As we discuss type II diabetic patients, we generally assume that they have coronary artery disease unless we have proven that they do not. Atherosclerotic complications occur very frequently in patients having type II diabetes. Current guidelines also make this assumption. Now we have a strong recommendation concerning statins in these patients.

Treatments: Statins and Diabetes: New Advice

Most patients with Type 2 diabetes should start taking statins, the cholesterol-fighting drugs, as a preventive measure against heart disease, whether or not they have high cholesterol levels, according to new guidelines released yesterday.

The recommendations, from the American College of Physicians, call for moderate doses of statins by people with diabetes who are older than 55, and for younger patients who have any other risk factor for heart disease, like high blood pressure or a history of smoking.

The new guidelines are outlined in April 20 issue of The Annals of Internal Medicine, in an article that noted that about 16 million Americans have Type 2 diabetes and that 800,000 new cases are diagnosed every year.

The lead author of an article accompanying the guidelines, Dr. Sandeep Vijan of the University of Michigan, said that "almost everyone with Type 2 diabetes should be on a statin."

The average age at diagnosis is 48, and even many patients under 55 have high blood pressure as well as diabetes, he said.

Traditionally, diabetes treatment has focused on regulating blood sugar levels by careful control of diet or through insulin injections. But researchers have come to understand that controlling sugar really protects only against the destruction of small blood vessels, which can lead to blindness or loss of fingers, toes or limbs.

Heart disease is, in fact, the more serious threat. Up to 80 percent of diabetes patients will develop heart problems or die of them, the article said. And Dr. Vijan emphasized that controlling hypertension remained the highest priority. He ranked control of lipids, the fats in the blood stream that can affect coronary health, second, ahead of glucose regulation.

I believe that this guideline makes sense in lieu of the mounting data.

Amazing! I just ranted about this issue yesterday. This article bemoans our expenditures on hypertension management - Following Evidence-Based Hypertension Guidelines Could Save Billions. Great! We can do a better job!

As they say on the Guiness commercial (I only wish that I could get some royalties here) - BRILLIANT! .

Quit bemoaning, and develop strategies to fix the problem. Identifying the problem is not enough. These researchers (who are excellent and well regarded) must address solutions.

If they do that, then it really will be BRILLIANT! .

I love General Internal Medicine - both outpatient and inpatient. The intellectual and patient interaction challenges never diminish.

We must maintain broad knowledge and develop the skills to apply that knowledge to our patients. Unfortunately, most physicians can improve their performance.

However, I am often frustrated by the repeated complaints about generalist performance. Here are the two most recent examples:

CDC: Fewer doctors urge weight loss and Statins Underused in High-Risk Elderly Patients

These two examples represent an entire class of such articles. What do these articles tell us? How should we interpret the articles? What should we (the medical community) do with this information?

Using the medical paradigm, one should seek more than making a diagnosis. One should consider the possibilities of treatment. Moreover, we should not stop at making a diagnosis. We must understand what causes the problem.

Consider outpatient medical practice. Each day we see multiple patients with multiple medical problems. Each patient requires attention to a variety of medical problems, including the interaction of those problems. In addition to those problems, we must consider a variety of preventive measures. Careful consideration of all issues might take as long as 30-40 minutes for some patients. But our current reimbursement system dictates shorter visits. Our current reimbursement system dictates seeing too many patients.

Any interest group (and yes the CDC report on obesity represents an interest group) can seek and find deficiencies. However, I do not see much work on helping diagnose and treat the problem. We focus on symptoms, but do not understand the disease.

Thus, I decry these articles. They are no longer constructive, rather they are destructive.

We need a new attitude amongst the health services research community. Quit looking for deficiencies, rather focus on diagnosing and improving health care provision. We need constructive approaches to outpatient and inpatient care. We need to improve.

If I am slicing my drives, I go to my golf pro to diagnose why, and then work on techniques to improve my drives. If the pro just tells my that I have a lousy swing, but does not teach me how to improve, I would likely look for another pro (I say likely, because some golfers are not willing to really try to improve).

Our research group has a committment to understanding medical practice and the barriers to meeting guidelines. We hope to find solutions. I believe that rather than moan about errors and deficiencies, we should champion successes. We can learn more from the positives than the negatives. Physicians will strive towards excellence. Show us how!

Physicians are damned if we underprescribe narcotics to pain patients, and damned if we prescribe to those who abuse drugs. Some pharmaceutical companies are trying to make oral narcotics effective, yet not abusable. Drug Makers Hope to Kill the Kick in Pain Relief

Cooperating closely with government officials and pain specialists, the companies are educating doctors, rewriting warning labels and tracking pills as they move from pharmacy to patient.

They are also reformulating pills with added ingredients. One combination blocks euphoria. Another produces a nasty burning sensation.

So we may soon see effective oral pain control without the option of using the pills in alternate ways. This is good news for pain control. We need the ability to prescribe without worrying about the possibility that we are contributing to drug abuse. These pills will help those patients who really need pain relief.

The End of Primary Care

The very quality of primary care that made it so attractive is what led to its downfall. Legislators, insurance companies, even physicians themselves began to look for ways to harness the expertise of primary care doctors to expand care and limit cost. But no one seemed to recognize that the basis for these economies was the bond between patient and doctor. And without that trust, the economies of primary care were lost.

The initial and most serious blow came when H.M.O.'s persuaded primary care doctors that they should take on the role of gatekeeper. Research indicated that care provided by primary care physicians was more cost-effective than that delivered by specialists. From the insurance companies' perspective, if these doctors were already curtailing costs by getting rid of unnecessary referrals and testing, then providing them with incentives to cut costs would make the savings even greater. What could be better?

The appeal of this system for doctors was more complicated, said Dr. Steve Schroeder, a self-proclaimed card-carrying generalist and the former head of the Robert Wood Johnson Foundation. It flattered primary care physicians by placing them right where they felt they should be: deciding the best, most cost-effective options for their patients. And directing them to a specialist, if need be. That was the theory.

So one can certainly lay some blame on the insurance companies for perverting the primary care concept. However, we must take blame ourselves. We did not think through the "unintended consequences" of the gatekeeper model.

Can we save primary care? Should we save primary care?

I believe that the answer to both questions is yes. Patients need generalist physicians. We need physicians who care for the entire patient. I suspect that most of our patients understand this.

Several movements bode well. Retainer medicine speaks to the concept loudly. While some argue that retainer medicine is just a money ploy, I would argue that some patients are willing to pay to have one intelligent caring physician available, knowledgeable and capable. Similarly, the cash only practice movement shows that patients will pay for good service.

Thus, I expect primary care to transform (albeit slowly and begrudgingly). The change will take time, because few adults embrace change. But the change will help our health care.