Physician Shortage

The health care delivery system in the United States is currently undergoing a transformation. One key element to this transformation is to assure every American has a primary care provider. Primary care providers are increasingly often “mid-level providers,” these include nurses and physician assistants who are often required by law to work under the direction of a licensed physician. Unfortunately, the medical educational system is unprepared to tackle this task. Applications to medical school are the highest they have ever been but medical schools have not increased their capacity until recent federal mandates have been imposed. Another aspect of the physician shortage that has not been addressed is physician burnout. A recent study looked at physician satisfaction at three career stages. Physicians in practice 10 years or less (early career), 11 to 20 years (middle career) and over 21 years (late career). Interestingly, middle career physicians had the lowest satisfaction with their work-life balance and the highest rates of emotional exhaustion and burnout. This group was also most likely to leave the practice of medicine for reasons other than retirement in the next 24 months. It is apparent that the increased demand on physicians must be addressed to preserve and hopefully increase the physician work force. This is a crucial element for health care transformation to be successful.

Joint Replacement is Growing

My guest on Healthy Rounds this week was Dr. John Grady-Benson. Dr. Grady-Benson is the Director of Quality and Clinical Research at the Connecticut Joint Replacement Institute at St. Francis Hospital. He informed us about the rapidly growing numbers of hip and knee replacements being performed in the United States today.Thus far 719,000 total knee replacements and 332,000 total hip replacements have been performed. By the year 2030 this number is expected to rise by 175% for hips and 673% for knees. This huge rise is due to the aging baby boomer population and their desire to remain active. The most common reason joint replacements are performed is severe crippling arthritis. Centers like CJRI collect outcomes data to assure the highest quality in performance and materials used. More specialty centers will most likely be established in coming years for joint replacement and other specialty areas in medicine.

Cuba and Florida

The relationship between Floridians and Cuba is often contentious. Many fled the Caribbean nation in the late 1950s at the beginning of the Castro dictatorship.

In Haiti, I have worked with several physicians from Cuba. Health care in Cuba is delivered by physicians hired by the state and paid approximately $50 per month. Physicians are responsible for all the people living in a particular geographic area. Many of the high tech tools that we have become accustomed to in the US are lacking.

Historically, Cuba has isolated itself and continues to prohibit many basic freedoms. Cubans cannot travel nor speak freely.

A recent bill passed in the Florida legislature prohibits companies with business operations in Cuba or Syria from obtaining any state or local contracts valued at more than $1 million. The goal of this bill is to place pressure on Cuba to allow free trade or remain isolated from the rest of the world.

I am personally in favor of isolating Cuba. While it is clear that they now need the support of capitalist countries like the United States, they continue to remain communist and denounce the American way of life.

How do you feel?
Should we open further trade with Cuba?
Should we encourage Americans to spend American dollars while vacationing in a communist dictatorship?

Kidney Transplant Chain

Over 90,000 people in the United States are waiting for a kidney to become available for transplantation. While many friends and family members are willing to donate a kidney, they are often not an appropriate tissue match. A kidney transplant chain provides an alternative, lifesaving route.

The chain begins when a person is willing to donate but may not be a match for their intended recipient. The potential donor agrees to donate to a perfect stranger who may be a match in return for that recipient having a person willing to donate to someone else. This process repeats itself until the original recipient receives a kidney.

Recently, 30 people received kidneys in a chain. The chain included ex-boyfriends, former prom dates and close friends all willing to pay the steep price of admission to this special group.

The logistics for this complex chain are handled by an ex-Marine named Garet Hill through the National Kidney Registry.

Sadly, chains like this have become a necessary means of making organs available. Many Americans have not committed to becoming organ donors upon their demise. Their reasons for burying healthy organs vary, but none are based on logic, religion or science.

Many European countries consider everyone an organ donor unless they specifically "opt out" of organ donation. This has increased the number of organs available in those countries while alleviating some of the bizarre obstacles to donation.

How do you feel? Should organ donation after death be understood unless someone opts out?

Creating a Culture of Safety

I recently had an opportunity to interview Dr. Amy Ship on the Healthy Rounds radio program. Dr. Ship is a primary care internist at Beth Israel Deaconess Hospital and assistant professor at Harvard Medical School. She recently published a column in the New England Journal of Medicine that addressed the responsibility of physicians to inquire about safe habits among our patients.

Specifically Dr. Ship addresses the topic of texting while driving and other distracted driving practices. She points out that physicians already direct patients' health habits regarding smoking, diet and sexual practices safe driving should be an extension of that responsibility.

Interestingly, a recent law was passed in Florida prohibiting physicians and specifically pediatricians from asking if there are weapons in the home and if they are safely secured. This law was passed despite the rising number of gun-related injuries in children.

In conclusion, it is the responsibility of all adults, and not just physicans to work toward creating a "culture of safety" by directing the behavior of children and setting a good example.

Do you think physicians should inquire about guns in the home?
What ideas do you have toward creating a "culture of safety" in America?

Bicycle Safety

I have recently spent time in the Tampa Bay area as part of my annual spring training tour. I have been consulting for the New York Yankees for fifteen years and this year, I have also been invited up to Lakeland, Florida to discuss the early recognition and treatment of concussion with the Detroit Tigers medical staff.

While here, two bicyclists have died from injuries after being hit by motorists. A total of 15 bicyclists have died in the Tampa Bay area since July of 2010. This situation has captured my attention because it may indicate that we should expect more injuries in Connecticut this year as weather warms and gas prices soar.

I am also alarmed by the fact that despite the usual precautions of wearing a helmet, making yourself visible and remaining alert, many may still be harmed. The reason for many of these incidents is distracted driving. More drivers are now texting, or trying to make a call while operating a vehicle. In the split second that these drivers divert their attention away from the road, bicycle riders can be hit and severely injured.

The only recourse is for bicyclists to be vigilant at all times and to avoid riding in traffic when possible. If we are to encourage bicycling as an alternative means of transportation, communities must crack down on distracted drivers and create safer bike lanes for travel.

What ideas do you have for safer bicycle travel?

A Pulmonary Embolism Can Strike Anyone

Tennis champion Serena Williams was recently hospitalized for treatment of a life-threatening pulmonary embolus. While it may be surprising to hear about a world class athlete being stricken by a condition typically associated with inactivity, athletes can be particularly susceptible to this condition.

A pulmonary embolus is the result of a clot traveling through the circulatory system and lodging in the lungs. There it will obstruct blood flow to the lungs. These emboli usually originate in the veins of the lower extremities as a thrombosis.

Symptoms of a pulmonary embolus include; chest pain, shortness of breath, unexplained coughing and rapid heart rate. Each year 600,000 Americans suffer a pulmonary embolus and 60,000 of these patients will die.

Traveling long distances, dehydration, trauma, immobilization, oral contraceptive use and family history are all risk factors. Many of these factors are common among injured athletes.

Ms. Williams has recently had two surgeries for a foot injury and has been wearing an immobilizing brace. The event occurred shortly after a transcontinental flight. Fortunately, her condition was treated quickly with anti-coagulant (blood thinning) medications.

The best way to prevent pulmonary emboli is to stretch often when traveling, remain well hydrated and be aware of symptoms.

Pulmonary emboli can affect anyone, but a few simple steps can avoid serious injury.