Tag: Harvard Women

Burnout is causing physicians to leave the profession.

Reading the book The Doctor Stories by William Carlos Williams seared into my mind the ways in which a primary care physician (PCP) can transform the lives of patients with a nuanced blend of careful listening, emotional connection, and medical skill. This book inspired me to become a PCP.

According to a 2021 report by the National Academy of Sciences, Engineering, and Medicine, an increased supply of PCPs is associated with better population health and more equitable outcomes. With our country’s fraying healthcare system, it is essential to have a PCP who knows you, because it is almost impossible to access any type of coherent medical care without the coordination of a PCP.

The most common question I get asked as a doctor — by friends, acquaintances, relatives, families of patients, colleagues — is “Can you help me find a PCP?” I can’t. None of us can. Why is it so difficult to find a PCP nowadays?

Unfavorable demographics and PCPs leaving the profession

While the COVID pandemic certainly pushed a large subset of already burned-out PCPs over the brink into semi- or full retirement, or into less stressful jobs, the current primary care crisis has been brewing for much longer. The US is expected to face a shortage of primary care physicians ranging from 21,000 to 55,000 by the year 2033.

Both patients and doctors are getting older. As patients age, they tend to need more care from their PCPs to address the proliferation of medical problems and medications that inevitably comes with aging. At the same time, the Association of American Medical Colleges reports more than 40% of active physicians in the United States will be 65 or older within the next decade. The American Medical Association notes that 29% of physicians retire between the ages of 60 and 65, and 12% retire before the age of 60.

These numbers have daunting implications for the future supply of seasoned doctors. Further, one-fifth of doctors say they will likely leave their current practice within the next two years, and one-third of doctors are intending to reduce their work hours within the next 12 months.

PCPs have higher burnout and lower pay than many specialties

Primary care is getting hit harder than most specialties, due to having lower salaries, higher ratings of burnout, and a growing feeling that their job is generally impossible and thankless on all fronts. According to a 2019 physician survey, the burnout scores among PCPs were up to 79%. Many hospitals are happy to replace PCPs with even lower-paid NPs and PAs, who do a good job with routine care but aren’t trained in subtleties and complexities, which come into play if you develop a challenging or rare medical condition, or if you have multiple medical comorbidities.

Multiple causes of primary care dissatisfaction

Many PCPs are facing requirements by their hospitals to see a greater number of patients, who get sicker and whose care gets more complicated every year, in the face of significant salary and benefit cuts and with dwindling administrative and clinical support. PCPs have more to do at each visit, as new requirements and treatments come up, but none of the work aimed toward preventive health seems to disappear, such as managing blood pressure and cholesterol, as well as discussing and providing hospital scheduling requests for health screenings like mammograms and colonoscopies.

Further, when patients are finally able to get in to see us in person, they have many more unaddressed problems and concerns because they often haven’t seen us for a year or two. This creates a vicious feedback cycle, with PCPs having ever-growing issues to address under a time pressure and patients having increasingly unmet medical symptoms and needs.

Time devoted to electronic medical records is further impacting burnout

It is estimated that for each hour a PCP spends with a patient, up to two hours of work are generated, which includes writing summary notes and treatment plans in a patient’s electronic medical record (EMR) and communicating test results or other important information to patients and their caregivers. Many PCPs that I know go home at the end of crushingly stressful days, spend an hour or two with their families, and then stay up late to finish all the computerized documentation that their day in clinic has generated. Many also have second jobs or side gigs to pay off their medical school debts.

What we are managing in today’s clinics is increasingly complicated and out of our control. As our entire health care system struggles, it is more difficult to get patients into the emergency department, into the hospital, and scheduled to see medical specialists. PCPs are left managing many things in the absence of the support that we are ordinarily used to.

We are also managing greater mental health needs and dealing with the brunt of our patients’ problems, such as lack of housing and employment, unaffordable medications, and widespread financial problems. The fact that we are unable to care for our patients nearly as well as we previously could is considered to be a “moral injury” that many of us are suffering. And there is research that when your doctor is struggling like this, the quality of your health care can suffer.

What can patients do to find a PCP?

If your current PCP quits or retires, ask the practice to assign you to someone new. In theory, practices aren’t supposed to leave patients stranded and abandoned, even if they, like many places, don’t truly have enough experienced physicians to take adequate care of patients. If that doesn’t work, or if you don’t feel that your new doctor is a good match for you, you can call your health insurance and see which doctors are accepting new primary care patients.

If you happen to have a friend who is a doctor or a nurse, perhaps they can advocate for you by asking a colleague to accept you into their practice. Our system shouldn’t work this way, but it often does. Most practices have waiting lists, so if you are without a PCP, put your name down, as late is better than never.

What might reverse the primary care crisis?

We need to train and financially support more PCPs by encouraging trainees to go into primary care, and to eliminate the pay gap between PCPs and specialists. We need to buttress those doctors who are currently trying to stick it out as primary care doctors, so they don’t cut down hours or quit. These doctors urgently need emotional, financial, logistical, and psychological support.

Finally, we need to cultivate in new doctors the magic of primary care, so eloquently spelled out by William Carlos Williams, so that people can, in fact, access the care that will enable them to live and enjoy the long and healthy lives they deserve.

If you have a family history of heart disease, you probably try to stick to a healthy diet to reduce your heart risk. But did you know that focusing on combinations of foods vetted for their disease-fighting ability can help lower risks for many chronic illnesses, including cancer, diabetes, and cardiovascular disease that can lead to heart attacks and strokes?

The Alternative Healthy Eating Index (AHEI) assigns ratings to foods and nutrients predictive of chronic disease. Harvard T.H. Chan School of Public Health researchers created the AHEI as an alternative to the US Department of Agriculture’s Healthy Eating Index, which measures adherence to the federal Dietary Guidelines for Americans.

“The Healthy Eating Index and the Alternative Healthy Eating Index are similar, but the AHEI is more oriented toward reducing the risk of chronic disease,” says Natalie McCormick, a research fellow in medicine at Harvard Medical School.

Rating your diet

The AHEI grades your diet, assigning a score ranging from 0 (nonadherence) to 110 (perfect adherence), based on how often you eat certain foods, both healthy and unhealthy fare.

For example, someone who reports eating no daily vegetables would score a zero, while someone who ate five or more servings a day would earn a 10. For an unhealthy option, such as sugar-sweetened drinks or fruit juice, scoring is reversed: a person who eats one or more servings would score a zero, and zero servings would earn a 10.

Research links high scores on the AHEI with a lower risk of chronic disease. One key study reported in the Journal of Nutrition, which included 71,495 women and 41,029 men, found that people who scored higher on the AHEI had a 19% lower risk of chronic disease, including a 31% lower risk of coronary heart disease and a 33% lower risk of diabetes, when compared to people with low AHEI scores. Another study in the American Journal of Clinical Nutrition found that among 7,319 participants, those who got high scores on the AHEI had a 25% lower risk of dying from any cause, and more than a 40% lower risk of dying from cardiovascular disease, than the low AHEI scorers.

Separate research on older men and older women has shown that those who score highest on the AHEI perform better on activities like climbing stairs, lifting groceries, walking a mile, and engaging in moderate or vigorous activities than those who score lowest.

A global study noted wide variations among nations in diet quality, and predicted that improving current diets could prevent millions of deaths from cancer, coronary artery disease, stroke, respiratory diseases, kidney disease, diabetes, and digestive diseases.

Can you use the AHEI to score your own diet?

It’s probably not practical to use the actual AHEI scoring system, says Kathy McManus, director of the department of nutrition at Harvard-affiliated Brigham and Women’s Hospital. But you can easily incorporate more of the healthy AHEI foods into your diet.

Some top choices include the following:

• Vegetables. Aim for five a day, and focus on squeezing in extra servings of green leafy vegetables, which may help reduce the risk of diabetes. Try to skip the potatoes and fries.
• Fruit. Try to eat four servings a day, an amount that might help protect against cardiovascular disease and some cancers. Avoid fruit juice, because drinking too much might actually increase your risk of diabetes.
• Whole grains. Eating five to six servings a day might help head off cardiovascular disease, diabetes, and colorectal cancer, says McManus. Minimize refined grains, which are associated with a higher risk of diabetes, heart disease, and potentially other chronic diseases.
• Nuts, legumes, and vegetable protein (tofu). Getting a serving a day of protein from these sources is a healthy way to add nutrients to your diet, and might help protect against diabetes and cardiovascular disease.
• Fish. Adding fish to your weekly meal plan can give your body a dose of healthy fatty acids, which could help reduce your risk of cardiovascular disease and potentially diabetes.
• Healthy fats. Adding healthy unsaturated fats to your diet helps reduce your risk of heart disease and diabetes. Some good options are olive oil, canola oil, peanut oil, or safflower oil, says McManus. These healthy fats are particularly beneficial if you are swapping them for saturated fats, such as butter.

Also look to the MyPlate tool for guidance (available in multiple languages). It’s based on much of the same research that experts used to develop the AHEI. Adding more of these chronic disease-fighting foods into your diet can help keep you in good health over the long term.

Suppressing inflammation may be the key.

Rheumatoid arthritis (RA) is an autoimmune condition affecting up to 3% of the population. Joint inflammation, the hallmark of the disease, causes swelling, stiffness, and limited motion, especially in the small joints of the hands and wrists.

But inflammation in rheumatoid arthritis isn’t limited to the joints — it’s present throughout the body. As examples, skin nodules, eye inflammation, and lung scarring are well-recognized features of rheumatoid arthritis, all related to unchecked inflammation. Interestingly, inflammation may play a major role in dementia. So, could inflammation-suppressing medicines for rheumatoid arthritis affect the odds of developing dementia?

Can treatment of rheumatoid arthritis lower dementia risk?

Recent studies suggest that the answer may be yes. Perhaps this shouldn’t be surprising. The role of inflammation in Alzheimer’s disease and other types of dementia has been a focus of research for decades, and treatments for rheumatoid arthritis reduce inflammation.

Considering that there are currently no effective preventive treatments for Alzheimer’s disease or other forms of dementia, the observation that RA treatments might prevent dementia could be groundbreaking.

What’s the evidence supporting this idea? Here are a few of the latest and most compelling observational studies.

• A study published in 2019 reported that people with RA treated with standard medications had less than half the risk of developing dementia over a five-year period compared with people without RA.
• A 2021 study found dementia rates declined among people with RA and increased among the overall population in recent decades. During that time, treatments for RA had been improving.
• A 2022 study looking at people taking different types of RA treatment provides some of the most convincing findings. It found that people with RA taking the newest, most effective treatments developed dementia 19% less often over the three years of the study compared with those treated with older medicines. When people taking a range of newer medicines were compared, there was no significant difference in the dementia rate.

Together, these studies suggest that certain treatments that help rheumatoid arthritis might do more than protect the joints; they might also protect the brain. This isn’t the first time a medicine was found to cause an unexpectedly positive side effect. But it could be one of the most important.

Is additional research needed?

While evidence is mounting that inflammation-suppressing medicines might reduce dementia risk, more research is needed:

• Observational studies cannot prove cause. They simply observe rates of dementia among different groups of people, which means other factors could account for the results. For example, the 2022 study didn’t assess smoking and family history, which contribute to dementia. If the group receiving older RA treatments had more risk factors for dementia, the medicines might not explain the findings. More powerful evidence comes from randomized controlled trials, in which otherwise similar people are randomly assigned to different treatment groups and their health is analyzed over time.
• Results might differ with different or more diverse groups of study participants. For example, participants in the 2022 study were older adults (average age 67), mostly white (75%), and mostly female (80%).
• Independent research is necessary to confirm results. A single study from one group of researchers is rarely convincing, especially for an issue as important as preventing dementia.
• Longer-term follow-up is needed. Rheumatoid arthritis is a lifelong disease, so studies lasting three to five years may not tell the whole story.
• We’re not sure how certain medicines for RA might protect the brain. We also don’t know whether these treatments could be effective for people who don’t have RA.

It’s reasonable to believe that reduced inflammation, rather than a particular drug, is providing a benefit because different medicines with different ways of damping down inflammation have been linked to lower dementia risk in people with RA. But we’ll need more research to prove that’s true.

The bottom line

Treatments developed over the last 50 years have transformed rheumatoid arthritis from an often disabling disease to a chronic condition that usually can be well-controlled. The initial choice of treatment depends on a combination of factors, including effectiveness, side effect profile, how a drug is given (most people prefer pills over injections), cost, and whether a drug is covered by health insurance.

Soon, another consideration may be added to this list: the ability of a medicine to lower dementia risk. This might be particularly relevant to the person with rheumatoid arthritis who has a strong family history of dementia.

And what about people without RA? I think it’s only a matter of time before studies explore whether anti-inflammatory medicines can reduce the risk of dementia even in people without an inflammatory condition like RA. While it’s impossible to predict what those studies will show, one thing’s for sure: the impact of a positive study would be enormous.