Archive for March, 2011

Shingles Vaccine Approved for Younger Patients

Monday, March 28, 2011 // Uncategorized



For Immediate Release: March 24, 2011
Media Inquiries: Shelly Burgess, 301-796-4651, [email protected]
Consumer Inquiries: 888-INFO-FDA

FDA approves Zostavax vaccine to prevent shingles in individuals 50 to 59 years of age

The Food and Drug Administration (FDA) today approved the use of Zostavax, a live attenuated virus vaccine, for the prevention of shingles in individuals 50 to 59 years of age. Zostavax is already approved for use in individuals 60 years of age and older. 

In the United States shingles affects approximately 200,000 healthy people between the ages of 50 and 59, per year. It is a disease caused by the varicella-zoster virus, which is a virus in the herpes family and the same virus that causes chickenpox. After an attack of chickenpox, the virus lies dormant in certain nerves in the body. For reasons that are not fully understood, the virus can reappear in the form of shingles, more commonly in people with weakened immune systems and with aging. 

“The likelihood of shingles increases with age. The availability of Zostavax to a younger age group provides an additional opportunity to prevent this often painful and debilitating disease” said Karen Midthun, M.D., director of FDA’s Center for Biologics Evaluation and Research.

Shingles is characterized by a rash of blisters, which generally develop in a band on one side of the body and can cause severe pain that may last for weeks, and in some people, for months or years after the episode.

Approval was based on a multicenter study conducted in the United States and four other countries in approximately 22,000 people who were 50-59 years of age. Half received Zostavax and half received a placebo. Study participants were then monitored for at least one year to see if they developed shingles. Compared with placebo, Zostavax reduced the risk of developing shingles by approximately 70 percent.

The most common side effects observed in the study were redness, pain and swelling at the site of injection, and headache. 

Zostavax was originally approved on May 26, 2006, for the prevention of shingles in individuals 60 years of age and older.

Zostavax is manufactured by Merck & Co. Inc., of Whitehouse Station, New Jersey.

For more information:
Zostavax Product Page1 



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Diabetes Forecast

Monday, March 28, 2011 // Uncategorized

We all know that the population is getting larger, as it gets older too, diabetes is bound to increase.  I was surprised by the magnitude of the impending explosion in this disease.

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Sex, Exercise and Death

Thursday, March 24, 2011 // Uncategorized

Good News And Bad News About Physical And Sexual Activity and Cardiac Events

Larry Husten, PHD

The bad news is that physical and sexual activity can trigger acute cardiac events. The good news is that the immediate increase in risk becomes much smaller with more frequent activity, and the long-term overall benefits of activity remain unchallenged. These are the key findings of a meta-analysis by Issa Dahabreh and Jessica Paulus published in JAMA of 14 case-crossover studies.

The authors write that their “results are not incompatible with the well-established beneficial effect of regular physical activity on the risk of acute coronary events: active individuals are overall at a lower risk of such events compared with inactive individuals; however, during the short time period of acute exposure to physical or sexual activity, an individual’s risk of an event is increased compared with unexposed periods of time.”

Their findings, they write, suggest “that physicians counseling patients regarding their exercise habits may need to tailor their advice to the patients’ habitual activity levels: sedentary individuals should be counseled to increase the frequency and intensity of physical activity gradually.”


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Update on Online Calorie Trackers

Wednesday, March 23, 2011 // Uncategorized

I’m back from spring break and catching up on my reading and blogging.  In spite of my best efforts, I still managed to get sunburned.  Today’s Medical Letter has an update on sunscreens which I will need to distill down to practical advice for my patients.   While I’m working on that here is a review from last Thursday’s Wall Street Journal that reviews some commonly used online calorie trackers.  Once again, MyNetDiary scores well.  This is the one that had been recommended by a personal trainer and a number of patients have used with good results.

Calorie Trackers: When a Kati Roll Is Like a Burrito


Eating healthy can often feel like a chore. Many diet and nutrition experts say one of the best ways to improve your daily diet is to keep tabs on food intake. Online calorie trackers can simplify the job with point-and-click-options.

Douglas JonesCalorie-counting websites have long been common, but in recent years the sites have ramped up their food databases and added better tools to make it less tedious to monitor what you eat.



Calorie-counting websites have long been common, but in recent years the sites have ramped up their food databases and added better tools to make it less tedious to monitor what you eat. In addition to calories, some websites let individuals know what’s on their plates in terms of cholesterol, carbs and other nutrients.

While companies are careful not to promote scientifically unproven information, the trackers’ nutrition and exercise data is mostly reliable for the average user, says Joanne Kouba, a registered dietitian and assistant professor who teaches at Loyola University’s dietetics education program in Chicago. “What you’re getting from any of these is a guesstimation,” Ms. Kouba says, but adds that steady use can yield more accurate results.

“These programs could be very helpful for a lot of people,” says Marjorie Nolan, an American Dietetic Association spokeswoman. “But they are only as good as the information that they are inputting.”

Personal Information

We tested four sites by going online and logging our daily food intake for a week. (Most sites offer some mobile versions.) To get started, we answered questions about our height, weight, daily activity level and how many pounds we wanted to shed. We asked Ms. Kouba to look over the information we got from the sites to see if it was on track with dietitians’ advice.

Overall, we found the sites’ data useful and a nice wake-up call for the poor nutritional quality of some of our meals. We were surprised our fat consumption was 50% of our daily intake on several days. The sites also pointed out the differences in what we consumed on the weekends compared to the rest of the week.

The sites have features beyond calorie-counting for those who want to spend more than a few minutes a day tracking their every move: from water intake to calculating the calories burned on sexual activity. Justin Yandell, founder of, says after weeks of use, many people become interested in knowing metrics far beyond their caloric intake. “People who never cared about fiber suddenly feel that they are not getting enough,” says Mr. Yandell.

It was difficult to gauge serving size especially when we were eating at home or at restaurants that weren’t required to post calories. Based on seeing our weekly menu and the calorie totals, Ms. Kouba says and were the most precise, but adds that accuracy varies by an individual’s food choices. was our favorite site for browsing additional info about healthy eating. The more we used the sites the easier it became to log food intake because all have the capability to store frequently consumed meals.

When it came to calorie counting, the sites listed similar numbers for popular supermarket and restaurant brands and all showed calories, fat, carbs, protein, fiber as well as sugars and cholesterol.

A Slice of Bread

Serving sizes, however, varied among the sites. One site would list the actual size of a slice of bread in ounces, while another would list it as just one serving of carbs. Calorie listings for generic food or items added by site contributors also varied. On a sample day, which included fresh vegetable juice, restaurant tacos and a supermarket granola bar, the sites’ calorie totals came within 311 calories of each other. Where they differed most was in providing nutrition information beyond brand names and the ease in inputting meals.

At, which has an easy-to-use food and exercise diary, we searched for each item and then dragged it to our calendar in the site. Most of our items popped up right away but we spent more time than expected entering the ingredients of a sandwich. (The site does allow user to save items in favorites for future reference.) Unusual menu items like a kati roll from an Indian restaurant had to be logged to what we figured was its nearest equivalent on the site: a burrito. Chief Executive Keith McGuinness says users are encouraged to substitute similar foods if an item isn’t in the database and they don’t know the calorie count themselves.

We could set targets for calories, fat and cholesterol levels. While the site didn’t show vitamin intake, we could see a weekly average of minerals consumed. After a week, we discovered we consumed 1,328 calories a day with 35% of our daily diet in fat, which the sites point out is above the 20% to 30% range recommended for our body. (The sites recommended an average of 1,200 calories for weight loss.) One surprise: A Thai curry lunch we thought was fairly healthy clocked in at over 1,000 calories.

At, a search bar let us add each item, but we had to click on an item to see the nutrition label, which then gave us the calorie information. (At the other sites, calorie counts appeared after we selected the items.) The database was thorough but we found it time-consuming to sort through pages of similar results to log a piece of French bread. The daily reports, showing totals of vitamins, fats and other metrics, were useful and easier to understand than other sites’ reports. Pointers noting our healthy and unhealthy eating habits, such as a high sodium intake, and how many calories we could consume to lose weight motivated us to keep logging. The reports color-coded meals’ data to show how healthy (or unhealthy) they were.

Fast to Use was the quickest to use because it guesses what users are searching for as they start to type. Many of the specific foods we ate (like Japanese Kani salad) were listed thanks to 300,000 contributions from the site’s community. Most of the food on our daily log was from contributors. (The other sites let users contribute as well.) We especially liked that our food diary could track things like caffeine and folate. Charts tracking eating patterns were sometimes difficult to understand and didn’t have enough detailed information.

The free site had a good food database (including hard-to-find grilled eggplant) and the fewest bells and whistles, which made the food diary simple to understand. Daily food intake was clearly conveyed in charts but long-term nutrition reports couldn’t track multiple nutrients at the same time. Co-founder Mike Lee says they are working to improve this feature. A daily metric pointed out how much weight we would lose or gain if we consumed that same amount of calories for five weeks, which kept us motivated to eat healthy. Ms. Kouba pointed out on some days MyFitnessPal may have overestimated calorie totals.

Counting What You Eat

Here’s how four online calorie trackers compare:

WEBSITE MONTHLY COST APPS FEATURES COMMENT $12 ; free food database available. Mobile app at Exercise log, able to set nutrition targets. Easy to use and thorough list, though some ethnic foods not available. Great for browsing for additional info about healthy eating. $9 Mobile app. Easy to read graphs, nutrition labels. Good quality database, searching can take time. To get an item’s calorie count, you have to click on it to get its nutritional information label. $9 (apps included). Free option available, but doesn’t provide a daily food analysis. iPhone, Android, BlackBerry, iPad. Can customize to track nutrients, exercise tracking. Excellent, quick food input, large community database. As-you-type search feature guesses the item you want to select. Free iPhone, Android, BlackBerry. Recipe builder, active online community. Easy-to-use, some irrelevant search results. Few bells and whistles made the information from the food diary easy to understand.

Write to Alina Dizik at [email protected]

Copyright 2011 Dow Jones & Company, Inc. All Rights Reserved

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Update on Shingles

Wednesday, March 9, 2011 // Uncategorized

I can’t remember a year when I have seen so many cases of shingles.  I need to search my electronic medical record and see how many cases I diagnosed this year versus last.  Even my wife had shingles.  There is a review article on the painful rash caused by the chickenpox virus.  According to it, shingles is on the rise.  It has increased from 3.1 episodes per 1000 persons per year in 2000 to 5.2 cases per 1000 persons per year.  I’ve got a synopsis of practical information about shingles as well as an update on the vaccine and the chance of getting shingles more that once.


What is herpes zoster?

• Herpes zoster, commonly known as shingles, is a
painful skin rash caused by the varicella zoster virus.

• Varicella zoster virus is the same virus that causes

chickenpox. A person who had had chickenpox is at

risk for herpes zoster because the virus lies dormant

in the nerve cell and can reactivate later in life.

• Herpes zoster can occur at any age, but it is most

common among people 50 years of age and older.

• People who have medical conditions or take medications

that suppress their immune system are at increased

risk for herpes zoster.

What are the symptoms?

• Painful, itchy tingling skin and rash with blisters.
• Rash is usually limited to a small area on one side of

the body, usually on the trunk or face, and lasts for

2 to 4 weeks.

• Symptoms can include a general feeling of being

unwell, headache, chills.

How is herpes zoster diagnosed?

• Your doctor will diagnose herpes zoster after performing
a physical examination and analyzing your

symptoms. Sometimes laboratory tests are performed

to confirm the diagnosis.

• Your doctor may consult with a specialist who has

special knowledge of diagnosing and treating complications

of herpes zoster.

How is it treated?

• Three orally administered antiviral drugs are approved
in the United States for treatment of herpes

zoster in healthy patients: famciclovir, valacyclovir,

and acyclovir.

• Treatment is shown to reduce the duration of pain

and accelerate the healing of the rash.

• Early treatment may reduce the risk for complications.

What are the complications?

• The main complication is pain called postherpetic
neuralgia that lasts after the rash heals.

• Postherpetic neuralgia causes severe skin sensitivity,

called allodynia, which is described as a burning or

sharp pain or itchiness in the area where the herpes

zoster rash appeared. It can sometimes be severe

enough that it disrupts sleep and makes everyday

activities difficult.

• Herpes zoster can also cause other serious complications,

including vision loss; ear pain; and inflammation

of the spinal cord, which causes weakness in

legs and arms and back pain.

Can herpes zoster be prevented?

• A live vaccine to prevent herpes zoster is available.
• The Advisory Committee on Immunization Practices

recommends a dose for most adults


60 years of agewho have a good immune system.
• Without vaccination, approximately one third of

healthy adults have an episode of herpes zoster

during their lifetime; risk increases with age.

• The herpes zoster vaccination also prevents postherpetic



For More Information

Information on herpes zoster, available in pamphlet form from
the American Academy of Dermatology.

Information on varicella vaccination and herpes zoster
vaccination from the Centers for Disease Control and


Information on herpes zoster from the National Institute of
Neurological Disorders and Stroke.


Real-World Effectiveness of Herpes Zoster Vaccine

The HZ vaccine was as effective in the community as it was in controlled trials.

In the original study of the efficacy of herpes zoster (HZ) vaccine, vaccination was associated with 51% fewer HZ cases (JW Gen Med Jun 14 2005). To assess the vaccine’s real-world effectiveness, researchers conducted a retrospective cohort study using data from a large prepaid health plan. Nearly 76,000 vaccinated patients were age-matched with 227,000 unvaccinated patients (age, ≥60; all immunocompetent). At baseline, vaccinated patients had slightly fewer emergency department visits, hospitalizations, and chronic disease diagnoses.

During a mean follow-up of 1.6 years, HZ incidence in vaccinated and unvaccinated enrollees was 6.4 and 13.0 per 1000 person-years, respectively. An adjusted analysis showed an overall 55% lower HZ incidence for vaccinated patients, with roughly similar results across all age groups. Risk for ophthalmic HZ was lower by 63%, and risk for hospitalization for HZ was lower by 65%. The estimated 3-year risk was about 2.0% for vaccinated patients and 3.4% for unvaccinated patients — a 1.4% absolute risk reduction.

Comment: According to these findings, 1 case of HZ would be prevented during 3 years of follow-up for every 70 people vaccinated. Vaccinated patients of all ages (including those 80 or older) and those with chronic diseases benefited, which suggests that older and less-healthy patients should not be denied vaccination. The benefit in lower incidence of more-severe HZ infections was particularly impressive.

Thomas L. Schwenk, MD

Published in Journal Watch General Medicine February 1, 2011


Tseng HF et al. Herpes zoster vaccine in older adults and the risk of subsequent herpes zoster disease. JAMA 2011 Jan 12; 305:160. (

Recurrent Shingles Is More Common Than You Might Think

Shingles recurred in 6% of patients during 8 years of follow-up.

Conventional wisdom holds that recurrent shingles (herpes zoster) is exceedingly rare among immunocompetent people. To determine whether this belief is valid, Mayo Clinic researchers analyzed the medical records of all residents of Olmsted County, Minnesota. In a previous publication, the researchers reported that 1669 people had developed shingles from 1996 through 2001 (JW Gen Med Nov 15 2007). Now, they report the incidence of shingles recurrence in the same population, during average follow-up of nearly 8 years.

Ninety-five people had recurrences; 87 had one recurrence, and 8 had more than one. The 8-year recurrence rate was 6.2%. This incidence was similar to the expected incidence for a first episode in this population, according to data from the authors’ previous study. Most recurrences occurred in immunocompetent people.

Comment: This study suggests that immunocompetent people with histories of shingles remain susceptible to recurrent episodes; risk for recurrence is surprisingly high — similar to the background incidence for a first episode. Thus, recommendations to offer shingles vaccine to people with histories of shingles are reasonable.

Allan S. Brett, MD

Published in Journal Watch General Medicine February 17, 2011


Yawn BP et al. Herpes zoster recurrences more frequent than previously reported. Mayo Clin Proc 2011 Feb; 86:88. (

So if you have had shingles, you can get it again.  I’m going to get the vaccine when I turn sixty.  I hope it is available by then.  It is on backorder now and has been periodically since it first came out.  It is also expensive.  Retail is about $250.00.  Most doctors can’t bill Medicare patients for it since it is covered on the prescription part of Medicare, Part D.   Pharmacies can bill Group D, but doctors offices can’t.  That’s why you doctor might give you a prescription for it and suggest that you get it at your local pharmacy.

Real-World Effectiveness of Herpes Zoster Vaccine

The HZ vaccine was as effective in the community as it was in controlled trials.

In the original study of the efficacy of herpes zoster (HZ) vaccine, vaccination was associated with 51% fewer HZ cases (JW Gen Med Jun 14 2005). To assess the vaccine’s real-world effectiveness, researchers conducted a retrospective cohort study using data from a large prepaid health plan. Nearly 76,000 vaccinated patients were age-matched with 227,000 unvaccinated patients (age, ≥60; all immunocompetent). At baseline, vaccinated patients had slightly fewer emergency department visits, hospitalizations, and chronic disease diagnoses.

During a mean follow-up of 1.6 years, HZ incidence in vaccinated and unvaccinated enrollees was 6.4 and 13.0 per 1000 person-years, respectively. An adjusted analysis showed an overall 55% lower HZ incidence for vaccinated patients, with roughly similar results across all age groups. Risk for ophthalmic HZ was lower by 63%, and risk for hospitalization for HZ was lower by 65%. The estimated 3-year risk was about 2.0% for vaccinated patients and 3.4% for unvaccinated patients — a 1.4% absolute risk reduction.

Comment: According to these findings, 1 case of HZ would be prevented during 3 years of follow-up for every 70 people vaccinated. Vaccinated patients of all ages (including those 80 or older) and those with chronic diseases benefited, which suggests that older and less-healthy patients should not be denied vaccination. The benefit in lower incidence of more-severe HZ infections was particularly impressive.

Thomas L. Schwenk, MD

Published in Journal Watch General Medicine February 1, 2011


Tseng HF et al. Herpes zoster vaccine in older adults and the risk of subsequent herpes zoster disease. JAMA 2011 Jan 12; 305:160. (


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Zinc and the Common Cold

Monday, March 7, 2011 // Uncategorized

Sometimes we awaken with pain and irritation in the back of our throats and know that we are coming down with a cold. Denial sets in and we try to convince ourselves that it is an allergy, but we know in our heart of hearts that we are getting sick. What can we do? There has been evidence over the years that zinc lozenges, if taken early might shorten the duration of the illness. Blinded studies which involve half of the participants using zinc and half placebo have been difficult to perform since the zinc users often guess that they are not taking placebo due to the metallic taste of zinc and the nausea that it may cause.
This is  an analysis of the studies done to date and it suggests that zinc may help.  There is a “Plain Language Summary” at the end which contains the key points.

[Intervention Review]
Zinc for the common cold

Meenu Singh1, Rashmi R Das1

1Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Contact address: Meenu Singh, Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh, 160012, India. [email protected]

Editorial group: Cochrane Acute Respiratory Infections Group.
Publication status and date: New search for studies and content updated (conclusions changed), published in Issue 2, 2011.
Review content assessed as up-to-date: 31 May 2010.

Citation: Singh M, Das RR. Zinc for the common cold. Cochrane Database of Systematic Reviews 2011, Issue 2. Art. No.: CD001364. DOI: 10.1002/14651858.CD001364.pub3.

Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.


The common cold is one of the most widespread illnesses and is a leading cause of visits to the doctor and absenteeism from school and work. Trials conducted since 1984 investigating the role of zinc for the common cold symptoms have had mixed results. Inadequate treatment masking and reduced bioavailability of zinc from some formulations have been cited as influencing results.

To assess the effect of zinc on common cold symptoms.

Search strategy
We searched CENTRAL (2010, Issue 2) which contains the Acute Respiratory Infections Group’s Specialised Register, MEDLINE (1966 to May week 3, 2010) and EMBASE (1974 to June 2010).

Selection criteria
Randomised, double-blind, placebo-controlled trials using zinc for at least five consecutive days to treat, or for at least five months to prevent the common cold.

Data collection and analysis
Two review authors independently extracted data and assessed trial quality.

Main results
We included 13 therapeutic trials (966 participants) and two preventive trials (394 participants). Intake of zinc is associated with a significant reduction in the duration (standardized mean difference (SMD) -0.97; 95% confidence interval (CI) -1.56 to -0.38) (P = 0.001), and severity of common cold symptoms (SMD -0.39; 95% CI -0.77 to -0.02) (P = 0.04). There was a significant difference between the zinc and control group for the proportion of participants symptomatic after seven days of treatment (OR 0.45; 95% CI 0.2 to 1.00) (P = 0.05). The incidence rate ratio (IRR) of developing a cold (IRR 0.64; 95% CI 0.47 to 0.88) (P = 0.006), school absence (P = 0.0003) and prescription of antibiotics (P < 0.00001) was lower in the zinc group. Overall adverse events (OR 1.59; 95% CI 0.97 to 2.58) (P = 0.06), bad taste (OR 2.64; 95% CI 1.91 to 3.64) (P < 0.00001) and nausea (OR 2.15; 95% CI 1.44 to 3.23) (P = 0.002) were higher in the zinc group.

Authors’ conclusions
Zinc administered within 24 hours of onset of symptoms reduces the duration and severity of the common cold in healthy people. When supplemented for at least five months, it reduces cold incidence, school absenteeism and prescription of antibiotics in children. There is potential for zinc lozenges to produce side effects. In view of this and the differences in study populations, dosages, formulations and duration of treatment, it is difficult to make firm recommendations about the dose, formulation and duration that should be used.


Plain language summary

Zinc for the common cold
The common cold is often caused by the rhinovirus. It is one of the most widespread illnesses and is a leading cause of visits to the doctor and absenteeism from school and work. Complications of the common cold include otitis media (middle ear infection), sinusitis and exacerbations of reactive airway diseases. There is no proven treatment for the common cold. However, a medication that is even partially effective in the treatment and prevention of the common cold could markedly reduce morbidity and economic losses due to this illness.

Zinc inhibits rhinoviral replication and has been tested in trials for treatment of the common cold. This review identified 15 randomized controlled trials, enrolling 1360 participants of all age groups, comparing zinc with placebo (no zinc). We found that zinc (lozenges or syrup) is beneficial in reducing the duration and severity of the common cold in healthy people, when taken within 24 hours of onset of symptoms. People taking zinc are also less likely to have persistence of their cold symptoms beyond seven days of treatment. Zinc supplementation for at least five months reduces incidence, school absenteeism and prescription of antibiotics for children with the common cold. People taking zinc lozenges (not syrup or tablet form) are more likely to experience adverse events, including bad taste and nausea. As there are no studies in participants in whom common cold symptoms might be troublesome (for example, those with underlying chronic illness, immunodeficiency, asthma, etc.), the use of zinc currently cannot be recommended for them. Given the variability in the populations studied (no studies from low- or middle-income countries), dose, formulation and duration of zinc used in the included studies, more research is needed to address these variabilities and determine the optimal duration of treatment as well as the dosage and formulations of zinc that will produce clinical benefits without increasing adverse effects, before making a general recommendation for zinc in treatment of the common cold.


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The Blog is Back! Farewell to the Family Doctor

Friday, March 4, 2011 // Uncategorized

It’s hard to believe that it has been a month without blogging.  My four year old laptop kept having meltdowns and multiple attempts to repair it were futile.  I was also unable to transfer old documents to the new computer.  I hope to be catching up with some articles that have been blogworthy.  The following article was sent to me by a patient.  It’s from Smart Money.

SmartMoney Magazine by Angie C. Marek (Author Archive)

Say Farewell to the Family Doctor


On tourist maps, it might get eclipsed by the nearby Abraham Lincoln Presidential Library. But St. John’s Hospital, a tan, 11-story building, is beginning to cast a long shadow in Springfield, Ill. For several years most of the physicians in this town of 120,000 have been split into teams like kids in a summer-camp color war: SIU HealthCare and The Springfield Clinic, huge medical groups employing 450 doctors between them, have dominated the market for years. But recently, the Franciscan nuns and executives behind St. John’s have been trying to put together their own dream team and have bought up some of the few independent medical practices left in this pocket of the Midwest.

The effort is all being laid out in a cramped off-site conference room, where Kelly Ford and a dozen other executives huddle in a buzz of conversation, plotting the next steps in the expansion of Hospital Sisters Health System Medical Group, the network St. John’s belongs to. A mosaic of pastel pink, yellow and blue Post-it notes covers one wall, each inscribed with an item from what looks like the world’s longest medical shopping list (“Order lab coats/business cards”; “Update insurance contracts”). It adds up to a lot of work for executives like Ford, the director of medical-staff affairs for Hospital Sisters. But the mood in the room is upbeat, and with good reason. In less than two years, the group has grown from just a handful of executives to become a squad of almost 200 doctors and nurse practitioners, recruiting the likes of a pulmonologist from Joliet, Ill., and an internist with hundreds of patients at a big, independent practice across town. “We like to think of ourselves as a fast-moving start-up,” says Ford.

hosp-maternity-The University of Washington is one of a few fast-growing hospital groups in the Seattle area. Frustrated consumers have raised objections about facility fees added to their bills by the expanding hospital chains; in some cases, those fees raised the cost by 65% or more. (The University declined to comment.)

Remember the solo family doctor? In places like Springfield, it has become increasingly likely that she’s collecting a paycheck from a large regional hospital—and practicing medicine according to the hospital’s strict playbook. The experience in Springfield is just a needle prick compared with what’s going on nationwide. At least one in six doctors—more than 150,000 nationwide—now works as an employee of a hospital system. And with about half of recent medical school graduates deciding to work for hospitals and many established doctors looking to unload their practices amid the tough economic climate, what was a trickle of change has turned into a torrent. Jim Pizzo, a Chicago-area hospital consultant, says the blistering pace of these mergers is leading some colleagues to joke that there are two types of physicians today: “Those employed by hospitals and those about to be.”

Whether they wear suits or scrubs, many medical pros think they’re doing the right thing. Hospital executives say they’re adapting to the rapid evolution of the health care business, while physicians, fed up with running businesses during the recession, are drawn to the safety of a salary and regular hours. What’s less clear is how the fever to buy up local doctors’ offices will affect the paper-gowned patients caught in the middle, with many saying they’ve already seen costs rise or treatment choices dwindle. Consumer advocates say the demise of the neighborhood doctor could turn out to be as big a change for medicine as anything happening at the national level with health care reform. “The story of how well these collaborations will actually work, day after day, hasn’t been written yet,” says Roland Goertz, president of the American Academy of Family Physicians.

Ruth Taylor, a 44-year-old woman in Bozeman, Mont., started seeing Robert Hathaway as her doctor during college, and she stuck with him through everything from routine blood tests to a kidney transplant. Taylor, a professional nurse with warm blue eyes, describes Hathaway as a “classic small-town doctor” who knew all his patients by name and socialized with them at local basketball games; he was accessible and thorough—even catching a health problem of hers that other doctors had missed. But after Hathaway sold his practice to the local hospital, Taylor says, things began to sour. She was more likely to be assigned to see the physician assistant rather than Hathaway himself. And when she went in for a comprehensive physical (also run by the assistant) in late 2008, she was charged $360, more than double what she’d paid for a workup in previous years. Her insurance covered very little of the higher tab; now, fearful of the cost, Taylor is putting off a mammogram. “When a nurse is skipping out on care she knows she needs,” Taylor says, “you know there are problems.”

Stories like Taylor’s aren’t uncommon in Bozeman, a funky, college-kid and retiree paradise surrounded by soaring mountains. Bozeman Deaconess Hospital sits high on a hill outside town, cross-country ski trails circling it like lassos. Five years ago Deaconess, the lone hospital here, didn’t own any medical practices. Since then it has gone on such a buying binge that more than half the doctors in town are on its payroll. Hathaway says the arrangement was eventually a godsend for him, letting him avoid the evening ritual of wondering whether his office could eke out enough funds to pay its overhead, and he disputes the notion that he saw his patients less. He acknowledges, however, that rising costs for patients were a troubling side effect. “It was the one thing I lost control of,” Hathaway says wistfully.

Gordon Davidson, chief financial officer at Bozeman Deaconess, says that some price increases have been related to Medicare billing rules; he also says that the hospital’s pricing has helped keep doctors from leaving Bozeman. While this isn’t the first time that hospitals have tried to buy up doctors’ offices, Boze-man’s merger drama sheds some light on why the trend is picking up again now. Davidson says that Deaconess first started buying practices when cash-strapped doctors turned to the hospital for help; they did so largely because of Medicare, whose payments have been criticized by doctors for not keeping up with medical inflation. With the 2010 health care reform law aiming to trim $500 billion from projected Medicare spending levels, many doctors’ economic anxiety is increasing.

hosp-stress-tesAurora is one of a few health systems that provide most of the health care in Milwaukee. According to independent research, insurers pay doctors here about double what they pay for the same care in Miami or Los Angeles, where large health groups aren’t as prominent. Aurora says the system ultimately saves money by coordinating care.

But hospital executives also believe that buying doctors’ practices could yield a big payday, thanks to a different provision in the health care law. The law will encourage doctors and hospitals to share some payments when treating each patient; as collaborative teams, they could earn bonuses for holding down costs and meeting quality markers. “The real question for everyone is how that pie—that money—is going to get split up,” Goertz says; hospitals think they’ll have the upper hand if they employ the doctors that they’re sharing their banana crème with. And that’s touched off a flurry of mergers everywhere—from Seattle to Roanoke, Va.

Hospitals are also scrambling to get a bigger share of one of the most lucrative arenas of medicine: outpatient surgeries. These options have become popular with patients because they’re often cheaper and faster than hospital surgeries and boast lower infection rates (and often, better parking). Timothy Eckels, vice president for government relations at Hospital Sisters in Springfield, says the outpatient-care trend is one factor that jump-started his institution’s acquisition boom: “We really could see the writing on the wall.” One recent study by health care consultancy Sg2 predicted demand for outpatient surgeries will grow by 22 percent from 2010 to 2019, while growth for hospital-based surgeries will remain flat; another study showed profit margins at outpatient centers are five or six times as high as at hospitals.

Now that the acquisition spree is in full swing, some experts worry that price increases could become the dominant narrative for patients. When hospitals run medical practices, federal law allows them to add substantial “facility fees” to patients’ bills to cover overhead expenses. The new bosses also often rip equipment like X-ray machines and MRIs out of the physician’s office, preferring to have patients get those tests from radiologists at the hospital. That, too, can cost patients. A consumer with a high-deductible Aetna plan, for instance, would pay up to $1,400 for an MRI of her back at the University Medical Center at Princeton, N.J., according to data that the insurer makes available to its members. The same scan would cost about a third as much at nearby Radiology Affiliates of New Jersey, a nonhospital facility. Based on a review of insurance databases and state regulatory records, that’s a fairly typical price gap. (Barry Rabner, president and CEO of the Princeton system, says the hospital’s fees cover expenses like 24-hour staffing and caring for uninsured patients.)

Price increases also have the potential to bleed outward—affecting not only the patients of the absorbed doctor, but also the cost of health care citywide. That’s because when hospitals sit down at the bargaining table with insurers, they’re almost always able to negotiate higher payment rates for their big groups of doctors than a lone physician with little bargaining power. Fast-growing hospital systems, including Hospital Sisters and Bozeman Deaconess, say that their growth will eventually make care more efficient and bring costs back down, since they’ll be able to cut back on unnecessary care and duplicate tests. But Robert Berenson, a fellow with the Urban Institute, a think tank, says the new relationship sets up a vicious cycle: Hospitals become emboldened to ask for 60 or 75 percent price increases one year, and then insurers have to step up premiums to cover costs. “Unless something major changes in how we pay for care,” Berenson says, “this could be the Achilles’ heel of our health care system.

hosp-sleep-1This eight-hospital chain has recently gotten involved in contract tangles with major insurers in the area over its attempts to negotiate higher fees. A hospital spokesperson attributed the sleep-study discrepancy to the higher overall costs of impatient care; the hospital declined to comment further.

For some patients, there may be an even bigger headache that comes from all of this consolidation—potentially much less choice in which doctors they see. By their own admission, most hospitals are eager to keep patient referrals under the same corporate umbrella, to save on costs and share medical records but also to boost revenue. The hospitals say they wouldn’t force an internist, for example, to refer a patient with heart problems to their own cardiologists, but critics say there’s certainly financial pressure. Under a little-noticed regulation that took effect in 2007, hospitals are allowed to pay doctors less if they don’t do enough internal referrals.

Doctors in Bozeman and Springfield who granted interviews said they didn’t feel pressure to be “team players” with referrals. But some of those who’ve left large health systems tell a different story, including Mark Callenberger, an orthopedist in Merritt Island, Fla. Callenberger says that the hospital group where he used to work urged him to direct more patients to the MRI machine owned by the hospital. The doctor preferred a more advanced machine at a private practice that he says offered clearer pictures. But after he ignored the recommendations, Callenberger says, the hospital told his office manager to schedule patients at the hospital’s MRI anyway, leaving him to perform surgery using “crummy images.” (The hospital declined to comment on Callenberger’s case but says its doctors can use whatever facilities they choose.) Patients may never know about these power struggles, because doctors aren’t required to disclose how they choose specialists. And while patients who ask can always see a specialist outside the network, in practice few are likely to challenge their doctors’ judgment, says Bruce A. Johnson, a Denver health care lawyer. “Face it, when we’re really sick,” says Johnson, “if the doctor tells us to jump off a roof, we’ll probably consider doing it.”

Sometimes the hospital and its doctor jump ship on the patient. As hospital groups get more clout and demand more money in negotiations with insurers, some employers and insurers are now showing a willingness to ax them out of their networks. When Kaiser Permanente went through contract negotiations for 2010, it couldn’t reach an agreement with one hospital-owned, 400-doctor network in the Atlanta area, so it dropped them. For Stephannie Owen, a 42-year-old mother of two, that meant losing access to all her family’s doctors. Owen, who was being treated for suspected breast cancer, says her primary-care doctor and breast-care clinic refused to keep seeing her, fearful that she’d be unable to pay her higher, out-of-network bills. “It was like they cut ties altogether,” she says. “I was really upset and scared.” Kaiser Permanente says it opened more clinics in the Atlanta area so consumers could see Kaiser physicians instead, but for Owen, that created some awkward moments. At one point, she says, she wound up being treated in an office in a strip mall.

As more patients face such disruptions, regulators are taking notice. In October, the Federal Trade Commission and the Department of Health and Human Services met with doctors, insurers and other health officials to discuss the referral and pricing problems that could arise from “accountable-care organizations”— those new groups of hospitals and doctors that will share financial incentives. The Federal Trade Commission will offer guidelines on what’s permissible by midyear. But hospitals are already lobbying for accountable-care groups to be exempt from antitrust and antifraud rules, even as they scoop up more and more medical practices. Under current regulations, officials in Washington must green-light all mergers involving companies valued at more than $63 million. But by buying up tiny medical practices one at a time, critics say, hospitals stay below the threshold and avoid getting much attention. And by the time regulators settle on more-formal legal guidelines, those mergers may be hard to undo, says Cory Capps, a Washington economist specializing in health care antitrust issues.

With their expansion a sensitive topic, many hospitals have kept a low profile, declining to discuss their plans and encouraging their doctors to do the same. But in Springfield, the Hospital Sisters system is willing to give us a long, if somewhat stage-managed, tour. A brisk young executive who manages PR is glued to our side as we visit the office of Michael Nenaber, a primary-care doctor who made the switch a year ago. After he signed on, Hospital Sisters quickly moved Nenaber to this new facility. Outside, we find a giant blue sign that identifies the clinic as St. John’s Health Center: Prairie Crossing—without mentioning Nenaber’s name. Inside, the office is gleaming new, with a TV playing the History Channel in one corner of the waiting area and a crucifix in another. “I’d follow Dr. Nenaber anywhere,” says Hazel Jenne, a 90-year-old patient waiting for her husband to be called in for an appointment. In a few months Jenne will get to test that theory again. Across the street a green and white construction trailer and a torn-up plot mark the clinic where Nenaber will be moving in March. Designed by the same architect, the PR manager tells us, it’ll be a lot like this office—”but bigger!”

hosp-allergy-1Sutter Health, which recently absorbed a 900-doctor practice in San Francisco, holds considerable bargaining power: One study found that a stay at a Sutter hospital costs 37% more than the state average. A spokesperson says Sutter’s prices reflect “other obligations and commitments,” like building facilities to withstand earthquakes.

It’s clear that transitions like these are sometimes rocky. Last spring Hospital Sisters tried to shift all of its Springfield medical offices to electronic medical records simultaneously. But there wasn’t enough tech support to deal with all the problems physicians ran into on day one, and wait times spiked at the system’s walk-in locations. Nenaber, a soft-spoken 64-year-old with wire-rim glasses, sounds acquiescent about the situation. “We’re getting the hang of these things,” he says slowly, sitting at his desk overlooking a gas station and a strip-mall parking lot. But his practice is still waiting for its electronic payoff: While other Hospital Sisters’ doctors enthusiastically show off the iPads and iPhones they can use to access and share patient files, Nenaber has a sign tacked to the back of each exam room door urging visitors to “be patient” while he upgrades technology.

At Hospital Sisters, the role model everyone wants to emulate is the Advocate Health Care System in Chicago, a four-hour drive north of here on Interstate 55. That 13-hospital behemoth has been buying doctors’ practices for more than a decade, and today it says its patients are healthier, thanks in part to efforts to get doctors to follow uniform guidelines when treating common ailments. Frank Mikell, chief physician executive for Hospital Sisters, says standardization can “make the patient experience dramatically better” through collaboration and a plethora of checklists. Executives here are also hoping to push the needle further—standardizing everything from how long patients wait on hold to the ease of parking at the doctor’s office (valets, luxury-restaurant style, are one solution under consideration).

Still, Mikell acknowledges, “doctors don’t want follow-the-directions, cookbook medicine.” And for many physicians, the idea of following new rules triggers a much larger unease at giving up their independence—a feeling of loss, both for the businesses they built and for their patients. Back in Bozeman, Blair Erb, the sole cardiologist in town, is a picture of resignation as he prepares to sign a contract with Deaconess. “I feel defeated,” Erb says, looking around at the office furniture he and his wife, Liz, chose from a catalog years ago. The weathered ranchers and bundled-up women that come through his door mostly express disbelief when they hear that this frank-talking Tennessee native will sell his practice. His staffers say they’re not looking forward to the questions the hospital’s medical records system will soon prompt them to ask patients. (Do you wear a bike helmet regularly? Do you have a smoke detector?) “We’ll try to retain as much professional independence as possible,” Erb says, gazing at the hospital building, whose bulk he can see through his window. “But the fact of the matter is, we’ll have a new master.”

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