Will Good Doctors Be There When You Are Most in Need?

The American Medical Money Machine ^ | July 7, 2015 | James R. Goldberg

[musicman]

"Will Good Doctors Be There
When You Are Most in Need?"



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[Pearls Before Swine]

Doctors offices are disappearing.

I was seeing a local doc for primary care. A few months ago, he announces he's moving to a practice in another state. I asked his nurse if he was selling his practice--and she said, "No, because nobody wants to buy a single doc practice these days."

[Chickensoup]

COMMENTARY Skip the Weigh-in for Type 2 Diabetes Patients? Gregory A. Nichols, PhD June 29, 2015 The Obesity Paradox in Type 2 Diabetes Mellitus: Relationship of Body Mass Index to Prognosis Costanzo P, Cleland JG, Pellicori P, et al Ann Intern Med. 2015;162:610-618 Does overweight/obesity really protect people with diabetes? To examine this controversial issue, known as the "obesity paradox," an international group of investigators used data from England's National Health Service to identify a large prospective cohort of patients with diabetes and no known history of cardiovascular disease (CVD). They followed this cohort for a median of nearly 11 years to ascertain all-cause mortality, with a secondary outcome of hospitalizations for CVD events. The main explanatory variable was body mass index (BMI) assessed at baseline. Consistent with other studies, they categorized BMI as low (< 18.5 kg/m2), normal (18.5-24.9), overweight (25-29.9), obese (30-34.9), and very obese (≥ 35). Cox regression analyses adjusted for age, sex, duration of diabetes, baseline systolic blood pressure, smoking, and comorbid conditions, including COPD, cancer, chronic kidney disease, and previous CVD. Increased CVD Risk but Lower Mortality Risk Of the 10,568 patients, 20% were normal weight, 38% were overweight, 25% were obese, and 17% were very obese at baseline. Compared with patients of normal weight, overweight patients had a 13% lower mortality rate. Mortality among patients who were obese or very obese did not differ from normal-weight patients; however, risk for CVD hospitalization events, including acute coronary syndrome and heart failure, was greater for overweight/obese patients. The analyses did not account for BMI changes that may have occurred during follow-up, fitness (either at baseline or during follow-up), differences in pharmacotherapies, or other key risk factors such as cholesterol levels. Abstract Cardiorespiratory Fitness and Incident Diabetes: The FIT (Henry Ford Exercise Testing) Project Juraschek SP, Blaha MJ, Blumenthal RS, et al Diabetes Care. 2015;38:1075-1081 How important is fitness in reducing the risk for diabetes? The Henry Ford Exercise Testing (FIT) project was a large-scale study of patients who underwent physician-referred stress testing between 1991 and 2009. After excluding patients with a history of coronary artery disease, heart failure, or diabetes, the researchers followed 46,979 patients for a median of 5.2 years to determine how many patients developed new onset of diabetes. The main analysis variable was cardiorespiratory fitness expressed in metabolic equivalents (METs) as calculated from a treadmill stress test, and divided into four ascending fitness groups: < 6, 6-9, 10-11, and ≥ 12. Using nested Cox proportional hazards models, the association between fitness and incident diabetes was analyzed, adjusting for a wide range of covariates, including age, sex, race, smoking, hypertension, hyperlipidemia, physical activity, and history of obesity. One sensitivity analysis examined the association across strata of glycated hemoglobin (A1c), and another also adjusted for BMI in the subpopulation that had BMI data available. Fitness Matters During follow-up, 14.6% of patients were newly diagnosed with diabetes. Compared with patients with METs < 6, the hazards for developing diabetes among those with METs 6-9 were not significantly different, but those with METs 10-11 had a 23% lower risk for incident diabetes, and those with METs ≥ 12 had a 54% lower risk after full adjustment. Each additional MET unit was associated with an 8% lower risk. These results were not different among those with and without a history of obesity, and there was no statistical difference across strata of A1c. In the sensitivity analysis of those with BMI data, adjustment for BMI somewhat attenuated the results, but the findings were not meaningfully changed. Abstract Analysis and Commentary The "obesity paradox," in which overweight or even obese patients experience better survival than normal-weight patients, has been a puzzling phenomenon for scientists and laypeople alike. While the relationship between CVD and obesity is largely unquestioned, the paradox emerges once CVD develops, where obesity seems to confer a survival advantage.[1] These unexpected findings have been reported in general populations and in patients with diabetes, leading us to believe that the paradox must be real and applicable to specific subpopulations.[2-4] Indeed, Costanzo and colleagues include a table of 16 studies investigating the relationship between obesity and mortality in type 2 diabetes, the sum of which leads to inconsistent and contradictory conclusions but generally supports the notion of the paradox, or at least no association between obesity and mortality. The authors point out that each of the 16 studies contained methodologic flaws that their study does not, but that is not to say that the study by Costanzo and colleagues is flawless. Two important shortcomings are critical to the interpretation of the study. First, obesity as measured by BMI was assessed at baseline with no accounting for BMI changes during follow-up. Although this is a common approach in epidemiology, BMI trajectories may be a more important predictor of outcomes. To assume that BMI is constant among patients who are frequently (we hope) being counseled to lose weight while at the same time being prescribed drugs that induce weight gain (such as insulin and sulphonylureas)[5] is heroic and likely inaccurate. A second shortcoming of the Costanzo study is that it could not account for fitness level. The FIT study gives us some sense of how important this is, at least with respect to diabetes incidence. No one would argue that obesity and elevated glycemia are the two primary risk factors for diabetes.[6,7] Nevertheless, the FIT study found that greater fitness substantially reduced the risk of developing diabetes, an important finding that did not differ by history of obesity, A1c level, or BMI. The authors briefly mention that their findings were limited by the primary entry criterion—referral for a treadmill stress test—which would probably place the study population at elevated risk for CVD. Because CVD is itself a risk factor for developing diabetes,[8] it is possible that these findings would not apply to a more general population. Still, the results were consistent across all analyzed strata, suggesting an inherent robustness. The main message to take from examining these two studies in parallel is that fitness may at least partially explain the obesity paradox, and our understandable focus on body weight could be a misleading aspect of the weight/health relationship. Patients are counseled to lose weight through diet and exercise to prevent diabetes and CVD, but weight loss is often hard to achieve and even harder to maintain. Perhaps the message should be to increase fitness regardless of whether weight loss accompanies the exercise. Ignoring the scale and striving to walk a little further and faster each day may be a more achievable and sustainable goal that leads to lower CVD and diabetes risk.

[Chickensoup]

Doctors will all become hospital drones except for the high end ones who will serve our masters.

[Lizavetta]

Patients are counseled to lose weight through diet and exercise to prevent diabetes and CVD, but weight loss is often hard to achieve and even harder to maintain.

Are broken joints, diabetes, high blood pressure, heart disease and all the other fat-related illnesses easier?

If doing today what you did yesterday to stay fit, i.e. consistency in exercise and eating right, is too much trouble, then yeah, weight loss is "hard". If it was easy everyone would be slender. You either want to stay healthy as long as you can or you don't.

[Rona Badger]

Yep, that’s been my experience, Liz. My 3 older sisters are all on the “heavy side” going into their 60s and I’ve stayed at 125 lbs (I’m 5’6”). After a wild youth (that sounds so funny) I haven’t had any alcohol for 22 years. They all do enjoy their adult beverages daily, and that does put on the weight. I used to smoke socially and I loved smoking, but gave that up back then, too. I ate macrobiotic style for years and always exercised. I was never sick in my life, and had only spent one night in the hospital for a torn ligament.

However, at 51 I ended up with stage 3 endo cancer despite all that healthy living. But here’s the thing I believe: All of those years of healthy living allowed me to endure the heavy chemo and radiation treatments. Today (5 years past my last treatment), I’m in great shape, back to where I was before in terms of health. Well, maybe not mental health, lol. That’s going to be up for debate :-).

[Twinkie]

Had a routine doctor’s appointment yesterday. He has to juggle a laptop the whole time he’s examining people. I think it’s getting tiresome for him, too.

[Rona Badger]

[Rona Badger]

He has to juggle a laptop the whole time he’s examining people.

Wow. That's crazy. The docs are totally stressing out. I hear this constantly from my RN and doctor friends. They are squirreling away money so they can get out ASAP and a few are considering getting completely out of the country.

[Lizavetta]

Yay, good for you!!

For those that think eating properly and exercising is hard, go to your local nursing home and take a long hard look. Mostly-preventable ailments have made people bedridden, weak and miserable.

Does that look "easy" to you?!

[gattaca]

bump

[Hot Tabasco]

They studied anatomy on a dog, in a tin shack, in Bangladesh.

They obviously learned enough to pass their respective state's medical boards..........

[Hot Tabasco]

Many of the good doctors cannot afford malpractice insurance anymore.

It's much more than malpractice insurance. I cite my BIL as an example......

He's an Oncologist who was a member of a specialty group and was responsible for purchasing all the chemo therapy drugs for his patients, most of whom were medi-gap and medicare recipients.......

Unfortunately for him, the govt. was not reimbursing him for the full costs of the drugs he had to administer (in the tens of thousands of dollars) to his patients and he was forced to drop out of the group and go on staff to the hospital he was working out of.......

[Organic Panic]

Why would anyone become a doctor now? It is innevitable that Obamacare will force doctors in to miserable conditions (more so) and take a massive pay cut. To make up for it obamacare will undertake a massive “free” affirmative action med school program that will take anyone and pay off their loans if they become doctors.

[AEMILIUS PAULUS]

Do they or do they receive credit for their mistreatment over the years? /s/ You are welcome to treat with them.