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Image Credit: Dan Page, Boston Globe
What is the US going to do about our current and future primary care physician shortage? Many believe that the solution is to expand the scope of nursing practice, and license non-physicians (such as naturopaths) to practice medicine. In the face of scarcity, 17 states have licensed naturopaths to provide primary care and nurse-led, in-store pharmacy clinics are gaining popularity.
Studies have shown that nurse practitioners are as capable as physicians at treating common primary care complaints such as strep throat and headache. What studies have NOT shown is that nurse practitioners recognize and diagnose less common diseases with similar symptoms. What if the strep throat were throat cancer? What if the headache were meningitis? Substituting practitioners with half the training and experience of an MD comes at a price. And that price may include missed diagnoses, delay of appropriate treatment, and life threatening consequences.
But the lure of cost savings cannot be ignored. Nurses are paid less to practice primary care, so in theory we could save untold millions each year by having patients see nurses instead of doctors. That sounds good, but now nurse practitioners are lobbying to receive the same salary as MDs for their time. After all, they’re doing the same work, right? Never mind that everyone they treat must be squeezed into a limited set of diagnosis codes – when all you have is a hammer, then everything starts looking like a nail. “Poof” goes the savings, while care quality standards are permanently reduced by forced limitations on differential diagnoses.
A better solution would be to find ways to extend physician reach and expertise with telemedicine platforms, longer patient visit times, and by reducing their non-clinical practice burden. Nurses and ancillary providers are valued members of the clinical team who are dearly loved by patients and doctors alike, but they simply do not have enough training to be ruling out tens of thousands of rare diseases and conditions. This is why we need physicians at the helm of the clinical team – to make sure that patients are on the right treatment pathway.
Some nurses cry “prejudice” when physicians suggest that MDs provide better primary care. But we all know that knowledge and experience are a critical asset when lives are at stake. As the research results begin to roll in regarding better patient outcomes under the care of physicians versus nurse practitioners, common sense tells us that outsourcing primary care to the less qualified will have undesirable consequences for some. And if you choose to get your primary care from a naturopath or nurse, you’ d better hope that headache isn’t anything serious. Because a little savings now could cost you your life.
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Dr. Val "After" Photo #1
I just completed 8 weeks of what I’d call “extreme dieting and exercise.” I don’t mean dangerous starvation and constant exercise, I mean the hardest “medically safe” amount of diet and exercise possible. It involved about 3 hours of exercise per day (6 days/wk), along with a calorie-restricted diet of 1500 calories/day (no refined carbs, only healthy fats, relatively high protein). My exercise consisted of heavy weight lifting, kettle bell sets, kickboxing, and sprints on the bike, summit trainer, and on an outdoor track, with long walks each afternoon. Trust me when I say – I pushed myself to the very limits of what my body could handle without becoming sick or injured. I did this with the help of my dear friend and trainer Meredith Deckert.
Why on earth would I do something so extreme? Well, first of all, I wanted the “right to bare arms” on my wedding day. I just woke up and realized I was getting married in 8 weeks and that I’d have photos of the event memorialized for my future kids and grand kids… so the “bat wings” had to go (you know what I’m talking about, ladies), and the time till “lift off” was pretty short – hence the need for maximum effort.
Secondly, I was scientifically curious to know what a “best case scenario,” two month, physique optimization strategy might produce. I knew I wouldn’t cheat on the diet or fall off the exercise wagon, so at least I could be sure that results were based upon strict adherence. Self-reports of diet and exercise regimens are notoriously inaccurate, so this doubting Thomas had to see for herself! (Of course n=1 in this experiment and won’t correlate exactly with others’ experiences due to differences in starting fitness, body fat, age, genetics and gender).
And Thirdly, I wanted to experience (first hand) what is possible so that I could empathize with my patients who were trying to lose weight, and provide personal anecdotes of encouragement. Since America’s biggest health challenge (pun intended) is obesity, I feel obliged to do my part to model lean living. Otherwise, what right do I have to teach others what to do? (Note that heavier physicians are less likely to educate overweight patients about weight loss).
So what did I learn? Each of these probably merits its own blog post, so I’ll summarize briefly and dig into the details with you soon…
1. Calorie math doesn’t necessarily work with the bathroom scale. We’ve all heard that a pound of fat equals 3,500 calories, so that if you decrease your calorie intake (or increase your calorie burn) by that much, you WILL lose a pound on the scale. That has not been my experience (I lost an average of only 30% of what the scale should have shown based on the math). I have some theories as to why that might be (which I’ll share later), but suffice it to say that if you are “doing everything right” and the scale is not rewarding you – take heart!
2. Weight training improves how you look MUCH more effectively than cardio. Before my extreme diet, I was running 1/2 marathons and spending hours on the spin bike. I was in excellent cardiovascular shape, but I had a relatively high percent body fat (about 30%) and I was certainly not getting “skinny” from all the running. I was actually losing muscle and looking softer and more “out of shape.” Dialing down the cardio and increasing the weight training had a rapid, visible impact on how athletic I looked.
3. Your leaner self may not look the way you think it will. When I first began my weight loss journey, I imagined that I would slowly melt away all the excess fat to reveal a lovely ballerina inside. What I found was that after the fat was gone, I wasn’t a ballerina at all. I looked a lot more like a wrestler! People really have different genetically determined body types – and no amount of diet and exercise will make us look like someone else. We’ll just look like our best selves, which is ok! Don’t fall into the trap of thinking that success only looks like a Sports Illustrated swimsuit model. After all, Olympic athletes all have very different bodies, and are at the top of their respective games! (This fun, height and weight database shows how you compare to recent Olympians.)
4. Clothing size is the most helpful measure of success. After 2 months of intense diet and exercise the scale only changed by about 6 lbs. The body impedance analyzer told a little different story (the InBody 520 estimated that I had lost about 10 lbs of fat and gained 5 lbs of muscle with an overall percent body fat loss of about 4%.) But the truth is, that nothing measured my success as well as clothing. I dropped nearly two dress sizes and had to buy a new wedding dress a week before the event! So if your scale isn’t showing you love, what are your jeans saying? Listen to them.
Conclusion: In my experience, the best a slightly overweight, middle aged woman can do (safely) in 8 weeks is lose 10 lbs of pure fat and gain 5 lbs of muscle. It is extremely difficult to achieve that much, and I would highly recommend doing it over a longer period of time. Is the pain worth the effort? Here are my “before” and “after” photos. What do you think?
Before: (151 lbs)
After (145 lbs):
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A recent, 358-person survey conducted by researchers at Yale University (and published in the International Journal of Obesity) suggested that patients may be less likely to follow the medical advice of overweight and obese physicians. Survey respondents were 57% female, 70% Caucasian, 51% had BMIs in the normal or underweight category (31% overweight and 17% obese), and were an average age of 37 years old.
Respondents rated overweight and obese physicians as less credible than normal weight doctors, and stated that they would be less likely to follow advice (including guidance about diet, exercise, smoking cessation, preventive health screenings, and medication compliance) from such physicians. Although credibility and trust scores differed between the hypothetical overweight and obese providers and normal weight colleagues, the respondents predicted less of a difference between them in terms of empathy and bedside manner. Respondents said they’d be more likely to switch physicians based on their weight alone. There was no less bias against overweight and obese physicians found in respondents who were themselves overweight or obese.
The study authors note that this survey is the first of its kind – assessing potential weight bias against physicians by patients of different weights. Previous studies (by Puhl, Heuer, and others) have documented weight bias against patients by physicians.
While the study has some significant limitations (such as the respondents being disproportionately Caucasian, thin, and female), I think it raises some interesting questions about weight bias and physicians’ ability to influence patients to adopt healthier lifestyles.
Considering the expansion of pay-for-performance measures (where physicians receive higher compensation from Medicare/Medicaid when their patients achieve certain health goals -such as improved blood sugar levels), being overweight or obese could reduce practice profit margins. If patients are less likely to follow advice from overweight or obese doctors, then it stands to reason that patients’ health outcomes could suffer along with the doctors’ income.
I’m certainly not suggesting that CMS monitor physician waist circumferences in an attempt to improve patient compliance with healthy lifestyle choices (Oh no, did I just give the bureaucrats a new regulatory idea?), but rather that physicians redouble their efforts to practice what they preach as part of a commitment to being good clinicians.
Some will say that the problem here is not expanding provider waistlines, but bias against the overweight and obese. While I agree that weight has little to do with intellectual competence, it does have to do with disease risk. Normalizing and destigmatizing unhealthiness is not the way to solve the weight bias problem. We know instinctively that carrying around a lot of extra pounds is damaging to our health. It’s important to show grace and kindness to one another as we join together on the same health journey – a struggle to make good lifestyle choices in a challenging environment that tempts us to eat poorly and cease exercising.
To doctors I say, let’s fight the good fight and model healthy behaviors to our patients. To patients I say, show grace to your doctors who carry extra pounds – don’t assume that they are less competent or knowledgeable because of a weight problem. And to thin, female, 30-something, Caucasian survey respondents I say – Wait till you hit menopause before you judge people who are overweight!
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When I first started blogging in 2006, the medical blogosphere consisted of a small group of physicians, nurses, and patient advocates. We knew each other well, and spent time each day visiting our favorite blogs and posting personal comments of encouragement and insight. We developed real friendships, and were optimistic about our brave new online writing frontier. We thought we could change the healthcare system for the better, we believed that our perspectives could influence policy, and we were sure that our writing could help our patients lead healthier lives.
I remember with great fondness the medical blogger conference that I attended in Las Vegas in 2009. It was the first time I’d met most of my blog friends in real life (IRL) – it was like seeing your favorite pen pals after years of correspondence. We talked all night, had marveled at how a love of writing had brought together a surgeon from South Africa, an ER nurse from California, and a Canadian rehab physician, among others. We figured that social media was the glue that held us all together. Since then, I am sad to say that for me, the glue has lost its stickiness due to dilution by third parties and a glut of poor quality content dividing attentions and exhausting our brains’ filter system.
Fast forward 7 years and most of my email correspondence is from strangers wanting to embed text links in my blog, people selling SEO services, or PR agencies inviting me to provide free coverage of their industry-sponsored conferences and webinars. I can’t think of a single friend who has left a comment on my blog in the past three months. Sure we see each other’s updates on Facebook and occasionally on Twitter, but I can’t remember the last real conversation we’ve had. Social Media has become irreversibly cluttered, and I’ve never felt more isolated or guarded about the future of medical writing.
My thoughts on this subject gelled when Twitter announced that LeBron James was following me (along with a select 80,000+ others). Obviously, LeBron has no idea who I am, and I’m almost certain he had nothing to do with his Twitter account following me. He, like many others, has outsourced his online relationship-making. It’s the ultimate irony – using social media to distance yourself from others, while maintaining an appearance of engagement. Sort of like sending a blow up doll of yourself to a party.
So what keeps some people going on these social media platforms? Perhaps it’s the allure of influence – the idea that many people are listening to you gives a sense of importance and meaning to your efforts. But take a cold hard look at your followers – do you know who most of them are? Or is there a large group of “hotchick123″ type Twitter accounts counted among them? I used to block followers who didn’t seem real or relevant, but it became so much of a chore that I couldn’t keep up. I was overwhelmed by the Huns.
One could argue that my social media fatigue is my own fault – I didn’t screen my followers properly, I didn’t follow the “right” people, I haven’t curated my friendships with as much care as I ought to… But I know I’m not alone in my pessimism. A recent Pew Research poll suggests that people are leaving Facebook at a rapid rate. And as far as Twitter is concerned, it’s not for everyone.
I guess the bottom line for me is that social media isn’t as much fun as it used to be. I miss my blog friends, I miss the early days of being part of an online community. I don’t write as much as I used to because I don’t know my audience by name anymore. This “party” is full of strangers and I don’t like the familiarity that continues in the absence of true friendship.
Time to spend more of my energy on my patients, family, and friends IRL. And that’s a good lesson for a doctor to learn…
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Although most doctors say they believe in the immediate free flow of information from physician to patient, the reality is that many hospitalized patients don’t receive a full explanation of their condition(s) in a timely manner. I’ve seen patients go for days (and sometimes weeks) without knowing, for example, that their biopsy was positive for cancer when the entire medical staff was clear on the diagnosis and prognosis. So why are patients being kept in the dark about their medical conditions? I think there are several contributing factors:
1. Too many cooks in the kitchen. During the course of a hospital stay, patients are often cared for by multiple physicians. Sometimes it’s unclear who should be the first to give a patient bad news. Should the news come from their primary care physician (who presumably has a long standing, trusting relationship with the patient) or the surgeon who removed the mass but doesn’t know the patient well? In many cases each assumes/hopes the other will give the patient the unpleasant news, and so the patient remains in the dark.
2. Family blockades. It often happens that a patient’s spouse or family member will request that news of an unpleasant diagnosis be delayed. They argue that it would be best for the patient to feel better/get stronger before being emotionally devastated by a test result. In some cases the family may be right – grief and shock could impair their participation in recovery efforts, resulting in worse outcomes. Cultural differences remain regarding how patients like to receive information and how families expect to be involved in care. American-style, full, immediate disclosure directly to the patient may be considered rude and inappropriate.
3. Uncertainty of diagnosis. Sometimes a clear diagnosis only develops with time. Biopsy results can be equivocal, the exact type of tumor may be unclear, and radiology reports may be suggestive but not diagnostic. Some physicians decide not to say anything until all the results are in. They cringe at the prospect of explaining uncertainty to patients, and without all the answers they’d rather avoid the questions. What if it looks as if a patient has a certain disease but further inquiry proves that she has something else entirely? Is it right to frighten the patient with possibilities before probabilities have been established?
Although sensitivity must be applied to the nuances of individual care scenarios, my opinion is that patients should be immediately informed of their test results and their physician’s thought processes at every step along the diagnostic pathway. Family member preferences, however well-meaning they are, cannot trump the individual’s right to information about their health. If physicians are unclear regarding which of them should break the news to a patient then they should confer with one another and come up with a plan ASAP.
The right time to tell the patient the truth is: now. To my colleagues who avoid giving patients information because it is personally uncomfortable (often leaving me or other third party to be the messenger), I have two words: “man up.”