for disease. As discussed earlier this week, one should screen regularly for depression. There may be other screening issues related to the patient's underlying diseases. Fifth, one should offer lifestyle counseling and advice. Most patients need dietary and exercise encouragement. Internists rarely invest in show advice, both due to lack of training but more important the lack of time. Yet such lifestyle advice can successfully reduce the risk of diabetes in many of our patients (Prevention of Type 2 Diabetes Mellitus by Changes in Lifestyle among Subjects with Impaired Glucose Tolerance - N Engl J Med 2001; 344:1343-1350). Sixth, one often needs to spend a short time listening to the patient's concerns or eliciting feelings and responding. This ideal visit cannot often occur in 20 minutes.

How much does Medicare pay for that visit? $39!!!!! And the office cost more than that to keep open - assuming the physician were independently wealthy and didn't deserve a salary. Thinking, talking, interacting and caring isn't reimbursed in our current system. This angers internists. Internists have wonderful training, handle medical and psychosocial complexity, can provide care for inpatients and outpatients, yet the payors seem to not value what we do. They value a lab test, or a radiologic procedure, or a surgical procedure, but they don't value careful thought. And remember that the time spent is greater than the patient's visit. The internist reviews laboratory data, radiologic data, and gets back to the patient about the tests (at least in an ideal world). The internist responds to phone and email inquiries (no charge). His office receives approximately 2 calls for each actual visit. Someone has to answer those calls, triage the questions, and often the physician either responds or crafts a response. $39!!!!!!!!! Are they serious?

Just to add fuel to the fire, over the past 10 years, governmental bureaucracy makes things even worse. We can no longer charge for looking at a urine sample, or a gram stain, or do a few lab tests (CLIA standards). Our documentation requirements skyrocket each year both for inpatient and outpatient visits. Each insurance company has differing requirements, leading to a plethora of business staff for this office that gets peanuts per visits. ARRRRRRGGGGGGGHHHHHHHHHHH!

From these concerns arose a new concept - retainer medicine. For a fixed fee, the patient has the doctor's total attention. He/she can reach the physician 24 hours a day. The physician cares for the patient in the hospital, in the office, in the home when appropriate, by phone, or by email. If the patient needs a visit today, he/she gets that visit. Such care costs more than insurers pay. Thus, a retainer is required. A sound business concept which allows the physician to practice a more ideal medicine, a more satisfying medicine, a more thoughtful medicine, a more comprehensive medicine. A sound business concept which gives the patient what he/she desires - access, comprehensiveness and continuity.

So what's the problem, why does anyone criticize this concept? I'll try to address that later today. Now off to hospital rounds!

I generally shudder when I hear about total body scanning. Why do I shudder? Because I haven't seen the data. As a general internist I pride myself in practicing evidence based, data driven medicine. I spend time each week staying up to date. Along comes the total body scan, accompanied by logic but no data - Cheaper Body Scans Spread, Despite Doubts

As one considers the issue of physician assisted suicide, the Australian story gives one pause - Australian Suicide?. Oregon is currently the only state with a physician assisted suicide law.

The Justice Department said Friday it will fight a judge's ruling that banned the department from interfering with Oregon's voter-approved law that allows doctors to help terminally ill people kill themselves.

While I certainly understand the desire to prevent suffering, I'm not ready to slide down the slippery slope of physician assisted euthanasia. Oregon voters haved supported this measure twice - Justice Department Plans Challenge to Oregon's Assisted Suicide Law

Not all retainer models cost $1500 or more per year. This article describes a more modest and affordable approach - Dropping insurers, docs charge a monthly fee

Surprise, surprise, congress weighs in heavily - Retainers for doctors under attack. But have you seen any bills restricting legal practice?

The orginators call it retainer medicine. This story from Seattle talks about the beginning of this movement - In 'retainer medicine,' the doctor is always in

Just a brief interlude from the concierge thread. ABCnews has a nice summary of the negative impact of boring (defined as no automony, no decision making potential) jobs - Boring, Passive Work May Hasten Death -Study. Maybe the ancient Chinese curse isn't really a curse.

May you live in interesting times

This is the original article that caught my attention. Doctors' New Practices Offer Deluxe Service for Deluxe Fee. The Times presents another well balanced presentation of the phenomenon.

Excellent indepth reporting from the Internal Medicine newsletter - Fed up, some doctors turn to 'boutique medicine'

This nice article from Hampton Roads, Virginia presents a balanced view of the problem - Insurance hassles give rise to cash-only doctors I like this article, as it discusses the origins of concierge medicine and emphasizes the problems we have with insurance reimbursement. As I formulate my ideas, I'm focussing on why this small movement has occurred, and don't assume it evil.

Many links discuss MDVIP in particular (although there are other concierge practices). Here is their web site for your perusal - What is MDVIP?

WebMD/Lycos recently featured this balanced discussion - Old-Fashioned Medicine Back Again

Is concierge medicine illegal by federal law? Some advocates and Congressmen think so. Boutique medicine may run afoul of Medicare rules

I've decided to devote this blog to concierge medicine this weekend. As I gather my thoughts and arguments, I will start with as many links as I can find. This one comes from a first year medical student - Point of View

Since last August I have worked out with a personal trainer twice a week. Admittedly a luxury, I love the combination of motivation, goal setting and cheerleading that a personal trainer provides. The results are excellent, I've lost weight, lost waist inches, gained chest inches, and general look and feel better. Having worked with 3 different trainers over that time, I find their nutrition advice interesting. They know that I'm a physician, and we joust over what makes sense, and what might be urban legend. I always thought that the 8 glasses of water a day had some scientific background. Apparently I was wrong - All Wet: No Consensus How Much Water One Ought to Drink and How much water do we really need?

What were they thinking? Over the previous decade, predictions were rampant that we were facing a surplus of physicians, especially specialists. But today, most specialties in internal medicine have a shortage. At the same time, I believe we will soon hear much about the shortage of generalists. Finding a doctor isn't easy. And many doctors are cutting back or even leaving practice.

Last week the Indianopolis Star published an article about the current cardiology shortage - Need for cardiologists is far outpacing supply. What is going on? How did we not understand the needs?

Several factors contribute to the growing shortage. Our population is aging, and we do a better job treating them. They live longer, and have more medical needs. Medical science remarkably advances care rapidly. When I was a houseofficer ('75-'78), we had two drugs for congestive heart failure - digoxin and furosemide. Actually, as a senior resident we started adding hydralazine. We had no ACE inhibitors or beta blockers. Even when we had beta blockers, they were contraindicated in CHF. Class IV CHF had a 50% mortality rate at 6 months. We could really prevent CHF.

Today we prevent much CHF. Patients with CHF live much longer. Patients with coronary artery disease live a long time, having many procedures, tests and hospitalizations. Our success in prolonging often good quality life comes at a cost. And much of that cost relates to needing more cardiologists.

Another reason for the growing shortages stems from the goals of our trainees. Life style issues are more important to the current generation of trainees than they were in the '70s. With the dramatic increase in female physicians, we have more physicians working shorter hours. This accentuates our need for more physicians.

I certainly haven't covered all the reasons in this short rant. Bottom line, the pundits blew it. We need more doctors, now and will need even more. We are getting better at treating patients, but our success does demand more care (i.e., more doctors). Reimbursement makes the challenge even greater. We are consigned to the famous Chinese curse, "May you live in interesting times.".

Never know what to think about WHO. They do tends towards the "politically correct", however they also sponsor some very important programs. One of my colleagues works with them on the growing problem of multi-drug resistant TB.

This time I think they're getting it mostly right. While the occasional alternative medicine may work, we have woefully little data. They are sponsoring a major initiative to bring science to this field - WHO LAUNCHES THE FIRST GLOBAL STRATEGY ON TRADITIONAL AND ALTERNATIVE MEDICINE. I worry greatly about patients being duped and injured from using unproven therapies. Hopefully, this initiative will encourage more research.

I greatly admire Medpundit. I read her daily. Today I must disagree with her.

She critiques the US Prevention Task Force recommendations on depression - especially the two question screening test. I've been using and teaching the 2 question screen since the initial publication in the Journal of General Internal Medicine. The results of the screen - A positive response to the two-item instrument had a sensitivity of 96% (95% confidence interval [CI], 90-99%) and a specificity of 57% (95% CI 53-62%). These results come from Journal of General Internal Medicine Volume 12 Issue 7 Page 439 - July 1997 Case-Finding Instruments for Depression .

Why do we disagree on this issue? Perhaps in how we ask the questions, or even interpret the questions. I commented on this yesterday, but let me expand. I ask the questions in a slightly different less directive way. A good example was a patient I saw with a resident in clinic today. She is a 50 year old woman with diffuse joint and back pains. After getting a series of non-specific answers to arthritis questions, I noted a sad affect. Then I asked, "What do you do for fun?" She said, "I don't have fun, I hurt too much." I followed with, "On a scale of 1-10, with 10 being very happy and 1 being very sad, rate your mood." She responded, "2.5". By then we knew to ask more specific questions to explore depression as a diagnosis.

As a screening test these questions tell me when to explore further. Since these questions are very sensitive, a negative screen (and I get many) virtually rules out depression. Since the questions are not that specific, a positive screen moves me to ask further questions. This works for me in practice and teaching.

Most physicians find the internet a double edged sword. We want our patients well informed, and good information helps greatly. However, not all health information on the web meets a desirable standard. This report from the LA Times, gives us solid data about those concerns - Study Looks at Health Web Site Use and get the original report from the Pew Internet site - Pew Internet & American Life

Why do so many people eat themselves into obesity? Clearly the obesity epidemic in this country is multifactorial - we often eat the wrong foods, we don't exercise enough, we eat unnecessarily large portions. While physiology probably doesn't explain everything, it may explain why some people get so hungry. A newly discovered hormone - ghrelin - is featured in today's New England Journal of Medicine. The New York Times features this information - Hormone May Explain Difficulty Dieters Have Keeping Weight Off . The NEJM link (works only for subscribers) - Plasma Ghrelin Levels after Diet-Induced Weight Loss or Gastric Bypass Surgery . This research is worth following. In the meantime, I continue to emphasize exercise, and changing dietary habits - portion control, and markedly decreasing high fat intake.

The single most useful question that I ask patients - what do you do for fun? This one question serves at least two purposes. It screens for anhedonia and helps paint a picture of the patient as a person. Knowing, and remembering the patient's passions helps me with the personal connection so important to the doctor-patient relationship. When the patient answers - nothing or I don't have fun - then I have good reason to explore depression as a likely diagnosis. Research published in the Journal of General Internal Medicine several years ago showed that a simple two question screen was reasonably sensitive (while not as specific) for depression.

The US Preventive Task Force has endorsed the two question screening strategy for depression - "Over the past two weeks, have you felt down, depressed or hopeless?" and "Over the past two weeks, have you felt little interest or pleasure in doing things?" CNN's report on the Task Force's recommendation - Checkups should include depression screen, says panel .

For those who want to study the evidence and read the recommendations - Screening for Depression in Adults: A Summary of the Evidence for the U.S. Preventive Services Task Force

As a frequent ward attending, I regularly work with sleep deprived residents. A previous rant discussed the personality alterations that we often feel when we don't sleep enough. We don't really understand sleep and how to gauge the right amount. Yesterday's Washington Post had a most interesting article on this issue - Do We Really Need to Sleep? And Why?

Years ago my father, a retired psychologist, told me that he believe the stress reaction was very important in long term health. Jane Brody has summarized the data in a well written article - Ancient Tool of Survival is Deadly for the Heart .

As an exercise zealot, I embrace the message. The various benefits of exercise are overwhelming, especially related to heart disease and Type II diabetes mellitus. The psychological well-being associated with exercise is well known.

Then why is it so hard to get adults to exercise. We have a wonderful prevention tool, if we can figure out how to get patients to use it. MSNBC.com has an interesting article on the health of those over 50. At the end of this article they state -

AARP has launched its own pilot project to promote physical activity among older Americans. The project, operating in Richmond, Va. and Madison, Wis., will push the 50-and-over set to engage in at least 30 minutes of activity five times a week. The organization hopes to take the project nationwide.

Bravo, and I hope they get some positive results. Meanwhile, I keep preaching exercise to everyone.

I work out regularly and try to maintain a prudent diet. Thanks to the pizza police I have more information - Watchdog group hunts for healthy pizza . And I do like California Pizza Kitchen.

RangelMD.com featured this article yesterday - Surgery residents' long hours draw warning for Yale. We all understand that 120 hours a week is too much. I believe that some night call is necessary. What is the right proportion? Internal medicine seems to lead in such reforms. Our residents have 4 days each month of no work. They cannot come to the hospital on those days - even if they want to come.

They work every 4th night and we limit both the number of admissions and the total workload. If we assume that most days average 10 hours (just averaging), and most days post-call they can leave by around 6 p.m. (giving a 34 hour shift which sometimes includes sleep), then they have approximately 84 hours per week or less (figuring 2 call days, 4 regular days and 1 off day). This is generally an overestimate of their workload, since they leave earlier than 6 p.m. many days - and we encourage that.

Is that a reasonable work load? How do we define reasonable? I'm comfortable with this configuration, and our housestaff seem happy.

To decrease hours at this point would require a night float system. While many programs use such a system, our housestaff consistently reject implementing a night float. I do believe that we have a humane program. The days off really work. This month one intern had a 2 day vacation last weekend, the other has a 2 day vacation this weekend. Nothing like a mini-vacation to boost the spirits.

Apparently, we (medical school faculty) must proactively fix this situation. Some schools have done a good job. Paying attention to these details has helped our recruitment of housestaff. Maybe Yale will finally "get it". I hope all surgery programs start to get it.

What is the downside of hours? We did a small study several years ago and found out that one night of sleep deprivation seemingly caused free floating anger. When I mention this to our housestaff, they always nod in agreement. My recollections confirm this finding. Does this explain some of the hostility we see in some residents?

I hope we can fix this without the courts. Whenever the courts get involved, we get collateral damage.

Several years ago primary care was all the rage. Applicants for primary care positions (family medicine, pediatrics and internal medicine) increased. The job market supported the enthusiasm. Various factors have changed that trend, now primary care residencies have fewer applicants each year - Pay and hours driving losses in this year's Match. I suspect that the marketplace (i.e., insurers and society) will adjust over the next 5 years. However, these are the dark days for primary care. And this is a bad trend for patients.

With the high cost of new drugs, many physicians have had major problems with drug company handouts. New standards are coming - Pharmacy group details what drug reps can give physicians .

One can only hope that these new guidelines will bring some sanity to drug promotion. Sadly, I'm skeptical. We've had guidelines in the past, they are consistently abused over time. Nonetheless, this seems like a positive step.

During the 80s and 90s we thought that we had the centuries long tuberculosis epidemic under control. We were wrong. Several factors make TB a major concern at this time. The most important concerns incomplete treatment, leading to resistance. Tuberculosis makes the pages of the New York Times today - The New Front in the Battle Against TB . The article nicely paints the picture of the problem, especially with immigrants. However, here is Alabama we have few immigrants, yet we have a TB problem.

How should we proceed? First, we must fund DOT aggressively. What is DOT? Directly Observed Treatment! Public health workers find the patient each day and watch them take their medicines. This costs less that sanitaria and has proven efficacy. The program pays for itself from a public health perspective, by decreasing the spread of this deadly epidemic.

Other blogs, especially the excellent Medpundit (see my links), have addressed the suit over freedom to choose a residency, and salaries for residents. Today's New York Times has a very interesting analysis - Of Saints, Servants and Cynics . By the way, I'm strongly against the suit. I should write several paragraphs about it in the near future.

The AMA news has this comment on the Medicare problem - AMA weighs in.

The ACP-ASIM has a well researched position on the Medicare issue - ACP-ASIM position on Medicare cuts . They also published an article in the Observer highlighting this problem - the Observer article.

Increasingly physicians are closing their practices to new Medicare patients. We physicians can provide better longevity and quality of life for those over 65, but we can't afford to see the patients.

The economics are simple. The reimbursement for a patient visit are less than the corresponding overhead. Consider this carefully. A Medicare only practice would cause bankruptcy. Thus, frontline physicians will have to limit their Medicare patients.

I find this situation difficult to understand completely. The finances of medicine have confounded my understanding since I finished my residency in 1978. Who makes money these days? Clearly the pharmaceutical companies have done very well (a rant on that in the near future). Diagnostic studies seem to do quite well (CT scanners, MRIs, etc.). Surgery makes money for hospitals. Thinking, considering and talking to patients has little apparent value.

This is not a new situation, but I believe it has become a critical situation. Patient care becomes more complex every year. We need excellent general internists and subspecialists who can take the time to properly care for patients. But apparently society and the insurance companies don't value that interaction. We have not made the compelling case that excellent medical care starts with a CAREFUL consideration of the entirety of the patient. Fifteen minutes is not enough. $39 is not enough.