Medicine and Social Justice: January 2013

Saturday, January 26, 2013

The flu is a virus!

It is winter and a lot of people are sick. Around here, and around the country, there are two big kinds of sick – one is mainly gastrointestinal disease with vomiting and diarrhea as the main symptoms, and the other upper respiratory infections with congestion, cough, and sometimes shortness of breath as the main symptoms. The first (GI) are mostly caused by norovirus in adults and adolescents and rotavirus in small children (and, recent reported, the elderly). The respiratory version is frequently influenza, or other viruses. Viruses. Not bacteria, which can be treated with antibiotics. Viruses do not respond to antibiotics.

This is not to say that they cannot make you very sick. They can, and do. Especially in the old and very young and immunocompromised, influenza virus can lead to major bacterial complications and death; the swine flu outbreak of 1918 killed more people than WW I. When there are major influenza epidemics, there is a big excess of deaths. This is a really good reason to get the flu shot. Everyone who does not have a firm contraindication (e.g., allergy to eggs, a previous episode of Guillain-Barre syndrome) should receive the vaccine. People should expect that their health care providers have received the vaccine. It is not 100% effective, but it is very effective, and helps make the disease milder even if you contract it, and it decreases transmission.

It is not a reason to get antibiotics for a viral upper respiratory infection or bronchitis. Pneumonia, yes (even though a fairly large percent of pneumonias are viral, it is hard to tell); pneumonia as a complication of influenza, particularly in elderly or immunocompromised people with other chronic diseases (heart, lung, kidney, diabetes, cancer) is very serious. But these people, who have or are likely to have bacterial pneumonia and need antibiotics, represent a tiny fraction of the people treated with antibiotics for viral bronchitis (not to mention even less severe viral upper respiratory infections such as sinusitis, non-strep pharyngitis, and otitis). Bronchitis is no fun. It can make you feel miserable, create chest pain when you cough, and generally make you really sick. It can also last a really long time – 4-6 weeks of coughing is typical. But viruses don’t respond to antibiotics, even if you’ve been sick for a week or a month.

A recent study published on-line-before-print in JAMA-Internal Medicine by Gonzales and colleagues[1] looked at the use of decision support by either paper algorithms or computer systems in reducing the use of antibiotics for acute bronchitis in a very large multi-practice group in rural Pennsylvania (Geisinger Health System). They found basically two things: both the paper and computer assisted decision support tools reduced the rate of antibiotic prescribing about equally and both did so significantly more than in “control” practices that got neither. Unfortunately, the rate dropped from about 80% of to about 68%; that is, a large majority of those presenting with acute bronchitis received antibiotic prescriptions even after the intervention.

In a “Commentary” in the same issue, “Antibiotic Prescribing for Acute Respiratory Infections—Success That’s Way Off the Mark”[2] , Jeffrey Linder notes that the problem with the study is that the “success” was very limited; that is, it moved the inappropriate use of antibiotics down, but it was still many times too high. His comparison is to the use of aspirin after heart attack, and how improving the rate from 30% to 40% would have been inadequate; luckily we are now at 94-99%. Another metaphor, more graphic, would be if we were happy that, over 10 years, the number of people killed by the average mass murderer dropped from 15 to 12!

“Since 2005," Linder notes,"a Healthcare Effectiveness Data and Information Set measure for patients aged 18 to 64 years states that the antibiotic prescribing rate for acute bronchitis should be zero. Despite the evidence, meta-analyses, and performance measures, antibiotic prescribing for acute bronchitis in the United States remains at more than 70%.” He is critical of the Gonzales study because, even after its “statistically significant” intervention, “The antibiotic prescribing rate—an event that should never happen for these patients—in ‘successful’ intervention practices was still more than 60%. For individual clinicians…we need to redefine success. Success is not reducing the antibiotic prescribing rate by 10%; success is reducing the antibiotic prescribing rate to 10%.”

Or less. Many people will say “I got antibiotics and I felt better in a couple of days”. Almost all of these people would have gotten better anyway. There are some studies that show, in large populations, taking antibiotics can shorten symptoms by about a half-day. (This is probably because of some minor bacterial co-infection in some folks, especially those with chronic lung disease). But not by a week, or 2 or 3. Length of time of symptoms is not an indication for antibiotics for a viral illness. And that half day? Linder points out that “5% to 25% of patients who will have an adverse reaction. Worse, at least 1 in 1000 patients who take an antibiotic will wind up in the emergency department with a serious adverse drug event.” This is, to put it mildly, not good.

Let’s review this: acute bronchitis, much less other “colds”, are viral and viral infections do not benefit in any way from treatment with antibiotics. They can, however, last a long time, and make you miserable. These symptoms are still not indications for antibiotics. The algorithm used by the Geisinger group, and posted on the walls of their examination rooms, is attached. There are some people, particularly the old, immunocompromised, and those with chronic bronchitis (mostly long-time smokers) who can develop pneumonia, which should be treated with antibiotics. They do not have acute bronchitis.

Doctors and other health professionals should know this, and most of them do. Sadly, however, they not only frequently prescribe antibiotics for viral illnesses because their patients “want them”, but also take them themselves for the same non-indications. Doctors, nurses, and others are among the greatest “abusers” of antibiotics (by which I mean taking them when they are not needed). Amazingly, many of these same health care providers are those who do not get the influenza vaccine, which they should be getting! The justification of “I need to stay healthy, and can’t miss work, because I need to care for my patients and don’t want to transmit illness to them” is wrong on 3 counts: 1) Taking antibiotics for a virus won’t make you less sick or shorten the course of your illness, 2) Taking antibiotics won’t prevent you from transmitting a viral illness, and 3) Taking antibiotics for a viral illness increases the risk of superinfections (e.g., yeast vaginitis), drug reactions, and the development bacteria that are resistant to common antibiotics, which you can spread to your patients. By the way, you also don’t need antibiotics for norovirus or other viral (or, indeed many forms of bacterial) gastroenteritis.

This Batman-and-Robin cartoon illustrates the frustration that many of us feel. Obviously, we cannot even think about literally or figuratively treating our patients that way, but I think one of the interesting parallels is that the person asking Batman for antibiotics is not a “regular person” but Robin, a kind of Batman-in-training, and thus Batman’s frustration mirrors that many of us feel when our own trainees (students and residents) inappropriately use antibiotics for themselves.

Linder says “We should address patients’ symptoms, but for antibiotics we need to tell our patients that ‘this medicine is more likely to hurt you than to help you.’” Those of us who are sick and not health care providers need to understand that; those of us who are health care providers have an even greater responsibility.

[1] Gonzales R, et al., A Cluster Randomized Trial of Decision Support Strategies for Reducing Antibiotic Use in Acute Bronchitis, JAMA-Internal Medicine Published online January 14, 2013. doi:10.1001/jamainternmed.2013.1589

[2] Linder, J, “Antibiotic Prescribing for Acute Respiratory Infections—Success That’s Way Off the Mark” JAMA-Internal Medicine Published online January 14, 2013. doi:10.1001/jamainternmed.2013.1984

Saturday, January 19, 2013

Weight and class: who is obese and why should we care?

One of the things that people are most fixated upon, in both the health arena and in society at large is weight. In popular culture, weight is a major issue. Celebrities are (mostly) thin; when they are not, and look like more of the regular people who are around us, they are seen as unusual. Diet books and “fad” diets abound as do classes to help us exercise. Issues of body image are major stressors for adolescents in particular, and health problems like anorexia are all too common. And, yet, an increasing number of Americans are obese, and health problems that are certainly associated with obesity – notably, but not only, Type II diabetes – are rapidly growing.

There is a major class association with weight; as income and class go down, prevalence of obesity goes up. Perhaps ironic compared to earlier centuries, when being heavy was associated with money – that is, the ability of the person to afford all that food – and poor people were starving. But if ironic, it is serious; the abundance of cheap, high-calorie foods in our society mean that poor people are not denied the opportunity to have lots of calories, but the stressors of poverty that affect all aspects of social life are still there, creating obesity as just one more problem to be confronted (or not).

In this context, a recent article in JAMA by Katherine M. Flegal and colleagues has garnered a lot of attention. “Association of All-cause mortality with overweight and obesity using standard Body Mass Index Categories: A systematic review and meta-analysis”[1], reviewed 97 studies with over 2.8 million people and encompassing 270,000 deaths, and performed a meta-analysis (a set of statistical techniques that allows accounting for studies that are somewhat different in design and have different numbers of people). The results were that people whose body mass index (BMI, a ratio of weight to height) was in the “overweight” range (25-30) had lower all-cause mortality than those in the “normal” range (18.5-25). In fact, the all-cause mortality rate was no higher for those in the range of “grade 1 obesity” (30-35) than for those in “normal” weight range. However, it was higher for those with grade 2 obesity (35-40), grade 3 obesity (>40) and for all obesity taken together (>30). In addition, unsurprisingly, the “hazard ratios” for mortality were greater for the same BMI when heights and weights were self-reported rather than measured (suggesting people under-estimate or under-report their weight, which would mean their BMIs are actually higher than reported).

This is not, of course, really new news, since all of the studies reviewed had been previously published. There was already a sense among many in the medical field that people at the “low end” of overweight (say 26-27) might be as least as healthy (have as low a mortality risk) as those at the low end of “normal” (18.5-25). Heymsfield and Cefalu, in their editorial commenting on this study, “Does body mass index adequately convey a patient’s mortality risk?”,[2] say “Persons with a BMI between 18.5 and 22 have higher mortality than those with a BMI between 22 and 25. Placing these persons in a single group raises the mortality rate for the normal weight group. The average resulting from combining persons in the lowest mortality category (BMI of 22-25) with those who have greater mortality (BMI of 18.5-22) might explain why the NHLBI category of normal weight has an observed mortality similar to class 1 obesity (BMI of 25-30).”

If people with a BMI of 18.5-22 have a higher mortality rate than those with a BMI of 25-30, why, for goodness sakes, is 18.5-25 considered “normal”. For reference, a 5’4” person with a BMI of 18.5 would weigh about 108lbs, at a BMI of 22 it would be 128lbs, at 25, 145lbs, and at 30, 175lbs. For a person who is 5’10”, the weights at the same BMIs would be about 129, 152, 174, and 207. I think most people would not think that the lower range was normal except for models and marathon runners (hey, I’m overweight and would like to lose about 10-15 pounds of fat, but I think I’d be pretty sick before I lost the 60 lbs needed to get me to 22! My son was heavy when he developed Type I diabetes as a young adult, and went from a BMI of about 32.5 to about 21; let me tell you, he looked bad!), but the real question is “what are the healthiest ranges to be at”? This is what official recommendations should be based on, and it is clear from the work reported by Flegal and colleagues that this is not the case for the current numbers.

The relationship between adiposity (presence of significant amounts of excess fat) and risk for many diseases is well-established; the relationship between adiposity and BMI less well so. Variables include amount of muscle mass (not a risk factor but leading to greater weight-for-height), sickness (people who lose weight as a result of disease), and overall body structure. I tried to find out where these ranges come from, but have, so far, been unsuccessful. I found the references to the “Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults”, put out by an expert panel in 1998, but at least their “Executive Summary”^{^[3]} does not reveal the source of how the “normals” were derived; they are just asserted.

Obviously, this is going to be controversial. Paul Campos’ op-ed piece in the NY Times on January 3, 2013, “Our absurd fear of fat”, makes many of the same points I have, but letters generated in response range from those lauding it and saying people (especially children) should be taught to be proud of their bodies, to those arguing it minimizes the health dangers of obesity. What is clear, though, is that the fixation on “ever thinner” that exists in much popular culture has no place in health discussions. The JAMA article strongly suggests that our standards for “normal”, “overweight” and “obese” BMI are too low, although not irrelevant. It calls our attention to a tendency to other similar areas in which health professionals have adopted uni-dimensional disease markers and driven them even lower, to result in poor health outcomes for many. Recent examples include blood sugar (or its related value, hemoglobin A1c), blood pressure, and cholesterol. Studies that held everything else equal found benefit in lower values, so experts kept driving down the definitions of normal and desirable for these tests. Unfortunately, not everything else is equal. Pushing the desirable hemoglobin A1c level of people with diabetes to 5% instead of 6% led to a lot of morbidity from hypoglycemia; lowering cholesterol goals led to toxicities from drugs; lowering blood pressure goals to poorer functioning and greater mortality in some populations, especially the elderly. Most people don’t exercise regularly, but rather than lauding all efforts to exercise, “experts” keep raising the bar for how often, how long, and how intense exercise should be.

So let’s get back to class, and its associated characteristics. It is time for health professionals to recognize that they are also social service professionals and members of a society whose broad policies have a much more profound impact upon health than small numbers variation in BMI, blood pressure, cholesterol, and blood sugar. We need to treat, as well as support and encourage, people at the extremes whose health is at risk, but we shouldn’t fall prey to definitions that name more people as diseased and needing interventions and distract us from the real business at hand.

Which is creating a more just, fair, equitable and safe society.

[1] Flegal KM, et al., “Association of All-cause mortality with overweight and obesity using standard BMI Categories: A systematic review and meta-analysis, JAMA Jan 2 2013;309(1):71-82

[2] Heymsfield SB, Cefalu WT, Does body mass index adequately convey a patient’s mortality risk?” JAMA Jan2 2013;309(1):87-88.

[3] Expert panel, “Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: executive summary”, Am J Clin Nutr, 1998;68:899-917.

Saturday, January 12, 2013

Mental Illness and Guns: A public health perspective

I have been somewhat reluctant to write about the issues surrounding the mass shootings that have become epidemic in our country. Since the Newtown elementary school massacre it appears as if everyone else has done so, and I didn’t know what, if anything, I could add that would be of value. I still don’t, but I would like to try to emphasize the public health and medical issues here. Everyone talks about getting beyond rhetoric, but mostly we hear rhetoric and have yet to see results.

In his column in the New York Times on December 28, 2012, “Guns and Mental Illness”, Joe Nocera addresses those two aspects of the controversy, which I agree are the key ones. However, while I generally think his points are valid, I disagree with his characterization that gun control is a “liberal” issue while mental health has been the focus of conservatives. For good, or bad, and too often bad, both issues have been neglected by too many for too long. When it comes to death, dramatically in the case of mass killings such as Newtown or Aurora or Columbine, much more commonly in “simple” individual killings, and most commonly in the case of suicide, they are tied together. Nocera starts with mental health, so I’ll start with guns.

I have written about guns several times before (“Mexican Murders and US Guns”, March 24, 2009,

“The Arizona shootings: When will we ever learn?“, January 9, 2011, “Why we don’t spend enough on public health”, September 22, 2011, and even discussed a New England Journal of Medicine article (Why we don’t spend enough on public health”)[1] by Dr. David Hemenway of the Harvard School of Public Health and Director of their Injury Control Research Center and Youth Violence Prevention Center (“Public Health and Changing People's Minds, May 15, 2010). Guns are efficient and effective killing machines. This is, after all, the reason that hunters and warriors like them. They can be made more efficient, by being automatic or semi-automatic, and by having magazines that hold many bullets. These are generally considered positives on the war side (and by gangsters), but are often seen as “un-sporting”, so that most states have laws governing their use in hunting. The statistics on gun violence in the US are staggering, and seen from a public health perspective represent a severe and continuing epidemic. Likely the best book on this topic is “Private Guns, Public Health”[2], by Dr. Hemenway. He presents extensive statistics on injury and death resulting from guns, and emphasizes a addressing this problem through efforts to both increase the safety of guns themselves (as we have for cars) and limiting their availability (as we have for cigarettes). This is a harm-reduction approach.

Much of the data cited by Hemenway is sobering, and some is so downright shocking that one might think it difficult to ignore. There are over 30,000 suicides in the US per year, and a high proportion are from guns, because guns are much more effective, and are less likely to allow a second chance; the “success” rate for suicide by gun exceeds 95% while for intentional overdoses it is less than 5%. One of the populations most at risk for suicide is young men; Hemenway notes that the successful suicide rate in this group is several times higher in “low gun control” states (mostly Southern and Mountain) than in “high gun control” states (mostly Northeast and Hawaii). This is not because of less suicidal intent in, say, Massachusetts than Montana, but the easy availability of guns.[3]

But we know about the effectiveness of guns. You can kill someone with a baseball bat, or a knife, or a lead pipe or wrench or candlestick in the Library, but not as efficiently, reliably, effectively, and potentially randomly as you can with a gun. The recent episode of a knife-wielder in China is one example. Adam Lanza wouldn’t have been able to kill many with a candlestick. Innocent children are rarely victims in drive-by knifings. The NRA used to say “guns don’t kill people, people kill people”. Yes, but they do it much better with guns. Now they say that the solution to “bad guys with guns” is “good guys with guns”. This is so ridiculous (can you imagine a bunch of “good guys” blazing away at whoever they thought might be the shooter in the dark in the Aurora, CO, theater?) that NRA bumper stickers are now being amended by new ones saying “Not MY NRA!” in response.

What about mental health? Nocera does an excellent job of summarizing the problem confronting the chronically mentally ill; with a progressive philosophy of “de-institutionalization” mental hospitals were closed with the promise of comprehensive, community-based mental health services being available in the community. But, of course, funding was not forthcoming for those services, nor does it appear that it will ever be adequate. Nocera is correct in saying conservatives have pointed to mental illness (rather than guns) as the cause of such violence, but in addition to not supporting any gun regulation, these same “conservatives” have led the charge in de-funding and under-funding mental health services. The constituency supporting such services, especially for those who cannot afford private care, is not big or effective enough. Apparently these politicians are in favor of supporting (retroactively) mental health care for those who commit mass murder, but not prospectively for the millions in need. One word that is commonly used for such an approach is “hypocrisy”, but this does not shame politicians.

I have written about the “sensitivity” and “specificity” of tests, particularly with regard to screening. However, the same concept can be used for assessing risk of any condition, such as mental illness and the probability of committing gun violence on a large scale. If “committing mass murder” (as opposed to individual homicide or suicide) is considered the disease, then assessing for mental illness would be pretty sensitive – that is most mass murderers are mentally ill and there are relatively few “false negatives” – people who are mass murderers but not mentally ill. But it is pathetically not specific, for the overwhelming number of mentally ill persons will never be mass murders. They would be “false positives”. But this in no way means that they should not receiving comprehensive and effective mental health services.

So, which is the greater problem? Which should be addressed first? The answer is both, and, more to the point, either would be an improvement. On guns, there need to be bans on assault and automatic weapons and on high-capacity clips and “cop-killer” bullets, and background checks on gun purchasers and closure of the “gun show loophole”. On mental health, there need to be ubiquitous and well-funded mental health treatment programs in all of our communities, with outreach workers and close collaboration with primary care medical providers. Both strategies are critical, both are quite (although, obviously, not completely) effective in other countries.

But I would be happy if we would do one of them. I mostly, however, hear a lot of talk and am fearful that we will, ultimately not do either.

[1] Hemenway D, “Why we don’t spend enough on public health”, NEJM 6May2010;362(10);1657-8.

[2] Hemenway D. “Private Guns, Public Health”. University of Michigan Press. Ann Arbor. 2004.

[3] Full disclosure: Ten years ago, my 24-year old son committed suicide with a gun. As far as I know, he’d never used one before. He left his home in a “high gun control” state and went to a “low gun control state” where he knew no one, acquired the gun, and completed his suicide. A testimony to the impossibility of preventing suicide? A condemnation of the ease with which he obtained the gun? Make of this what you will.

Saturday, January 5, 2013

When is the doctor not needed? And who should take their place?

A lengthy editorial in the New York Times, December 16, 2012, "When the doctor is not needed”, discusses how a variety of other health professionals can help to meet the health care needs of the American people when there are not enough physicians. The editorial names, specifically, pharmacists, nurse practitioners, retail clinics (mostly staffed by nurse practitioners), “trusted community aides”, and self-care. It is very good that the Times recognizes the shortage of doctors (and, here, primary care doctors) and the fact that the planned fixes in the Affordable Care Act are not likely to solve the problem, issues that I have often addressed, recently in Health reform, ACA, and Primary Care: Is there still a conundrum? (November 24, 2012). It is also good that the Times recognizes the important contributions that can be made by health professionals other than physicians, by “trusted community aides” and very importantly, by self-care.

As the editorial points out, both pharmacists and nurse practitioners (and physician’s assistants) have a significant knowledge base, and can (depending on state law) practice independently. In our clinic, we work closely with both, and even have a real interdisciplinary educational clinic in which medical students, nursing students, and pharmacy students see actual patients together, under the supervision of faculty from all three disciplines. We have long had nurse practitioner faculty seeing patients with us, and an NP is the medical director of our clinic. Pharmacists work collaboratively with us, particularly in the hospital, and can manage not just drug refills but dosage adjustments and alternative drug regimens in the outpatient setting as well. As the Times editorial and my earlier posts make clear, the promise of ACA to produce sufficient numbers of primary care physicians is likely to take a long time, if it comes at all, as a result of the combination of adverse reimbursement and the long pipeline to produce doctors. If we are to have any hope of having adequate primary care for our population, everyone – doctors, nurses, nurse practitioners, pharmacists, physician’s assistant, et alia, will have to work “at the top of their license” so that doctors are not expected to “do it all”, and the others have the opportunity to really demonstrate their skills.

Unfortunately, however, it will not solve the problem. I don’t say this because I am a doctor (I am) or a primary care doctor (I am), or because most of the statements about the effectiveness of pharmacists and nurse practitioners cited by the Times come from pharmacists and nurse practitioners. I say it because the biggest problems in access to health care are economic and geographic, about people in rural areas and poorer parts of urban areas not being able to access health care because there are no providers there. This is not going to change if we have more pharmacists or nurse practitioners; they want to stay in the cities and suburbs from which they come just like the doctors. They do not “diffuse” into underserved areas. The retail clinics at which many work, often actually based in chain pharmacies, may provide a significant service (see my previous post, Retail clinics: power to the patient, June 28, 2012), but they are also located in cities and suburbs, and serve basically the same population that more traditional medical practices do.

In addition, there is the issue of money / health insurance. Many people, particularly the working poor, whether in cities or rural communities, do not have health insurance. And while some may have the cash to go to a retail clinic, if one is available, most are unlikely to have enough to cover a big ER or hospital bill. Maybe ACA will help, but its primary method of expanding coverage will be through expansion of Medicaid, and this looks as if it will not happen in many states, which have said they will not participate or (like mine, Kansas) have not yet said. Plus, even if Medicaid is expanded, this does not mean that people will be able to access care. Maybe through a retail clinic, maybe via a nurse practitioner or primary care doctor. But specialist care is becoming increasingly unavailable to Medicaid (and, of course, uninsured) patients, as noted in this recent article by Anna Gorman in the Los Angeles Times, “Health care crisis: not enough specialists for the poor”, December 15, 2012. Health policy expert and retired family physician Don McCanne commented on this in his “Quote of the Day” (December 17, 2012), noting that from the beginning of Medicaid (Medi-Cal in California) this has been a problem.

Dr. McCanne says that there have been enough specialists for Medicare, but I fear even this may be changing; our hospital notes that Medicare is its worst payer and that it loses money on Medicare patients. And, as physician practices continue to be acquired by hospitals (which I discussed on December 1, 2012, in Gaming the system: Integration of healthcare services can just raise costs, not quality), the cost of care is increasing (as noted by the Charlotte Observer, in “As doctors flock to hospitals, bills spike for patients”, December 17, 2012). And pharmacists and nurse practitioners are even more likely than physicians to be employed by big hospitals or health system or other corporations (such as the chain pharmacies in which most pharmacists work and which host most retail clinics).

Now “trusted community aides”, as the NY Times editorial calls them, are something different. While that editorial refers to two pediatric practices, in Houston and Harrisonburg, VA, where patients pay about $17 a visit, this concept is in much wider use – and should be used even more. Sometimes called community health workers or (from the Spanish) promotoras (health promoters), these are lay people, not doctors or nurses or pharmacists, who have been trained to do basic health assessments, recommend treatment (usually in consultation with a nurse or doctor by phone) and help patients do a better job of taking care of their own health. They are most effective when they are from the community and culture of the patients they care for (see the discussion of community health workers in Camden and you: the cost of health care to communities, February 18, 2012). Why do I believe that they have more promise? Because they are recruited from the communities that they will serve, and in which they have roots and ties, they are going to continue to serve those communities. This model has worked for dental care in Alaskan Native communities, and in urban inner city communities like Camden. In the case of rural communities, the concept can also be used to increase the skills of nurses. Enhancing and expanding the training of a nurse in a rural community, someone who has family there, or training community health workers who live there, will improve access in those areas in a way that simply will not happen by producing more doctors and nurse practitioners who come from and train in major urban centers.

And self care? Sure, for the right things. These things include most of the diagnoses (notably excluding immunizations) that retail clinics provide care for. For colds, for minor injuries, people have should be able to care for themselves. Where it gets tricky is when the “self” has multiple chronic diseases (say diabetes, hypertension, congestive heart failure, chronic lung disease, arthritis, low thyroid, and high cholesterol – a very common combination in any primary care practice). These people can provide more of their own care, but need the guidance of a skilled health professional, most often a primary care physician. The NY Times article provides some examples of the use of self-care and it has great potential, particularly when coupled with “trusted health aides” who can help, and teach.

All of these ideas have merit, but the issue of geographic and socioeconomic diffusion is largely ignored by most of those who tout their profession as the solution. Of course, as Dr. McCanne concludes his comments on specialists not seeing poor people, “I'll say it once again. If we had an improved Medicare single payer system that treated everyone equitably, we would not have this problem.”

Yes, certainly there would still be problems, but that would be a great start.