Recently several patients have asked me the question "Doc, how much time does it really take to be a physician?" The answer depends on your type of specialty. Below is a response to this that I hope will help others understand how much time and training is involved in becoming a Family Physician.

The road to becoming a licensed, board certified physician is a long and hard but worth the work in the end. Physicians spend the equivalent of 20 years of full-time work just learning how to be a physician. This sounds like an incredible claim but after evaluation it is seen to be true.

First, one must earn a bachelor’s degree from an accredited four year college. This takes about four years or 6,400 hours of work (4 years x 40 wks/yr x 40 hrs/wk = 6,400 hours). In order to be a competitive student one must study more than this. This usually includes performing volunteer work and research but this is a hard number to quantify and so I won’t count it here. After college future a student must attend medical school. Medical students spend about 80 hours per week for 48 weeks each year studying, training and clerking which amounts to 15,360 hours over four years. After medical school, physicians must complete a post-graduate training program of some short which is known as a residency. Residents work long hours, weekends, nights and holidays. Most approach the legal work hour limit of 80 hrs/wk for 50 weeks each year. Many residents exceed 80 hrs/wk studying and doing research in addition to their clinical responsibilities. During my training (before the limitations to the time a resident could work) I was working between 100-120 hours per week in my intern year, and 80-100 hours per week during my second and third years of residency.

While in medical school student are required to take and pass Part I and II the United States Medical Licensing Exam (USMLE©). Part III is taken after the intern year. Specialty board testing is then taken after completion of the Residency. For example, to become board certified in Family Medicine you must graduate from medical school, pass all 3 USMLEs, complete a 3-year Family Medicine residency and pass the board exam. A board certified Family Physician will spend about 34,000 hours training. A board certified Thoracic Surgeon one must graduate from medical school, pass all 3 USMLEs, complete a 5-year General Surgery residency, take the specialty board for General Surgery, complete a 2-year thoracic surgery fellowship and pass the Thoracic Surgery board exams. A board-certified Thoracic Surgeon will spend about 49,760 hours training. The shortest residency training programs are 3 years long and include the primary care specialties of Internal Medicine, Family Medicine and Pediatrics.

The long hours don’t necessarily end after residency but after completing this training the hours don’t seem that long. In 2007, physicians from over 20 specialties were asked how many hours per week they generally work – the average was 59.6 hours per week. So even after physicians finish their 40,000 hours of training they continue to work long hours, but in order to maintain and grow your medical skills and expertise, this is necessary.

The dedication that is required to finish all of this shows in the quality of physicians practicing in the U.S. No other country in the world (that I know of) has such a strenuous and demanding physician training program.

Over the past several decades there has been a movement in the U.S. to increase the awareness of concern over the side effects of vaccines. This has resulted in a decrease in vaccination rates and an increase in public concern over vaccine safety. The resulting “antivaccine” movement and public awareness campaigns have resulted in a generalized public fear of vaccines such as the Measles/Mumps/Rubella and Influenza vaccines. The following information summarizes briefly a history of this movement and ends with data in favor of vaccination.

In 1982 a documentary called “DPT: Vaccine Roulette” aired that attributed childhood epilepsy and mental retardation to the pertussis vaccine. The result of this was the mobilization of a group called Dissatisfied Parents Together and through its lobbying efforts congressional hearings occurred to assess vaccine safety. A slew of lawsuits occurred shortly thereafter and due to the costs of litigation most of the vaccine makers of this particular vaccine went out of business. At the same time the costs of the vaccine went from about $0.19 in 1980 per shot to over $12 in 1986 to cover the legal expenses that had ensued. Another inadvertent effect of the newly increased legal costs of the vaccine business was the number of manufacerors of the OPV/MMR/DPT fell from 3 to 1,6 to 1, and 8 to 1 respectively. In 2006 a research article was published by Berkovic that showed the majority of children who were purportedly harmed by the DPT vaccine in fact had a genetic defect (SCN1A mutation) that caused their seizures. This article never received any publicity and most physicians are not even aware of it. To this date there are significant concerns about the DPT's safety despite this study and information to the contrary.

The National Vaccine Information center claims that the infectious diseases we once had have been replaced by chronic diseases caused by the vaccines that eliminated those diseases. This group claims that the Hib Vaccine causes diabetes, pneumococcal vaccine causes seizures, the HPV vaccine causes chronic fatigue syndrome and the hepatitis B vaccine causes sudden infant death syndrome. This information has been disseminated through various media outlets and is commonly found on the internet which is the most common single outlet for medical information.

The legal requirements for getting vaccinated in the U.S. dates back to an outbreak of small pox in Boston in 1905. During this epidemic 200 residents died and the city placed a $5 fine on any resident of the city who refused to get vaccinated. Since then it has become commonplace to require childhood vaccines in order to prevent communicable diseases.

The logical question to all of this is what have we seen happen in local communities where people voluntarily refuse to have their children vaccinated. In 1972 there was an outbreak of polio in a Christian Science school in Greenwich, CN (at that time almost none of the students were vaccinated due to the religious convictions of their parents). Eleven of 128 students were paralyzed (8.5%). Of note, the epidemic did not spread to the vaccinated local community. The incidence of such outbreaks has increased in recent decades. In 2008 about 140 contracted measles in California, this outbreak was started by a single unvaccinated child who visited Switzerland. Over the last several years there have been several outbreaks of pertussis in Chicago and several other major cities. These are but a few of the current examples.

It is easy to forget that during our grandparents childhoods’ polio, meals, meningitis were all common illnesses and many children were disabled or died from these diseases. In 1900 there were 21,064 cases of smallpox, in 1920 469,924 cases of measles and 147,991 of diphtheria. In 1922 there were 107,473 cases of pertussis. In the 1950’s there were an average of 16,000 cases of polio annually. Prior to the implementation of the Hib vaccine in 1987 there were 20,000 cases of invasive disease annually. To put this impact into perspective, smallpox in now eradicated from the U.S., there were only 152 cases of polio from 1980-1999. In 2008 there were only 131 cases of measles and in 2001 there were 17 deaths from pertussis. It is easy to see from these numbers that the reduction is disease has been dramatic yet the movement against such common vaccines as the flu vaccine and TdAP is still alive and strong. Since we no longer see these devastating diseases, we have forgotten their impact and now are debating rare and questionable side effects. When we talk about the adverse events from vaccines we usually use numbers ranging from 1 in 500,000 to 1 in 1.2 million. So even if there is a negative impact it is extremely rare.

For a comparison chart of diseases from the prevaccine era vs. today please visit www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/G/impact-of-vaccines.pdf
The reduction is disease is staggering.

If you want more information about this you can reference the CDC website at www.cdc.gov/mmwr/preview/mmwrhtml/00056803.htm

As always, if you have additional questions or concerns please discuss this with your physician.

THE FIVE MOST INTERESTING THINGS I READ THIS PAST YEAR.
I am routinely asked by individuals what the newest literature and research is showing and how it is affecting the practice of medicine. Every year I review this information to see if or how it will affect my practice. Sometimes I learn interesting things, sometimes I learn that what I recommended last year I won't recommend this year and sometimes I think I'll wait until more information is out there before I start making any medical decisions based on what I've heard or read.

The following is a brief summary of last year's "Top Things." Some are boring, some are interesting and some may surprise you but all are limited to the current medical literature available and liable to change in the future. Hence the 'practice' of medicine.

1) The Mediterranean diet has been correlated with a decrease in heart disease, a possible decrease in cancer rates and increase in life expectancy. This diet includes high quality fruits, vegetables, olive oil and nuts. The correlation is thought to be due to the relative high quantity of antioxidants found in these foods. This makes sense, especially in light of a statement made by the head of the Harvard School of public health that 80% of heart disease can be attributed to diet and exercise.

2) A recent study of 8000 women given vitamin C plus vitamin E and/or vitamin A showed no health improvements after 8 years. Another study of 1400 men given vitamin C and/or vitamin E showed no decrease in prostate cancer risk. Another of selenium in men showed no decrease in cancer rates after 5 years but a slight increase in type II diabetes. A review of the Women's Health Initiative (study of 161,000 women over 8 years) also showed no benefit to vitamin supplementation. So am I going to stop taking my vitamins? No. The problem with these studies is that they extract out single elements (vitamins) and then study them in complex systems (humans) without regard to how vitamins exist in nature. Some medical groups are now no longer recommending certain vitamin supplementation. I'm going to wait for more info on this one prior to changing my practice.

3)We have been recommending aspirin use for almost a decade. A study in 2009 showed that patients over 80 years of age probably shouldn't be taking aspirin due to the risks (i.e.- bleeding, ulcers, ect . . .) being greater than the benefits. It also showed that men are different from women. Aspirin works better for stroke prevention in women over 55 years of age and better for heart attack prevention in men over 45 years of age. However in both populations there are significant risks of GI bleeding and bleeding strokes. Each individuals risk factors should be considered prior to a blanket recommendation of taking aspirin. You should ask your doctor about this based on your personal risk factors.

4) Currently obesity related diseases account for 10% of all health care expenditures. A recent study at an elementary school showed that giving kids access to water fountains increased their water consumption by only 220ml daily but decreased their risk for obesity from 6% to 3.8% (a 37% reduction!). That is just from drinking a little more water every day!

Other interesting facts: 78% of patients who are successful at losing weight eat breakfast daily, 62% watched less than 10 hours of TV a week and 90% exercised an hour a day. Eating until you are full if you're a man or eating fast if you are a women doubles your risk for being overweight.

So drink more water, watch less TV, exercise daily, eat breakfast, eat slowly and don't eat until your full.

5) This is the most interesting and most controversial of the five. An editorial from the Cancer Journal for Clinicians published some results from their recent prostate cancer screening trial. What they showed was 1400 men must undergo prostate screening and 48 men must undergo diagnosis and treatment to prevent one death from prostate cancer. Screening doubled the rate of diagnosis for prostate cancer but does not significantly decrease the risk of death. They recommended against mass screening and recommended shared decision-making between patients and physicians based on informed consent. This is similar to the current recommendation by the American Academy of Family Physicians.

I am routinely asked by my patients what new medical advances will greatly improve their health. With the news, media and internet we are bombarded with new and exciting medical breakthroughs that are touted as the wave of the future. The reality is that these new technologies don't always pan out and what has been tried and true still has the most impact on your health. Below I am going to discuss the 'top ten' prevention priorities for your health in 2010. These 'top ten' will have the most impact on your immediate health in regards to morbidity and mortality (i.e.-increase your quality of life and life expectancy). You will be surprised what makes the list and what doesn't. After reading them you will see that none of them are high-tech or expensive.

#1&2- Heart Disease Prevention and Smoking.
Heart disease is the single biggest killer in our country, one out of five persons living in our country will die from heart disease and many more will have some heart related complications. The single biggest player in this is smoking. If you add up all the health benefits from all other health screening recommendations (i.e.-mammograms, cholesterol checks, colonoscopies, blood pressure checks, ect . . .)
they do not equal the benefit to your health if you quit smoking. The next biggest 'bang for your buck' in heart disease prevention is aspirin. If you are a male over 55 years old or a high risk patient, your risk for a heart attack can be decreased 25% just by taking a baby aspirin daily. It's amazing that a 3 cent pill can be more effective that any of the newer medications that we hear about daily. Blood pressure control, cholesterol control, weight loss, ect . . . are other important factors in consider in reducing your risk for heart disease.

#3-Colorectal Cancer Screening.
Colon cancer is the 3rd most common cancer killer in the U.S. It can be treated easily and early with a simple colonoscopy. The current recommendations are to begin screening in the general population at 50. If you have a family history of polyps or colorectal cancer you should begin sooner. How soon depends on the age and relation of your family members. You should discuss this with your doctor.

#4-Hypertension Screening.
It's amazing that the 4th most effective preventative health screening tool is a simple blood pressure check. If you develop high blood pressure and it is detected early and treated, you can literally add years to your life and prevent the many complications of high blood pressure. The problem with high blood pressure is that most people feel fine when they have it and so don't feel they need to treat it until their 1st event (i.e.-heart attack, stroke) but treating early makes a huge difference. The current recommendation is to screen for high blood pressure every two years.

#5- Immunizations.
It interesting that one of the top preventative health innovations in the last two centuries (the other being antibiotics) would cause so much controversy. Currently for the appropriate patients the American College of Immunization Practices recommends an annual flu shot and a pneumonia vaccine at age 65. Over 30,000 people die annually from influenza and its complications and 70% of invasive pneumonia can be prevented by the Pneumovax. There are other vaccines for adults but these two have the most evidence for disease prevention in this age range.

#6- Alcohol Screening and Counseling.
About 75,000 people die annually from Alcohol related events. These include liver disease, accidents, abuse, suicide and drowning. Screening for alcohol abuse with four simple questions (CAGE questionnaire) in the doctor's office can detect most people who abuse alcohol and interventions have been shown to decrease the morbidity associated with it.

#7- Vision Screening.
This is recommended for patients 65 years or older. Five percent of this population are blind and 50% have vision problems. Decreased visual acuity is associated with a high risk of falling, motor vehicle accidents and accidents with mediations. This can be easily evaluated in your doctor's office using a Snellen Chart.

#8- Cervical Cancer Screening.
Since the implementation of the PAP smear in the 1960's, the incidence of death from cervical cancer has decreased 10 fold. In the 1960's cervical cancer was the most common cause of death in middle age women, it is still a common cause of death in the rest of the world. This disease can be detected during a routine gynecologic exam in your doctor's office. The current recommendation for 2010 is to start screening at age 21 or three years after the start of sexual activity and to continue screening every two years.

#9- Cholesterol Screening.
The best current evidence suggests that cholesterol screening is most effective in the age ranges of >34 for men and >44 for women. If caught earlier, dietary and lifestyle modification are usually the 1st line of treatment but after the above ages you should be screened with the intent to treat if you are found to have an elevated cholesterol.

#10- Breast and Colon Cancer Screening.
Breast cancer is the 2nd most common cancer in women (behind lung cancer) and colon cancer is the 3rd most common cancer in both men and women. Both can be easily detected and treated if caught early. Colon cancer screening starts at 50 years old for men and women unless you have additional risk factors. Breast cancer screening in the U.S. starts at age 40. For more information about breast cancer screening please see my last post about it.

So there you have it. If you have any questions about the above or haven't had them done, call you doctor to schedule a routine physical. During this exam the above can be addressed and scheduled

Screening mammograms in the U.S. have reduced the death rates of women ages 50-74 from breast cancer by over 67%. Yet there is insufficient data to know if the same benefits occur in women less than 50 or over 75. In the U.S. most women begin their breast cancer screening at 40 but in England they don't start until 50 and then it is only every other year. So which is best, does it even matter?

Several recent reviews have been done and the US Preventative Health Task Force attempted to tackle this issue. What they found was that if we continue to screen women annually until they are 79 we get an additional 8% reduction in breast cancer deaths and if we lower the age of screening to 40 we get an additional 3% reduction. So this sounds good, right? Well, to save one life of a women in her 40's one thousand mammograms would need to be performed. At an average cost of $102/mammogram, it would cost $102,000 to save that one life (though the person whose life was saved thinks it was worth it). Also for every 1000 women screened annually at the ages of 40-69, 2250 false positives would occur (that's when you have something show up on mammogram, have additional testing and it turns out to be nothing). Because of these costs involved, the number of false positives and relatively little (though significant) gain in cancer detection, the recommendation changed to every other year screening starting at 50. That is when all the controversy began. How young is too young to screen and how old is too old?

A recent review article showed that the death rate of women aged 75 to 84 who didn't receive screening mammograms was two times higher than those who did. With our aging population, it will take years before we will know the true risks/benefits of screening in this age range. A similar delimma is encountered with younger women.

I've had two women this past year in whom breast cancer was found in their 40's, one at 42 and one at 45. I joked with them that saving their lives was not 'cost effective.' They chuckled but then realized that's exactly what the new recommendations were implying. Medicine is quickly becoming more of a business and less the practice of a healing art. National recommendations address population health not individual health. What about the woman who has smoked 20+ years, or who never breast fed, or who started her periods at an early age, who's mom had breast cancer? This is where a physician with years of training and experience can help each individual decide what is best for them and not apply the cookie cutter, one size fits all model of health care that is becoming the new norm. We create potential patient risks when we take general information and attempt to apply it to all women without taking into account their individual risks.

All of that is to say, Ask your doctor what's right for you. Only someone who knows your history, current health status, concerns, risk factors, ect. . . . can help you decide which screening regimen is right for you.

We've known about the need for vitamin D for centuries. Rickets caused by vitamin D deficiency started to occur in the 18th and 19th centuries as Europe and the U.S. became industrialized and its prevalence greatly declined in the U.S. after vitamin D milk fortification began in the 1930's. It is only recently that we've learned vitamin D does more than help build strong bones and teeth.

Vitamin D receptors are on almost every cell line in your body and it is easily obtained by going into the sun. Enough full body sun exposure to make your skin slightly red is enough to make 20,000 units of vitamin D. To put that into perspective, a half gallon of milk contains 800 units and the average OTC vitamin D supplement contains 1000 units. With the industrialization of America, the warnings about sun exposure related skin cancer and the usage of sun screens, vitamin D deficiency has become an epidemic. Forty eight percent of adolescent girls in Maine are vitamin D deficient prior to the summer and 20% remain so by its end. Thirty two percent of Boston medical students are deficient and the medical literature has vitamin D deficiency ranging from 30-80% with the highest deficiencies in inner city African American populations in the north east.
Ok, vitamin D deficiency is real. Should you care? Is this just the next vitamin craze or fad?

Vitamin D deficiency as been linked in children to increased incidence of respiratory tract infections and eczema. In Finland in the 1960s a group of newborns were given 2000 units daily for one year and followed for 30 years, they had a huge reduction in Type I diabetes. Maternal deficiency as been associated with increased rates of asthma in their children. In adults it has been linked to increased rates of colon, lung and breast cancer as well as multiple sclerosis. In the elderly it's been associates with osteoporosis and increased rates of falling. The problem with most research is that the studies are based on population studies (epidemiologic and observational studies) and so may be prone to bias. However drug companies are not going to spend millions to research an OTC vitamin supplement and the NIH has yet to do randomized controlled trials on it.

Right now we don't know for sure how much daily vitamin D someone needs. In Canada it's recommended for infants to take 800 units daily. For adults in the U.S. most experts recommend 1000 units daily but some data suggests that may not be enough. The biggest question then is how much is too much. Dr. Sidbury (professor of dermatology at the University of Washington) thinks that less than 10,000 units a day is "probably safe." In the above Finish study the newborns took 1000 units daily for one year and no toxicity was found. What we definitely know is the current U.S. RDA of 400 units a day is woefully inadequate.

A safe recommendation would be for an adult to take 1000-2000 units daily and for a child to take 400-800 units daily.

Yes, your mom was right and deep down on the inside we all knew it. However, Americans love the latest and greatest thing and this has translated into a love of fad diets. In the 70’s Dr. Atkins wrote his now famous book “Dr. Atkins Diet Revolution” and in the 90’s the low fat craze translated into high carbohydrate diets. What we have been learning since the beginning of the new millennium is a radical change from what has been taught.

Walter Willett of the Harvard School of Public Health once stated that 80% of heart disease and 70% of most cancers can be prevented by diet and exercise alone. Dr. Alger-Mayer of Albany Medical College stated this past year that 72% of deaths from heart disease are due to lifestyle and diet. Multiple studies have been done on nutrient and vitamin supplementation (i.e. - Vitamins A/E/C) but results have never shown a definite link between supplements and health. To date there only two supplements that I can say from a medical perspective will make you live longer and healthier: Vitamin D and Fish Oil. So why is that?

What we have been learning is that we need the nutrients found in whole foods, not processed foods which have their nutrition removed then resupplemented. For example, white breads and white rice have the most nutritional part removed. The wheat germ and husk of the kernel are processesed, and then the remainder is ground into flour. The processed flour is bleached and then has a few essential nutrients (e.g., folic acid and vitamin B12) added back in. Pasteurization of milk destroys its vitamin D and A so these are later added back in (of note in Europe vitamin D isn’t added back and currently they are having an epidemic of vitamin D deficiency and osteoporosis much greater than ours).

A recent study was done with two groups: one received 210g a week of refined carbs and the other 210g of unprocessed carbs. Both groups had the same caloric intake and vitamin counts but the refined carb group showed a increase in the expression of 62 genes fount in fat tissues that are associated with stress responses; increased insulin, increased cortisol and an increased in fat build up in the abdominal area. We have also recently learned about Rho-iso-acids (e.g., Acai Berries) and polyphenols (e.g., Resveratrol), two non-nutrient metabolic regulators that have been associated with cancer fighting, gene preservation and antioxidant effects. These only exist in whole, unprocessed foods, working in concert with vitamins and minerals to decrease cell inflammation, improve immune response and help in cell repair at the level of DNA expression.

So what should you do? You should eat whole, unprocessed foods. The good news is that these can be bought at almost any local farmers market or even at the grocery store Whole Foods. This includes fresh fruits, vegetables, nuts, legumes, roots, organic whole milk, free range chicken and grass fed beef to list a few.

Skin cancer is the most common cancer in the U.S where 1 in 8 people will get skin cancer in their lifetime and 1 in 50 will get melanoma. This makes skin protection important for everyone.

The best sunscreens are those that block both UVA and UVB light from damaging your skin and will last all day without reapplying. Think of UVA as the “aging” rays and UVB as the “burning” rays. Most sunscreens protect against UVB rays, while not really protecting against UVA. This explains why often people would spend a day in the sun and not burn, but notice the freckles on their skin got darker or they became more tan/brown. Most commercial sunscreens today use chemicals that absorb UVA or UVB but then over a few hours they break down and no longer work. They also often only block UVA2 and not UVA1 which also can affect your skin. The best sun protectants are sunblocks that contain titanium dioxide or zinc oxide. These block both UVA1/UVA2 and UVB and, if applied correctly and you do not sweat or get into water, they can last all day. SPF measures only UVB protection, which causes sunburns, but does not reflect UVA protection. UVA exposure has been associated with melanoma and other kinds of skin cancer. A SPF of “2” blocks 50% of UVB radiation, a SPF of “10” blocks 90%, SPF 15 blocks 93% and SPF 30 blocks 97%. So you can see that once you get to a SPF of 15 you don't get much additional sunburn protection. You should look for a product with excellent UVA protection.

When applying sunscreens you should use one ounce to cover your entire body. The average person uses less than half that amount and so loses some benefit from the lotion. You should also limit sun exposure during the times of day when the amount of UV radiation intensity is the highest, typically between 10 a.m. and 3 p.m. For a map of up-to-date UV intensity for your area, you can visit the EPA site http://www.epa.gov/sunwise/uvindex.html and type in your zip code. Also if you would like to research this more a great resource is http://www.ewg.org/2010sunscreen/best-beach-sport-sunscreens/

There are hundreds of sun protection products on the market, but most need to be applied every 90 minutes and even more often if you are sweating or in the water. One good product available at your local pharmacy is Neutrogena sunscreen with Helioplex. It does not, however, contain zinc or titanium dioxide to maximize your UVA protection. One of the best overall products on the market is Blue Lizard, which is an Australian grade product. Unfortunately, it can be more difficult to obtain as most stores don't carry it and it can often only be purchased online. They have an array of products containing micronized zinc oxide and titanium dioxide, which is easy on sensitive skin and absorbs in so that it doesn't leave a residue on your skin. In other words, you won’t look like you put the white stuff from a lifeguard’s nose all over your body. There are several other products which are also good, and I will try to update this post as I become aware of anything that is readily available for purchase.