Friday, March 18, 2011

Good Bye Primatene Mist

As reported today by the Washington Post, Primatene Mist’s days are numbered. The FDA announced today that "the only over-the-counter asthma inhaler sold in the United States will no longer be available next year as part of an international agreement to stop the use of substances that damage the environment."

This is because, similar to the old albuterol meter dose inhalers, Primatene Mist uses a CFC as a propellant which is harmful to the environment. I blogged about this previously (see FDA Announces End for CFC-Propelled Inhalers Asthma inhalers and More on Asthma Inhalers ).

However, the loss of Primatene Mist is a good thing in my opinion. Primatene Mist is epinephrine. It is a bronchodilator, which is why it relieves the symptoms of asthma. However, it is quite dangerous, especially without a prescription. First, it is not just a beta 2 agonist like albuterol which works almost exclusively on beta receptors in the lungs. It also aftects beta 1 receptors in the heart and alpha receptors in the blood vessels. The primary use of epinephrine is medicine today is to give it to patients who are a risk of immediate death in order to restart their hearts. In addition, having any bronchodilator, even albuterol, over the counter, is a bad thing. We know that increased albuterol use is associated with increased ER visits, hospitalizations and even death. But at least we can monitor albuterol use, because it must be prescribed by a physician. We have no way of knowing if a patient is taking too much Primatene mist until they are dead.

Under a physician's supervision, with a proper asthma plan and additional chronic maintenance medications for asthma, such as inhaled corticosteroids, bronchodilators can be used safely and effectively. However, over-use of these medications especially in the absence of inhaled corticosteroids is dangerous. This is why I never write an albuterol prescription with any refills. If your asthma is well controlled, one albuterol inhaler should last you a year and you shouldn't need refills. If you are refilling the albuterol more than one time in a year, by the NIH's criteria, your asthma is not under control and you may need to change to a stronger daily medication (for example, switch from Singulair to an inhaled corticosteroid or ICS, or switch from an ICS to an ICS/LABA combination).

For those patients without prescription insurance who relied on the relatively low cost of OTC Primatene mist, be advised the GSK makes a sample size of Ventolin HFA (60 inhalations) that is only $9 out of pocket (regardless of insurance) at most major retail pharmacies. This will of course require a doctor's prescrition, but I believe that is a good thing for the reasons stated above.

Thursday, March 17, 2011

2011 Residency Match NOT Good News for Primary Care

The there are currently few reports of this in the mainstream press, the AMA news announced "Residency Match sees continued growth in primary care." The American College of Physicians reports on their web site states "Residency Match Results Encouraging for Adults Needing Primary Care." Kevin Pho of KevinMD appropriately wonders whether this increase is enough to save primary care in his post "Match Day 2011: Family medicine grows, but enough to save primary care?" based on the assumption that this year's match meant good news for primary care.

Don't believe the hype.

This was not a good match for primary care or our health care system in general. These positive reports are based on the press release from the National Resident Matching Program or NRMP which is the group that runs the match. They stated that

"The number of U.S. seniors matched to family medicine positions rose by 11 percent over 2010 . Among primary care specialties, family medicine programs continued to experience the strongest growth in the number of positions filled by U.S. seniors. In this year’s Match, U.S. seniors filled nearly half of the 2,708 family medicine residency slots. Family medicine also offered 100 more positions this year.

The two other primary care specialties that increased in popularity among U.S. seniors were pediatrics and internal medicine. U.S. seniors matched to 1,768 of the 2,482 pediatric positions offered, a 3 percent increase over 2010. In internal medicine, U.S. seniors filled 2, 940 of 5,121 positions, an 8 percent increase over last year."

At first glance, this seems like good news for primary care. However, their use of statistics is misleading. They are not taking into account that there were almost 500 more US medical students in the match this year. This is equivalent to a drug company telling you that their medication reduces hearts attacks by 30% (from 50 to 35), but forgets to tell you that there were 1000 patients in each group, so that the real reduction in heart attacks is only 1.5%.
What you need to look at is the percent of US medical students that matched into that speciality and whether or not it changed from last year to this year. If you go to the NRMP web site, you can get the actual raw numbers. For Pediatrics, though more US seniors matched into Pediatric residencies (remember there was about 500 more students this year than last), the percent of US seniors matching into Pediatrics was unchanged. For Family Medicine, there was a slight bump, but compared to last year, only about 1/2 of a percent more of US seniors chose to go into Family Medicine (far less impressive than the relative increase of 11%). The real big bump was in Internal Medicine, where almost 1% more US seniors matched into Internal Medicine. However, we know from previous studies, that only 2% of seniors that choose Internal Medicine plan to go into primary care. (See here for previous post).

What is also in the NRMP press release (that some are paying less attention to)

"Dermatology, orthopaedic surgery, otolaryngology, plastic surgery, radiation oncology, thoracic surgery, and vascular surgery were the most competitive fields for applicants. At least 90 percent of those positions were filled by U.S. medical school seniors.

The number of U.S. medical school seniors in emergency medicine increased by 7 percent and grew for the sixth year in a row, as they filled 1,268 of the 1,607 first-year positions available. Anesthesiology offered 44 more positions and matched 45 more U.S. seniors who filled 671 positions of the 841 offered "

Essentially, though there are more medical students this year than last, and thus more doctors available to society when they are done with their residencies, the same low numbers of students are choosing residencies that will lead to careers in primary care. This small increase will not make up for the many patients in the US who lack a primary care physicians and certainly won't even begin to fill the gap when many of our now close to 50 million uninsured patients suddenly gain insurance under health care reform. Rather, despite the clear need for more primary care physicians, our students continue to choose the more lucrative subspecialties.

America, this is a crisis. Many of the few primary care docs we have are retiring, leaving practice, or going cash only or retainer. Our students see this and continue to choose other specialties. If something is not done to increase the value, reimbursement, and job satisfaction of our primary care doctors; we will have no one left to care for our sick and aging population. (And before you post a comment about NP's and PA's filling this gap, those students aren't going into primary care either. A surgical PA makes more money than a primary care MD).