Getting Back to Medicine

Two weeks ago I opened a new medical practice. It's been a long haul. One year ago, after 12 years in practice as an academic general internist, I decided to make a change. After sifting through a wide range of opportunities within the Atlanta metropolitan area I made the decision to open a solo general internal medicine practice. Some might consider it crazy, in an era when physicians are increasingly leaving private practice in favor of large employed groups. Employed groups do offer certain advantages for physicians, including being able to negotiate better contractual rates from insurers, cost-sharing with respect to benefits and pricey equipment, including electronic health records, and more opportunity for shared night call and weekend coverage. 


However, I had just left a large employed group and was witness to the kinds of problems with patient care, access, and continuity that can occur in this type of practice setting. Cost reducing practices, implemented under the guise of efficiency, such as off-site call triage centers, tend to reduce doctor-patient communication, in favor of "teamwork" so that doctors can be left to their revenue generating activity of frenetically seeing 20 to 25 patients daily. 


What I was after was a smaller, more personal practice, where I wouldn't have to spend the first five minutes of my fifteen minute doctor-patient encounter apologizing to my patients for systemic problems that affected the care that they were receiving.


In opening my practice there were several keys decisions to make: first, my practice location. I left my old practice with a two year non-compete covenant restricting me from the practice of general internal medicine in the area where I had built my life and home for twelve years. Would I be forced to move? Or, would I add on an extra hour of driving, and practice outside of my non-competition perimeter? I grappled with this decision for six months. It's funny how many of my friends questioned the legality of this type of contract within the state of Georgia. However, the three lawyers that I spoke with felt it was too risky to violate it. Fortunately this issue is now resolved, and I have established my practice close to home and plan to have a good working relationship with the institution that I left.


Another major decision was whether or not to purchase an electronic health record. The final "meaningful use" criteria tying Medicare and Medicaid reimbursement and incentives to the adoption of electronic health records by eligible medical professionals and hospitals were released two weeks ago. Being somewhat of a techno-geek and a relative "early-adopter," I opted to shell out the cash and buy an electronic medical record (EMR), with hopes that a promised link to my main referral center would become functional in the near future. We'll see how this pans out. I am already concerned that the commercial lab that I have contracted with is hesitating on what I thought was an agreement to upload my lab data directly into my EMR.  Apparently EMR providers charge extra to "turn on" this interface.  If the lab refuses I will be left to cover that cost as well. Those of you in the process of purchasing electronic records should be sure to verify in writing all of the links and interfaces that you want to function, and who will cover the costs associated with turning them on.  Meaningful use requires that lab data is entered into one's EMR as structured data, as opposed to scanned in, which makes the data usable when looking for trends and for generating quality reports and automated reminders.   Don't get me wrong, I am still happy with my expensive new "toy," though it's taking me twenty minutes, instead of two, to type in my office note, as opposed to dictating. Hopefully that will get faster. My implementation support has been wonderful, which I am grateful about.


Finally, I had to decide on staffing. I had originally planned to hire an office manager, but with the purchase of my EMR I decided to outsource my billing to the same company, which meant that I had more flexibility. An opportunity became available for me to hire a wonderful LPN with whom I had worked for many years. I feel so fortunate to work with a capable and loyal employee, who "knows my ways," and with whom I have shared common processes and protocols in the past and who is partnering with me in this endeavor. This is the decision that I am most confident about.


As I began to see patients again two weeks ago, I was surer than ever about my career choice to become a general internist. I can only hope that in the near future my practice will become something more than an expensive hobby.  In the meantime I will continue to work on the side at Georgia Tech in student health to make ends meet.

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.