nos-trum. pronunciation: \nos'-trum\. noun. Etymology: Latin, neuter of noster our, ours.
1. a medicine of secret composition recommended by its preparer but usually without scientific proof of its effectiveness.
2. a usually questionable remedy or scheme.
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Monday, November 10, 2008

Hibiscus tea...NOT; pay for performance; and Where Did All the Doctors Go?

Herbal tea containing hibiscus may lower blood pressure in prehypertensive, mildly hypertensive patients, study suggests. HealthDay (11/9, Gardner) reported that "drinking three cups a day of hibiscus tea (found in most commercial tea blends in the United States) lowered blood pressure over a six-week period, most significantly among those with the highest blood pressure to begin with," based on the results of a trial presented by Diane McKay, assistant professor at Tufts University, and colleagues at the American Heart Association meeting. Doc D: Wait a second. You’ll not be surprised to hear that there were only 65 experimental subjects, and the study lasted only 6 weeks. Plus, don’t you want the health benefits of lowered pressure, rather than just a good number? Secondly, the data was significant for systolic pressure (the first number; i.e., if you’re 120/70, then 120 is the systolic pressure), but not so for the diastolic pressure. While both measurements are potentially significant, it’s the diastolic that traditionally shows the minimum that your pressure drops to. Thirdly, the ‘commercial tea blends” may not have enough, or in the right form. Lastly, does anybody know what’s IN hibiscus tea? Like most herbals, probably about 200 compounds, some of which may have undesirable effects. So, this is an interesting nature note, and they’ll probably write a grant for more of your tax money to look into it, but it ain’t time to prescribe tincture of hibiscus every 6 hours. Health advice utility rating: Disregard. Physician discusses flaws in P4P program. In an essay published in the New York Times (9/9, F5), Sandeep Jauhar, M.D., writes that these days, patients often receive "antibiotics without solid evidence of an infection. And, part of the blame lies with a program meant to improve patient care." This "program is called pay for performance, P4P for short," and "employers and insurers, including Medicare, have started about 100 such initiatives across the country." It is intended "to reward doctors for providing better care." For instance, physicians "receive bonuses if they prescribe ACE inhibitor drugs to patients with congestive heart failure." Dr. Jauhar argues that this may seem like a sound idea, but "in a survey [conducted] in New York State, 63 percent of cardiac surgeons acknowledged that because of report cards, they were accepting only relatively healthy patients for heart bypass surgery." In addition, while Medicare requires that "antibiotics be administered to a pneumonia patient within six hours of arriving at the hospital," physicians "often cannot diagnose pneumonia that quickly." Dr. Jauhar concludes that the program's "deep flaws must be addressed before patient care is compromised in unexpected ways." Doc D: I’m conflicted about Pay for Performance programs. Do we really want a program in place that will influence doctors to cherry-pick their patients? The insurance industry started the cherry-picking process many years ago, and it resulted in more regulations to keep them from doing it. I’m a great believer in incentives, but I would prefer ones that are strictly positive. I also think that some of the criteria that are being adopted by administrators don’t make good sense. The decision by Medicare to not pay for bladder catheter infections in hospitalized patients is a good example: while a lot of these infections are avoidable, you can do all the right things, and your patient will still get an infection, especially patients with a lot of medical problems. So, guess what message doctors and hospitals take from this? Study indicates fewer medical students intend to become primary-care physicians. NBC Nightly News (9/9, story 10, 0:30, Williams) reported that a new study shows that few medical school students plan to become primary-care physicians. Most "are going into specialized fields instead." USA Today (9/10, Rubin) reports that "medical students are shying away from careers in general internal medicine, which could exacerbate the U.S. doctor shortage expected by the time the youngest baby boomers head into their senior years," according to a study published in the Sept. 10 issue of the Journal of the American Medical Association. In fact, "only two percent of graduating medical students say they" were considering practicing as primary-care physicians, the AP (9/10, Johnson) adds. By comparison, a similar survey conducted in 1990 showed that nine percent of medical students were interested in primary care. The data showed that "paperwork, the demands of the chronically sick, and the need to bring work home are among the factors pushing young doctors away from careers in primary care." Salaries in primary care dissuade medical students from the field. The Columbus Dispatch (9/10, Hoholik) reports that "fewer U.S. medical students are choosing careers in family medicine because of long work hours and low pay," according to a research letter published in the Sept. 10 issue of the Journal of the American Medical Association. Doc D: I see this as a crisis in the making. Some people say that the primary care mission is evolving, that we will see routine family medicine move to retail clinics and practices that are staffed by nurse practitioners and physician assistants. These non-physician providers do great work in the context of what they are trained and allowed to do. However, by law, these folks have to be supervised by a physician. So, do we cut these folks loose from physician oversight? Does 1-2 years of clinical education make someone safe to treat independently? Or are we back to square one, with a need for family practice physicians? I don’t know how all this will come out, but as you might imagine, universal healthcare coverage will stretch the capacity of the system: it doesn’t help to have coverage, but not be able to get an appointment. For those of you who have been driven to our country’s emergency rooms, and waited hours, what will it be like when waiting periods increase further? Doc D Opinions are entirely my own. Quotations excerpted from AMA Morning Rounds (© U S News Custom Briefings)

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