Is Distance Running Really Good For Your Heart?

By guest blogger: Kreton Mavromatis, MD, Assistant Professor of Medicine, Emory University, Director of Cardiac Catheterization, Atlanta VA Hospital
It's Sunday morning, July 4^th and I have just returned from running a 10K race and I am feeling good.  I run approximately 3 or 4 days per week, and I run a race or two, including a half-marathon, each year, mainly to serve as a training goal. My motivation for running is primarily so that I can afford to eat more food, my favorite daily activity. However, as a cardiologist, seeing people with heart attacks from occluded coronary arteries day-in and day-out, I have always believed that running (and exercise in general) is good for my vascular health. After all, doesn't running lower blood pressure and cholesterol, and haven't studies shown that people who exercise more live longer? In fact, prospective epidemiological studies have suggested a dose related effect, implying more exercise of greater intensity is better.
To my dismay, however, several recent studies have suggested that running may not be good for my heart or arteries after all. Mohlenkamp et al showed that 108 apparently healthy marathon runners had more coronary artery calcium (which is found in coronary artery atherosclerosis) than patients matched for age and Framingham risk score (a commonly used measure of a person's risk for cardiovascular disease based on their risk factor profile). Furthermore, they showed that the amount of coronary artery calcium, as well as the number of marathons run, was directly associated with myocardial (heart) damage, which was detected in 12% of the marathon runners. Finally, four of the runners had cardiovascular "events" over the next 2 years, all of whom had high levels of coronary artery calcium. Similarly, Schwartz et al. showed that 25 marathoners had more coronary artery plaque than 25 non-marathoners who had similar ages, blood pressure and cholesterol levels.
These studies are far from conclusive. The marathon runners may have had more predisposition to coronary artery disease than the non-runners despite similar Framingham risk scores, perhaps due to prior lifestyle differences (i.e. smoking, diet) or a more extensive family history of such disease. On the other hand, there are plausible mechanisms by which running could increase vascular disease. Intensive exercise is well-known to increase oxidative stress and inflammation, which are fundamental to the development of coronary artery disease.
Runners like me like to believe that running is good for our heart and blood vessels, based on the principle of "use it or lose it". However, maybe the cardiovascular system is more like a car (and just about everything else), the more "mileage" it has, the more likely it is to break down.

Does Sunscreen Really Work?

This weekend I’m spending the Fourth at the beach with my family in South Carolina. Today, after spending 20 minutes slathering sunscreen on my somewhat disgruntled children and myself, I gathered up my straw hat, sunglasses, book, two kites, a couple of chairs, and several more tubes of sunscreen, making our daily exodus to the beach. Things have changed a lot since I was a teenager, back in the eighties--the Hawaiian Tropic Coconut Oil is nowhere to be found, despite my Brazilian heritage and cultural proclivity toward small bathing suits and a good tan.

But just how much protection do these bottles of SPF 30+ sunscreen actually provide us?

Skin cancer is the most common form of cancer diagnosed in the United States. There are three major types: basal cell, squamous cell and melanoma. Of those, basal cell and squamous cell are most common, accounting for about 3.5 million cases in the United States per year. Although, these types typically do not metastasize, they can be quite disfiguring, particularly after resection when they occur on the face. On a population level, melanoma is the most dangerous type of skin cancer, accounting for approximately eight thousand of the ten thousand deaths per year attributed to skin cancer.

This year the Environmental Working Group and Senator Charles Schumer brought to light concerns that have arisen about a form of vitamin A, retinyl palmitate, found in 41 percent of sunscreens. This compound has been found to accelerate the development of skin cancer in laboratory animals. Schumer and EWA were critical of the FDA for its slowness to address the existing studies and for its failure to regulate the safety and efficacy of sunscreens. Although there is significant evidence that sun exposure is a strong risk factor for skin cancer, there is relatively scant evidence that sunscreen use mitigates this risk. Randomized controlled trials have demonstrated a decreased incidence of actinic keratosis (a skin cancer precursor) and squamous cell cancer in sunscreen users. In these same trials, basal cell skin cancer was not similarly impacted. Moreover, no studies have confirmed a protective relationship with respect to melanoma incidence, and in fact several studies have shown increased risk in sunscreen users, perhaps because high SPF sunscreen users spend more time in the sun than those who user lower SPF’s.

Other factors reduce the effectiveness of sunscreen, including the failure of people to apply it appropriately, in adequate quantity, and to reapply after sweating, swimming or toweling off. A whole host of high SPF sunscreens are available, but labels touting high SPF content may be inaccurate. In addition, beyond SPF 15 the difference amongst sunscreens is minimal--SPF 15 filters 93% of UVB light, compared with SPF 30, which filters 98%. The SPF refers to the UVB blocking property. Sunscreen components that block UVA include zinc oxide, titanium dioxide and avobenzone and Mexoryl SX.

What can you do to avoid skin cancer risk?

• Avoid the sun between the hours of 10 AM and 4 PM.
• Use protective clothing when outdoors, including wide brimmed hats and shirts. Tighter weaves and darker colors do a better job, and UV protective fabric is also effective.
• Use sunscreen of SPF 30 or greater that blocks both UVA and UVB light, applied in adequate quantity, and reapplied frequently
• Avoid sunlamps and tanning equipment.
• Practice skin self-examination.

Can the Patient Centered Medical Home Save Primary Care?

For years now we’ve been hearing about the trials and tribulations that have evolved in the practice of primary care medicine. However, the discussion has intensified in recent months with passage of national health reform. Recent publications highlight the problems. A paper in the New England Journal of Medicine by Dr.Richard Baron entitled “What Keeps Us So Busy in Primary Care?”discusses the time spent by primary care doctors on non-visit related work, which according to his findings, interrupts us 43 times daily. Health insurance reimbursement to physicians is “fee for service,” thus leaving all of this work uncompensated. Moreover, health insurance pays better for procedures than it does for talking to patients. These factors have contributed to perverse incentives: “see more patients, run more tests.”

With current relative shortages of primary care physicians, and the anticipation of more patients entering the health system, attracting new physicians to pursue a career in primary care is seen as critically important. However, medical students hesitate to choose it as a career because of its difficult lifestyle, lower remuneration, and the current practice environment. Yesterday I read that HHS Secretary Kathleen Sebelius announced the release of $250 million in new funding to strengthen the primary care workforce. Of this, $168 million is set aside for training more than 500 new primary care physicians by 2015. That's good news, but who is going to want to pursue this training if the value placed on our time remains so low, and the practice pace remains as hectic as it is today?

What is the answer? There are several current responses to the primary care crisis. On the one hand, the advent of retail clinics and retainer fee medical practices, and on the other hand, the Patient Centered Medical Home model, which has established itself with increasing legitimacy as the best solution. The May issue of Health Affairs was dedicated to “Reinventing Primary Care.” For those of you who have not heard of it, the “Patient Centered Medical Home” (PCMH) is a model of primary care that reorganizes the care team in a way that gets non-physicians more involved, supports patient “activation” toward improved self-care, and uses electronic systems—electronic health records and patient portals—to better manage populations of patients, particularly those with chronic illness. In many ways the Patient Centered Medical Home might really be called the Computer-Centered Medical Home.

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The PCMH addresses the problem of access to primary care and is particularly appealing as a solution within certain segments of the insured population, namely, Medicaid and Medicare. Physicians have increasingly dropped Medicaid because of its very low reimbursement rates. This has made access to care, despite insurance coverage, very difficult. A similar problem may soon exist within the Medicare population, with physicians dropping or capping Medicare patients, if an acceptable solution is not reached with respect to the SGR and Medicare's payments to physicians drops further.

Intrinsic to the PCMH is the concept that primary care should be reimbursed differently. Under this model payment is both fee-for-service and additionally capitated per patient member within the practice. Results of implementation of the PCMH have been published from Group Health Cooperative in Washington and also recently from Medicare's pilots projects. The Group Health results look promising, showing overall cost savings, related to decreased inpatient and emergency room use. However, reports from the large TransforMED pilot, published in the Annals of Family Medicine, are less promising. "Working feverishly, the 36 participating family practices registered only modest improvements in quality-of-care measures but backslid in terms of how patients rated them." The authors of the summary conceded that medical home transformation "requires tremendous effort and motivation," and that most practices would need outside help, as well as adequate compensation, to make the switch."

Simulateous with the PCMH, retainer fee medicine has appeared in many areas of the United States. Similar to the PCMH, retainer fee medicine, also known as “concierge medicine,” provides extra funding to a medical practice in a capitated manner with a per patient annual fee. The difference is that in the PCMH, the hope is that insurers will provide the additional capitated funding. Another key difference is that PCMH designated practices must prove that they deliver certain elements of care to their patients. In fact, to become certified a practice needs to achieve a long and complex set of criteria. The model has been criticized as being “out of reach” for many small practices, who simply cannot afford the additional layer of clinic administration needed to complete the check list.

In contrast to the PCMH standardization, among retainer fee practices there is significant variability in the type of care delivered, the annual fee charged, and the practice's adoption of electronic systems and quality reporting. This type of practice typically emphasizes a more "Marcus Welby" approach, with emphasis placed on personal communication and the traditional doctor-patient relationship. Whereas PCMH practices emphasize care teams with more participation of non-physician members, and may in fact increase the number of patients cared for by each physician, retainer fee practices typically guarantee that they will care for fewer patients per doctor.

As I see it both the PCMH and retainer fee medicine are reasonable solutions to current short-comings. What's wrong with a "Patient-Sponsored Medical Home" practice, structured as a hybrid of these two primary care models, with built in systems to ensure quality, but also structured with the promise of a smaller patient panel for those want a more traditional doctor-patient relationship ? Can the Medical Home have it's cake and eat it too? Or, will it fail to support the personal aspects of the doctor-patient relationship, the value of which is more difficult to measure with quality metrics and clinical outcomes?