If the Affordable Care Act works like it’s supposed to, 32 million Americans will obtain health insurance for the first time over the course of this decade. Authors of the health reform law expect primary care physicians (PCPs) to care for most of these people. Unfortunately, the nation’s severe and worsening PCP shortage means these expectations are unrealistic.

How big is the PCP manpower problem? The Association of American Medical Colleges estimated we’d be short 45,000 of ‘em by the end of this decade, and that was before the Big O signed the Affordable Care Act into law.

Many studies have linked the dwindling supply of PCPs to long work-hours, administrative hassles and most importantly, a widening income gap between PCPs and specialists.

A recent study by Martin Palmeri and colleagues at Dartmouth has shed light on one aspect of this income gap: the excessive debt burden faced by PCPs in the first years after they complete residency training.  

To quantify the early-career financial situation for PCPs, Palmeri’s group developed a net income and expense model based on data from the 2007 Physician Compensation Survey and several other databases. Their model looked at physician reimbursement, medical student debt, college savings, retirement planning and cost-of-living expenses.

The scientists found that in contrast to specialists, most PCPs do not earn enough in the first 3 to 5 years post-residency to cover expenses.

PCPs who deferred loan payments until after residency averaged $199,159 in debt, the scientists found. To pay this off in 10 years, they had to fork-out monthly payments of $2,261. When their debt repayment was combined with housing costs, retirement savings, children’s college savings and other expenses, PCPs ended-up $801 short each month, assuming their average starting salary was $130,000. This doesn’t even include the costs of entertainment, clothing and travel expenses.

In the researchers’ model, the only way PCPs ended-up with a net positive income in the first 3-5 years after residency was if they had no debt coming out of medical school or exhibited a lifestyle considered by the researchers to be “optimal low cost” (Mad Men reruns on a Saturday night, anyone?).

The sliver of good news in the study was that PCP income did rise quickly during those first few years, but the scientists were unequivocal in their conclusion: the short-term financial realities faced by primary care physicians create strong disincentives to the pursuit of a career in that field.

Palmeri himself is training to be an Oncologist, by the way. His study appears in the November issue of Academic Medicine.

Last week, the American Board of Internal Medicine sanctioned 139 physicians for sharing test questions and answers from the board’s certification test.

The move came a few months after the ABIM sued New Jersey-based Arora Board Review for theft of trade secrets and copyright infringement. The sanctioned physicians had disclosed actual board questions to Arora while participating in one of its exam prep courses.

ABIM and Arora reached a settlement in the case in which Arora’s manager agreed not to offer a live board review course. Terms of the agreement did not require Arora to admit wrongdoing.

ABIM CEO Christine Cassel told AMedNews that her organization became aware of the issue after stumbling upon copyrighted exam questions on Arora’s website.

“At the Arora Board Review courses, [the manager] was not only bragging that he had ABIM questions but soliciting people who remembered questions to report them back to him,” Cassel said.

Physicians must sign a “pledge of honesty” 3 separate times during the exam. The pledge warns test-takers not to disclose, copy or reproduce test-related material, and threatens penalties for those who do.

Camille Miller, the lawyer who represented Arora in the suit, said that Arora disagreed with ABIM’s actions. “Physicians routinely discuss examination content with others,” she said. “ABIM has not apparently enforced this consistently against other physicians.”

Penalties levied by ABIM against the physicians may include revocation of board certification or suspension of certification for up to 5 years depending on the particular offense. Noncertified physicians would need to wait for a year or more before retaking the test.

The physicians have 2 months to appeal the ABIM’s decision. After that, the board will start notifying state medical licensing boards of its actions.

Medical students begin losing empathy after their first year in school, and the decline accelerates after clinical rotations, according to a study in Academic Medicine.

To reach these conclusions, Bruce Newton and colleagues followed 419 medical students from four consecutive classes from freshman through senior year at the University of Arkansas for Medical Sciences.

Researchers assessed vicarious empathy, which is a person’s emotional response to the perceived emotional experiences of others. Using a 9-point scale, they asked students to agree or disagree with statements like, “I cannot feel much sorrow for those who are responsible for their own misery.”

The scientists found that student empathy scores dropped after the first year of medical school and then again after the third year. Female students turned in higher empathy scores than their male counterparts, and students entering primary care showed more empathy than those entering pathology, radiology and surgery.

They attributed the early decline in empathy to stress and anxiety associated with students’ competitiveness and worry about exam scores. The late decline was assumed to be caused by the intensity of hospital practice. Teaching on the wards was likely to have been rushed, and students may not have received as much mentoring or bedside teaching as they wanted.

“We know that really good communication skills (helps) patients…to comply with the instructions of the physician,” said Newton. “A bond of trust is established, and if something unfortunately goes wrong, if you have this bond, you are less likely to be sued.”

“We start with students who are very caring but have no diagnostic skills and end up with physicians with great diagnostics skill but who don’t care,” summed up Richard Frankel a professor of medicine at Indiana University School of Medicine, for AMedNews.

A version of this post originally appeared in the Practice Fusion Blog.

The US Department of Veterans Affairs will allow clinical investigators to use de-identified patient information contained in its EMR as a means to support clinical research initiatives on subjects ranging from MRSA to posttraumatic stress disorder, heart failure and cancer.

Matthew Samore, an epidemiologist from the VA Salt Lake City will be involved with the project. He opined that the so-called Consortium for Healthcare Informatics Research “will not only inform new guidelines but help resolve some conflicts in current guidelines.”

Only VA-associated investigators will get the keys to the highway.

Samore said he hoped the project would show how data-mining techniques could be used in other EMR systems, but worried that since most EMR systems are so poorly interoperable, it would be quite some time before they could match the VA’s capabilities in this area.

Pam Matthews, a senior director of health care information systems at HIMSS concurred with this prediction. “The VA is a closed system. When you apply (what they are doing) to the commercially available products, their data model, their software model may be different,” she said to AMedNews.

Web-based EMRs eliminate these problems, however, by securely storing patient records in a central repository that is continually available to all health professionals involved with the care of a particular patient. 

The VA begins its initiative under a dark cloud caused by the heist of a laptop containing data on 26 million vets, a bit of a privacy issue that is avoided with Web-based solutions since the data are housed in secure, off-site locations.

The Agency for Healthcare Research and Quality is reporting an 18% increase in hospitalization rates for eating disorders between 1999 and 2006, and that’s not the whole story.

Although women between the ages of 19 and 30 are still the most commonly affected group, hospitalization rates are growing faster in demographic categories not usually considered to be at risk.

In particular, hospitalizations for children younger than 12 grew 119% over the same period, while admissions among males rose 37%. Hospitalizations for people between the ages of 45 and 55 grew 48%.

“Many people in my field are seeing younger and younger people appearing more severely ill, and we’re seeing more atypical patients,” David Rosen told AMedNews. Rosen is a professor of pediatrics and psychiatry at the University of Michigan.

The study, based on data from the Healthcare Cost and Utilization Project, revealed there were 28,155 hospitalizations for eating disorders in 2006.

The incidence of more serious diagnoses also increased during the study period. Patients discharged with cardiac dysrhythmias jumped from 650 to 1,462, for example. The number of patients that sustained acute renal or liver failure increased from 99 to 216.

Mortality remained stable at 0.6%.

Some believe the trend may be explained by improved awareness and diagnostic acumen, but others worry it may be collateral damage from the effort to stem the obesity epidemic.

“BMI testing or weighing of kids may wind up triggering something even worse,” warned Edward Tyson, medical director of Austin’s Cedar Springs Eating Disorder Treatment Center.

“I have a lot of patients who start out wanting to get healthy, but they don’t keep things in balance with exercise and food. Eating disorders are all about being out of balance.”

One month after MinuteClinic struck a heady deal to link EMRs with the Cleveland Clinic and one week before the US government announced a health emergency due to Swine flu, the CVS Caremark subsidiary announced it planned to shutter 16% of its locations during spring and summer, normally the off-season for colds and flu.

Industry experts claimed that poor business performance during these periods represented “a structural flaw” in the retail clinic business model, and predicted a gloomy future for all but those with storefronts in close proximity to, or otherwise affiliated with hospitals and physician groups.

That’s because provider-associated retail clinics have large enough catchment populations to sustain themselves year-round, or at least offset lower off-season traffic with business at other venues and facilities.

MinuteClinic’s decision risks nullifying the very image of convenience that drives success in the first place, according to Tom Charland, CEO of Merchant Medicine, a consultancy specializing in retail clinics.

“You can’t preach convenience and consistency out of one side of your mouth and then have it sort of up in the air as to whether that clinic is open or not,” Charland told AMedNews.

With over 500 stores, MinuteClinic is the largest retail clinic chain in the US. It’s not clear whether other clinic chains will follow suit, or how the Swine flu scare might shuffle the deck.

The retail clinic business is not for the faint of heart.

On average, it takes 3 years before outlets turn a profit, and many fold before then.

CheckUps for example, closed 23 of its Wal-Mart housed clinics in January 2008, and last summer SmartCare shuttered 15 venues which had also been housed in Wal-Mart.

Still, the number of retail clinics continues to rise.

About 1,100 clinics are open today, as compared with only 200 at year end, 2006.

And soon after announcing the seasonal shutdowns, MinuteClinic itself opened several new, year-round locations in Massachusetts.

They’re stocking up on Tamiflu and Relenza as we speak.

Just 2 years ago, Big Pharma fielded 102,000 sales reps. That number has already dropped to 92,000 and it’s headed to 75,000 by 2012, according to Chris Wright, a principal at ZS Associates.

That’ll save $3.6 billion for the beleaguered pharmaceutical companies, who are dealing with desiccated drug pipelines, patent expirations on blockbusters, blood thirsty politicians, and populist rages against the industry…and that’s before breakfast.

Decisions to make the cutbacks haven’t been that difficult since sales force effectiveness is way down.

Nowadays, only 37% of the drug reps who visit medical practices get to place products in the sample cabinet, and a measly 20% speak directly to a physician, according to TNS Healthcare.

About 25% of physicians belong to a practice that bans the reps altogether, and that was before new regs prohibited them from distributing tchotchkes!

“The old sales model is broken now, and who knows how it will look in the future,” Peter Nalen told AmedNews.

The president of Compass Healthcare Communications added “what’s happening is that pharmaceutical companies are realizing there are other ways to reach the doctor instead of banging on the door of the doctor who just doesn’t want to talk.”

Ari Silver-Isenstadt persuaded his Baltimore pediatrics practice partners to adopt a “no soliciting” policy for drug reps. “More than half of us doctors still just have a feeding frenzy of reps in our offices,” he told AmedNews.

“We should be ashamed of ourselves for allowing such an intertwining of our patients’ best interests with the convenience and niceties of drug reps.”

But Ken Johnson, a senior VP for the Pharmaceutical Research and Manufacturers of America disagrees.

“Interactions between physicians and pharmaceutical company representatives benefit patient care through the exchange of information about new medicines, new uses of medicines, the latest clinical data, appropriate dosing and emerging safety issues,” he insisted.

Efficacy data on flu vaccine is decidedly mixed, surprisingly enough.

Many trials suggest it has a beneficial effect.  For example, an October, 2007 meta-analysis in NEJM pooled the results of 18 studies involving 713,872 elderly people and concluded the vaccine cut hospitalizations for flu and pneumonia by 27% while reducing all-cause death rates by 48%.

Those findings confirmed a March, 2002 analysis in which non-institutionalized elderly folks who received flu vaccine experienced 35% fewer flu-like illnesses and a 50% lower mortality risk than those who didn’t take the spike.

But many well-designed trials conclude the vaccine is ineffective. The most recent of these, published in Lancet in August, 2008 showed that flu vaccine had no impact on the risk of community-acquired pneumonia in a cohort of 4,000 elderly people.

That study confirmed a February, 2005 piece in the Archives of Internal Medicine which concluded that flu-related mortality reductions in the early 1970s were attributable to immunity acquired during the pandemic of 1968, not the vaccine.

These scientists also noted that although vaccine coverage skyrocketed from 15-20% in 1980 to 65% in 2001, there was no associated drop-off in flu-related mortality.

So what’s a mother to do, not to mention everyone else that’s supposed to queue up each fall for the jab?

Authors of the negative studies who were interviewed by Amednews say flu vaccine does work, just not all that well. (more…)