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Showing posts from February, 2011

Fast medicine, slow medicine and the trend towards shared decision making

It is very common for patients to complain that they don't get to spend enough time with their physician, or that their questions don't get answered.  This is more true now than it was 20 years ago, and is a direct result of the fact that physicians are paid, not for taking care of patients, but for seeing patients, not for solving their problems but for spending time, even a very small amount of time, physically in an office with them. Physicians are not paid for talking on the phone with patients, for e-mailing them, for discussing their case with learned colleagues, for evaluating their complex medications with pharmacies or for coordinating care with specialists, caregivers or family members. What we do get paid for, and often well paid for, is office calls.

The other day I read an article published in a trade journal called the American College of Physicians Internist reviewing suggestions made by Dr. Neil Baum, a urologist in New Orleans, in a session of the Medical Grou…

Health care "rationing" and the case of Pradaxa, the new drug to prevent blood clots

Very recently a new drug came out which is significantly better than the drug it seeks to replace. Every year many new drugs are marketed, and most of them offer no improvements over what is already in use, but confuse physicians and patients with false choices, and contribute to increased drug costs. Dabigatran, or Pradaxa (its brand name) is a drug which prevents the blood clots that can cause strokes or other serious mischief, and may eventually replace warfarin (Coumadin) which has been in use for decades. It has several very significant benefits, including the fact that frequent blood test monitoring is not necessary and bleeding risk is reduced.

Some background may be useful.

Warfarin (coumadin) was originally introduced as a rat poison because it reduced the little guys' vitamin K levels and thus prevented the production of a few proteins involved in blood clotting. With no available vitamin K rats would bleed to death from minor injuries. Not long after its release as a po…

will there be enough primary care docs to go around?

no, probably not.


There are a couple of articles in the New England Journal of Medicine about the upcoming shortage of primary care doctors as the newly insured finally are able to pay for medical care. This problem will be most acute in the states with the lowest number of primary care physicians and the highest number of uninsured people. Oklahoma tops the list. My state, Idaho, is right in the middle, and Massachusetts will have plenty of primary care capacity.

The challenge is to get enough graduating doctors to choose to go into primary care. Presently there are not enough graduates choosing specialties such as family practice, internal medicine and pediatrics to replace the docs who are retiring. This leaves foreign medical graduates, midlevel providers such as nurse practitioners and physician assistants and specialists to fill the gap. All of these options have limitations. Midlevels can be excellent providers, but don't have the more extensive training that is provided to…