The Pharmaceutical Journal
Vol 277 No 7419 p374
23 September 2006

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Problems in US primary care medicine more
Finding a remedy for the knotty problem of an invasive alien giant more
The higher up the mountain the more difficult becomes survival more

Problems in US primary care medicine

A contribution to the 31 August issue of the New England Journal of Medicine, from Thomas Bodenheimer of the University of California, raises the problem of the survival of primary care medicine in the US in the face of changing patient expectations. The article follows a recent warning from the American College of Physicians that “primary care, the backbone of the nation’s health care system, is at grave risk of collapse”.

Most patients prefer to seek initial care from a primary care physician rather than a specialist. But it appears that patients are increasingly showing dissatisfaction with the care they are offered and the difficulty experienced in achieving timely access to a physician.

Most patients suffering from chronic conditions have insufficient time to understand what their physician has advised during the interview. Excessive demands contribute to longer waiting times and inadequate care for the individual.

At the same time, primary care physicians are frustrated that the knowledge and skills that they are expected to exhibit tend to exceed the time and effort available. In such circumstances their best care may be impossible to achieve.

As medical students increasingly choose not to enter the field of primary care, many doctors who offer primary care services are finding their workload increasing. They also believe they are inadequately rewarded for their work. In 2004 the median income of a primary care doctor in the US was half that of a specialist, and the new systems of payment are believed to have widened the gap.

No evidence is to be seen of any serious attempt to improve the situation. Payments on a fee-for-service basis reward quantity rather than quality and introduce an element of haste in disposing of a problem. Legislators seem unaware of the growing dissatisfaction, and an educational campaign is called for, argues Dr Bodenheimer.

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Finding a remedy for the knotty problem of an invasive alien giant

I was intrigued recently by a report in my local newspaper regarding a vexatious problem on my doorstep in respect of an imported invasive garden weed.

In the early 1800s there was a craze for cultivating an ornamental plant called Japanese knotweed (Fallopia japonica). This is a tall and slender plant with tassels of minute white blossoms. So popular did Japanese knotweed become that, finding the British climate agreeable, it made its escape from gardens in the 1880s and became quite common on waste ground adjacent to streams. Unfortunately, when it found its way into the verges of watercourses, it produced dense thickets some three meters high. Throughout Europe it has become a major environmental problem.

Eradication of the plant is difficult and an additional challenge is presented by its ability to grow through built structures. Causing the weed to spread has been made an offence under the Wildlife and Countryside Act 1981 and the disposal of weed materials or contaminated soil is subject to control under the Waste Regulations.

In West Cornwall, where a mild climate, an abundance of minor watercourses and areas of uncultivated land resulting from former mining operations favoured its development in the valleys, the threat to the native flora and fauna was regarded seriously. A group of conservation bodies led by the National Trust has now undertaken to eradicate Japanese knotweed from a seven-mile stretch along a river.

Previous work in an adjacent valley has indicated that the remedy is practicable. But it is by no means simple to achieve. The technique is to hack down the stems and inject each hollow stump with a systemic herbicide such as glyphosate. Nothing less drastic will suffice. Although laborious, the technique is more effective than using foliar sprays and has the advantage of not affecting any plants other than the target species.

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The higher up the mountain the more difficult becomes survival

According to Andrew Sutherland of Oxford, writing in the BMJ of 26 August, it used to be thought physiologically impossible to climb Mount Everest with or without supplementary oxygen. It was not until 1953 that Edmund Hillary and Tenzing Norgay showed that with oxygen the summit could be achieved, and in 1978 Reinhold Messner and Peter Habelar managed it without oxygen.

Logic would indicate that the Everest climb would subsequently have ceased to be deadly, but experience has not confirmed this. Between 1980 and 2002, one death attended every 10 successful ascents, and this 15 climbers have died on the mountain.It is calculated that anyone making the summit has a one in 20 chance of not descending alive.

The main reasons for individuals dying during an ascent of Everest are injuries and exhaustion, but many also die from altitude-related illness — high altitude cerebral oedema and pulmonary oedema. Details are always difficult to confirm, but it is likely that altitude illness may also contribute to deaths from injuries and exhaustion. At altitudes of above 7,000m, exhaustion may often frustrate people’s attempts at descent.

Andrew Sutherland takes the view that few climbers deliberately overstretch their physical powers but many of them overestimate their ability to adapt to altitude. Without experience of ascents beyond Camp 3 (8300m), climbers may be unable to assess their ability to descend. When cerebral oedema sets in, the sense of reality is distorted and hallucinations distract the climber. It may be that it is the disorientation that persuades climbers that they can reach the top and then descend successfully. When pulmonary and cerebral oedema have appeared there will be limited time in which to adapt and descend.

In general, a mountain ascent time should not exceed 60 to 90 minutes per 100m. At a slower pace than this the chances of survival are much reduced. “However, with the summit in sight, this advice is too often ignored.”

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