Archive for April, 2014

New Drugs Aim to Reverse Age Related Muscle Loss

Tuesday, April 29, 2014 // Uncategorized

Sarcopenia is the term for muscle loss.  Muscle loss is more common in older people.  It can be mitigated by resistance training, but that is not always successful.  Muscle loss may lead to increased frailty and risk of falls and fractures. The following is an article from the Wall Street Journal which outlines research aimed at a protein which may regulate muscle loss.



Drugs Aim to Help Elderly Rebuild Muscle

A Half Dozen Companies Work on Treatments That Block the Protein Myostatin


April 27, 2014 8:34 p.m. ET

The ‘Mighty Mouse’ on the right was treated to be more muscular. Se-Jin Lee

In 1997, scientist Se-Jin Lee genetically engineered “Mighty Mice” with twice as much muscle as regular rodents. Now, pharmaceutical companies are using his discovery to make drugs that could help elderly patients walk again and rebuild muscle in a range of diseases.

“I am very optimistic about these new drugs,” says Dr. Lee, a professor of molecular biology at Johns Hopkins University in Baltimore, who isn’t involved in any of the drug trials.

“The fact that they’re so far along means to me they must have seen effects.”

Myostatin is a naturally occurring protein that curbs muscle growth. The drugs act by blocking it, or blocking the sites where it is detected in the body, potentially rebuilding muscle.


“I think the enthusiasm around myostatin is quite clear,” says Nathan LeBrasseur, an associate professor and muscle specialist at the Mayo Clinic in Rochester, Minn. “If you were to ask for the perfect drug target, it’s hard to argue against myostatin because it’s so unique to skeletal muscle.”

The ultimate prize for these drugs would be in treating the elderly.

Experts say muscle wasting and Alzheimer’s—the decline in physical and cognitive functions, respectively—are the two major causes of institutionalization among the elderly.

One of the most important aspects of aging is frailty, which means you slow down and become weaker. “A lot of that is due to muscle strength, which we are looking to improve,” says Mark Fishman, head of the Novartis Institutes for Biomedical Research.

Novartis and Sanofi are both testing their drugs in age-related muscle wasting, called sarcopenia. Lilly is testing its drug in elderly patients undergoing hip replacements or those recovering from falls.

“However you cut it, muscle wasting that has an impact on function is a very, very large patient population,” says Bill Evans, a specialist in aging and muscle-metabolism at GlaxoSmithKline.

“It really depends where the regulators put the cutoff point, but my guess is it could affect 15% to 20% of the population over the age of 65 or 70.”

Still, there are major hurdles to getting a sarcopenia drug approved. Regulators haven’t yet defined sarcopenia as a disease, meaning there is no easy way to approve a drug to treat it.

“People tend to look at muscle loss as something that’s just an inevitable process of aging,” says Dr. Lee.

Drug companies also fear the herculean task of recruiting thousands of elderly patients—preferably not on other medications—for expensive, multiyear clinical trials.

“I think a number of companies have pulled out because there’s not the grand-slam home run,” says Dr. Evans.

Another concern is misuse, by athletes, bodybuilders or by those looking for an antiaging elixir, even when muscle wasting isn’t the problem.

“If you think your mother can be kept out of a nursing home by using a compound—I think there’s going to be a pretty large demand for something like that,” he adds.

The drugs are still some way off being approved to treat elderly patients. But Dr. Lee is eager to see any medical application for his discovery, after a series of myostatin drug failures in the late 2000s.


Myostatin drugs got an “early blemish,” says Dr. LeBrasseur. The new treatments work in a slightly different way.

Hopes for Novartis’s drug BYM338 are now high. Analysts estimate peak annual sales of $4.9 billion, according to a study compiled by consultancy Defined Health, cited by MorphoSys. J.P. Morgan analysts give an estimate off $3.4 billion.

The most advanced testing of BYM338 is in patients with a rare muscle-wasting disease called sporadic inclusion-body myositis. In trials, patients showed a small increase in their thigh muscle volume, and were able to walk farther than those taking a placebo, although the effects waned after treatment.

BYM338 is now in the late stages of clinical testing in the disease, with data from another trial expected in late 2015. Drugs for rare diseases can gain swift approval after relatively small trials.

Myostatin drugs are also being tested for muscle wasting caused by a chronic illness—a condition called “cachexia.” That would be a far larger market.

By some estimates, cachexia is responsible for nearly a third of cancer deaths, as well as leading to the deaths of tuberculosis, heart-disease and lung-disease patients. Current appetite-stimulant treatments aren’t always effective, and steroids can have bad side effects.

Others think the drugs could even be used to treat obesity and Type 2 diabetes one day, since building more muscle means a bigger storage area for sugars that might otherwise accumulate in the liver or pancreas.

Building muscle also increases the body’s need for calories, which means patients burn off more of the food they eat.

“There’s not a single drug on the market today that targets muscle growth in diabetics,” says Dr. LeBrasseur. “That’s pretty profound when you think of muscle playing such a key role in metabolism.”

Still, he cautions there is a lot of work ahead.

“One thing we don’t understand yet is why myostatin is released from muscle—is it playing an important role in other organ health? I think it’s great we’re going after this as a drug target, I just feel like we need to understand the biology a little bit better.”

Write to Hester Plumridge at [email protected] and Marta Falconi at [email protected]

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Do Statins Make You Fatter?

Monday, April 28, 2014 // Uncategorized

Often when I prescribe proton pump inhibitors (PPI’s) such as Nexium or Prilosec for reflux patients remark< “Great, now I can eat whatever I want.”  Giving a medication may enable patients to disregard normal dietary advice to avoid foods that bring it on and eat foods that they normally wouldn’t.  Likewise, people on medications to lower cholesterol when faced the results of impressive cholesterol reduction with medication may choose to eat foods that they otherwise wouldn’t which results in weight gain.  The statins don’t cause the weight gain, but a change in behavior as evidenced by the following JAMA article summarized in Journal Watch.

Calorie, Fat Consumption Up Among Statin Users By Amy Orciari Herman

Calorie and fat consumption increased significantly from 1999 to 2010 among statin users — but not among nonusers — according to a JAMA Internal Medicine study. The researchers conclude that “the importance of dietary composition may need to be reemphasized for statin users.”The researchers evaluated 24-hour dietary recall data from nearly 28,000 adults participating in U.S. nutrition surveys over the 12-year period. They found that among statin users, caloric intake was 10% greater, and fat intake 14% greater, in 2009-2010 than in 1999-2000. No significant increases were observed among nonusers. In addition, statin users had a greater increase in BMI than nonusers did (1.3 vs. 0.4 units).The authors speculate that statin use “may have undermined the perceived need to follow dietary recommendations.” They add that the aim of statin therapy “should be to allow patients to decrease risks that cannot be decreased without medication, not to empower them to put butter on their steaks.” – See more at:

Here is the abstract of the original JAMA article:

Between Statin Users and Nonusers Among US Adults:  Gluttony in the Time of Statins? FREE ONLINE FIRST

Takehiro Sugiyama, MD, MSHS1,2,3; Yusuke Tsugawa, MD, MPH4,5; Chi-Hong Tseng, PhD1; Yasuki Kobayashi, MD, PhD2; Martin F. Shapiro, MD, PhD1,6
[+-] Author Affiliations

1Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at University of California, Los Angeles
2Department of Public Health/Health Policy, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan
3Department of Diabetes, Endocrinology, and Metabolism, National Center for Global Health and Medicine, Tokyo, Japan
4Harvard Interfaculty Initiative in Health Policy, Cambridge, Massachusetts
5Center for Clinical Epidemiology, St Luke’s Life Science Institute, Tokyo, Japan
6Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles
JAMA Intern Med. Published online April 24, 2014. doi:10.1001/jamainternmed.2014.1927
Text Size: A A A
Published online

Importance  Both dietary modification and use of statins can lower blood cholesterol. The increase in caloric intake among the general population is reported to have plateaued in the last decade, but no study has examined the relationship between the time trends of caloric intake and statin use.

Objective  To examine the difference in the temporal trends of caloric and fat intake between statin users and nonusers among US adults.

Design, Setting, and Participants  A repeated cross-sectional study in a nationally representative sample of 27 886 US adults, 20 years or older, from the National Health and Nutrition Examination Survey, 1999 through 2010.

Exposures  Statin use.

Main Outcomes and Measures  Caloric and fat intake measured through 24-hour dietary recall. Generalized linear models with interaction term between survey cycle and statin use were constructed to investigate the time trends of dietary intake for statin users and nonusers after adjustment for possible confounders. We calculated model-adjusted caloric and fat intake using these models and examined if the time trends differed by statin use. Body mass index (BMI) changes were also compared between statin users and nonusers.

Results  In the 1999-2000 period, the caloric intake was significantly less for statin users compared with nonusers (2000 vs 2179 kcal/d; P = .007). The difference between the groups became smaller as time went by, and there was no statistical difference after the 2005-2006 period. Among statin users, caloric intake in the 2009-2010 period was 9.6% higher (95% CI, 1.8-18.1; P = .02) than that in the 1999-2000 period. In contrast, no significant change was observed among nonusers during the same study period. Statin users also consumed significantly less fat in the 1999-2000 period (71.7 vs 81.2 g/d; P = .003). Fat intake increased 14.4% among statin users (95% CI, 3.8-26.1; P = .007) while not changing significantly among nonusers. Also, BMI increased more among statin users (+1.3) than among nonusers (+0.4) in the adjusted model (P = .02).

Conclusions and Relevance  Caloric and fat intake have increased among statin users over time, which was not true for nonusers. The increase in BMI was faster for statin users than for nonusers. Efforts aimed at dietary control among statin users may be becoming less intensive. The importance of dietary composition may need to be reemphasized for statin users.

Figures in this Article

The National Cholesterol Education Program Adult Treatment Panel guideline,1– 4 which was updated by 2013 American College of Cardiology/American Heart Association (ACC/AHA) guideline recently,5 has consistently recommended dietary modification as a key component of antihyperlipidemic therapy. Since 2001, these guidelines also have stated that statins are more effective than other pharmacotherapies.3 Statin use has grown rapidly in the United States over the past 25 years,6,7 while caloric intake has increased overall in US adults from the 1970s through the 1990s8 reaching a plateau starting in the 1999-2000 period.9 The proportion of calories from fat ingested by US adults decreased from the 1970s to the 1990s,8 followed by a stable trend since the 1999-2000 period.9 To our knowledge, no studies have examined whether the temporal trend in food intake is related to statin use, although previous studies have investigated the cross-sectional and short-term relationship between statin use and food intake.10– 12 In this context, we examined whether the time trends of caloric and fat intake differed between statin users and nonusers.


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Miserable Doctors?

Sunday, April 27, 2014 // Uncategorized

From Daniela Drake at  The Daily Beast

How Being a Doctor Became the Most Miserable Profession

Nine of 10 doctors discourage others from joining the profession, and 300 physicians commit suicide every year. When did it get this bad?
By the end of this year, it’s estimated that 300 physicians will commit suicide. While depression amongst physicians is not new—a few years back, it was named the second-most suicidal occupation—the level of sheer unhappiness amongst physicians is on the rise.

Simply put, being a doctor has become a miserable and humiliating undertaking. Indeed, many doctors feel that America has declared war on physicians—and both physicians and patients are the losers.

Not surprisingly, many doctors want out. Medical students opt for high-paying specialties so they can retire as quickly as possible. Physician MBA programs—that promise doctors a way into management—are flourishing. The website known as the Drop-Out-Club—which hooks doctors up with jobs at hedge funds and venture capital firms—has a solid following. In fact, physicians are so bummed out that 9 out of 10 doctors would discourage anyone from entering the profession.

It’s hard for anyone outside the profession to understand just how rotten the job has become—and what bad news that is for America’s health care system. Perhaps that’s why author Malcolm Gladwell recently implied that to fix the healthcare crisis, the public needs to understand what it’s like to be a physician. Imagine, for things to get better for patients, they need to empathize with physicians—that’s a tall order in our noxious and decidedly un-empathetic times.

After all, the public sees ophthalmologists and radiologists making out like bandits and wonder why they should feel anything but scorn for such doctors—especially when Americans haven’t gotten a raise in decades. But being a primary care physician is not like being, say, a plastic surgeon—a profession that garners both respect and retirement savings. Given that primary care doctors do the work that no one else is willing to do, being a primary care physician is more like being a janitor—but without the social status or union protections.

Unfortunately, things are only getting worse for most doctors, especially those who still accept health insurance. Just processing the insurance forms costs $58 for every patient encounter, according to Dr. Stephen Schimpff, an internist and former CEO of University of Maryland Medical Center who is writing a book about the crisis in primary care. To make ends meet, physicians have had to increase the number of patients they see. The end result is that the average face-to-face clinic visit lasts about 12 minutes.

Neither patients nor doctors are happy about that. What worries many doctors, however, is that the Affordable Care Act has codified this broken system into law. While forcing everyone to buy health insurance, ACA might have mandated a uniform or streamlined claims procedure that would have gone a long way to improving access to care. As Malcolm Gladwell noted, “You don’t train someone for all of those years in [medicine]… and then have them run a claims processing operation for insurance companies.”

To make ends meet, physicians have had to increase the number of patients they see. The end result is that the average face-to-face clinic visit lasts about 12 minutes.

In fact, difficulty dealing with insurers has caused many physicians to close their practices and become employees. But for patients, seeing an employed doctor doesn’t give them more time with the doctor—since employed physicians also have high patient loads. “A panel size of 2,000 to 2,500 patients is too many,” says Dr. Schimpff. That’s the number of patients primary care doctors typically are forced to carry—and that means seeing 24 or more patients a day, and often these patients have 10 or more medical problems. As any seasoned physician knows, this is do-able, but it’s certainly not optimal.

Most patients have experienced the rushed clinic visit—and that’s where the breakdown in good medical care starts. “Doctors who are in a rush, don’t have the time to listen,” says Dr. Schimpff. “Often, patients get referred to specialists when the problem can be solved in the office visit.” It’s true that specialist referrals are on the rise, but the time crunch also causes doctors to rely on guidelines instead of personally tailoring medical care. Unfortunately, mindlessly following guidelines can result in bad outcomes.

Yet physicians have to go along, constantly trying to improve their “productivity” and patient satisfaction scores—or risk losing their jobs. Industry leaders are fixated on patient satisfaction, despite the fact that high scores are correlated with worse outcomes and higher costs. Indeed, trying to please whatever patient comes along destroys the integrity of our work. It’s a fact that doctors acquiesce to patient demands—for narcotics, X-rays, doctor’s notes—despite what survey advocates claim. And now that Medicare payments will be tied to patient satisfaction—this problem will get worse. Doctors need to have the ability to say no. If not, when patients go to see the doctor, they won’t actually have a physician—they’ll have a hostage.

But the primary care doctor doesn’t have the political power to say no to anything—so the “to-do” list continues to lengthen. A stunning and unmanageable number of forms—often illegible—show up daily on a physician’s desk needing to be signed. Reams of lab results, refill requests, emails, and callbacks pop up continually on the computer screen. Calls to plead with insurance companies are peppered throughout the day. Every decision carries with it an implied threat of malpractice litigation. Failing to attend to these things brings prompt disciplining or patient complaint. And mercilessly, all of these tasks have to be done on the exhausted doctor’s personal time.

Almost comically, the response of medical leadership—their solution— is to call for more physician testing. In fact, the American Board of Internal Medicine (ABIM)—in its own act of hostage-taking—has decided that in addition to being tested every ten years, doctors must comply with new, costly, “two year milestones.” For many physicians, if they don’t comply be the end of this month, the ABIM will advertise the doctor’s “lack of compliance” on their website.

In an era when nurse practitioners and physician assistants have shown that they can provide excellent primary care, it’s nonsensical to raise the barriers for physicians to participate. In an era when you can call up guidelines on your smartphone, demanding more physician testing is a ludicrous and self-serving response.

It is tone deaf. It is punitive. It is wrong. And practicing doctors can’t do a damn thing about it. No wonder doctors are suicidal. No wonder young doctors want nothing to do with primary care.

But what is a bit of a wonder is how things got this bad.

Certainly, the relentlessly negative press coverage of physicians sets the tone. “There’s a media narrative that blames physicians for things the doctor has no control over,” says Kevin Pho, MD, an internist with a popular blog where physicians often vent their frustrations. Indeed, in the popular press recently doctors have been held responsible for everything from the wheelchair-unfriendly furniture to lab fees for pap smears.

The meme is that doctors are getting away with something and need constant training, watching and regulating. With this in mind, it’s almost a reflex for policy makers to pile on the regulations. Regulating the physician is an easy sell because it is a fantasy—a Freudian fever dream—the wish to diminish, punish and control a disappointing parent, give him a report card, and tell him to wash his hands.

To be sure many people with good intentions are working toward solving the healthcare crisis. But the answers they’ve come up with are driving up costs and driving out doctors.  Maybe it’s too much to ask for empathy, and maybe physician lives don’t matter to most people.

But for America’s health to be safeguarded, the wellbeing of America’s caretakers is going to have to start mattering to someone.

From Daniela Drake at  The Daily Beast

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Why Doctor’s Ratings Are Misleading

Saturday, April 26, 2014 // Uncategorized

This is one of my pet peeves.  This article summarizes very well the hazards of believing online ratings for doctors.

Why Doctor Ratings Are Misleading

By Richard Gunderman

Like many of the over 800,000 physicians in the United States, I regularly receive emails concerning my online reputation. In just the past week, I have received three that open with:

“Dear Dr. Gunder. Do you know your doc score?”

“Congratulations, RG. You are eligible for the Hippocrates Award.”

“Hello, Dr. Richard. How many bad reviews do you have?”

The messages come from online vendors whose services include compiling and publishing patient satisfaction scores, providing free medical advice to unseen patients, and helping physicians manage (read: improve) their online reputations.

Never mind the fact that most physicians have never heard of these companies, that most recipients of such messages never requested a reputational biopsy, or that many of these solicitations convey all the sincerity of a bulk mail notice from a bank bearing congratulations on the news that you have been pre-approved for a credit card.

Some naive patients may take such ratings seriously, but very few of my colleagues in medicine do. For one thing, these ratings are often based on a very low number of reviews. A physician that treats hundreds of patients might have less than a handful of ratings. This poor participation rate lowers the probability that the online rating truly reflects the aggregate views of the physician’s patients, and necessarily exaggerates the influence of even a single disgruntled or highly laudatory reviewer.

In most such online ratings, there is no guarantee that the person submitting the review was even cared for by the physician. Like other online ratings for services as diverse as lawn care, college professors, and automobile dealers, there is no practical way to verify that any particular rater knows what he or she is talking about. And the more influential such ratings become, the greater the incentive to manipulate such scores artificially.

Major aspects of a physician’s overall quality tend not to be readily apparent to patients. There is a natural tendency to overrate aspects such as accessibility, affability, and bedside manner. Friendliness of office staff and even ease of parking may figure prominently. Though important, these features do not tell the whole story. Other vital aspects of care, such as the physician’s fund of knowledge, technical skill, and professional judgment may be difficult or impossible for most patients to evaluate thoroughly.

Good outcomes do not necessarily reflect good medical care, and the same can be said conversely for bad outcomes. A patient with a minor and self-limited viral infection might be very satisfied that a physician ordered several diagnostic tests and prescribed antibiotics, despite the fact that such measures did nothing to hasten recovery. Conversely, a patient with an incurable disease might express great dissatisfaction, despite receiving the very best care possible under the circumstances.

Most disturbingly, it is possible to be highly rated by such online services and yet be a remarkably bad physician. In one celebrated case last year, a New Jersey cardiologist who admitted to employing unlicensed personnel, allowing poorly qualified staff to treat patients, and defrauding insurers of nearly $20 million as also found to have online scores of “very good” to “excellent” and had received three quality awards from one of the most prominent online physician rating services.

This is not to say that patient satisfaction and physician reputation do not matter. To the contrary, satisfied patients are more likely to return to their physician, practice, or hospital for care. They are also generally more likely to follow a physician’s recommendations, and may even enjoy better health outcomes. Everyone knows that one of the most important sources of referral for physicians is the personal recommendation of a satisfied patient.

Yet there is real danger in making too much of online doctor ratings. Doing so may lead physicians to do things that conflict with their professional judgment—such as providing unneeded medications and procedures—in the interest of improving scores. It may also lead them to spend too much time worrying about and buffing up their reputations, rather than focusing their attention on taking the best possible care of their patients.

To top it all off, there is evidence that satisfied patients are not the best cared for or healthiest. A March 2012 study in the Archives of Internal Medicine showed that patients with the highest satisfaction scores were more likely to be taking prescription medications, visit doctors’ offices, and enter the hospital. They were also likelier to be in poor health and die in the ensuing years.

This article available online at:

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Primary Care Burnout

Thursday, April 10, 2014 // Uncategorized


Preaching to the choir.

Burnt Out Primary Care Docs Are Voting With Their Feet

Topics: Delivery of Care, Health Costs, Hospitals, Public Health, Quality

By Roni Caryn Rabin

Apr 01, 2014


This KHN story was produced in collaboration with wapo

Janis Finer, 57, a popular primary care physician in Tulsa, Okla., gave up her busy practice two years ago to care full time for hospitalized patients. The lure? Regular shifts, every other week off and a 10 percent increase in pay.

Illustration by Doug Chayka

Lawrence Gassner, a Phoenix internist, was seeing four patients an hour. Then he pared back his practice to those who agreed to pay a premium for unhurried visits and round the clock access to him.  “I always felt rushed,” said the 56-year-old. “I always felt I was cutting my patients off.”

Tim Devitt, a family physician in rural Wisconsin, took calls on nights and weekends, delivered babies and visited his patients in the hospital. The stress took a toll, though: He retired six years ago, at 62.

Physician stress has always been a fact of life.  But anecdotal reports and studies suggest a significant increase in the level of discontent-especially among primary care doctors who serve at the frontlines of medicine and play a critical role in coordinating patient care.

Just as millions of Americans are obtaining insurance coverage through the federal health law, doctors like Finer, Gassner and Devitt are voting with their feet. Tired of working longer and harder because of discounted insurance payments and frustrated by stagnating pay and increasing oversight, many are going to work for large groups or hospitals, curtailing their practices and in some cases, abandoning primary care or retiring early.

“I was thinking of leaving medicine; I didn’t think I could maintain the pace,” Gassner said about why he switched to a concierge-style practice with the help of consultant MDVIP.  “I went to bed many nights lying awake, worrying that I missed something.”

The timing couldn’t be worse. “The lack of an adequate primary care infrastructure in the U.S. is a huge obstacle to creating a high-performing health care system,” said David Blumenthal, president of The Commonwealth Fund, a health care research foundation.

A 2012 Urban Institute study of 500 primary-care doctors found that 30 percent of those aged 35 to 49 planned to leave their practices within five years. The rate jumped to 52 percent for those over 50.

Stressed doctors, meanwhile, often mean anxious, dissatisfied patients. Many consumers report feeling shortchanged after waiting weeks or even months for an appointment, only to get a quick once-over and be told there isn’t time to address all their complaints in one visit.

“Your actual one-on-one with the doctor is getting to be less and less,” said Christine Miserandino, 36, of Valley Stream, N.Y., who sees many doctors to manage her lupus.

Unhappy Doctors, Unhappy Patients

There are no hard national data on physician burnout. But nearly half of more than 7,200 doctors responding to a survey published in 2012 by the Mayo Clinic reported at least one symptom of burnout that indicated a loss of enthusiasm about medicine or cynicism about it. That’s up from 10 years ago, when one quarter of doctors reported burnout symptoms in another survey.

A RAND study for the American Medical Association last year found that nearly half of surveyed physicians called their jobs “extremely stressful” and more than one-quarter said they were either “burning out,” experiencing burnout symptoms “that won’t go away,” or “completely burned out” and wondering if they “can go on.”  Nonetheless, many described themselves as satisfied with their profession.

But should the happiness of physicians – a fairly privileged lot – be of concern to their patients? Experts answer with a resounding ‘yes,’ saying that unhappy doctors can make for unhappy patients.

Indeed, one of the drivers of physician dissatisfaction is their sense they are shortchanging patients: that they are too rushed, don’t have enough time to listen and aren’t always providing good care.

“Being a doctor is a bit like being a parent, where they say you’re only as happy as your least happy child,” said Martin Kanovsky, 61, an internist in Chevy Chase, Md., who reduced the number of patients he is seeing from 1,200 to 400 last December when he switched to an MDVIP concierge practice. “At the end of the day, if you have one patient who’s unhappy, you’re unhappy.”

Research shows that patients of satisfied doctors are more likely to show up for their appointments and adhere to treatment for diabetes and high blood pressure. Another survey found dissatisfied physicians reporting more difficulty than other doctors in caring for patients.

And in another study, burned-out surgeons were more likely to report having made a major medical error, in the past three months.

“What drives physician satisfaction is also what patients and payers want – delivering good care. And we’re less and less able to do that,” said Christine Sinsky, an internist in Dubuque, Iowa, who is working with the AMA to try to improve physician satisfaction. “You spend less time listening to patients, getting to know them, and thinking more deeply about their care.”

‘I Knew I Had To Be Able To Sleep At Night’

That was the situation that confronted Janis Finer, who loved – but ultimately left -primary care to work with hospital patients.

Like many physicians, she did not want to be bothered with the business of medicine -dealing with insurers, hiring staff and making bank deposits -and sold her practice to a hospital.

But hospital administrators dictated the pace, telling her she needed to see 22 to 28 patients a day.  “At one point, we were scheduled to see patients every 11 minutes,” Finer said.

She was supposed to suggest they schedule another visit if they had more than one or two medical complaints. But Finer worried they wouldn’t come back.

“I knew I had to be able to sleep at night,” she said. “I was trained to dot every ‘i,’ and cross every ‘t’ and leave no stone unturned.”

If a patient had anemia, for example, she could simply prescribe iron, but she wanted to find out what was causing it.

But she found she was unable to do such things while seeing so many patients.

At the same time, her income lagged far behind that of her peers in specialties, a pay disparity that irked her more over time. Salaries of primary care physicians were around $220,000 in 2012, according to the 2013 Medical Group Management Association’s compensation survey, while specialists were averaging close to $400,000, with cardiologists and orthopedic surgeons earning over half a million dollars.

Efforts to boost compensation for primary care doctors have been largely unsuccessful. Specialists’ pay is based largely on procedures, but primary care doctors are usually paid per visit, and not reimbursed for managing their patients’ care outside of visits, which can consume a lot of their time.

Richard J. Baron, president of the American Board of Internal Medicine, set out to document how much time a doctor spends managing care and discovered that on a typical day, he or she handles 18.5 phone calls; reads 16.8 e-mails; processes a dozen prescription refills (not counting those written during a visit); interprets 19.5 lab reports; reviews 11 imaging reports; and reads and follows up on 13.9 reports from specialists.

“This is not just busy work — this is about meeting the patients’ needs,” Baron said.  “But … it doesn’t generate revenue.”

‘I Used To Be A Doctor; Now I’m A Clerk’

Perhaps the single greatest source of frustration for many physicians is a tool that was supposed to make their lives easier: electronic medical records.

Many do not merely dislike electronic health records – they despise them. “We were surprised by the intensity of their reports,” said Mark Friedberg, a physician and co-author of last year’s RAND study.

In 2009, President Obama committed billions of dollars to help defray providers’ costs of going digital. The goal was to boost coordination of care and to reduce errors and rampant duplication. Most primary care doctors got financial help from the federal government and also face potential penalties beginning next year if they don’t use the new systems.

But many physicians say that instead of speeding things up, digital records have slowed them down. They say the designs often frustrate patients and providers -with the doctor’s face often turned to the computer screen while the patient is talking.

Digital records often contain numerous, repetitive information fields but leave little room for the kind of personal, nuanced observation that was captured in an old-fashioned doctor’s note. And restrictions on who is allowed to input the data have shifted many administrative tasks from medical assistants and nurses to physicians.

Using electronic medical records is often more time-consuming for primary-care physicians than for specialists, because they are often taking more comprehensive medical histories, tracking more tests and lab results and filling in more fields.

“Many physicians said to us, ‘I used to be a doctor, now I’m a clerk,'” said Dr. Jay Crosson, a pediatrician and vice president of professional satisfaction for the AMA.

Worsening Shortage Forecast

Meanwhile, the promise of electronic health care records to reduce errors and duplication and facilitate communication has so far gone largely unfulfilled, as far as many doctors are concerned.

John Schumann, a primary care doctor who teaches at the University of Oklahoma’s School of Community Medicine in Tulsa, sees patients at three different hospitals, with three different record systems. “They’re all different and none of them talk to each other,” he said. “That’s the kind of thing that drives doctors’ nuts.”

To ease the burden, some physicians have started using scribes – laptop-carrying assistants who follow them in and out of the exam room.

Scribing is one of several proposals to provide greater support to physicians by giving more responsibility to nurses, health coaches and health educators. But adding personnel involves additional costs, which worries physicians trying to limit their overhead.

The trend line, meanwhile, is troubling. The Association of American Medical Colleges estimates the United States will be short 45,000 primary-care doctors in 2020, when 268,000 are projected to be practicing. That compares to a shortfall of 9,000 in 2010, with 254,800 practicing.

Even a recent uptick in medical students who are electing primary care is not enough to avert the projected shortage. Meanwhile, experienced doctors are joining large groups or becoming hospital employees, which some argue reduces clinical autonomy and discretion -such as deciding how much time to spend with patients -and which may potentially drive up health-care costs because hospitals may tack on additional fees to their bills.

“They want a place to shelter from the storm,” Blumenthal said.

© 2014 Henry J. Kaiser Family Foundation. All rights reserved.

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How Much Did Medicare Pay Your Doctor?

Wednesday, April 9, 2014 // Uncategorized

After much debate Medicare has released the amount of money that they paid to doctors.  Bottom line: a small percentage of doctors were paid a quarter of the money.  Here is the article from the New York Times followed by how much they paid me.

Sliver of Medicare Doctors Get Big Share of Payouts


Marilyn Tavenner, chief of the Centers for Medicare and Medicaid Services, which will make the data publicly available. Credit J. Scott Applewhite/Associated Press

A tiny fraction of the 880,000 doctors and other health care providers who take Medicare accounted for nearly a quarter of the roughly $77 billion paid out to them under the federal program, receiving millions of dollars each in some cases in a single year, according to the most detailed data ever released in Medicare’s nearly 50-year history.

In 2012, 100 doctors received a total of $610 million, ranging from a Florida ophthalmologist who was paid $21 million by Medicare to dozens of doctors, eye and cancer specialists chief among them, who received more than $4 million each that year. While more money by far is spent for routine office visits than any other single expenditure, one of the most heavily reimbursed procedures — costing a total of $1 billion for 143,000 patients — is for a single treatment for an eye disorder common in the elderly.

The Medicare data — all for 2012 and the subject of an intense legal battle — provides an unprecedented look at the practice of medicine across the country, shedding fresh light on the treatment decisions physicians and other practitioners make every day. It will also provide consumers with an ability to compare doctors and treatments in a way they have never had until now.

Continue reading the main story

Interactive Graphic

How Much Your Doctor Received From Medicare

Find a doctor or other medical professional among the more than 800,000 health care providers that received payments in 2012 from Medicare Part B.

OPEN Interactive Graphic

Fraud investigators, health insurance plans, researchers and others will spend weeks poring over the information about how many tests were ordered and procedures performed for every provider who received Medicare payments under Part B, which excludes payments to hospitals and other institutions. The Centers for Medicare and Medicaid Services is making the data publicly available on Wednesday. While total Medicare spending — including hospitals, doctors and drugs — is approaching $600 billion a year, payments to individual doctors have long been shrouded in secrecy. For decades, the American Medical Association, the powerful doctors’ group, and others have blocked the release of the information, citing privacy concerns and the potential for misuse of the information. But a federal judge ruled last year that the information could be made public.

Medicare paid $12 billion for 214 million office and outpatient visits, most of them described as between 15 and 25 minutes long. The practitioners — usually doctors, but sometimes nurse practitioners, were paid an average of $57 a visit.

Much of Medicare spending is concentrated among a small fraction of doctors. About 2 percent of doctors account for about $15 billion in Medicare payments, roughly a quarter of the total, according an analysis of the data by The New York Times. These figures exclude commercial entities like clinical laboratories and ambulance services, which account for $13.5 billion of the $77 billion total. Only a quarter of the doctors are responsible for three-quarters of the spending. Medicare provided The New York Times with an advance look at the information but requested that individual doctors not be contacted until the data was made public. A database, searchable by doctors’ names, is available at

“This is actually the most useful data set that Medicare has ever released,” said Dr. Bob Kocher, who served in the Obama administration and is now a partner at Venrock, a venture capital firm. People will be able to see just how many elbow surgeries a given orthopedic surgeon has performed on Medicare patients, he said, and they will be able to better judge a doctor’s style of practice, for example, whether a CT scan is performed on every patient or only rarely. “You’re going to see variation,” he said.

The American Medical Association, which chose not to try to block the release of the information, questioned the usefulness of these payments to assess doctors.

“We know there are going to be limitations,” said Dr. Ardis Dee Hoven, the president of the association. “It’s raw claims data. This gives us no window into quality or anything of that nature.” While patients may know who performs a high number of procedures, like hip replacements, for example, they will not be able to tell anything about whether the patients needed the surgery or whether they benefited from the surgery.

What’s more, Dr. Hoven cautioned, doctors were not able to review the data, and some of the information being made public could be wrong.

But the release of the information is likely to increase attention to particularly controversial areas of spending. About 3,300 ophthalmologists, for example, were paid a total of $3.3 billion from Medicare, according to the Times analysis. Much of the spending was the result of an expensive and frequent treatment for a kind of age-related macular degeneration, the leading cause of severe vision loss in the elderly, and the cost of the drug is factored into the payments doctors receive. Ranibizumab, known by the brand name Lucentis, is injected into the eye as often as once a month. A cancer drug that is used as an alternative can cost much less. Other specialists also account for large portions of Medicare spending. Fewer than 1,000 radiation oncologists, for example, received payments totaling $1.1 billio

The Best-Paid 2 Percent of Doctors

Among doctors who bill Medicare, the highest-paid 2 percent accounted for almost one-quarter of total Medicare payments.

How Much Your Doctor Received From Medicare: Here is What They Paid Me. Look at how much they discount the fees!

Use the form below to find a doctor or other medical professional among the more than 800,000 health care providers that received payments in 2012 from Medicare Part B, which covers doctor visits, tests and other treatments. APRIL 9, 2014

All SpecialtiesAddiction MedicineAllergy/ImmunologyAnesthesiologist AssistantsAnesthesiologyAudiologistCertified Registered Nurse AnesthetistCardiac ElectrophysiologyCardiac SurgeryCardiologyCertified Clinical Nurse SpecialistCertified Nurse MidwifeChiropracticClinical PsychologistColorectal SurgeryCritical CareDermatologyDiagnostic RadiologyEmergency MedicineEndocrinologyFamily PracticeGastroenterologyGeneral PracticeGeneral SurgeryGeriatric MedicineGeriatric PsychiatryGynecological/OncologyHand SurgeryHematologyHematology/OncologyHospice and Palliative CareInfectious DiseaseInternal MedicineInterventional Pain ManagementInterventional RadiologyLicensed Clinical Social WorkerMaxillofacial SurgeryMedical OncologyNephrologyNeurologyNeuropsychiatryNeurosurgeryNuclear MedicineNurse PractitionerObstetrics/GynecologyOccupational therapistOphthalmologyOptometryOral SurgeryOrthopedic SurgeryOsteopathic Manipulative MedicineOtolaryngologyPain ManagementPathologyPediatric MedicinePeripheral Vascular DiseasePhysical Medicine and RehabilitationPhysical TherapistPhysician AssistantPlastic and Reconstructive SurgeryPodiatryPreventive MedicinePsychiatryPsychologistPulmonary DiseaseRadiation OncologyRadiation TherapyRegistered Dietician/Nutrition ProfessionalRheumatologySleep MedicineSpeech Language PathologistSports MedicineSurgical OncologyThoracic SurgeryUrologyVascular Surgery
Results: 1 internist named “mark thornton” in 78216 Total Reimbursed
by Medicare in 2012

Source: The information presented here is from a database released by the Centers for Medicare and Medicaid Services. The database excluded, for privacy reasons, any procedures that a doctor performed on 11 or fewer patients. The total reimbursements for each doctor does not include those procedures either. Results shown above include only the individuals like doctors, nurses or technicians but not organizations like Walgreens. While some providers could have multiple offices, the address shown is the main address indicated in the database. Descriptions of the procedures are from the American Medical Association.

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Malcom Gladwell’s Advice to Physicians

Tuesday, April 1, 2014 // Uncategorized

Some interesting thoughts from the man who gave us “Blink” and “The Tipping Point”.

Robert Pearl, M.D.Robert Pearl, M.D. Contributor

I cover the business and culture of health care every Thursday. full bio →

As a CEO, practicing physician and business school professor, I have a unique perspective on the business of health care and the culture of medicine. My passion is helping people understand the interactions and consequences of these powerful forces. I am the CEO of The Permanente Medical Group – the largest medical group in the nation – and CEO of the MidAtlantic Permanente Medical Group. In these roles, I am responsible for 9,000 physicians, 35,000 staff and the medical care of 4 million Americans living on both the west and east coasts. I am chair of the Council of Accountable Physician Practices (CAPP), a board-certified plastic and reconstructive surgeon, a clinical professor of surgery at Stanford University, and on the faculty of the Stanford Graduate School of Business where I teach courses on strategy, leadership, and health care technology. I received my M.D. from the Yale University School of Medicine and completed my residency in Plastic and Reconstructive Surgery at Stanford. Follow me on Twitter @RobertPearlMD.

The author is a Forbes contributor. The opinions expressed are those of the writer.


Pharma & Healthcare 3/13/2014 @ 1:00PM 380,859 views

Malcolm Gladwell: Tell People What It’s Really Like To Be A Doctor

Laura Henze Russell Thank you, Dr. Robert Pearl, and Malcolm Gladwell. Medicine, hospitals, lab testing, pharmaceuticals, medical devices, care services and consults are big b […] Ashleigh Blatt, PMP Bravo to anyone bringing attention to this matter. It is long overdue! Hospitals are making hand over fist and private practice doctors are struggling to “ […] Jeffrey L Gum MD Agree Ashleigh! Hospital revenue has increased 3-fold over the last decade, insurance companies are close to this as well. All while physician payments hav […] davisliumd Did not expect that question from one of our generation’s most influential thinkers. Great question. Great answers. The brutal reality of a small primary c […] Henry L. Abrons, MD, MPH Dr. Pearl writes eloquently about the duality of being a doctor and the affliction of “Claims and Pains: The Clerical Side of Practicing Medicine”. Thanks a lot Robert for sharing such a great piece of writing; we will hope that Malcolm Gladwell will get huge response and success as well. It is really […] Robert Pearl, M.D., ContributorAs Atul Gawande has shown, most medical errors result from systems, not individuals. Our focus as a nation has to be on improving the totality of medical c […]

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In last week’s article, Malcolm Gladwell dissected and diagnosed American health care.

Throughout our interview, he tackled controversial topics from the Affordable Care Act and medical malpractice to the contrasting Canadian health care system and much more. I expected him to dive deep below the surface and provide new and intriguing perspectives. He didn’t disappoint.

But it was his closing comment that caught me off guard. When I asked Gladwell what topics he thought I should cover in future Forbes blogs, he said, “Help people understand what it is really like to be a physician.”

I did not see that coming. I figured he’d request an expose on Big Pharma, an in-depth examination of various medical conditions or a portrait of preventive care. But explaining what it’s really like to be doctor is a much more personal request and, as it turned out, much more challenging.

English: Malcolm Gladwell speaks at PopTech! 2...Malcolm Gladwell speaking at a 2008 conference. (Photo credit: Wikipedia)

The Duality Of Being A Doctor

Most physicians go into medicine with a mission-driven spirit, committed to helping people. They are grateful for the opportunity to care for others, proud of their ability to diagnosis and treat, and inspired by the trust their patients put in them.

But those experiences contrast vividly with the economic side of being a physician. Each day, mundane financial tasks distance doctors from the reasons they chose medicine as a career in the first place.

That’s the duality of being a doctor. There’s the fulfilling personal side and the frustrating impersonal side. The personal side reminds doctors why they love practicing medicine. The impersonal side poses a significant threat to the future of medicine. Let me begin by explaining the personal side.

Awe and Terror: The Clinic Side Of Practicing Medicine  

For academically outstanding students with a desire to improve the lives of others, becoming a physician is a great career choice. They work hard in their training to master both the science and art of modern clinical practice.

This hardworking and altruistic spirit is necessary for aspiring doctors to endure the physically, emotionally and financially taxing aspects of medical school and residency training. And that’s where future physicians experience both awe and humility as they navigate the complex journey of becoming a doctor.

They spend their days exploring the mysteries of the human body. They learn to decipher medical secrets by looking into the eye, listening to the heart and palpating the abdominal organs. They gain the competence and confidence needed to cut open a body with a scalpel, insert scopes into the different orifices and cavities, and remove damaged tissue to eradicate disease and restore health.

Out of context, these practices would constitute assault and battery. In medicine, these activities are essential. Being entrusted to perform them is a privilege afforded only to those who earn the title of “doctor.” It is an awesome responsibility.

Physicians are permitted and often required to ask deeply personal questions. Patients answer willingly. The intense and intimate nature of the doctor-patient relationship represents a unique bond, a trust forged in just a matter of minutes during a standard clinical encounter.

The majesty of the human body, the importance of health, and the personal fulfillment that comes from healing define the physician’s world and the clinical practice of medicine.

But along with the awe and pride comes an underlying terror.

As physicians treat patients, they are afraid of making a mistake or harming someone. Physicians worry about missing a life-threatening diagnosis, unintentionally spreading infection or committing a technical error. This fear isn’t just the self-protective paranoia of being sued for malpractice. It stems from a profound anxiety of violating the deeply embedded, core principle of the profession: Primum non nocere or “first, do no harm.”

Most nights, physicians go to sleep fulfilled and grateful for the honor of becoming a part of their patients’ lives. And overall, the opportunity to make a difference is fulfilling and satisfying.

But when something goes wrong, the agony runs deep. There are sleepless nights filled with tossing, turning and painful reflection.

Claims and Pains: The Clerical Side Of Practicing Medicine

As fulfilling as patient care is, most doctors (particularly those in individual and small practices) lament the other side of the job: the business of health care.

As much as half of each day can be consumed with clerical and administrative tasks: completing insurance claims forms, navigating complex coding requirements, and negotiating with insurance companies over prior approvals and payment rates. And this affects not only physicians, but also their patients – further complicating medical practice and increasing the level of frustration.

In my conversation with Gladwell, he spoke about a doctor’s office he’d recently visited. He described interacting with four support staff: three doing paperwork and only one assisting the physician with medical care.

“That’s insane,” he said. “The only other industry in America that has a higher ratio of back-office to front-office is financial services, which also is a massively crazy business. It’s just wrong. It’s a misuse of resources.”

He also expressed concerns about the economics of medical practice and the consequences for physicians:

“I don’t understand, given the constraints physicians have in doing their job and the paperwork demanded of them, why people want to be physicians. I think we’ve made it very, very difficult for them to perform their job. I think that’s a shame. My principal concern is the amount of time and attention spent worrying about the business side. You don’t train someone for all of those years of medical school and residency, particularly people who want to help others optimize their physical and psychological health, and then have them run a claims-processing operation for insurance companies.”

It’s this side of medical practice that wears down even the best physicians.

Yet it’s the reality for many American doctors, particularly those in small offices, who are reimbursed on a fee-for-service basis. Filling out claims forms and managing thousands of billing codes are frustrating and exhausting tasks. No wonder multiple surveys over the past two decades show a progressive decline in doctor satisfaction among those in community practices.

It’s not the long hours or the demands of patient care that have eroded their satisfaction. It’s the insurance side of health care.

And in 2012, a study found that 9 out of 10 physicians across the country are unwilling to recommend the profession to others.

Where Does That Leave The Future Of Medical Practice?

The life of a practicing physician can be incredibly rewarding. Making challenging diagnoses, helping patients deal with and overcome devastating illness and comforting families after the loss of a loved one – these are powerful emotional experiences. Across history, they have provided physicians with a profound sense of fulfillment.

But the insurance system can erode the professional and personal satisfaction of even the most dedicated physicians. That’s why it has to change.

The solution is not a government-run program with the inevitable red tape and endless regulations. This will only make matters worse. Instead, improving the situation will require a systematic shift – one that moves away from doctors being paid for volume to one that rewards value in a predictable, prepaid way.

It will require helping doctors transition their practices from individual and small office settings to working in integrated, physician-led medical groups. The organizations that have done this have seen higher quality outcomes and increased physician satisfaction.

Malcolm Gladwell: A Much-Needed Catalyst For Change

I left Gladwell’s New York residence hoping that he would apply his powerful and paradigm-shifting insights to the health care world. I’m optimistic he can help create a new language and lens through which our nation can discuss the health care challenges we face.

If he decides to write a book about American health care, I predict the opening chapters of his book will contrast the past five millennia of clinical practice (ones filled with dedication, commitment and fulfillment) against the harsh reality and financial challenges the profession faces today. And maybe, just maybe, his words will serve as a catalyst for system-wide change. Let’s hope so.

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