Archive for October, 2010

Health Reform and the Physician Shortage

October 29th, 2010 | No Comments | Source: AAMC, MedPageToday

The Affordable Care Act is the most important piece of federal health care legislation since the Social Security Act of 1965 established the Medicare program. It assures that 32 million Americans will have access to health insurance for the first time. But who will care for these people?

Our health care system was plagued by a severe and worsening physician shortage even before the new law took effect. In fact, a 2008 study by the Health Resources and Services Administration projected shortages of 35,000 surgeons and 27,000 medical specialists within 10 years, and that’s not even counting expected shortfalls among primary care practitioners like those in Family Practice and Obstetrics.

Those 32 million newly insured people will create an unprecedented surge in demand for physician services, exacerbating this shortfall by at least 50%, according to a new report by the Association of American Medical Colleges.

The report estimates that by 2015—which is one year after the major provisions of the Affordable Care Act take effect—the US will be short a whopping 63,000 physicians—including both PCPs and specialists. Previous analyses had pegged the shortage at 39,600 physicians.

Nearly half the shortfall, 33,100 to be exact, involves specialists like cardiologists, oncologists and emergency medicine experts. For certain specialties like urology and thoracic surgery, the number of physicians is actually expected to decrease.

The report adds that the shortage will get worse in the following 10 years. For example, by 2020, our nation will be short by 45,000 primary care physicians, and 46,000 few specialists.

The physician shortfall will be exacerbated by demographic trends. The number of Americans who are at least 65 years old (a group known to require more medical care than younger folks) will increase by 36% during the upcoming decade, according to the Census Bureau. The graying of the US population is also expected to mean that nearly a third of today’s practicing physicians will retire within the next 10 years, according to the AAMC report.

The physician shortfall will hurt everyone, but the AAMC projects that the impact will be particularly severe on medically underserved populations where finding a doctor is already quite difficult. The population in question includes nearly 20% of Americans living in inner-city and rural areas where shortages of health professionals are already acute.

Offsetting this trend to some degree is the fact that (provisions in the Affordable Care Act aside) the number of medical school students will increase by about 7,000 graduates per year during the next decade. Unfortunately, according to the AAMC this increase doesn’t keep up with the projected surge in demand for physician services.

What Should We Do?
While team-based approaches like “medical homes” can ameliorate the looming crisis to some degree, few believe they will eliminate it.

Recognizing this, the AAMC recommends that Congress should mandate at least a 15% increase in residency training slots which would add 4,000 physicians per year to the pipeline. This surge is not contemplated by the Affordable Care Act, which in the most optimistic of projections will add approximately 350 physicians per year for the next decade via small primary care grants and the reshuffling of residency programs.

The only way to reach the AAMC’s proposed target of 4,000 new physicians per year, it seems, would be for Congress to overturn a 1997 law that froze Medicare-funded residency positions and increase by at least 15% the number of GME positions funded by Medicare. However with Congress mired in partisan gridlock and public opinion now pretty entrenched against new spending programs, this seems like a long shot at best.

Beyond this, the options are relatively slim and controversial. We either agree to increase the numbers of foreign medical graduates or expand the scope of practice for nurse practitioners so they can help shoulder the burden of an accelerating demand for medical services.

To those who would disagree with these latter solutions, which can work, I ask, “What alternatives do you propose?”


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Why Can’t Some People Make Decisions?

October 27th, 2010 | 1 Comment | Source: Wall Street Journal

Why is it that some people can make life-altering decisions like deciding to get married without hesitation, while others take  hours to decide on trivial matters like whether to buy black or navy blue underwear?

The reason, psychologists tell us, has to do with the amount of ambivalence people have: Do they see the world in black-and-white or in shades of gray?

Although psychologists have just begun to study ambivalence, they already agree that people who tend to be ambivalent in one aspect of their lives tend to be ambivalent in other aspects as well.

It’s unclear why some folks tend to be more ambivalent than others. Personality traits like the need to reach a definitive conclusion for a particular situation tend to drive some towards black-and-white thinking. It also likely that parental influences and cultural aspects play a role. For example, many people in Asian cultures tend to be more comfortable with dualism, the concept that good and bad coexist in all aspects of life from relationships to the workplace. This cultural influence often translates to greater degrees of ambivalence.

Behavioral scientists have shown that ambivalence affects the way people solve problems. Black-and-white thinkers make decisions more quickly but tend to end up in conflict with others more frequently. Ambivalent problem solvers are more capable of feeling empathy and display healthier coping strategies during periods of stress. On the job however, ambivalent employees tend to perform more erratically, consistent with changing feelings about the job.

Though the field of ambivalence research remains in its infancy, there is an evolving consensus that the ability to remain open to different points of view reflects emotional and cognitive maturity: It amounts to “coming to grips with the complexity of the world,” Texas Tech psychologist Jeff Larsen explained to the Wall Street Journal.



Teens Think Sports Drinks are Good for Them

October 26th, 2010 | 1 Comment | Source: MedPageToday, Pediatrics

Teenagers with otherwise healthy lifestyles consume large amounts of sports drinks and high-calorie fruit drinks, probably because they believe the products are “healthy,” according to scientists from the University of Texas.

To reach these conclusions, Nalini Ranjit and colleagues surveyed 15,000 students attending grades 8-11 during academic year 2004-2005. The survey asked about dietary and exercise habits, as well as time spent watching TV, playing video games and using computers.

The scientists found that teens who preferred flavored and sports beverages (FSBs) over soda tended to exercise harder and more frequently, and to consume truly healthy foods more often.

“The most likely explanation for these findings is that FSBs have been successfully marketed as beverages consistent with a healthy lifestyle, to set them apart from sodas,” Ranjit’s team concluded in their write-up, which appears in Pediatrics.

FSBs contain miniscule amounts of fruit juice and about the same amount of sugar as carbonated soda.

The link between FSB intake and a healthy diet turned out to be stronger in girls. Girls who consumed 3 or more FSBs per day were more likely to consume more milk, fruit and vegetables.

The link between FDB intake and exercise was more apparent in boys. Boys who consumed 3 or more FSBs per day engaged in more vigorous exercise and participated more regularly in gym class and organized sports.

Commenting on the team’s findings for MedPage Today, Vanderbilt University sports medicine expert Alex Diamond said that, “marketing has a great deal to do with the perception that sports drinks are generally healthy. They have a role when it comes to prolonged activity or exercise, but on a regular basis, it’s not something kids should be drinking just to get hydration.”


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Genetically Engineered Salmon

October 25th, 2010 | No Comments | Source: BurrillReport

An FDA advisory panel has recommended that the agency approve a Massachusetts-based company’s plans to commercialize its genetically-engineered salmon, which grow to adult size nearly twice as fast as their natural-born counterparts.

If the FDA follows the recommendations of the Veterinary Medicine Advisory Committee, the modified salmon will be the first such animal to be marketed in the US.

The Committee is comprised largely of veterinary scientists. It concluded that the new salmon was safe to eat and that the process used to grow it would not pose a significant threat to the environment.

The FDA is not required to follow the recommendations of its advisory panels. It will probably take months before deciding the matter.

Waltham-based AquaBounty has been working on its AquAdvantage Atlantic salmon for over a decade. They grow quickly because company scientists inserted genes encoding for growth hormone from both the Chinook salmon and an eel-like creature known as the ocean pout into their DNA.

The modified fish produce growth hormone year-round. Native Atlantic salmon don’t produce the stuff, and hence don’t grow, each winter. The AquAdvantage salmon end-up being sterile females, for the most part.

AquaBounty plans to grow its genetically-modified salmon in inland tanks to prevent them from interacting with native species. “The possibility of an escape or an event with any possibility to interact with the wild population is infinitesimal,” Ronald Stotish, AquaBounty’s CEO told BurrillReport.

By the way, the Advisory Committee suggested that the FDA monitor the environmental impact of AquaBounty’s commercial operations if they are approved, and that consumers be appraised about what they are buying. Current FDA rules ban labeling that is based exclusively on how foods are produced.



Texting-Related Automobile Fatalities

October 22nd, 2010 | No Comments | Source: MSNBC

Drivers who were distracted by talking or texting on cellphones killed approximately 16,000 people between 2001 and 2007 according to an scientists at the University of North Texas Health Science Center.

To make their estimate, Fernando Wilson and Jim Stimpson compiled data on deaths attributed to distracted driving from the National Highway Traffic Safety Administration. For ancillary analyses, they also used FCC data concerning cell phone ownership and text messaging volume.

The scientists found that in 2002, Americans sent about 1 million text messages per month. By 2008, this figure had exploded to 110 million per month. “Our results suggest that recent and rapid increases in texting volumes have resulted in thousands of additional road fatalities in the United States,” they wrote in the American Journal of Public Health.

The shocking statistic comes at a time when overall traffic fatalities are actually down in the US. In fact according to the Transportation Department, the number of traffic fatalities in 2009 (33,963) was lower than at any time since the mid-1950s.

“Distracted deaths as a share of all road fatalities increased from 10.9% to 15.8% from 1999 to 2008, and much of the increase occurred after 2005,” wrote the scientists. “In 2008, approximately 1 in 6 fatal vehicle collisions resulted from a driver being distracted while driving.”

Numerous studies have shown that talking on a cell phone distracts drivers, even if they use a hands-free set-up. Of course, texting, emailing and other smartphone applications provide an even greater distraction since users must take their eyes off the road in order to carry out those functions.

Approximately 30 states have made it illegal to text message while driving. In other jurisdictions, hands-free devices are required for drivers who use cellphones.



Non-Surgical Treatment for Severe Aortic Stenosis

October 21st, 2010 | No Comments | Source: NEJM, Wall Street Journal

Aortic Stenosis (AS) is a condition caused by progressive narrowing of the valve that governs blood flow from the heart to the brain and most other internal organs. About 1.5 million Americans have AS, one-fifth of whom have a severe form that is life-threatening.

Traditionally, the treatment for severe AS involves open heart surgery, an expensive procedure that is associated with its own risks and contraindicated in frail, elderly folks…just the kinds of people that develop the condition in the first place.

Now, scientists have shown that a relatively non-invasive treatment for severe AS may obviate the need for open-heart surgery.

The new approach involves attaching a replacement valve to a catheter, and then threading it through blood vessels to a place where it can serve the role of the malfunctioning valve. 

The replacement valve is produced from cow tissue and is housed within a metal frame. 

A study of the new device was published 2 weeks ago in the New England Journal of Medicine. In the study, a group of elderly patients received the catheter-placed device while others received various other non-surgical interventions.

The one-year mortality rate for people that received the replacement-valve was 31%. This was lower than the 51% mortality observed in controls. Of note, the study also revealed a higher incidence of early strokes (5% vs. 1%) in patients who received the new device. The increased stroke risk was nevertheless deemed “an acceptable price to pay” by Craig Smith, a study co-author.

The study was funded by Edwards Lifesciences, the same company that designed the valve. Several authors have financial ties to the company. Catheter-delivered valves “should be the new standard of care” for patients with severe AS that can’t tolerate open-heart surgery, they concluded. 

Edwards hopes to gain FDA approval for its device in 2011.



Google’s War on Rogue Pharmacies

October 20th, 2010 | No Comments | Source: Wall Street Journal

Recently, search giant Google filed a lawsuit attempting to prevent what it describes as “rogue online pharmacies” from posting ads alongside its search results and websites.

The complaint was filed in a US District Court. In it, Google claims that an unidentified individual and 50 other defendants “violated policies and circumvented technological measures” when they used its online-ad program, Adwords, to promote prescription-drug operations and pharmacies that had not been approved by the National Association of Boards of Pharmacy.

By doing that, Google claims, the defendants violated their contracts. Google prohibits sites from distributing prescription drugs unless the distributors meet certain criteria, one of which includes verification by the NABP.

Google’s action is just the latest step in the company’s escalating cat-and-mouse game against rogue pharmacies. Every time the company creates new safeguards and guidelines to prevent their activities, the culprits devise more sophisticated methods to circumvent the protections.

Google’s lawsuit was filed the same day that Web address provider eNom Inc. announced a deal to collaborate with the Internet pharmacy verication company LegitScript, to identify and ban Web sites that host illegal online pharmacies.

“Rogue pharmacies are bad for our users, for legitimate online pharmacies and for the entire e-commerce industry—so we are going to keep investing time and money to stop these kinds of harmful practices,” wrote Google lawyer Michael Zwibelman on the company’s blog recently.

“We work hard to make sure that ads shown on Google provide useful information for our users. But sometimes we need to take action against ads that violate our policies. This is especially true when it comes to advertising for products such as pharmaceuticals, which can be dangerous without the right prescription.”



DNA of Chocolate Almost in the Bag

October 18th, 2010 | No Comments | Source: Washington Post

A team of scientists at the Mars candy company announced recently that it has almost completed a project to sequence the genome of the cacao tree, whose seeds are used to produce chocolate. The team hopes its contributions will help scientists create cacao trees that are less vulnerable to disease and easier to grow.

Mars makes all-time favorite candies like Snickers and M&Ms. The company spent nearly $10 million on the project, yet it intends to make its findings public once the work is done.

“The information is so rich and so accurate we felt there was no reason to hold back,” Howard-Yana Shapiro, Mars’ global staff officer of plant science and research told the Washington Post.

Traditional cacao tree breeding methods involve a time-consuming, hit-or-miss process in which plant scientists try to find the trees with the best traits (for example, producing the sweetest chocolate or a tendency to be disease-free) and reproduce them. That process can require 15 years to complete because it takes that long to be sure the tree can defend itself against diseases.

But once the cacao tree’s DNA has been sequenced, scientists hope they can complete this process in 2-3 years. For example, by studying the genetic code from a young tree, they can find out quickly whether it possesses genes that can help it fend off diseases.

It’s possible the Mars group’s discovery might lead to better-tasting chocolate as well. According to Shapiro, the amount of fatty acids in the cocoa is key to the taste of the end-product. “Now finally, we have insight on how to stabilize it and raise it over time,” Shapiro told the Post.

Nearly 70% of the world’s chocolate comes from the cacao trees of West Africa, particularly Cote d’Ivoire and Ghana.



More Women than Men Gettin’ PhDs

October 15th, 2010 | No Comments | Source: Washington Post

A funny thing happened on the way to the graduation podium last year. For the first time in US history, more women than men earned doctoral degrees, according to a report from the Council of Graduate Schools.

The statistic reflects yet another milestone in a 30-year transformation of educational trends among the sexes in our country. In recent years, women had risen to represent nearly 60% of all people that earned degrees from 4-year colleges and Master’s degree programs, but it wasn’t until last year that they claimed the lead among doctoral degrees as well.

Doctoral degrees typically require about 7 years to obtain, so it’s to be expected that this reversal would be the last among these trends to appear. “It is a trend that has been snaking its way through the educational pipeline,” Council director Nathan Bell told the Washington Post. “It was bound to happen.”

Men had retained a narrow lead in the number of doctoral degrees awarded because of their overwhelming predominance in mathematics, engineering and the physical sciences. To this day, men still account for 80% of doctorate degrees awarded in engineering, for example.

Women have caught up though, based on consistent, longstanding gains in health sciences, education and the behavioral sciences. Women now account for 70% of all awarded doctorates in health sciences. They account for 67% of new doctorates in education, and 60% percent of those awarded in behavioral and social sciences.

The rise of women through the ranks of our educational system began in the early 1980s. The demographic shift is being driven by the same economic forces that have driven increasing numbers of women into the workforce. In short, people of both genders realize there is an “increased need for (women) to make money for their families,” Catherine Hill, director of research at the American Association of University Women explained to the Post.



The Role of Testosterone in Business Deals

October 14th, 2010 | No Comments | Source: LA Times

In a common version of the “Ultimatum Game,” Player A is asked to dole out $40 to himself and Player B. He can distribute the loot in either a $35-$5 split, or in a $25-$15 split. If Player B accepts the payout, both parties keep their cash, but if Player B says no, both players go home empty.

Theoretically, Player B should accept either offer: five dollars is, after all, better than nothing. It turns out though, that fairly often Player B will reject the lowball offer, presumably because he finds it insulting.

In a fascinating riff on this observation back in 2007, Harvard University professor Terry Burnham measured testosterone levels in a cohort of men that had volunteered to play the Ultimatum Game. Burnham observed that only 7% of Player B’s with below-average testosterone rejected the $5 offer, whereas 45% of Player B’s with above average testosterone rejected the offer.

Recently, a team of scientists led by Maurice Levi of the University of British Columbia wondered whether the notorious male sex hormone might similarly affect business outcomes from corporate take-over attempts. Merger-and acquisition deals are indeed similar to the Ultimatum Game with one important exception: companies that receive a takeover bid can negotiate a better price. And of course, stock price shifts, regulatory matters and a host of other variables often complicate matters.

Still, what the heck?

The researchers studied 357 takeover bids that took place between 1997 and 2007. Not being able to measure testosterone levels of the involved CEOs retrospectively, they used the age of the CEO as a proxy, since it is a known fact that testosterone levels decline with age.

Lo and behold they found that young (high-testosterone) CEOs who launched takeover bids were 20% more likely to withdraw their bids later after initially being rebuffed by the target company. They postulated that withdrawing the bid altogether rather than negotiating a higher price was a way for the young, high-testosterone bidder CEO to demonstrate “dominance.”

Maybe the Securities and Exchange commission should require publicly traded companies to disclose their CEOs’ testosterone levels in their quarterly reports…


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