The New England Journal of Medicine, long a standard in peer-reviewed medical research, has updated its website and become a portal of an essential library of text, audio, and video — a thriving primary online brand of itself. What a treat.

Our electronic archive now includes every issue back to the first one, published in 1812. The NEJM Archive from 1812 to 1989 has more than 150,000 articles. All articles are fully searchable, with the content back to 1945 presented in an HTML format similar to that for the current issues. For all the articles in the archive, the PDF files show the original versions as they appeared in print, complete with ads, notices, and various curiosities from earlier eras.

Nice. It was enough for me to subscribe to the Journal (and its online content) for the first time in over 10 years. | LINK

Research into better treatments and possible cures of Alzheimer dementia is one of the bright spots in the potential for better healthcare delivery in the decade of the 2010s. There are many signs that bode well for the approach to this disorder at the dawn of the second decade of the 21st century.

New research into alternate pathways of disease development is starting to generate excitement among primary care physicians and geriatricians (such as myself) as potential arenas for new classes of drugs to combat Alzheimer’s. Better care delivery models in long term care of the elderly as part of new initiatives in the Affordable Care Act are already starting to impact chronic disease care management strategies.

Perhaps most important, there is new evidence to suggest that earlier detection of this cognitive disorder can enhance those developments, and more. At an annual meeting of top dementia researchers, guidelines were proposed to expand on the research from the ’00s to diagnose the disorder earlier — a strategy that benefits more than just those potentially afflicted with Alzheimer’s.

If the guidelines are adopted in the fall, as expected, some experts predict a two- to threefold increase in the number of people with Alzheimer’s disease. Many more people would be told they probably are on their way to getting it. The Alzheimer’s Association says 5.3 million Americans now have the disease.

Heavier use of newly discovered biomarkers for earlier detection of the pathology behind Alzheimer dementia will be a closely watched process by both physicians and health policy analysts alike. | LINK

Sad to hear today of the death of Dr. Robert Butler from complications of leukemia. The appellation “father of modern gerontology” is a well-deserved one, as I referenced his research and teachings throughout much of my training as a  resident and fellow. Many of the I principles incorporate into my daily practice have come from what this pioneer so dutifully studied in over 300 scholarly articles and publications. Although he was a psychiatrist by training, his contributions to geriatric medicine virtually created the discipline itself.

Butler was the first clinician who coined the term “ageism”, the result of such forward-thinking approaches to the geriatric patient that was characterized by the medical practice free of biased attitudes and treatment assumptions that, if employed today, would cause harm to many elderly patients receiving chronic medical care. Indeed, many of his sound principles so sacrosanct to the practice of geriatrics and study of gerontology sprang forth from his diligence, inquisitiveness, and yearning for the dignified treatment of the elderly patient. He will be missed. | LINK

Although the results of a study from the Annals of Internal Medicine are out today noting an increase in the rate of sexually transmitted infections (STIs) among those taking drugs for erectile dysfunction, this item “hot off  the wires” practically invites the media to take a stance assuming direct causation.

Jokes aside — and you can assume that lead-ins are probably replete with them — the compelling numbers^[1] suggest a greater problem afoot: the overall numbers of sexually active men over 55 years of age is increasing. Re-evaluating incidence and prevalence rates to include this ever-burgeoning population will only become more commonplace in medical education as this retrospective study underscores one major point: the necessity of other types of trials studying the effects of preventive practices toward STIs in those much younger and applying them to this patient population. | LINK

1. Researchers followed over 1M men (average age of 60) by examining their insurance records. Among non-users of drugs like Viagra, 106 in 100,000 contracted an STD. That number increased to 214 in 100,000 for men who were using Viagra, Cialis or Levitra — the major drugs to treat ED. [↩]

Most attending physicians well out of training know of the continued discussions on local, regional, and national levels regarding the most “acceptable” amount of hours residents in training are able to work in any given week. I trained in New York state (Syracuse) in the mid-1990s, fresh off of statewide regulations limiting overage due to some high-profile cases out of NYC involving adverse patient outcomes at the hands of fatigued physicians in training. However, no matter how well enforced many of these statutes are by states, training hospitals have always seemed to have the final say — citing financial and training constraints.

This week’s NEJM includes guidelines (still in an advisory period before final recommendations are proposed) put forth by the residency programs’ accrediting body. Among other things, a tiered system of hours is offered for first year residents (interns) to cap hours at no more than 16h/day, as opposed to more senior residents who may be in a better position to supervise and prevent error. These proposals may not go far enough, though, as oftentimes there are a host of other factors at play in overall patient care delivery by residents in an academic hospital setting — qualitative measures that are difficult to quantify for the purpose of making simple preventive interventions. | LINK [PDF]

A new twist on old news. While practically everyone with a vague association to healthcare delivery in this country knows that there is a primary care shortage, it is always refreshing to see fresh innovation to lure more talented docs to the specialty on the part of some medical schools and educational entities (…even hospitals):

[Johns Hopkins] has launched programs to bring cheap specialty care to the uninsured and primary care to those who tend to go to the emergency room. And [John ]Feldman’s [director of the school's Urban Health Residency Program] six-year residency program aims to annually produce four primary care physicians who eventually could become leaders in the field by opening a federally backed health center, directing a primary care clinic or becoming a city health commissioner.

LINK

Medical residents are students of medicine. Medical residents are physicians in training. Is it one or the other, or both? For the purposes of the plaintiffs, the University of Minnesota will take up the issue of whether Social Security taxation applies to them before the U.S. Supreme Court. Thanks to a joint filing from the Mayo Foundation for Medical Education and the U of M, the SCOTUS will hear the case — whose bases stretch back some twenty years.

At issue: the potential for upwards of $700M or more yearly in income that would be gained in the U’s budget (and in training programs nationwide) if an exemption on residents is granted with respect to Social Security taxes. The Treasury Dept., which houses the Internal Revenue Service, currently taxes resdients’ incomes; the Internal Revenue Service asserts that doctors in training, and the teaching hospitals that train them, must pay Social Security taxes on the residents’ stipends (incomes).

Residents are taxed at 7.5 percent — as they are considered employees of their training program. Oral arguments could begin in as little as six months. President Obama’s current nominee, Elena Kagan, would not take part in such deliberations because she is part of a brief supporting the federal government’s stance. | LINK

The three-volume Oxford Textbook of Medicine, coming in at a staggering 6000+ pages, is officially and completely online. Its publisher, the Oxford University (UK) Press, is leading the way of e-reference for any interested party by aggressively placing much of its library on the online space (not free, however). What makes this event more compelling is that the text, referenced by everyone — from medical students to journalists — will be following a wiki-style constant update and renewal strategy. The medical reference is apparently also source for international evidence-based medical information, making its updates and revisions all the more timely. | LINK | LINK2

Enjoying Wikipedia (if you’re really into that kind of thing) just got a little cooler. Previously only available to logged-in members and admin, the option to create a physical paperback of one’s own editing is now open to anyone. The collaborative encyclopedia has a history of content delivery via third-party hardware devicers, but this is the first time the online giant has made such a decidedly retro approach to content delivery available to the masses. And it’s all possible as a result of its partnership with PediaPress. Check out the very interesting how-to below.

Becoming your own editor of your own specialized content. Talk about a sterling endorsement for narcissism…

Schools of medicine have largely remained timid about the introduction of courses on the business of medicine or any topics related to issues of medical economics. I graduated medical school in 1994, right around the time I first heard the term “HMO”. Physicians were set free after graduating from undergraduate education to fend for themselves and the postgraduate training programs which had no guarantee of preparing those new doctors for anything remotely resembling the financial aspects of the field which would define them for the rest of their professional lives. That’s slowly changing, however. You can credit the national debate on health reform for that.

[E]scalating costs and the national debate over the health care overhaul are forcing medical schools and residency programs to grapple with teaching about the financial side of their profession. Accrediting organizations now require such teaching, and students and residents recognize that they need to understand finances as well as blood tests.

Although physician employees may not have direct control over the day-to-day costs of providing care, there is nothing negative about keeping them in the dark about it until after formal training. They’ve gotta learn sometime. | LINK

Another day. Another story with the all-too-familiar refrain lamenting the impending shortage of physicians in…what is it now…fifteen years? Perhaps even more embarrassing than that statistic are the constant reminders brought forth by articles such as this.

The greatest demand will be for primary-care physicians. These general practitioners, internists, family physicians and pediatricians will have a larger role under the new law, coordinating care for each patient.

Earth-shattering news, I know.

Proponents of the new health-care law say it does attempt to address the physician shortage. The law offers sweeteners to encourage more people to enter medical professions, and a 10% Medicare pay boost for primary-care doctors.

Excuse me if I yawn. As a primary care physician myself I find such articles as nauseatingly irritating as I do mundane. The ivory tower elite healthcare policy wonks and well-meaning lawmkers (and Presidents of the United States, for that matter) constantly barrage us with information we already know. It isn’t the physician shortage that has great policythinkers up in arms, it’s the 300 pound gorilla in the room that is primary care and the feeble attempt by insurers, the federal government, and even some medical schools to throw starry eyed practical medical students the olive branch of concern.

Although primary care did enjoy a nice tidy “bump” in the recent match of new doctors-to-be, the sad reality is that this recognition of the need of primary care is a little too little and a lot too late. As long as tuition rates become more and more like second mortgages for newly-minted medical school graduates; as long as procedures are rewarded (and reimbursed) more than bedside manner; and as long as the growth of medical inflation fosters even more profligate innovation — recognition of primary care as a reasonable career choice for young physicians will continue to be muted and inspire many more articles which will also be saying the same thing…like in 2025.

It’s Match Day 2010 — the inevitable Day of Reckoning for all of that hard work in medical school as the nations’ med school grads jockey for their first choices in postgraduate (residency) slots. As expected, the vast majority of the country’s graduating class is opting for careers outside of primary care (FP, IM, Peds.), but the gains made within primary care do provide a small scintilla of hope cloaked inside the dark chasm of the realities of the medical discipline’s issues after residency training.

The numbers do not lie: FP slots saw an increase of positions filled of 9 percent (IM, of 3%; and Peds., of 2%). That’s tremendous news for FP, as the primary care specialty saw a 7 percent decline in slots filled last year. Too early to hope for a trend? Depends on how you take the results. As an eternal optimist, I like the glass-half-full option, as even in the darkest of times to consider going into medicine in general, approximately 3000 more U.S. fourth year students will be matching this year than last — maintaining the nobility of the profession. | LINK

It’s often said that the beleaguered emergency department (ED) is the initial point of care for many patients. In this current broken healthcare delivery system, that means an umbrella which “covers” the uninsured as well as those who are underinsured. The total cost for these points of acute care notwithstanding, how is the best way to explain new numbers out of the CDC this week?

The CDC’s National Center for Health Statistics reported the numbers in its annual summary of U.S. data on disease conditions, health behaviors and use of medical services. The scan figures are based on visits to roughly 500 hospitals and 3,000 doctor’s offices and outpatient clinics.

According to this survey data, the CDC says that the use of imaging modalities in the ED has quadrupled since the mid-1990s. Besides being just another point of confirmation of the origin of skyrocketing healthcare costs in this country, the heavy emphasis placed on tech will not abate anytime soon. Issues pertaining to defensive medicine, integration of such tech into ingrained training of new physicians, and the cost of using such technology within the medical device market are all good reasons to try to begin attacking this startling — yet, unsurprising — statistic. | LINK