In Defense of Primary Care, and of Sub-Sub-Sub-Specialists

An article in the March 24 NEJM called Specialization, Subspecialization, and Subsubspecialization in Internal Medicine might have some heads shaking: Isn’t there a shortage of primary care physicians? The sounding-board piece considers the recent decision of the American Board of Internal Medicine to issue certificates in two new fields: (1) hospice and palliative care and (2) advanced heart failure and plans in-the-works for official credentialing in other, relatively narrow fields like addiction and obesity.

The essay caught my attention because I do think it’s true that we need more well-trained specialists, as much as we need capable general physicians. Ultimately both are essential for delivery of high-quality care, and both are essential for reducing health care errors and costs.

Primary care physicians are invaluable. It’s these doctors who most-often establish rapport with patients over long periods of time, who earn their trust and, in case they should become very ill, hold their confidence on important decisions – like when and where to see a specialist and whether or not to seek more, or less, aggressive care. A well-educated, thoughtful family doctor or internist typically handles most common conditions: prophylactic care including vaccinations, weight management, high blood pressure, diabetes, straightforward infections – like bacterial pneumonia or UTIs, gout and other routine sorts of problems.

On the other hand, specialists can be lifesaving when highly-detailed expertise matters. There are limits to how much a general internist knows about chemotherapy, for example. Even within the field of medical oncology, a subspecialty of internal medicine, there are doctors who only see patients with particular kinds of cancers. When I had breast cancer, for example, I chose an oncologist whose practice consists almost entirely of patients with breast cancer and related diseases. If someone in my family has a lymphoma, I’d advise them to consult with someone who, for the most part, patients with lymphoma and similar disorders. Why? Because each of these cancers represent a complex group of malignancies, and successful therapy depends in part on the doctor’s familiarity with each of the specific subtypes and the relevant, current data for those. Treatment of lung cancer involves choosing among a different set of drugs than would be considered for brain or kidney cancer.

I mention oncology, here, because I’m most familiar with this field. But the same holds, for example, in the subspecialty of Infectious Diseases: knowing about all the new HIV drugs, in pregnant women, children and adults, involves a different set of knowledge than knowing about parasites in the tropics, and that differs from knowing about viral and other, unusual infections in patients are immunocompromised after kidney, heart or lung transplants.

In each of these settings, expertise can reduce errors – because specialists are more likely, in the first place, to establish a correct diagnosis and, next, to prescribe the right therapy based on the best evidence available.

The same holds for other medical specialties, apart from Internal Medicine. As I’ve described before, the radiologist who interpreted my routine mammogram and follow-up sono was a breast imaging specialist. The orthopedist who reconstructed my spine is a scoliosis spine surgeon. I am confident that I wouldn’t be here and feeling as well as I do if it weren’t for their expertise.

You could argue that it’s impossible to provide these kinds of sub-sub-specialists to people in rural areas, or that it’s too expensive, but I don’t think either of these factors should be limiting. To a large extent, experts might work with primary care providers and communicate with patients via Telemedicine and Skype-like technologies. As for surgical subspecialties, it may be that patients would find it worthwhile to travel to a regional center where a specialized procedure is done routinely, as opposed to having an operation in a local hospital where the doctors perform a certain kind of surgery – say a laparoscopic splenectomy, for example – only a few times each year.

There’s a tradeoff, as discussed in the NEJM piece, between increasing use of specialists and fragmentation of care. I think this concern is legitimate, based on my experiences practicing medicine and as a patient. But I do think we need specialists, and sub-specialists if we want doctors who can answer their patients’ questions, i.e. who really know what they’re doing.

I was a bit surprised that the article mentions a survey of physicians in which the majority of respondents reported that “professional image” was the primary reason for seeking subspecialty credentials. While this may be true, I don’t think doctors’ motivation matters in this. From the public’s perspective, what’s important is that hand surgeons know how to do hand surgery, and that a heart specialist knows how to interpret an echocardiogram, and that the hospitals where they work not let them practice if they’re not appropriately credentialed.

In cutting health care costs, or in trying to so, I don’t think it makes sense to reduce the number of physicians or to short-cut their educations by way of 3-year medical schools. Rather we need well-trained primary care doctors we can rely on, who know the limits of their knowledge as much as they understand medicine, and top-notch specialists, both.

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Hot Wasabi, and a Continuing Radiation Crisis

a poem for Wednesday:

I was touched by this headline in yesterday’s news: Japan nuclear crisis may have a silver lining for radiation health research. Yeah, and cancer is a gift.

The wasabi is too hot,

NPR shared yesterday, and I agree.

This radiation story has a long half-life, whether we write on it or not.

Sketch of a wasabi (Japanese horseradish) plant, from an 1828 in botanical encyclopedia, by Iwasaki Kanen (Wiki Commons)

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Thoughts on Geraldine Ferraro, and Myeloma

Like many New Yorkers, feminists?, hematologists and other people, I was saddened to learn yesterday of Geraldine Ferraro‘s death. The Depression-era born mother, attorney, criminal prosecutor, Congresswoman, 1984 Democratic VP-candidate and part-time neighbor to yours truly, succumbed to complications of multiple myeloma at the age of 75.

Abnormal plasma cells in a bone marrow sample said to be from a patient with myeloma (Wikimedia Commons). Plasma cells have nearly-round, eccentric nuclei and abundant cytoplasm (ES).

Myeloma is a cancer of plasma cells – specialized white blood cells (mature B lymphocytes) that make antibodies. Plasma cells normally develop in the bone marrow; they can exit into the bloodstream, which is why this condition is often called a tumor of the bone marrow or, occasionally, sometimes, as a leukemia. The term myeloma comes from Greek roots – muelo (which can refer to the bone marrow) and –oma, which in medical parlance has come to stand for a tumor and may derive from soma (body).

According to the NCI, over 20,000 North Americans receive a myeloma diagnosis, and approximately 10,000 die from the disorder each year. It tends to arise in older folks, and is slightly more prevalent in men than in women. According to the SEER data, in 2007 there were over 61,000 men and women in the U.S. alive with a history of this disease.

What’s notable to me, as a hematologist, about the former congresswoman is that she lived with myeloma for over 12 years: She survived with a disease for which there were few treatments available when she was on the Presidential ticket. This was partly due to luck – always a factor in cancer outcomes, as some cases are intrinsically more aggressive than others; partly due to her access to excellent doctors and good care; and, also, likely due to advances in myeloma treatment over the past two decades.

Some perspective: When I completed my fellowship in 1993, the median survival for someone with myeloma was less than 3 years. Starting around then, most specialists steered patients under the age of 65, and in some communities, older patients as well, toward autologous stem cell transplantation – an aggressive approach that’s been shown to prolong lives of patients in randomized studies. (For the record, I’ve never been convinced by those data.) More recently, old drugs like thalidomide and its fresher derivative, lenalidomide (Revlimid), along with new drugs like bortezomib (Velcade) have demonstrated efficacy in this disease.

In my opinion, what’s ahead for doctors caring for myeloma patients – and for the patients, even more so – in this next decade, is to see if these old and new pills might be better, less costly and less toxic than transplant-based treatment regimens.

A final thought on Ferraro’s care, is that it seems she benefited from the care of experts: hematologist-oncologists, transplant physicians and other specialists and subspecialists. With all the push now for more primary care doctors – who are indeed needed – her survival with what might have been a quickly terminal illness is a testament to the value of knowledgeable, well-trained physicians who keep up with developments in an evolving field.

As for the ceiling-breaking congresswoman, my thoughts are with her family now. She was a remarkable lady in many ways.

(all links accessed 3/27/11)

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Art, Science and Radiation Imagery on a Magazine Cover

This week’s New Yorker cover pretty well sums up my thoughts lately. It’s a bleak, semi-natural image that blends art and science, offers brightness amidst darkness, and reminds us of how little most of us know about physics, nuclear energy and radioactivity.

And it’s a strange, unsettling start for the Spring.

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Crowd-Sourcing a Medical Puzzle

The Times ran an intriguing experiment on its Well blog yesterday: a medical problem-solving contest. The challenge, based on the story of a real girl who lives near Philadelphia, drew 1379 posted comments and closed this morning with publication of the answer.

Dr. Lisa Sanders, who moderated the piece, says today that the first submitted correct response came from a California physician; the second came from a Minnesota woman who is not a physician. Evidently she recognized the condition’s manifestations from her experience working with people who have it.

The public contest – and even the concept of using the word “contest” – to solve a real person’s medical condition interests me a lot. This kind of puzzle is, as far as I know, unprecedented apart from the somewhat removed domains of doctors’ journals and on-line platforms intended for physicians, medical school problem-based learning cases, clinical pathological conferences (CPC’s) and fictional TV shows.

In this example, the patient’s diagnosis was known, and treatment successfully implemented, before publication. Surely the Times legal team carefully reviewed those scanned commercial lab reports with the wiped-out patient’s name and address, and likely they got the OK from the patient and her family to run the story as they did. There were sufficient details included that she’s likely identifiable to some people in her community.

The case is instructive at many levels: It’s not just about the girl and her symptoms and her disease, and how doctors think, but about how the population of New York Times readers approached it over the course of 24 hours. A question an editor, if happy with the “results” – i.e. the on-line turnout (clicks, emails, tweets…) and lack of flak – might ask is what sort of case to use next week or next month, and how perhaps to improve on the presentation.

The question I ask as a physician is this: why we don’t have this sort of crowd sourcing for tough, unsolved medical cases? Privacy is an obvious concern as is, perhaps, physicians’ fear of missing something or being wrong. Also, if a diagnosis isn’t already determined, the responsible doctor might end up (and likely would) order more tests and, perhaps, harm the patient by chasing zebras and heeding some well-intentioned but absurd or simply wrong suggestions from a diverse collection of world-wide readers. So there would be a problem of “too many cooks” among other issues.

On the other hand, a single physician dealing with a challenging case would have, potentially, access to the expertise of millions of people, perhaps a few who have genuine insight and have seen a rare situation before. Doctors needn’t think in silos.

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A Good Place to Find Information on Clinical Trials

If you’re thinking of participating in a clinical trial for cancer or any other medical condition, a good place to find out about the research is ClinicalTrials.gov.

The site, sponsored by the NIH, NLM and FDA, is one outcome of the FDA Modernization Act (FDAMA) of 1997. The database aims to provide information on clinical trials to patients and physicians, and to generally increase transparency on study funding, design and availability of other trials evaluating the same condition or drug.

A mouthful of jargon, as you’ll find regarding pretty much any trial. But better that it’s public –

In recent years, some medical journals have required that clinical investigators seeking to publish study results register their trials, from the start, with the Clinical Trials database. Since 2007, when Congress passed the Food and Drug Administration Amendments Act of that year (US Public Law 110-85) researchers must register and report results for most clinical trials of drugs, biologics, and devices.

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Bristol-Meyers Says Ipilimumab Prolongs Survival in Metastatic Melanoma

This morning health business mavens are chirping with bright results for ipilimumab, a monoclonal antibody that can extend life in people with metastatic melanoma. If the new data – which I haven’t seen – are true, it’s good news for patients.

In 2010, melanoma affected 68,000 people in the U.S. and led to death in approximately 8,700. The WHO estimates that over 50,000 people die of this disease worldwide annually. For patients with metastatic disease, median survival is less than one year.

Last August, investigators reported in the NEJM that ipilimumab prolonged overall survival in patients with metastatic melanoma from approximately 6 to 10 months. Those findings were based on a randomized, multicenter Phase III study funded by Bristol-Myers Squibb, the drug’s manufacturer. In that trial, the most common serious toxicity of the drug was deemed to be immune-based diarrhea. Now, the drug is up for FDA approval and Bristol-Myers is saying that another study (“024” – presumably that’s short for CA184-024) reveals prolonged survival in patients with advanced melanoma. The findings will be presented at the ASCO meeting in early June.

Ipilimumab binds a molecule called CTLA-4 (cytotoxic T-lymphocyte-associated antigen-4) on the surface of T cells. It works as a double negative kind of immune activator: by blocking CTLA-4, which normally clamps down on lymphocyte activity, the drug fosters an anti-melanoma response by the body’s healthy immune cells. Like other monoclonal antibodies, Ipilimumab is given to patients by intravenous infusion. So it’s costly in itself, and because of the need for nurses to administer the drug, IV equipment, etc.

In principle, this drug might be applied to other tumors or infectious diseases to which the immune system doesn’t adequately respond. The NIH Clinical Trials website lists other protocols, including other tumor types, for which this drug is being tried.

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A Nutritional Tidbit, on Quinoa

I first heard about quinoa a few years ago, when food-sellers started marketing the stuff as a cereal-like, cholesterol-lowering nutritious substance.

Chenopodium Quinoa (Wiki Commons)

It’s from the Andes, I knew, and comes in some varieties. If you purchase the raw stuff or receive a gift, say, from a Peruvian person who knows her quinoa, you’ll find quickly that you have to rinse it a few times with water before cooking it with whatever seasoning you choose, such as cilantro or just a pinch of salt, or with some olive oil and ground pepper, cinnamon or curry, because the starch has to be rinsed of its saponin (soapy) coating.

What I learned yesterday, beginning with an informative feature in the Times, is that quinoa is not a grain but a seed. According to that article and Wikispecies (a fabulous web-find, in itself), quinoa belongs to the chenopod family or subfamily of plants which includes the likes of beets and spinach. The word chenopod stems from the Greek roots: <chen> (goose) and pod (foot), as in goosefoot. These are said to be flowering plants that lack petals.

The U.S. MyFoodPedia site is devoid of information on quinoa, as is the USDA’s Nutrient Database, as of this morning. Sellers say it’s rich in fiber, protein and minerals. A research study published by agricultural scientists based in Santiago, Chile, found an ideal balance of amino acids and minerals mixed in the starch, along with omega-6 oils and vitamin E.

In my fourth year of medical school, I spent most of two months in Bolivia studying infectious and other diseases in Cochabamba. But I don’t think I ever tried quinoa. And it’s definitely not something I learned about in class.

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When Less Chemo is Just As Good, In Treatment for Acute Myeloid Leukemia (AML)

Today’s issue of the New England Journal of Medicine includes an article with the bland title Cytarabine Dose for Acute Myeloid Leukemia. AML is an often-curable form of leukemia characterized by rapidly-growing myeloid white blood cells. Cytarabine – what we’d call “Ara-C” on rounds  – has been a mainstay of AML treatment for decades.

The new report* covers a fairly large, multicenter, randomized trial of adult patients with AML. The researchers, based in the Netherlands, Switzerland, Belgium and Germany, evaluated 860 patients who received either intermediate or high doses of Ara-C in their initial, induction chemotherapy. According to the journal, “this investigator-sponsored study did not involve any pharmaceutical companies.”

The main finding was that at a median follow-up of 5 years there were no significant differences between the groups in terms of complete remission rates, relapses or overall survival. The high-dose Ara-C offered no clear advantage in any prognostic subgroup, including those with genetic changes that bear a poor risk. Not surprisingly, Grade 3 and 4 (severe) toxicities were more common in the patients who received higher doses of Ara-C. Those patients also had lengthier hospitalizations and prolonged reduction in their blood counts.

Why am I mentioning this report, besides that it hasn’t received any press coverage? First, because the findings might matter to people who have AML and are contemplating treatment options. But mainly it’s an example of how carefully dialing down some chemotherapy doses could reduce health care costs and lessen untoward effects of cancer therapy – in terms of early toxicities and, possibly down the line, fewer secondary malignancies – without compromising long-term outcomes.

*subscription required: N Engl J Med 364: 1027-36 (2011). The free abstract includes some details on the chemo doses.

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Change the Channel?

The situation in Japan remains grim. I can’t reasonably report on this, except to say what’s evident by the photographs, videos and usually-reliable sources: a second reactor may have ruptured. There’s been another burst of radioactivity into the air.

Flickr, Official U.S. Air Force photo stream

Meanwhile, thousands of bodies are being discovered in the post-Tsunami landscape along the northeast coast. The Emperor’s speech adds a feeling of gravity, essentially unfathomable to those who are not there, and maybe even to those who didn’t live, first, through the atomic bombings in that country 75 years ago.

people in a shelter, as shown on NHK world TV

Working my/our way* through The Pain of Others, Sontag writes:

What to do with such knowledge as photographs bring of faraway suffering? …For all the voyeuristic lure – and the possible satisfaction of knowing, This is not happening to me, I’m not ill, I’m not dying, I’m not trapped in a war – it seems normal for people to fend off thinking about the ordeals of others…

People can turn off not just because a steady diet of images of violence has made them indifferent but because they are afraid…

She considers the role of TV, and the CNN effect regarding images from the war in Sarajevo, and says now (in the book):

The question turns on a view of the principal medium of the news, television…Images shown on television are by definition images of which, sooner or later, one tires. What looks like callousness has its origin in the instability of attention that television is organized to arouse and to satiate…The whole point of television is that one can switch channels, that it is normal to switch channels….

*in reality, her book-essay – on war imagery – grips with relevance, I sped through.

Probably by now, my dear readers are wishing I’d write on something else, and somewhere else, which indeed I am doing with most of my time now. But I think the real-time contemplation of the images – and why we look at them, or don’t – is valuable in itself.

And also, maybe it would help the people of Japan, there, to know that people are thinking about their plight.

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