Johns Hopkins Magazine - November 1994 Issue

Health & Medicine

Surplus of specialists, etc.

Glut of specialty care doctors predicted

By the year 2000, the United States will have a surplus of 165,000 physicians, and specialty care doctors will account for most of the glut, reports Jonathan Weiner, a health policy analyst in the Hopkins School of Public Health.

Weiner determined that the United States will have 376,000 patient care specialists by 2000--60 percent more than he estimates are necessary. The number of primary care physicians, however, will be roughly in balance with what's needed, he wrote in the July 20 Journal of the American Medical Association. His study was commissioned by the Council on Graduate Medical Education, whose primary mission is to ensure the adequacy of the U.S. physician workforce.

Weiner based his conclusions on the assumptions that all Americans will be covered by health insurance and that the percentage of Americans enrolled in health maintenance organizations (HMOs) will grow to between 40 and 65 percent by 2000, from its current level of about 30 percent. Health reform proposals call for expanding HMOs. About half of the doctors employed by HMOs practice one of the three primary care fields--internal medicine, family practice, or pediatrics--as compared to approximately a third of all physicians in the United States.

The results don't mean cardiologists will walk the streets wearing "Doctor: Will Work for Food" placards. "But I think physician income will go down," says Weiner. "It will be more difficult for a specialist to have a lucrative private practice in the suburbs." Physicians may spend more time with each patient, and more specialists may shift to small cities and rural areas.

Weiner notes that since taxpayer dollars are used to subsidize a significant portion of medical education and training--$20,000 to $50,00 per year per medical student and $50,000 to $90,000 per year per resident--government may step in to cut back on the number of specialists being trained. "The role of the government is to watch out for society's well-being," even if that involves offering incentives to draw doctors into general practice, he says. Some specialists oppose that idea, however. They say that the market should dictate the physician workforce, just as it dictates other professions.

Though Johns Hopkins is widely regarded for excellence in its specialty programs, Dean Michael Johns notes that more than half of Hopkins's internal medicine residents and just under half of its pediatrics residents practice primary care following training.

He expects to continue training specialists, however. "Our role is as a pre-eminent research and specialty medicine institution. We need to continue to do that, as well as to provide a fertile place for students who want to pursue generalism. We train five ophthalmology residents per year. If we're the best in the country in ophthalmology, why should we reduce that number?" --MH

New hope for, maybe, the last socially unacceptable disorder

Did you think the talk shows had aired every human situation? That there remained no symptom so embarrassing that a person might just stay home, even from a daughter's wedding, to keep the condition secret?

Wrong. Fecal incontinence, from which at least two million Americans suffer, can be that devastating, says Hopkins physician Marvin M. Schuster. Inability to control the time and place when fecal matter or gas are expelled can lead to premature retirement, solitary living, and profound loss of self-esteem. People may give up hobbies, outings, and sex, while inability to control their bowels is the single largest reason that elderly people enter nursing homes. Some children with the problem cannot attend school.

The worst of it is, says Schuster, that much of this suffering is unnecessary. There is hope.

In Keeping Control, a new book published by the Johns Hopkins University Press and co-authored by Schuster and science writer/editor Jacqueline Wehmueller, that hope is outlined, beginning with a clear layperson's explanation of how the digestive tract works. The authors then proceed, chapter by detailed chapter, to answer all the questions a patient would ask: What is the standard examination like? What tests might be ordered? Why? What are those tests like? What can be done to help me?

What can be done varies for each patient, but may be as simple as "habit training," a variant of behavior modification that teaches the body to associate release with a particular time, like right after breakfast. Biofeedback, using a method developed by Schuster, can teach many people new control of their anal sphincters in as little as 20 minutes; success is generally permanent. Schuster considers surgery a last resort, because the scar tissue too often recreates the incontinence. Even if there's no cure, better management makes life more livable: there are pills that take the odor out of fecal matter, for instance. (No prescription needed--ask your druggist. To order the book, call 410-516-6956.)

In its first week on sale, Keeping Control sold a thousand copies, a number that pleases Wehmueller. An editor at the Hopkins Press, she really believes in this book: unable to find a co-author for Schuster, she just plunged in herself. Despite the topic's stigma, she is happy to say that national bookstores are stocking the book.

And why not? They may have learned from the success of Keeping Control's sibling, the earlier Staying Dry. That book, about urinary incontinence, took months to find its readers because Modern Maturity refused the ads, bookstores refused the books, and talk shows refused to talk. Ugh! was their reaction--until Ann Landers described the book, and five days later the Press was faced with 14 bulging sacks of mail. Even the director was opening orders. To date, Staying Dry has sold 125,000 copies.

Ann Landers, are you listening? There are two million people suffering out there. --EH

Herpes drug extends life for AIDS patients

AIDS patients who take the anti-herpes drug acyclovir along with the anti-viral drug AZT live an average of a year longer than patients taking AZT alone, reports a team of researchers from Hopkins and three other institutions.

The study involved 786 HIV-positive homosexual men who started taking AZT before developing AIDS. Of those, 488 also took the anti-herpes drug acyclovir. Many of the patients had herpes and were already using acyclovir; others took the drug to treat AIDS.

Ninety-four percent of patients who began taking acyclovir one year after developing their first symptoms of AIDS survived for two years, as compared to 86 percent of patients who used only AZT. "Acyclovir seems to add 12 months to survival time, on average," says Hopkins associate professor of epidemiology and medicine Alfred Saah, noting that some men gained two months while others gained 18. Saah directs the Multicenter AIDS Cohort Study (MACS), a long-term study of HIV infection in 5,000 homosexual men, from which the data were gathered.

Acyclovir may enhance life expectancy for AIDS patients both by directly slowing down HIV, the virus that causes AIDS, says Saah, and by hindering the replication of the herpes virus. Herpes infections appear to spur on the activity of HIV. The investigators reported their findings in the July 15 Annals of Internal Medicine. Other centers involved were the National Institutes of Health, Northwestern University, and the University of Pittsburgh. --MH

Little pitchers with sore elbows

It doesn't take a sports aficionado to see that Little League pitchers lack the grace of Nolan Ryan. But it took an orthopedic sports medicine specialist to observe precisely how their unseasoned pitching form could put them at risk of injury.

Edward McFarland, director of sports medicine at Johns Hopkins, with orthopedist C. Philip Volk, recently filmed the pitching movements of 10 Little Leaguers and 10 professional pitchers for clues that might explain a widespread injury known as "Little League elbow," a break or fragmentation in the cartilage that makes up the growth plate in the elbow. "It can hurt enough to keep a child from sleeping at night," says McFarland.

McFarland and Volk analyzed four phases of the pitch: foot contact on the ground during the pitch, rotation of the shoulder during delivery, release of the ball, and follow-through. Concludes McFarland, who presented the results in June at the convention of the American Orthopedic Society for Sports Medicine, in Palm Desert, California, "Little Leaguers get their elbows out front too much, which increases stress on the inside of the elbow."

Adults do not get Little League elbow partly because their growth plates have turned into bone. In addition, says Volk, "because professional pitchers have greater arm strength and more years of training than Little League players, they're better able to control how long their arms remain twisted during pitching." (Instead, adult pitchers risk tendonitis or torn ligaments, McFarland notes.)

To try to prevent the injury, says McFarland, "little kids shouldn't throw as frequently and as intensely as adults do." He also says that his studies may eventually help Little League coaches teach safer pitching techiques. --MH

"Green chemistry" yields new drugs

The environmental movement is taking hold in chemistry labs: In a specialty some chemists are calling "green chemistry," scientists are searching for production methods that consume fewer resources and produce less waste.

In that vein, Hopkins chemist Gary Posner developed an environmentally friendly way to synthesize analogs of the steroid vitamin D3. He has used the technique to synthesize a dozen new analogs, which show potential to be medically useful for diseases that involve excessive cell growth, such as psoriasis and cancer.

Conventional methods of synthesizing vitamin D3, says Posner, "are costly and not terribly efficient." They take about 14 steps. In general, the more steps in a chemical reaction, the more solvent is required and the more organic by-products are produced, with potential harm to the environment. In comparison, Posner's method requires just four steps. It uses an efficient chemical reaction called the Diels-Alder reaction, in which every atom in the reactants ends up in the product. (For the reaction's discovery, Diels and Alder won the Nobel Prize.) The "buzzword" for this type of reaction is "atom-economy," says graduate student Scott Bull. "The yield is excellent," adds Posner proudly, and the product is extremely pure.

Vitamin D3 is a natural steroid used by the body to control cell growth and differentiation. "There are receptors for vitamin D3 in virtually every organ," says Posner, a professor in the School of Arts and Sciences. Several drug companies are investing in research on vitamin D3 because it has been shown to inhibit cell growth in psoriasis and in cancer cell cultures, he says. Posner has demonstrated that several of his analogs inhibit the growth of cultured mouse cells. He has applied for a patent on the new class of compounds. --MH

Written by Elise Hancock and Melissa Hendricks.

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