The New York Times published an article titled “Doctor Shortage Likely to Worsen With Health Law“.  In this shocking article, they stated that by 2015 there will be a shortage of almost 63,000 primary care physicians.  Part of this will likely come from the expanded access to health care, but that still only accounts for some of the number.  We are already seeing a long wait time to see physicians in many parts of the US.

I think there are many reasons for this growing problem.  First, to become a physician in this day and age requires a large capital and time investment.  The average cost of medical school after obtaining an undergraduate degree is about $200k.  On top of that, residency can be as short as 3 years or as long as 9 years.  During this time a resident may make barely enough to live, and won’t be able to put even a small dent in his/her growing debt.  Other fields such as finance and law require much less training and hence are luring much of our talented youth away from healthcare.

In my medical school class, I recall students would boast about wanting to go into specialties such as orthopedics and dermatology.  These were the considered the “top” fields as they considered the highly compensated lifestyles more desirable.  It is sad to say that as a result of rewarding specialties with increased compensation, the healthcare system has shifted even more students away from primary care.

This trend continued on during my internal medicine residency.  Internal medicine is a gateway to a whole other host of specialties including gastroenterology and cardiology.  Again, it was considered de rigueur for everyone to apply to a specialy.  Over half of my residency class ended up in a fellowship for one of these.  A minority ended up practicing primary care like myself.  Sadly, many primary care practices are having to turn people away as they have reached maximum capacity.  It is not uncommon these days for doctors to say they won’t take certain types of insurance (generally the ones that don’t pay sufficiently), or that they are not taking new patients.  Others have decided to retire early, citing the uncertainties of the future of healthcare and the complexities of billing and receiving adequate compensation for their time.  Running a private office comes with huge pressures to generate money to pay for overhead costs such as equipment, rent, skilled healthcare providers, and secure electronic medical record keeping.

What can be done to prevent the shortage?  I think the government should help out those that are interested in primary care from the beginning.  Perhaps offering financial assistance to those students who will be making a commitment to serving as a general practioner would be a good start.  Many countries in the world require their physicians to work in underserved areas as a compensation for a free medical education.  Another answer would be to level the compensation for medical fields.  Don’t get me wrong, I’m not saying that treating a rash is any less important that treating hypertension, but the compensation should be proportional to the care delivered.

Summer is a great time of year for outdoor activities and vacations. However, we should all be mindful that heat waves can cause a great deal of stress on our bodies, especially if you have a chronic illness. Be mindful and listen to you body. You may start feeling mild thirst or dry mouth, but later may feel dizzy when getting up from a seated position. If you start getting these symptoms, it is imperative to lie down in a shady or cool place and drink copious amounts of fluids. An ice pack on the neck or under the armpit can cool down the body rapidly.

In severe heat stroke, organ damage can occur, causing abdominal pain.  As we age, we lose our sense of thirst when we are dehydrated.  This is why elderly people are at highest risk for heat related illness even though water may be accessible.  If you are taking care of an elderly person, make sure they drink at least one cup of water each hour or more if you notice them to be sweating.  It is rare for people to be “overhydrated” unless they have pre-existing kidney problems or congestive heart failure.

Increase intake of non-caffeinated, non-alcoholic beverages.  Stay in air conditioned rooms. Avoid unnecessary physical activity or trips outdoors. If you are taking a diuretic (“water pill”) for high blood pressure, consider stopping it for days when the temperature is above 85 degrees.  Dehydration can also lower blood pressure to dangerous levels and cause kidney damage.

If you must be outdoors, be sure to hydrate with a sports drink containing electrolytes such as Gatorade or Powerade. I recommended diluting them in a 50/50 proportion with water.  For hiking trips, be sure to bring more than enough bottles of water than you think you will need, perhaps bring some bottles that you have frozen beforehand.  It is also important to cover your face with a hat or umbrella and wear light colored clothing.  While we all like to get sun during the summertime, know your limits and be smart about sun protection by using sunscreen and a lip balm with SPF>30.

Calcium and Vitamin D supplement have long been the “backbone” of osteoporosis treatment and prevention.  As reported by the New York Times this week, the USPTF issued a draft statement that there is insufficient evidence to show that healthy postmenopausal would benefit by taking supplements with Vitamin D or Calcium.

I strongly disagree with this statement, as there are many factors which must be considered.  Bone health is not merely a factor of diet.  Genetics, ethnicity (Caucasian or Asian), lack of exercise, alcohol intake, smoking, early menopause, and chronic illnesses are all factors that can cause worsening of bone density.  How can we be sure that every “healthy” woman does not already have one of these risk factor or will not develop one of the risk factors later in life?

Calcium is an essential mineral that all humans must obtain from a diet rich in dairy, leafy greens, and soy products, among other items.  There is a constant creation and destruction of bone at the cellular level happening all the time.  We also lose some calcium in the urine.  It doesn’t take complicated math to see that if you do not replace the calcium in your diet, you will end up with less calcium in the bones than when you started.  After menopause, the destruction increases as estrogen, which is responsible for building bones, is lost.

Over the years, I have rarely seen women with adequate dietary intake of calcium.  In order to get the recommended daily allowance of 1200 mg for a post menopausal woman, one would have to consume 4 cups of skim milk or 3 cups of yogurt or 6 cups of spinach per day!  I don’t really know where the USPTF obtained the data for their studies, but it must be somewhere in Wisconsin or Switzerland with all the dairy products those women are consuming. Imagine if you were lactose intolerant, and not surprisingly so, 60% of Americans are lacking the enzyme that helps digest the sugars in dairy products, how much calcium would you be getting daily?  To make a blanket statement that all “healthy” women are getting adequate intake of calcium is negligent.

As I mentioned earlier, bone health is also dependent on weight bearing exercise.  When you do a workout that involves weights or running, the bones strengthen and more resistant to the destruction.  As our country is becoming more sedentary and spending more time on the computer, iPad, or on the phone, and less time in the gym, we are certainly going to see a rise in osteoporosis.  Excessive weight can lead to osteoarthritis of the knees and hips, which are also known to cause osteoporosis of those joints.  A woman’s peak bone density is reached before menopause, which means all women will lose bone throughout the rest of their lives thereafter.  Not having adequate calcium intake is certainly not a good idea for any woman.  The USPTF should revise their statement to include a clause that all healthy women should have their dietary intake of calcium assessed by a healthcare professional and if it is inadequate, supplementation should be considered.

Regarding Vitamin D, all healthcare providers in the U.S. are seeing a widespread epidemic of low Vitamin D.  Vitamin D is found in dairy products and requires sunlight to become activated.  Vitamin D is essential for processing calcium so that it can be made into bone.  You can imagine in the northern latitudes where it is cold 6 months out of the year how much people are lacking this vitamin.  Again, this is where supplementation is a necessity and another place where the USPSTF is making an error.

I understand the USPSTF’s motivation in it’s recent rage against doctors doing too much, in terms of PSA screening, Cervical cancer screening, and mammograms, but they must make a distinction between treating statistical numbers and individuals.  I shudder to think how many women who may have several risk factors for osteoporosis, but consider themselves “healthy” reading the guideline and throwing out their calcium and vitamin D pills only to realize 20 years later after falling and sustaining a hip fracture that they should’ve continued them.

How many times have you seen people eating something obviously unhealthy and saying they are just “rewarding themself” for completing a difficult task?  Have you wondered why no one says that while eating a plateful of broccoli or running an hour on the treadmill?  From an early age, we are given positive reinforcement with high fat foods.  Every child’s birthday has a large cake with icing and ice cream, grilled burgers and hot dogs are standard at every 4th of July or Labor Day.  Over time, our minds equate high fat foods with happiness and well-being.  Unfortunately, these foods are readily available at every street corner nowadays.

Think about changing how you reward yourself.  Maybe you could go for a massage or get a facial as a reward for losing weight?  How about buying a new dress in your slimmer size?  Obviously, don’t go overboard or you may develop a shopping addiction.  Set goals for yourself, like for every 10 pounds you lose, you can buy a new pair of shoes.  You could set up a jar on your kitchen table, or start a bank account where you deposit $10 for every 1 pound you lose.

At the office, start a pact to not bring in any unhealthy treats for birthdays and other milestones.  It’s always difficult to refuse a slice of cake in front of your office mates at a birthday party.  Think about if (and chances are good) someone in the office was diabetic.  It could be very awkward for them, and certainly unhealthy for them to eat the cake.  How about getting a large fresh fruit plate with a chocolate or caramel dipping sauce on the side?

Don’t get me wrong, I love a good chocolate cake and can’t resist pumpkin pie at Thanksgiving.  What I’m saying is that we should wary of becoming dependent on high calorie foods as little “pats on the back”, because over time they lead to “pains in the back” from all the extra weight.

There has been recent debate about the necessity of annual physical exams.  In the New York Times article titled “Let’s Not Get Physicals” the author, Elisabeth Rosenthal gives the case for people not to get physical exams.  I both agree and disagree with her view.  Who is getting physicals yearly?  I can tell you from experience, it is generally a small percentage of people who have insurance and stable jobs.  Many underinsured/underserved people have an extremely difficult time to get access to medical care in their neighborhoods, not to mention have time to do an annual physical.  By sending the message that we are doing too much is neglecting the fact that for every person we do “too much” we have a whole lot more for whom we are doing nothing.

An annual physical is extremely important in a population that is over 60% overweight or obese, and a rapidly aging population.  Are we supposed to wait until they develop complications of diabetes or have a heart attack to address their needs?  In my years of practice, I have seen a large number of patients who came in for annual physicals with absolutely no complaints, whom I later diagnosed with pre-diabetes, true diabetes, high blood pressure, and high cholesterol.  There is no doubt that early treatment and detection of these illnesses improves outcomes, and for many medical illnesses there are no symptoms in the early stages.  The most clear example of this is hypertension, which is nicknamed “The Silent Killer” as there are few symptoms until it results in a stroke or heart attack.

I do agree with Ms. Rosenthal that not everyone needs tests like an EKG.  There is no official guideline from any medical society that states everyone should get an EKG.  In my practice, I only do EKG in the setting of hypertension, chest pain, slow or fast heartrate, or if someone is getting a pre-op evaluation.  There may be physicians who are getting EKG’s on everyone, but those are the exception and not the rule.  Perhaps they need to be educated about what is the standard of care, or in some cases to not get EKG’s just because it is requested by the patient.  In all honesty, I can see how many doctors would find it easier to just order the tests a patient requests than taking the time to explain the actual usefulness, risk, and harm of testing.  An EKG may take all of about 5 minutes and can be done by a nurse.

Annual physical exams build a relationship with your Primary Care Provider (General Practioner, Physician Assistant, Nurse Practioner, Gynecologist).  Why would anyone want to wait until they face a catastrophic event, like developing pneumonia or diabetes, to begin a relationship to a health care provider/system that is totally unfamilar?  What if you don’t get along with that particular health care provider?  I believe people need to find a provider with whom they feel comfortable talking about all issues, including personal issues related to sexual health.

By establishing a primary care provider-patient relationship,  you are creating a friendship with someone who will be there when problems arise.  As I mentioned in a Q&A post, it’s like having an accountant when your taxes get audited.  You never want to be audited by the IRS and have to look for a CPA who may not know the years of financial information that you have accumulated.  I urge everyone to continue to get annual physicals.