Category Archives: U.K.

A Doctor Confides, “My Primary Doc is a Nurse”

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Last week I interviewed a doctor who told me that his primary care doc is a “physician assistant”  who has been trained to deliver primary care.   He said it casually, dropping the fact into a long conversation.

Dr. David Kauff is an internist at Seattle’s Group Health Cooperative (GHC), an organization that has a fabulous reputation–both among patients and among physicians—for its primary care program.  One reason is that at Group Health, doctors, physicians assistants and nurse practitioners work together in teams. “The success of our model is based on the fact that everyone in this together; we are corralled by a common purpose,” says Kauff, who also serves as GHC’s  Medical  Director for Practice and Leadership. 

I’ll be writing more about Group Health Cooperative in a few days.

 In this post, I would like to focus on the growing role of Nurse Practitioners (NPs) and Physician Assistants (PAs) as clinicians.  NPs are registered nurses who have gone on to earn a master’s or a doctorate. Some specialize in areas such as anesthesiology, pediatrics (pediatric nurses) or Ob-Gyn (certified nurse-midwives). NP’s can run clinics; some run their own practices.     

By contrast, physician assistants (PAs) don’t usually work alone. While physicians may not be on-site, typically doctors oversee their work.  

PAs are formally trained to provide diagnostic, therapeutic, and preventive health care services.  They take medical histories, examine and treat patients, order and interpret laboratory tests and X- rays, and make diagnoses. In many cases, they did not begin their careers as nurses. They may have been  paramedics, respiratory therapists, or emergency care technicians (EMTs) before becoming PAs.  

Currently, 17 states, plus the District of Columbia, let nurse practitioners operate independently.  In 33 states regulations vary. As this map  reveals, in some places NPs are not allowed to prescribe medication. In others, they may have to consult with a physician when treating patients.

It’s worth noting that NPs enjoy greater freedom in the Northwest, the Upper Middle West, and Northern New England (areas that some healthcare reformers refer to as “Canada South” because these states are in the vanguard of reform) as well as in the Southwest, where many NP’s started working in group practices, and they went out and established their own clinics. Nationwide, about 6,000 nurses operate independent primary-care practices.                                               

                                              Why Physicians Object

Today, 14 states are debating whether NPs should be allowed to practice on their own.  Many emphasize the difference in education and years of training. Though in truth, the length of training is not so different. Becoming a primary care doctor requires four years of medical school plus three years of residency. A nurse practitioner  attends nursing school for four years, then spends two to three years in graduate school, depending on whether he or she is getting an M.A. or a Ph.D. (In 2015, all nurse practitioners will be required to earn a Ph.D.) 

Most NPs also have nursing experience. At the University of Michigan, for instance, the average candidate admitted to the NP program has 7 years of hands-on experience as a nurse.  But while the number of years spent training are not so different, as I explain below, traditionally ,the nature of that training has been very different.   

Doctors say that they are worried about patient safety. “I see it as physicians being true to their oath ”  Dr. Adris Hoven, president-elect of the American Medical Association recently told Marketplace Health Care’s Dan Gorenstein.   Hoven insists that doctors are “not threatened” by NPs.  “At the end of the day what they want to do is deliver the best healthcare possible.”  

Dr. John Rowe, a professor of Health Policy and Management at Columbia’s School of Public Health, doesn’t buy the argument.  As he points out, nurse practitioners are already working without primary care doctors: “The fact is this is going on in 16-17 states,” he told Gorenstein, “and there is no evidence that it’s not good for the patient.”  A recent Health Policy Brief from Health Affairs and the Robert Wood Johnson Foundation backs him up: “studies comparing the quality of care provided by physicians and nurse practitioners have found that clinical outcomes are similar.”

At the same time, Rowe understands why doctors are uncomfortable. “The physicians feel they have something special to offer,” he explains. “And being told there are individuals who are less well trained can do it as well as they could is a very difficult lesson for them.”                                    

When I last wrote about nurse practitioners, back in 2010, one physician/reader (“Sharon M.D.”) was exceptionally candid on this point:

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Donating an Organ: Should It Be A Gift?

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A story in yesterday’s New York Times Magazine raised some very thorny questions about organ transplants. I spent the afternoon reading more about transplants; by evening I had stumbled onto what seems to me at least a partial solution.

The NYT piece tells the story of Sally Satel, a 49-year-old psychiatrist in need of a kidney transplant. In 2004, her kidneys suddenly, quite inexplicably, began to fail. (The cause may have been a medication she had taken in her twenties.)  She had no living relatives except a couple of cousins whom she rarely saw. A close friend came forward, was tested, found that her blood was a match, volunteered to donate a kidney–and then reneged. (It turns out that when she went to chorus practice one evening, “a fellow alto” talked her out of it. The fellow-alto was, of all things, an organ transplant specialist. Satel was enraged: “a transplant surgeon should know how hard it is to get a donor.”)

A second friend volunteered, and again proved a match. But then she, too, got cold feet– though she didn’t tell Satel right away.

Finally, a 62-year-old stranger in Canada saw Satel’s message on an organ match website, called and offered to help her.  He was the right blood type, he seemed “steady” and “honest,” and after a few weeks of phone calls and e-mails, they set a date to do the operations in early January. Then, just before Thanksgiving, he went dark. “Everything turned to radio silence as my e-mail and phone messages went unanswered,” Satel recalls. When her transplant coordinator contacted him, he waffled. He wasn’t sure he would be able to make it in January; he was too heavily involved in a political campaign…

“I was astonished at the Canadian’s . . . what? Negligence, cowardice, rudeness?” Satel writes. “It was a sickening roller-coaster ride: hope yielding to helpless frustration, gratitude giving way to fury. How dare he reduce me to groveling and dependence? Yet I assume he intended no such thing. I think the Canadian was actually quite devoted to the idea of giving a kidney — just not necessarily now or to me.”

By now Satel is desperate. She realizes that her only alternative is dialysis “three days a week, for four debilitating hours at a time, I would be tethered to a blood-cleansing machine… I had an especially morbid dread of dialysis,” Satel admits.  She was haunted by what she had read about “the playwright Neil Simon [who] received a kidney from his longtime publicist in 2004 . . .but before that he endured 18 wretched months on dialysis, suffering cramps and vomiting spells that kept him largely confined to his house. His memory deteriorated, and he hated the time away from his writing. Shortly before his donor came forward (unsolicited, it should be noted), Simon’s doctors said he might have to start spending more time on dialysis. If that were necessary, he said, he had decided, ‘I didn’t want to live my life anymore.’ Neither, I thought, would I.”

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ADHD and the Medication Feeding Frenzy in America

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CORRECTION: In the post below, I make mention that there has been no U.S. media coverage on the MTA report. But after some further digging, I found coverage from Investor’s Business Daily, along with popular sources the New York Post, and Fox News and technical/niche publications like Planet Chiropractic. So there is some American coverage.

But if you click around you can see that the American stories are much more brief than their international counterparts. Each of the stories in the mainstream outlets is more of a newswire dispatch than an actual article, where as the international stories are comprehensive. And while pretty much all of the news sources of record in the U.K. covered the story, the major U.S. outlets–like the WSJ, NYT, Time, Newsweek, etc–seem to have had nothing.

Given that the U.S. is 90 percent of the ADHD drug market, you’d think that MTA’s findings would make nation-wide headlines. But instead coverage is scattered and superficial. Stories are relegated to quasi-interest group literature (investors who may lose money on the drugs, chiropractors who have a professional interest in questioning medication), or to the News Corporation (which owns both the Post and Fox news)–a multinational company with a strong Australian and British component. There’s still no convincing evidence that the American media is, on the whole, ready to meaningfully cover MTA’s findings.

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Earlier this week the British press broke some startling news: the Multimodal Treatment Study of Children with ADHD (MTA), has issued a report that claims there are no long-term benefits of ADHD medication for hyperactive children. Report co-author Professor William Pelham of the University of Buffalo, is quoted in the British press as concluding that ADHD medication is, in the long-term, all risk and no reward.

“The children [on ADHD medication] had a substantial decrease in their rate of growth so they weren’t growing as much as other kids both in terms of their height and in terms of their weight,” he says. “And…there were no beneficial effects – none.”

This is an about face from MTA’s benchmark report in 1999 that asserted with certainty that ADHD drugs were the best way to address ADHD in children. The 1999 study claimed that “combination treatments” (i.e. drugs and behavioral training) along with “medication-management alone” (i.e. drugs) are “both significantly superior” to other ADHD treatments that don’t include medication.

But, according to Pelham, “we exaggerated the beneficial impact of medication in the first study. We had thought that children medicated longer would have better outcomes. That didn’t happen to be the case.” So, according to Pelham, here’s the bottom line: “in the short run [medication] will help the child behave better, in the long run it won’t.”

To some, Pelham’s report might be unwelcome news. Thanks in part to the medical credibility that MTA and other studies have conferred on ADHD medications, global sales of ADHD drugs are predicted to be $4.3 billion by 2012. This ADHD boom is a recent phenomenon, largely a product of the 1990s. According to the US National Ambulatory Medical Care Survey, the number of children who received a diagnosis of ADHD increased 250 percent from 1990 to 1998. A study from 1996 showed that from 1990-1995 child use of ADHD medication increased by a factor of 2.5 and drug production increased six-fold. The production of Ritalin (the most common ADHD medication) increased by 700 percent from 1990-1999.

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What Rudy–and Most Americans–Still Don’t Understand about Prostate Cancer

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Presidential candidate Rudy Giuliani recently made the mistake of trying to turn his brush with prostate cancer into a campaign issue: “I had prostate cancer, five, six years ago. My chance of surviving prostate cancer, and thank God I was cured of it, in the United States, [is] 82 percent. My chances of surviving prostate cancer in England, [is] only 44 percent under socialized medicine,” Giuliani declared.

Rudy, of course, was wrong.

Merrill Goozner has done the best job that I’ve see of cutting through to the truth of the matter. In a Nov. 2  post titled “Columnists Miss Chance to Educate on PSA Testing,” he points out that “Paul Krugman’s column in the New York Times and Eugene Robinson’s column in the Washington Post justifiably attack Rudy Giuliani’s misuse of prostate cancer stats, all but accusing him of lying.

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We Need to Begin A Conversation About “Cost Effectiveness”

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As any policy-maker knows, catering to public opinion, ensuring the public interest, and managing costs can seem an impossible task–especially when what the public thinks it wants is at loggerheads with what it needs. But in the case of health care, there may be an opportunity to do all three at once according to a proposal in the September/October Health Affairs.

The proposal argues for cost-effectiveness analysis (CEA) “to set priorities for Medicare coverage of new or costly interventions” through a citizens’ council made up of “a cross-section of users” who can provide leadership with “well-considered social-value judgments.” This citizens’ council model is borrowed from the UK, where a group of 30 men and women advise the National Institute for Health and Clinical Excellence (NICE) on behalf of the public.

The British experience shows that there are likely to be practical complications with implementing a citizens’ council, but it’s still an idea that’s on the right track. We need to turn “cost-effectiveness” from a bad word into a public interest issue in the US.

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Universal Coverage –Why Massachusetts is the Last Place to Begin the Experiment

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At the Massachusetts Medical Society’s 8th Annual Leadership Forum last Wednesday, Dr. Steven Schroeder, former head of the Robert Wood Johnson Foundation
and Distinguished Professor of Health and Health Care at the University
of California, San Francisco, told a provocative story about a poll
that asked patients in the U.S. `Canada,  Australia, New Zealand and
the U.K the following question:

“If your personal doctor told you that you had an incurable and fatal
disease, would you accept that diagnosis or seek a second opinion?

  • In the U.S.           91 percent of patients said they would seek a second opinion.
  • In Canada            80 percent                    “        “       “       “     “     “           “ 
  • In Australia          71 percent                  “        “   
  • In New Zealand     51 percent
  • In the U.K.           28 percent 

“You have to love the British,” Schroeder commented. “You can just hear
an Englishman saying ‘Well, Luv, it’s been a good life, hasn’t it? Now
let’s make a pot of tea and discuss the funeral arrangements.”

At the other end of the spectrum, we find the Americans who, Schroeder
noted, “are the only people in the world who expect to live ‘in
perpetuity’.”

Today, I would like to suggest that our expectations as patients help
to explain why we spend roughly twice as much per person on health care
as most developed countries—even when, overall, it’s not clear that our
healthcare is better. In fact, in some areas outcomes are worse.

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We Can’t Fund SCHIP, But We Can Save Merck

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Today, Bloomberg trumpeted the good news:  “Merck Profit Gains on Cancer Vaccine, Diabetes Pill.”

“Merck & Co., the third-largest U.S. drugmaker, reported a 63 percent gain in earnings,” Bloomberg reported, a victory made doubly by the fact that Merck has seen some rough times. “Competition from generics and the withdrawal of the pain pill Vioxx in 2004 over heart risks have pulled net income down 39 percent since 2001,” the story explained. Indeed, Vioxx gave Merck a black eye, and it’s still battling lawsuits in the courts. But Gardasil, Merck’s new vaccine to prevent cervical cancer, is turning out to be just the blockbuster the company needed. “Gardasil, introduced a year ago [already] has sales of $418 million”

Those of you familiar with my views on Gardasil may want to skip the below section, as it is pulled from an August post. I promise I won’t do this often, but this is an important subject and it’s example of how, if drug manufacturers and their lobbyists work quickly enough, they can sell their story to politicians and to the public before skeptics in the scientific community have a chance to weigh in. Remember the drug industry saying: “It’s important to sell a new drug while it’s still effective” (i.e. before people know too much about it).

On August 27, I wrote:

Earlier this month the FDA announced that the direct-to-consumer ads Merck has been using peddle its new cervical cancer vaccine, Gardasil, are “half-true . . .information currently being advertised could mislead the public.” 

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Why We Don‘t Have Enough Nurses (It’s Not Low Wages)

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Consider this: In the San Francisco area, a nurse with a bachelor’s degree can hope to start out with a salary of $104,000. The salary for a nursing professor with a Ph.D. at University of California San Francisco starts at about $60,000.

This goes a long way toward explaining why nursing schools turned away 42,000 qualified applications in 2006-2007—even as U.S. hospitals scramble to find nurses. We don’t have enough teachers in nursing schools and the fact that the average nursing professor is nearly 59 while the average assistant professor is about 52 suggests that, as they retire, the shortage could turn into a crisis. The most recent issue of JAMA (October 10, 1007) reports that in 2005 we had 218,800 fewer nurses than we needed and by 2020, it’s estimated that we’ll be short some 1 million nurses.

Hospitals have had to raise nursing salaries (as well they should), not just because nurses are scarce but because, in our chaotic hospital system, the work can be extraordinarily stressful.   

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Comment on Class and Health

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(To see the original post on Class and health, click here.  To add your comment, scroll down and click on “Contact” on the left-hand side of the page.)

From Alan Abrams (a.k.a. Alan_A
at the hpscleansing.com/group
community forums)

I just read Maggie
Mahar’s health blog after linking to it from an agonist.org blog on universal health care.
I then read Maggie Mahar’s blog [post] on
"Class and Health."  thus this quote:

"And yet, and yet . . . Schroeder sees reason for "cautious
optimism." Although we trail behind other countries, we are healthier than
we once were. We have reduced smoking ratse, homicide rates and motor-vehicle
accidents. Vaccines and cardiovascular drugs have improved medical care. But
progress in other areas will require "political action,"
Schroeder declares, "starting with relentless measurement of and focus on actual
health status and the actions that could improve it. Inaction
means acceptance of America’s poor
health status."

Healthier than we once were? Really?  Are…smoking, homicide rates, and
motor-vehicle accidents adequate measures of the overall improving general
health of Americans?

What about these:

  • 58 Million Overweight; 40 Million Obese; 3 Million morbidly Obese
  • Eight out of 10 over 25’s Overweight
  • 78% of American’s not meeting basic activity level recommendations
  • 25% completely Sedentary
  • 76% increase in Type II diabetes in adults 30-40 yrs old since 1990

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Class and Health

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When compared to other developed countries, the U.S. ranks near the bottom on most standard measures of health. Many people assume that this is because the U.S. is more ethnically heterogeneous than the nations at the top of the rankings, such as Japan, Switzerland, and Iceland. But while it is true that within the U.S. there are enormous disparities by race and ethnic group, even when comparisons are limited to white Americans our performance is “dismal” observes Dr. Steven Schroeder in a lecture  published in the New England Journal of Medicine yesterday.

Why? It’s not the lack of universal access to healthcare" says Schroeder, though that’s important. And it’s not just that we don’t exercise enough and eat too much—though that is a major cause. But there is one factor undermining the nation’s health that we just don’t like to talk about in polite society: Class. When it comes to health, class matters.

Schroeder, who is the Distinguished Professor of Health and Health Care at the University of California San Francisco (UCSF) underlines how poorly even white Americans stack up when compared to the citizens of other countries by pointing to maternal mortality as one measure of health. When you look at “all races” you find that in the U.S. 9.9 out of 100,000 women die during childbirth.  Focus solely on white women, and the number is still high—7.2 deaths out of 100,000 –especially when compared to Switzerland where only 1.4 women out of 100,000 die while giving birth.

Statistics on infant mortality reveal the same pattern: among “all races” 6.8 American children who were born alive die during infancy; limit the analysis to “whites only” and 5.7 infants die—compared to just 2.7 out of 1,000 in Iceland. .) When researchers compare maternal mortality and infant mortality in white America to rates of death in the 29 other OECD countries, white America ranks close to the bottom third in both categories.

Turn to life expectancy, and you find that white women in the U.S. can expect to live 80.5 years, only slightly longer than American women of all races (who average 80.1 years). Both groups lag far behind Japanese women (who, on average, clock 85.3 years). The gap between “all American men” (who live an average of 74.8  years) and white men in the U.S. (75.3 years) is wider—but not as wide as the gap between white men in the U.S. and men in Iceland (who live an average of 79.7 years).

“How can this be?” asks Schroeder. After all, as everyone knows, the U.S. spends far more on health care than any other nation in the world.

The answer is a stunner: the path “to better health does not generally depend on better health care,” says Schroeder. “Health is influenced by factors in five domains — genetics, social circumstances, environmental exposures, behavioral patterns, and health care. When it comes to reducing early deaths, medical care has a relatively minor role. Even if the entire U.S. population had access to excellent medical care — which it does not — only a small fraction of premature  deaths could be prevented.” [my emphasis]

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