Dear Mr. President.
Recently I responded to your request for a donation to help your administration pass health care legislation. I come from frugal Dutch stock, and I don't usually throw money at politicians. With this donation I'm asking you to improve our health care system and I'm giving you one primary care doctor's prescription for bettering our nation's health.
Evolution of the US Healthcare System: The Last 150 Years
Section titled “Evolution of the US Healthcare System: The Last 150 Years”When we look at the history of medicine as far back as the 1800s, Mr. President, the key developments become clear.
- Anesthesia
- Sterile techniques for surgery
- Result: Widening scope of surgical medicine
- Antibiotics
- Spread of healthcare insurance coverage
- Pharmaceuticals for high blood pressure, heart disease prevention, etc
- Refinements and advances in surgical subspecialty techniques
- Result: The age of medical specialism and the cost explosion
Now, you and I and millions of others are writing the next chapter of this story. The battles rage in the national capital and in town halls across the country to determine our new direction. It is imperative that all of us keep a clear head and focus in on the key: intelligent primary care and the reduction of medical expenses.
The Next Evolution: Intelligent Primary Care
Section titled “The Next Evolution: Intelligent Primary Care”I would like to suggest some additions, Mr. President, to the current proposals.
More Family Docs
Increase greatly the number of primary care physicians and give them the resources to do their job. Such a system has already been proven effective in Britain, where primary care docs work in teams of about five. Supported by about 25 nurses and other staff, they provide office care and house calls on a 24/7 basis. Patients enjoy better access to care and don't need to resort to expensive Emergency Department visits. Doctors, given the resources they need, enjoy their jobs. By comparison, about half of US primary care doctors would like to quit their practice1. Where are our 47 million uninsured going to get care2, when even now people with insurance have trouble finding a primary care doc here in Port Townsend?
Primary Care Coordination
For government health insurance programs, require all care to be coordinated by the primary care physician. This is standard in Britain. Patients accept this limitation as a condition of care at a reasonable price, and they are free to pay themselves if they really want to see that specialist. It works because they can choose and change their primary physician. Here in the US, I run into people who get their annual physical at their internist's office, a skin check at the dermatologist, and a pap smear from the gynecologist. Mr. President, this adds up! For those with a history of melanoma or cervical cancer, yes, see that specialist. But give your family doc the time to do it and she'll go over your skin in detail, handle your pelvic exam and pap smear and, on any given common medical topic, tell you about 90 percent of what the specialist would tell you. This saves the patient a few hundred bucks and the nation, billions.
Raise Standards
While returning the power to the Dr Welbys of this country, we should, at the same time, require that they do a good job. The malpractice system picks up only disasters, not a daily pattern of excessive testing, failure to listen to the patient, careless prescribing, and unreturned phone calls. We need vigorous measures to ensure quality control. We docs need to accept that frank online ratings of our services, coupled with intelligent oversight by payers and regulatory authorities, done well, works to our benefit.
An American Model
Mr. President, we already have a good start in this direction with the Federally Qualified Health Centers, a group of federally-supported non-profit health centers offering affordable healthcare in cities around the US. Let's build on that model.
Reduction of Medical Expense – Save Money Through Prevention
Section titled “Reduction of Medical Expense – Save Money Through Prevention”Another important way to cut costs is to maintain good health, which means adopting sound preventive measures: good nutrition, healthy activity, and competent self-care.
Let me give you an example of how this can work
Vitamin D – An Emerging Story
In early 2004, Mr. President, when you were surfing the web, you might have run into our two newsletters devoted to Vitamin D. We demonstrated that this sunshine nutrient:
- reduces the likelihood of developing certain cancers
- eliminates some kinds of pain
- strengthens bones
- prevents falls
- reduces blood pressure
- reduces the tendency for children to develop diabetes
We pointed out that the RDA of 400 units daily is much too low.
Family practitioners provide most of the services in our rural town. Like me, they have taken to measuring vitamin D levels when indicated, even in patients taking supplemental vitamin D. We find low levels3 in at least a third of patients tested. The benefits of treatment listed above are significant. Blood tests for vitamin D levels are inexpensive here, at $97 plus a draw fee.
A very recent study4 in the Journal of Clinical Oncology moves breast cancer to the top of the list of cancers proven to be prevented by vitamin D. These cancer specialists tested vitamin D levels in about 100 women with breast cancer. About 75 percent were deficient at the beginning of the study (with an average level of 17 ng/ml). Despite a year of supplementation at 400 units per month (the Recommended Daily Allowance), only one in six raised their vitamin D levels to the lowest acceptable value5. These researchers pointed out that women with lower levels of vitamin D are more likely to develop breast cancer and are more likely to die from it.
You might be interested to know, Mr. President, that those of us with darker skin are at an even greater risk6. In the study above, over 80 percent of women identified as black or Hispanic were deficient in vitamin D, therefore more susceptible to high blood pressure, breast cancer, osteoporosis, and other diseases. Think of the money we could save and the suffering we could prevent!
If you look at the national health bill, billions of dollars are spent on treatment of heart disease and stroke, money spent after the damage has been done. Billions are spent on cancers and unnecessary medical procedures. This emerging information about vitamin D bids fair to reduce those expenses and eliminate unnecessary suffering. We must integrate, at the primary care level, this knowledge of nutrition with the best of current medical protocols.
I know all this is a tall order, Mr. President, but I believe the way is open. With the energy and initiative of the individual patient and empowered primary care doctors, I believe we will see our way out of this health care morass.
Yours truly,
Douwe Rienstra, MD
P.S. While you are at it, please take two other critical steps.
First, curtail the distorting influence of pharmaceutical corporation money on medical research, medical publishing, medical schools, medical graduate education programs, post-graduation medical education, and legislation related to health care. While I give thanks every day for the pharmaceutical miracles from those corporations and their predecessors, I also see that the business imperatives of those corporations fraudulently drown out effective competitors to their products. Those competitors include intelligent primary medical care, nutritional measures, generic drugs, physical therapy, health education, and other patient-empowering measures.
Second, end the malpractice lottery. If something turns out wrong here in the US, the patient can only hope that their lawyer can pin it conclusively on the doctor; otherwise they're on their own. Other countries employ a no-fault system; if the patient is injured, they're compensated.7 Promptly. If the doctor was at fault, measures are taken to be sure it doesn't happen again. That doesn't always happen here.
Better Health Habits
Section titled “Better Health Habits”Conscious Eating/Conscious Living
Janet Goldenbogen, RN, starts this 10 week class Wednesday September 16 6:30-8:30pm at our office. More on our website.
Endnotes
Section titled “Endnotes”1 http://www.rxpgnews.com/usahealthcare/Nearly_Half_of_Primary_Care_Physicians_in_US_Would_Like_to_Quit_Medicine_130186.shtml
2 http://blogs.usatoday.com/oped/2008/03/shortage-of-pri.html
3 The lower limit for the Labcorp test is 32 ng/ml, and over half the patients getting this test are deficient by that standard, some of them markedly so, with levels well under 20. Vitamin D influences the manner in which our DNA is translated into bodily proteins, and how resistant to mutation that DNA is. Those who study this tell us that until vitamin D levels reach something in the range of 50 ng/ml, not all systems operate optimally. This usually requires, at least in our cloudy northern clime, supplemental amounts closer to 5000 units per day rather than the 400 unit RDA.
4 "High prevalence of vitamin D deficiency despite supplementation in premenopausal women with breast cancer undergoing adjuvant chemotherapy." (J Clin Oncol. 2009 May 1;27(13):2117-9.) Abstract: PURPOSE: Vitamin D deficiency is associated with increased breast cancer risk and decreased breast cancer survival. The purpose of this study was to determine the prevalence of vitamin D deficiency, as measured by serum 25-hydroxyvitamin D (25-OHD), in premenopausal women at initiation of adjuvant chemotherapy for breast cancer and after 1 year of vitamin D supplementation. PATIENTS AND METHODS: The study included 103 premenopausal women from the northeastern United States with stages I to III breast cancer who received adjuvant chemotherapy and participated in a 1-year zoledronate intervention trial. All patients were prescribed vitamin D(3) (cholecalciferol) 400 IU and calcium carbonate 1,000 mg daily. At baseline and at 6 and 12 months, bone mineral density (BMD) measurements were obtained and blood was collected and analyzed in batches for serum 25-OHD. Vitamin D deficiency was defined as serum 25-OHD less than 20 ng/mL, insufficiency as 20 to 29 ng/mL, and sufficiency as 30 ng/mL or greater. RESULTS: At baseline, 74% of women were vitamin D deficient (median, 17 ng/mL). Vitamin D deficiency was slightly less common in white women (66%) compared with black (80%) and Hispanic (84%) women. After vitamin D supplementation for 1 year, less than 15% of white and Hispanic women, and no black women, achieved sufficient 25-OHD levels. Vitamin D levels did not correlate with baseline BMD and were not altered by chemotherapy or bisphosphonate use. CONCLUSION: Vitamin D deficiency is highly prevalent in women with breast cancer. The current recommended dietary allowance of vitamin D is too low to increase serum 25-OHD greater than 30 ng/mL. Optimal dosing for bone health and, possibly, improved survival has yet to be determined.
5 about 30 ng/ml
6 Public health workers have known for decades that darker skinned people more frequently develop hypertension and heart disease. Now it becomes clear that vitamin D plays a role here as well, for it seems that vitamin D protects us from vascular disease. One form of vascular disease, peripheral arterial disease or narrowing of the blood vessels of the legs, results in pain while walking and can lead to amputation. This condition is more common in blacks than whites. Researchers found vitamin D levels to be much lower in blacks (averaging 16 ng/ml) than in whites (26 ng/ml, not such a great level either). Looking further, they found that these low levels accounted for much of the excess of PAD occurring in blacks compared with whites.
Here is the abstract from The American Journal of Clinical Nutrition:
"Differences in vitamin D status as a possible contributor to the racial disparity in peripheral arterial disease." BACKGROUND: Racial differences in cardiovascular risk factors do not fully explain the higher prevalence of lower-extremity peripheral arterial disease (PAD) in black adults. OBJECTIVE: We sought to determine whether any of this excess risk may be explained by vitamin D status, which has been widely documented to be lower in blacks than in whites. DESIGN: This population-based cross-sectional study included 2987 white and 866 black persons aged <or=40 y from the 2001-2004 National Health and Nutrition Examination Survey. PAD was defined as an ankle-brachial pressure index of <0.90 in either leg. RESULTS: Mean (+/-SEM) 25-hydroxyvitamin D [25(OH)D] concentrations were significantly lower in black than in white adults (39.2 +/- 1.0 and 63.7 +/-1.1 nmol/L, respectively; P < 0.001). Adjusted odds ratios for PAD decreased in a dose-dependent fashion with increasing quartiles of 25(OH)D in white adults [1.00 (referent), 0.86, 0.67, and 0.53; P for trend < 0.001]. In black adults, the association was nonlinear; models with cubic splines suggested evidence of greater odds for PAD and a trend for lower odds for PAD at the lowest and highest concentrations of 25(OH)D, respectively. After adjustment for racial differences in socioeconomic status and for traditional and novel risk factors, odds for PAD in black compared with white adults were reduced from 2.11 (95% CI: 1.55, 2.87) to 1.67 (1.11, 2.51). After additional adjustment for 25(OH)D, the odds were further reduced to 1.33 (0.84, 2.10). CONCLUSIONS: Racial differences in vitamin D status may explain nearly one-third of the excess risk of PAD in black compared with white adults. Additional research is needed to confirm these findings. The American Journal of Clinical Nutrition. 2008 Dec;88(6):1469-77