[ed. note: Michael Jorrin, who I call Doc Gumshoe, is a longtime medical writer (not a doctor) who writes for us about medicine and health a couple times a month. He has agreed to our trading and disclosure restrictions, but does not generally write directly about investment ideas. His ideas, thoughts and words are his own, and you can see all his past pieces here.]
Yesterday, the check-engine light in my Jeep came on. This, annoyingly, happens from time to time even when the vehicle is running just fine. As we all know, when the check-engine light starts blinking on and off when you’re driving, it’s a sign that something is really wrong and we shouldn’t obliviously keep going until disaster strikes, but even if it’s not blinking, we should get it checked out at “our earliest convenience,” which, for me, was this afternoon.
I drove to the establishment of the auto mechanics who have been taking care of our vehicles for about twenty years, and the owner plugged the little computer in, switched off the check-engine light, and told me that he would attend to it if came back on. This has happened quite a few times before, and the cause can be as trivial as the gas cap not being screwed on tightly. Or as non-trivial as a leak in the fuel line.
As I drove home, it struck me that having a reliable long-time auto mechanic who knows you and knows your car is something like having a long-time primary care physician who knows you and knows your state of health. And perhaps most important, “and cares about you.”
Here’s an example.
I had the same excellent primary care physician for 22 years, and, in addition to relying on his care for such ailments as afflicted me from time to time, I always had my annual complete physical with him. The routine was well established. I would pop into his office about a week before the physical and permit his nurse to draw blood for the complete blood count (CBC). Then I would return for the physical, and he would poke and press and peer according to the usual ritual. After the physical part of the physical, I would put my clothes back on and go into his office where he would review the results.
About 17 years ago, here’s what happened. First, he went over the results of the examination and the blood work – all excellent, he was glad to report. Except! One little detail in my CBC was disturbing, that being my PSA results. (PSA is prostate-specific antigen, in case you forgot – an early indicator of the possibility that a cancerous tumor is growing in the prostate gland.)
The PSA assay had been part of my regular CBC for nearly ten years at that point, and it had reliably been down in the “no worries” range. But then it had started to go up, quite slowly. And this particular year it had moved from the “no worries” range into the “worries” range, although perhaps only mild worries. It had gone from about 2.2 to 2.8 to 3.5 to 4.2 in a time span of just over three years.
My excellent doctor looked me in the eye and said, “Michael, I know you know everything. But I want you to go to a urologist and have this checked out. I’m not letting you out of my office unless you promise me you’ll do it.”
We discussed that a bit. I said that I had thought that a PSA of 10 or higher was the marker that predicted prostate cancer. He nodded in semi-agreement. “That’s right. But you don’t want to wait until you definitely have prostate cancer. The uptick in your PSA has been accelerating. If that had been your first PSA test in life, and it had been 4.2, I would have said, ‘let’s give it a year and see where it goes.’ PSA levels can fluctuate. But yours have been going up – not fluctuating.”
We talked some more. He told me that the needle biopsy that the urologist would perform was quick and essentially painless – a shot of local anaesthetic would deal with it. I might have a bit of bleeding, but that was about it. He recommended a urologist he knew very well – in fact, he was the urologist’s primary care physician.
So I agreed to go.
Indeed, the needle biopsy was nothing much. But a few days later I received the dreaded telephone call. A cancerous tumor was growing in my prostate gland, and I had to come in to the urologist’s office to discuss options.
Before the office visit, I did a bit of sleuthing on the subject (as is my wont!) and got some data on the outcomes of the available options, which included open prostatectomy, robotic prostatectomy, radioactive seed implantation, and external radiation beam treatment. I did not much like what I learned. The least invasive was the external beam procedure, but if that did not totally eliminate the cancerous mass, surgical follow-up was problematic because the area around the prostate gland would be so messed up that it would be difficult to tell healthy tissue from tissue invaded by cancer cells. According to a Mayo Clinic paper (which by that time was about seven years old) the best long-term outcomes were in patients who had had open prostatectomy.
(I should add here that when the prostate cancer is confined to the prostate gland itself, treatment is generally highly successful. But if cancer cells have escaped the prostate gland – metastasized – the outcomes are much more doubtful and treatment is much, much more difficult. And, incidentally, since PSA testing has declined, based on the dubious recommendations of the US Preventive Services Task Force, the incidence of metastatic prostate cancer has increased, almost certainly because in many untested men, the cancer is not detected until it has progressed to metastasis.)
Open prostatectomy, in fact, is exactly what the urologist recommended. (That urologist, whom I have now been seeing annually for 16 years, is now chief of urology at a major New York City hospital). The surgery took place in April 2002. I spent three nights in the hospital, came home feeling pretty spry, and have had a PSA in the undetectable range ever since. So I pronounce the whole experience a success.
Regarding the importance of having a primary care physician, consider this: prior to having settled on that particular doctor (and having stuck with him until he retired), I used to have annual complete physicals at a large New York City medical center that specialized in preventive care. No doubt, the examination was quite thorough, but never did anyone at the clinic communicate with me in person – no real feedback, no advice. I would get a very complete written report on the results of all the tests. Presumably, I was supposed to share that with my primary care physician. But I didn’t really have a primary care physician, so those results fell into a vacuum.
What prompted me launch into this topic was a piece in the New Yorker (01/21/07) by Atul Gawande, entitled “Tell Me Where It Hurts.” Atul Gawande is a surgeon, practicing at Brigham and Women’s Hospital in Boston. He is on the faculty in the Department of Health Policy and Management at the Harvard School of Public Health, and a professor of surgery at the Harvard Medical School. He is a regular contributor to the New Yorker and has written several books, including The Checklist Manifesto, which argues for checklists in hospitals, particularly relating to the essentials in a surgical procedure, and the very large impact checklists have on reducing errors in those procedures.
The piece by Gawande is mostly about incremental medicine, which essentially means persistently searching for and trying a succession of interventions to address stubborn medical problems. He described the case of a 57-year-old man who had been suffering from unimaginably severe migraine headaches for 40 years and had gone from one to another to yet another form of treatment without success, until he landed at a headache center in Massachusetts where a physician patiently worked with him, trying a range of different options, until, after four years, one particular regimen started to work. When Gawande met this man, he had not had a severe migraine for a year.
Gawande contrasted the spectacular, and highly-paid work by brilliant surgeons and interventional cardiologists with the more routine, and much less well-paid work done by primary care physicians (PCPs). He was discussing this with an associate when he “made the mistake of saying that (he, Gawande) had more opportunities to make a clear difference in people’s lives.” His associate, an internist, was having none of that and pointed him to studies showing that people living in states that have higher ratios of primary-care physicians have lower rates of general mortality, infant mortality, and mortality from specific conditions such as cardiac disease and strokes; also that individuals whose chief health-care providers are PCPs have lower five-year mortality rates than the general population overall.
A bit of sleuthing for the substantiation of the assertions by that associate of Gawande’s led me to a hefty paper by Barbara Starfield, Leiyou Shi, and James Macinko entitled “Contribution of Primary Care to Health Systems and Health,” published in Milbank Quarterly (2005;83:457-502; PMID 16202000).
The Starfield magnum opus
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Barbara Starfield (1932 – 2011), a physician and health services researcher, was University Distinguished Professor and professor of health policy and pediatrics at Johns Hopkins University. She turns out to have been among the most fervent and persuasive advocates for the essential nature of primary care in health care. She was the author of six books and 56 journal papers on the subject. Based on that, one could conclude that her views on the subject are perhaps somewhat biased, but we should look at the data she