several issues please see data below

as you can see there has been a huge decline in med school applicants since 1995

intersting to note that the US has 1.4 million lawyers

http://www.aamc.org/newsroom/pressrel/2005/applicants.pdf

certainly med schools have increased enrollments but the cost to train someone exceeds 90,000/year.

most state governments are in running budget shortfalls, med school funding is on the low list when compared to all the other pressing needs.

private schools generally cannot expand class size as they barely can fill their own slots. most people who apply to med school cannot and will not pay the 40 -45,000 dollar/ year tuition costs

essentially anyone who has a b aversage can go to med school.

remember that osteopathic schools often take the folks who do not get into MD granting schools. DO degrees are essentially identical to MD degrees.

also note that 50% of med school enrolles are females who are much more likely to wor part time.

there is expected a 50,000 doctor shortan 10 years.

since 911 there has been a dramatic drop in foreign trained doc’s.

As a scientist fixed, static ideas were “beaten” out of me in grad school so I think I get a little more frustrated than the ave patient when I get a fixed static idea from a dr. It is second nature to question everything and be open to the unknown factor.

When will the system collapse do you think? Is there a global solution? If you admit more more students than you will have more physicians in five years. Could you begin admitting students with the requirement that they practice in certain fields? Maybe “track” them and charge them different rates of tuition depending upon final workplace? This might sting a bit but, maybe admit lower caliber students to fill some of these empty PCP slots. Not saying PCPs aren’t smart-just a suggestion. You guys do turn away half the applying population. Perhaps loan forgiveness programs for PCP or GI positions? Maybe encourage more on call work by having some payment gaurentees for PCPs ang GIs.

Got a taste of the cognitive vs procedure reimbursement rate myself just last month. My ER physician exam costs about 400 usually. My husband fell and dislocated a shoulder ligament and got a 400 exam fee plus a 700 fee for a dislocation. The dr didn’t actually do anything but tell my husband it was dislocated and to go home. No cast, no repairs, nothing. My poor ER docs were stuck with a totally wierd case with high cognitive requirements and a high risk they might get sued if I dropped dead. Yet they get a third of the charge that the other guy got.

And yes, the cell phone drivers may kill us all soon.

no doubt you have invested a lot of time researching, questioning your thyroid condition. you particularly comment that correct treatment studies and paradigms target the 95% of the population and that the 5 % people who demonstrate pathophysiologic patterns out of the “norm” are getting short shrift, getting misdiagnosed and mistreated.

you further state you have had a variety of physicians including endocrinologists mis treat you.

what you corectly wan’t is individual physician to pay attention to you and spend enough time to establish good diagnsotic plan and therapeutic plan. you lament the fact that the 5 % of the population who do not present with symptoms typically are neglected.

you are right.

DB in his opening salvo comments
” But I also had to decrease each patient visit by approximately 3 minutes” due to the ugly economic climate of medicine.

Obviously if a doc is being pressured to cut visits shorter and shorter, people will lose out. DB is describing an all too common occurrence :
15 minute appts are being cut down to 12 minutes, the 9 minutes vists become 6 minutes.

you point out that the medical system had failed you for quite some time. the fact that visits are forced to become shorter does not bode well for personalized care.

According to the data there are less endocrinologists/person in 2005 than there was in 2000.

there are huge decreases in Family docs and Internist per capita. given the current debt loads of new doc’s and reimbursement climate, this trend is getting worse every year.

your dissatisfaction with physicians exactly mirrors
physician dissatisfaction with the system.

physicians are dealing with the dissatisfaction by choosing specialties that have higher pay, less stress.
thyroid care is not on the list of desirable specialty care.

DB comments
“Providing incentives to see patients faster (and make NO mistake – our current system rewards speed over thoroughness) leads to undesirable externalities. We must fight hard to rethink this system.”

no wonder your frustrated. so are doc’s.

as far as your specific thyroid ideas.

remember that there are several items which are discussed in the thyroid literature and they are broken down in a variety of ways.

1. diagnosis of clinical hypothyroidism
2 treatent of clinical hypothyroidism
3. diagnsosis of subclinical hypothryoidism
4. treatment of subclinical hypothyroidism

each of these entities is very different and you seem to be lumping the diagnoses and treatment of hypothyroidism into one entity. also clinical consensus statements published in 2002 0r 2003 will take several years to work their way into the actual mainstream practice of medicine , unless you are working with a specialist who is very current. also, you point out that their is debate on how low a TSH should be.

well your right, there is a debate.

anyone who thinks that medicine is fixed and static is wrong. it is an everchanging science. debate will alwasys exist. you are right about genetics, perhaps in a few decades genetic tests will be available to fine tune treatments. by that time global warming, pollution and drivers using cell phones will have killed off most everyone.

Gasper, I am glad you are open to at least educated pateients. I understand the pile of paperwork problem. I avoid taking my car to mechanics or my poor pets to the vet. I can’t afford “the problems” they find.\

Pj, check that about treating a tsh of 10 or above. I think that might be a bit of an error. I myself am down from a tsh of 200 to a tsh of 7. My endo is very keen on heading towards 1 or so. The TSH new guidelines I am quite certain are correct-maybe look a bit further: http://www.aace.com/pub/tam2003/explanation.php

The T4/T3 thing is totally out there at the moment. I only take T4 myself and do just fine. Perhaps the T3 supplement is placebo but I am more inclined to think it a pharmacogenomic varaition. Some folks metabolism keeps em great with T4 and some need the T3 to really do okay. I worry about broad population studies as I wonder if the “odd” ones get missed. You create a new rule or observation that applies to 95% of folks but 5% get left out. We are just now starting to understand how that 1% of genetic diversity that makes us unique influenecs our health. I have ran across way too many folks who swear by the combo and some endos who say thier patients swear by it. I don’t need it but they may.

As for the enzymes I actually found that in a website (thyroid manager) with chunks about T4 metabolism. It wasn’t my idea. In hypo or hyper thyroidism, the diiodinase (enzyme converts T4 to T3) expression levels are altered with respect the to the particular tissue. The expression levels of those enzymes are regulated by T3 not T4, thus if you want to restore the entire thyroid processing system to order more smoothly and quickly it might be best to add in some T3 to yield more correct enzyme expresion levels. Otherwise you might be setting up some odd kinetics. I am a dorky biochemist. I think this stuff is cool.

As for my “magic” moment and treatment suggestion that was mineralcorticoid supplementation for the presumed aldosterone shortage. It isn’t in any of your textbooks so you guys don’t think it’s real. It doesn’t matter if I go to the ER six times, it should just go away because it isn’t real. I came up with the suggestion of florinef and went from being unable to tolarate any T4 to being now at 75ug of T4. I’ma wierdo I guess. I educated my endo-the second one as dr satan sent me home to die.

Tina you state that concerning the treatment of hypothyoidism

“The old guidleines were to only treat at 5 and above.”
and you assert
“So now the endocrinologists are at war with one half saying treat at 3 and the other half (mostly old guys) saying treat at 5.”

you might be interested (or not interested)

in a 2004 consensus report for
Subclinical thyroid disease: scientific review and guidelines for diagnosis and management

it is suggeseted to treat subclinical hypothyroidism at tsh levels greater than 10

this clinical consensus group (comprised of representatives from the Endocrine Society, American Thyroid Association, and the American Association of Clinical Endocrinologists).

Most docs treat SYMPTOMATIC hypothyroidism to get the TSH into normal range

I do consider 2004 guidelines fairly recentut other might consider them very out of date.

Tina you also mention that in relatin to t3 and t4 therapy
”
These both suggest the combo approach may be better. Did you know that?”

the question of whether hypothyroid patients might benefit from substitution of some T3 for T4, an idea which has now been evaluated in eleven randomized trials [18-28], most of which are negative.

for example:

In a placebo-controlled trial, 46 patients were randomly assigned to receive their usual dose of levothyroxine or combination therapy (50 mcg less than their current T4 dose with T3 added (7.5 mcg bid)). After four months of treatment, there were no differences in measures of cognitive function or health-related quality of life between the two groups.Combined levothyroxine plus liothyronine compared with levothyroxine alone in primary hypothyroidism: a randomized controlled trial.
Clyde PW; Harari AE; Getka EJ; Shakir KM
JAMA 2003 Dec 10;290(22):2952-8.

another example
Using a regimen designed to mimic normal thyroid physiology more closely than in other trials, (100 mcg T4, or 75 mcg T4 and 5 mcg T3), there was no difference in cognitive, affective, or quality of life testing, although patients preferred combined therapy to T4 alone . Thyroid hormone replacement therapy in primary hypothyroidism: a randomized trial comparing L-thyroxine plus liothyronine with L-thyroxine alone.
Escobar-Morreale HF; Botella-Carretero JI; Gomez-Bueno M; Galan JM; Barrios V; Sancho J
Ann Intern Med 2005 Mar 15;142(6):412-24.

despite the negative data that t3 is effective many doc’s will use it , but sparingly

you then try to explain the bichemistry of t3 and t4
“When you check out the lit biochemically the enzymes responsible for thyroid hormone metabolism are actually regualted by T3 not T4″

a more accepted explanation exists:

T4 is a prohormone with very little intrinsic activity, which is deiodinated in peripheral tissues to form T3, the active form of thyroid hormone. This deiodination process accounts for about 80 percent of the total daily production of T3 in normal subjects; as a result, serum T3 concentrations are within the normal range in hypothyroid patients receiving adequate T4 therapy. The prohormone nature of T4 is an advantage over other thyroid hormone preparations, because the patient’s own physiologic mechanisms control the production of active hormone.

you also mention

“Magic! I am fine now, not from a drs suggestion but my own suggestion”

there is some explanantion for that as well

An important placebo effect was observed in a randomized trial of 697 patients in whom 50 mcg of T4 was replaced by 10 mcg of T3.
Partial substitution of thyroxine (T4) with tri-iodothyronine in patients on T4 replacement therapy: results of a large community-based randomized controlled trial.
Saravanan P; Simmons DJ; Greenwood R; Peters TJ; Dayan CM
J Clin Endocrinol Metab 2005 Feb;90(2):805-12. Epub 2004 Dec 7.

I DO NOT DISCOUNT THE POWER OF PLACEBO IN HUMANS, IT IS A VERY POWERFUL FORCE. IT DOES MATTER. It is what people benefit when their doc spends a lot of time listening.

As for educated patients – bring ‘em on, I love ‘em. I review web sites and sources with them in the room. I usually don’t accept a giant pile of internet droppings they have printed for “you to look over and call back”, usually from poorly sourced sites, done on my time and at my own cost.

Try taking a big legal pad of questions to your lawyer. Ask your mechanic to run a lot of unecessary tests on your car “just in case”. I suspect that you will not be happy with the bill and learn to more appropriately use the services. The amount of waste in the current system could probably finance appropriate healthcare for 1/2 of the uninsured. And don’t even get me started on obesity and diabetes, the 2 horseman of the medical apocolypse.

People view their insurance payments as part of the doctors compensation and therefore have certain expectations.

Our mutual complaint seems to be with the insurance companies.

We pay too much, you receive too little, and the outcome is a decline in patient care.

The uneeded “thyroid supplementation” issue is a big reason why that site was put together. I guess you can be symptomatic of thyroid hormone defieciency at a TSH of 3-5. The old guidleines were to only treat at 5 and above. It turns out that autoimmune thyroid disease is so common that in reality the original test ranges established included a large number of mildly hypothyroid individuals who went on to become more ill. So now the endocrinologists are at war with one half saying treat at 3 and the other half (mostly old guys) saying treat at 5.

Did you know that? Perhaps you did but more than likely it hasn’t hit your radar unless you are an endocrinologist or have a patient coming in your office claming “uneeded thyroid hormone treatment”. So what happens is the patients end up more educated than the drs about the specific illness and then get treated like they are stupid when they bring in new recommendations for thyroid hormone treatment.

The use of combination T3/T4 is another area where physicians assume thier patients are too dumb to really understand the issue. A lot of those folks swear they feel better overal taking both forms rather than just T4. When you check out the lit biochemically the enzymes responsible for thyroid hormone metabolism are actually regualted by T3 not T4. There are also some clinical studies that suggest patients do do better wih both. These both suggest the combo approach may be better. Did you know that? You might but I think you may not. That doesn’t mean the lady who brings this info in on a legal pad is a hyperchondriac, but she may have done some research on her own and is being proactive in her own care.

Yours is a very good example of fast food medicine and how it can hurt the patient when you don’t take time to listen. It is the exact reason many of those folks go to cash doctors. It may be very well true that 90% of those folks are wrong with thier pads of paper but by listening at least a few minutes you might find the other 10% are right.

You guys don’t have enough time. You can’t spend you time reading basic literature and keeping track of new developments in every field. So let your patients do some of the walking and don’t be dismissive when they have suggestions.

I am currently being treated for hypoaldosteronism. Nobody knows why. My adrenal glands are fine, my kidneys are fine. I am the one who looked at my symptoms after six ER trips and two endocrinologists and then requested a mineralcorticoid to address the shortage. Magic! I am fine now, not from a drs suggestion but my own suggestion. My Dr listened to me, and followed my suggestion and that is how I got better. Don’t dismiss patients please. You could kill them

many doc’s are doing just that, but only a very small minority. the number is growing but not rapidly

the major reason is safety,

it took me @ 5 years to pay off med school debt . while in debt, it is safer to work 70 hours/week to earn 120,000/year than to work 45 hours/week and make 70,000/year.

once out of debt then the decision to accept insurance
has mainly to do with perceived demand from patients.

the estimates are that 45 million folks in the US have no insurance, I would guess that perhaps 5 million have insurance but would pay cash if they found a doc who they perceive as a high quality doc. (i do not think they would pay cash on a regular basis and thus see a cash only doc only occasionally)

I would also guess @ 10 million folks who have no insurance would not pay for any health care under any circumstances. trust me on this one.

Thus that leaves about 40 million people in the US who would pay cash for their health care.

its a pure guess …….but I suppose that would equate to 1/in 12 people who would see a doc for routine health care and pay cash on a regular basis.

I provide this estimate as those cash paying individuals can also walk into any office ) as almost all docs who bill insurance companies also take accept cash)

it seems then the volume of potential patients who would just receive care in offices that take cash only
would be quite small and so would be the income of the doc.

some major expenses of offices are fixed whether or not the doc earns a lot or a little. malpractice premiums do not drop if you treat only 9 people/day or 22 people/day. medical education costs also are not discounted nor are the other customary costs ( fsmily health insurance, disability insurance, etc…)

I suspect as our national economic debt conitnues to rise
and companies like walmart employ people withoutoffering insurance and companies like Delta, United Airline, GM
start slashing health benefits more people will revert to cash and so will more doctors.

the topic of the business of medicine is directly related to the quality of medicine. I think this is far more important to outcomes of care than people realize.

careful, well considered, well researched care should lead to better outcomes and happier patients. Insurance companies create the opposite climate.

I realize it’s not THAT easy, but I fail to see why it’s not tried more. Is it just the security that even with having to take insurance payments, you still make (on average) well in excess of $100K?