bb Albert Provocateur: July 2009

Albert Provocateur

Friday, July 31, 2009

Vaccinator

Fathers, protect your daughters from the onslaught of that perverter of all that is right, good, pure, and just, namely, the HPV vaccine! The call to arms has been sounded from belfries across the nation, to the despair of health care providers who witness another arm in their arsenal against cervical cancer cast to the wayside. The feeling of utter impotence on their parts is both frustrating and devastating, in the face of an ever-mounting body of data that appears to indicate the resounding efficacy of a vaccine that is a relentless adversary in the fight against cervical cancer, when it is unleashed in a timely fashion. Getting down to the brass tacks of the matter, perhaps you, the reader, will become convinced, and lend your daughters to the safe haven and caring hands of those who would stop a virus, the human papilloma virus (HPV), and its progression to something far more sinister dead in their tracks.

Cervical cancer is the second most frequent cancer among women, and it has been associated with HPV. The general public has not been adequately schooled on that score, and remains ignorant as to just how diffuse HPV infection is. The statistics are staggering, and go something like this. Twenty-five percent of persons between 14 and 19 years of age and 45% of those between 20 and 24 years are infected with genital HPV, with more than 80% of both men and women in the United States infected at some point in their lives. Surprised? Read on. HPV is usually acquired within months after the first sexual intercourse, and is usually asymptomatic. If the infection is not prevented, if screening with a Pap smear for precancerous lesions owed to HPV is not conducted due to health information shortfalls or a sense of physical impunity, or if treatment of HPV’s legitimate heirs, anogenital warts and cervical disease, is not instituted thoroughly and immediately, the death knoll will be sounded and direct medical costs stemming from HPV will add insult to fiscal injury. As it stands right now, each year 490,000 of this planet’s women receive a diagnosis of cervical cancer and 270,000 die from it. In 2008, 11,000 U.S. women received such sad tidings and 3,900 were as a result summoned by the Grim Reaper, at a cost of $4.0 billion in health care dollars. A good portion of these victims, and, if not them, future generations might be spared if reliance were to be placed on the “Vaccinator,” a full series of the HPV vaccine, costing $375 dollars and a whole lot less blood, sweat, and tears.

The hero of the moment, called the “Vaccinator,” for purposes of literary color and license, but commonly known as the HPV vaccine, has received a great deal of bad press, with the public continuing to be misinformed in many cases. So, the record must be set straight here, and then, perhaps, heads of households will be more inclined to offer their daughters on its preventive altar in exchange for a welcomed and precipitous reduction in the body count. The HPV vaccine has been marketed by Merck & Co., Inc. since June 2006 under the name Gardasil®, and it is effective against the four high-risk types of HPV. Women between the ages of 9 and 26 years of age are targeted for vaccination in order to prevent genital warts and cervical, vulvar, and vaginal cancer. They should be vaccinated before their first sexual intercourse, because it is a sad, but true, “fact of life” that HPV infection is usually acquired within months after first sexual intercourse. While the vaccine is effective in immunocompromised women, the same cannot be said for pregnant women. A silver lining is the fact that women with cervical disease from one high-risk HPV type may be vaccinated against the other high-risk types. Gardasil is administered intramuscularly at 0, 2, and 6 months, and the vaccine series does not have to be restarted in its entirety if, girls being girls, a dose is missed. Let the buyer beware, however! Fainting spells may occur in adolescents immediately after vaccination. So, the rule of thumb is for the physician to observe the “vaccinee” for 15 minutes after vaccination. Wow, that was a lot of information! Exclusion of still another piece of stark reality could be construed as criminal, so it needs be said that abstinence from intercourse until marriage is no substitute for the HPV vaccine, as sexual abuse or an infected marriage partner make having been a “good girl” bad.

As the Vaccinator waits in the wings for the raging debate over whether to vaccinate preadolescents or not to play itself out, parents of young women should take no comfort in biding their time with a less is better mentality. Even with the jury out, some verdicts are forgone conclusions.

ã 2009, Albert M. Balesh, M.D. All rights reserved.

posted by Dr. Al at 7/31/2009 07:10:00 AM | 0 comments

Sunday, July 05, 2009

Temples to the Gods

What’s a house call, you ask? For those of us old enough to remember, a cough, a fever, an upset stomach, a runny nose, a child’s pinworms, or any manner of body wake-up call left us concerned, but never troubled, for we knew that we could depend upon our trusted physician in white armor to ride to our doorstep on four-wheeled steed. Something has been lost in translation, however, as that friendly domestic cup of tea shared by doctor and patient has been transformed into a mad dash to the emergency room and a rush to judgment, as we chastise a past hero who now reminds us that time is money. So, are the healers of today, with all their bells and whistles, airs of superiority, and self-built clinical temples, better at their art and science than their good-old, bespectacled ancestors, who bore little black bags instead of handheld computers? Is technology mightier than compassion? Are robot-guided catheters and probes more efficacious in the long term than the touch and comfort of a healing hand? Can some suitable compromise be reached? Those and other questions need to be answered, before we embark on that expensive overhaul of the health care system we call universal health insurance.
Medicine has become a business, like many other noble endeavors, and its proprietors seek growing clienteles through self-promotion, whether that be media advertisement or construction of palatial offices and clinics that provide a semblance of professional success to new generations raised on material excess. After all, a doctor in rags, driving a jalopy, certainly does not project or warrant trust, in much the same way as a down and out real estate agent or practitioner of the bar. Furthermore, a “mine is bigger than yours” attitude drives a competition for numbers, both in terms of patients and consequent hard cash, as physicians vie for their piece of the American dream by drawing patients across their thresholds and then treating them with production-line efficiency. Damn feelings and close interpersonal contact, as terse replies to questions and directives to consult the nurse engender little satisfaction, growing hostility, and a sense of loss and abandonment in those seeking solace and perhaps even a cure from the men and women in white.
Those venerable statistics we like to quote have shown big-clinic medicine is a drain on pocketbooks, resulting in 60 percent of all bankruptcies in the United States in 2007 being owed to runaway health care costs. Seeing a different patient every 15 minutes does little to reel in costs or improve patient satisfaction. It is high time for a new paradigm, called “patient centered” practices, that incorporates both increased time with patients and an emphasis on prevention and education to keep them healthy, so that incessant and expensive referrals to specialists become a thing of the past. Not an easy task, you say. You’re absolutely right. To streamline procedures, processes, and administrative costs, with consequent reduction in the health care deficit, all eyes will once again have to turn to that often-touted cure all for everything costly, namely, technology, in the form of online appointment scheduling, electronic medical records, prescription of medications by computer, and virtual office visits by telephone and e-mail. As impersonal as it may seem, and as uncomfortable as we may feel about it, technology can, indeed, raise the bar of primary health care and even personalize it, when placed in the hands of practitioners in the trenches who are unafraid to try something new to safeguard a nation’s health on the verge of financial chaos.
Technology is not for everyone, however, and it will not solve all of this country’s health care issues. The high priests, keepers, and gods themselves in the temples warn that electronic patient records can be hacked, computer downtime can make patient records inaccessible for hours, small primary care clinics are not the answer for patients with multiple health issues, and small practices do not provide safe haven for practitioners who lack technical or business skills or who fear private fees versus salaries in these times of economic uncertainty. Reducing daily patient loads from 25 to 10-12, with longer patient appointments of 30 to 60 minutes, may not be the answer either, as primary care physicians watch impotently as their salary dollars undergo erosion. That, in part, is the reason why primary care remains the most unattractive field of medicine, with practitioner numbers dwindling due to the lowest compensation of any medical specialty. In 2008, the average annual salary of a primary care physician was $201,555, versus $356,166 for a general surgeon and $614,536 for a neurological surgeon. Poor babies! Lest they recall the hordes of unemployed currently walking the bread lines!
All this discussion points to a need for something to be done, and immediately. When general practitioners are scheduled to see 25 or more patients per day in large clinics or temples, whichever you prefer, sufficient time for thorough examinations, adequate discussions, and proper preventive care goes out the window, and the end result becomes the needless ordering of superfluous tests and unnecessary referrals to specialists, all at the expense of national health care ledgers that are rapidly approaching the bottom line. And heaven forbid that we discuss the unquantifiable toll on patients’ psyches of noisy and crowded waiting rooms, and the status quo, for lack of a better word, of getting in and out without wasting the doctor’s time with questions. Ignorance not being bliss in this case!
Is technology the answer? Perhaps not, in all cases. However, it can streamline processes and make small primary care practices financially viable in the current health care market, reducing their costs to half, from 60 percent of income down to 30 percent. That translates into better patient care, with physicians able to see fewer patients without sacrificing their almighty incomes. Tearing down the temples in favor of small storefront clinics with advanced technology may be a return to the future, and the name of the game. Perhaps little black bags can even be made big enough to hold laptop computers.

© 2009, Albert M. Balesh, M.D. All rights reserved.

posted by Dr. Al at 7/05/2009 02:09:00 PM | 0 comments