Industry Insights Archives • William Kehoe, MD

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Specialdocs Featured in Popular Boston-Area Publication

The benefits and growing mainstream appeal of concierge medicine were recently explored in the prestigious Massachusetts consumer publication, Wellesley-Weston Magazine, featuring interviews with Specialdocs and our physician-clients. Writer Keri Bancroft shared compelling answers in her article titled “Concierge Medicine: Is it Right for You?” with insights from Specialdocs CEO Terry Bauer, Special Docs Alan Glaser, MD and Alyson Kelley-Hedgepeth, MD, highlighted below.

Concierge doctors have been around since the late ’90s. At first, having one was considered an option only for the super-rich, since these practices had retainers that were astronomical. But over the years that has changed as concierge medicine has become more affordable and mainstream. Demand has also increased during the past year as people look for reassurance and more personalized care during the COVID-19 pandemic.

It’s vital to go well beyond a patient’s immediate symptoms and consider every psychological, social, & emotional factor underlying the condition. In my new practice, there is time for patients to share their whole story, which allows us to explore the root cause of their illness. Only then can the real healing process begin. -Dr. Alan Glaser of Wellesley Primary Care Medicine

Specialdocs CEO Terry Bauer explained that for doctors, the concierge model lets them “focus on the art of medicine, not cranking patients through.” Additionally, concierge doctors are not beholden to the payers but to the patients, don’t go home exhausted, have more time to study and learn to be better physicians, and may earn more money. Concierge medicine has also become more available to a larger segment of patients. Dr. Alyson Kelley-Hedgepeth, a concierge cardiologist in the Lown Cardiovascular Group in Chestnut Hill, notes that the cost of concierge medicine has gone down so much that it is now equivalent to going out to eat a couple times a month.

Terry Bauer also detailed the value of membership in a concierge medicine practice for patients: “A concierge agreement pays for ‘noncovered services,’ which means you pay for your concierge physician to dramatically limit his or her number of patients to ensure direct availability and adequate time for each patient,” said Bauer. “This means same-day appointments, significantly longer and comprehensive appointments, and having your physician’s personal cell phone number.” He noted that during the pandemic, concierge practices across the country experienced an increase in patient enrollments as more people sought reassuring, personalized care.

Concierge medicine is becoming more affordable and more mainstream. Not only does it benefit the patient, but the doctor too. Doctors with a concierge practice can practice their vision of medicine. They are not beholden to an insurance company, but to their patients. Doctors don’t go home exhausted and have more time to study and become better physicians. And for patients, the biggest benefit is a doctor who knows them and spends time with them when they need it the most. Concierge medicine is the quality health care both patients and doctors deserve.

Read the entire article here and discover why concierge medicine benefits everyone.

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An Update on the Measles Outbreak in the US

What are the newest guidelines for measles vaccinations?

Adults with no evidence of immunity should get 1 dose of MMR. Immunity is defined as documented receipt of 1 dose, or 2 doses, 4 weeks apart if high risk, of live measles virus-containing vaccine, laboratory evidence of immunity or laboratory confirmation of disease, or birthdate before 1957.
High-risk people, including healthcare personnel, international travelers and students at post-high school educational institutions, should receive 2 doses.
Persons who previously received a dose of MMR vaccine in 1963–1967 and are unsure which type of vaccine it was, or if it was an inactivated measles vaccine, should be revaccinated with either 1 (if low-risk) or 2 (if high-risk) doses of MMR vaccine. At the discretion of the state public health department, anyone exposed to measles in an outbreak setting can receive an additional dose of MMR vaccine even if they are considered complete for their age or risk status.

Why does a birthdate prior to 1957 confer immunity to measles?

People born before 1957 lived through several years of epidemic measles before the first measles vaccine was licensed in 1963. As a result, these people are very likely to have had measles disease. Surveys suggest that 95% to 98% of those born before 1957 are immune to measles. Persons born before 1957 can be presumed to be immune. However, if serologic testing indicates that the person is not immune, at least 1 dose of MMR should be administered.

Why is a second dose of MMR necessary?

Between 2% and 5% of people do not develop measles immunity after the first dose of vaccine for a variety of reasons. The second dose is to provide another chance to develop measles immunity for people who did not respond to the first dose.

Are there any situations in which more than 2 doses of MMR are recommended?

There are two circumstances when a third dose of MMR is recommended, according to ACIP.

Women of childbearing age who have received 2 doses of rubella-containing vaccine and have rubella serum IgG levels that are not clearly positive should receive 1 additional dose of MMR vaccine (maximum of 3 doses). Further testing for serologic evidence of rubella immunity is not recommended. NOTE: MMR should not be administered to a pregnant woman.
Persons previously vaccinated with 2 doses of a mumps virus–containing vaccine who are identified by public health authorities as being part of a group or population at increased risk for acquiring mumps because of an outbreak should receive a third dose of a mumps virus–containing vaccine (MMR or MMRV) to improve protection. More information is available at www.cdc.gov/mmwr/volumes/67/wr/pdfs/mm6701a7-H.pdf

Many people age 60 years and older do not have records indicating what type of measles vaccine they received as children in the early 1960s. What measles vaccine was most frequently given in that time period? That guidance would assist many older people who would prefer not to be revaccinated.

Both killed and live attenuated measles vaccines became available in 1963. Live attenuated vaccine was used more often than killed vaccine. Without a written record, it is not possible to know what type of vaccine an individual may have received.

The killed vaccine was found to be not effective and people who received it should be revaccinated with live vaccine.
Persons born during or after 1957 who received killed measles vaccine or measles vaccine of unknown type, or who cannot document having been vaccinated or having laboratory-confirmed measles disease, should receive at least 1 dose of MMR.
Some people at increased risk of exposure to measles (such as healthcare professionals and international travelers) should receive 2 doses of MMR separated by at least 4 weeks.

Do people who received MMR in the 1960s need to have their dose repeated?

Not necessarily.

People who have documentation of receiving live measles vaccine in the 1960s do not need to be revaccinated.
People who were vaccinated prior to 1968 with either inactivated (killed) measles vaccine or measles vaccine of unknown type should be revaccinated with at least one dose of live attenuated measles vaccine. This recommendation is intended to protect people who may have received killed measles vaccine which was available in the United States in 1963 through 1967 and was not effective (see above).
Persons vaccinated before 1979 with either killed mumps vaccine or mumps vaccine of unknown type who are at high risk for mumps infection (such as persons who work in a healthcare facility) should be considered for revaccination with 2 doses of MMR vaccine.

Please explain the Advisory Committee on Immunization Practices (ACIP)’s revised definition of evidence of immunity to measles, rubella, and mumps.

In the 2013 revision of its MMR vaccine recommendations, ACIP includes laboratory confirmation of disease as evidence of immunity for measles, mumps, and rubella. ACIP removed physician diagnosis of disease as evidence of immunity for measles and mumps. Physician diagnosis was previously not accepted as evidence of immunity for rubella. The decrease in measles and mumps cases over the last 30 years has made the validity of physician-diagnosed disease questionable. In addition, documenting history from physician records is not a practical option for most adults. The 2013 MMR ACIP recommendations are available at www.cdc.gov/mmwr/pdf/rr/rr6204.pdf

What can be done for unvaccinated people who have already been exposed to measles, mumps, or rubella?

The measles vaccine, given as MMR, may be effective if given within the first 3 days (72 hours) after exposure to measles. Immune globulin may be effective for as long as 6 days after exposure. Post-exposure prophylaxis with MMR vaccine does not prevent or alter the clinical severity of mumps or rubella. However, if the exposed person does not have evidence of mumps or rubella immunity they should be vaccinated since not all exposures result in infection.

Make it personal: The only way to really interpret and effectively utilize today’s conflicting health news

By Terry Bauer, CEO, Specialdocs Consultants

Eggs are bad and should be avoided assiduously by those at risk for heart disease. On second consideration, they can be eaten with impunity. But wait, now they’re back on the taboo list. This scenario has been in play dozens of times over the past few decades, as a food, drug or lifestyle choice is touted as the best way to lower the risk of cancer or heart disease, only to be reversed within months or years. From cholesterol and calories in food to blood pressure management to Vitamin D, research continues to confuse with misleading conclusions resulting from a flawed hypothesis, bad data or the study design itself. Non-medical professionals, no matter how steeped in healthcare information they may be, can’t interpret the studies with any accuracy and most importantly, apply the findings to their own personal health situation.

We all want to eat the right foods, get the right amount of exercise and make the best choices, but determining exactly what those are is more challenging than ever before. In an era of medical information overload, the need for a concierge physician’s highly personalized approach to each patient is not just essential, but potentially life altering. A research study conclusion that appears sound may provide the wrong answer for patients wrestling with their own set of individual health issues. A recent article on identifying the best diet by Dr. Eric Topol, a brilliant proponent of artificial intelligence in medicine, sums up why:

“Now the central flaw in the whole premise is becoming clear: the idea that there is one optimal diet for all people.”

In nutritional studies especially, trials are rarely randomized and controlled, the gold standard for research, but instead are largely observational and can’t prove associations are causal. Important to note is that even randomized trials cannot control for all potential variables. As we’ve seen over the years, however, even extensive and well-executed studies like the Women’s Health Initiative can lead to reversals and counter-reversals. The counter-intuitive finding that hormone therapy actually increased the risk of heart disease and breast cancer in post-menopausal women ended the routine prescribing of these drugs to prevent chronic disease, as was entirely appropriate at the time. But numerous follow-up studies that dug deeper into the unexpected results showed that hormone therapy may still be reasonable short-term to manage menopausal symptoms in younger women.

Even more recently, the decades -long prevailing wisdom regarding use of a daily low-dose aspirin to prevent heart attacks and strokes has been revised. New guidelines based on a large, randomized study no longer recommend aspirin prophylactically for healthy older adults because the risk of internal bleeding often outweighs the benefit. However, the study’s lead author cautions, the results reflect the average for a large group, and healthy older people should consult their doctors before eliminating the daily dose of aspirin.

Like so many decisions in medicine, to take or not take aspirin or hormone therapy should be made on an individual basis, with a physician who thoroughly knows your history and personal risk factors. As Dr. John Levinson, a highly regarded Boston-area cardiologist and one of our pioneering Special Docs, says: “In our modern society we are looking for rules to follow. In medicine we call them guidelines and as guidelines they are terrific but as algorithms to follow slavishly for every patient they are crazy. Organized medicine has come to understand that like everything else in life, it depends.”

This is a real challenge to accomplish in a 10-minute visit at a traditional fee for service practice or during a cursory Medicare annual wellness exam. Returning to the egg question, Dr. Levinson illuminates the dilemma: “For the vast majority of people, blood cholesterol levels have much more to do with genetic predisposition, exercise habits and body weight than to specific cholesterol consumption. However, there are plenty of exceptions. Patients with severe atherosclerosis, history of heart attack, and lipids inadequately controlled on maximum tolerated medications will need to tighten their diets, sometimes drastically. Care must be individualized. Patient, talk with your doctor. Doctor, talk with your patient.”

We believe concierge medicine offers the most viable way to make that happen. Every one of the exceptional physicians in the Specialdocs network is dedicated to making a real difference in their patients’ lives by providing time to listen and advise on new and evolving trends as well as tried and true treatment plans, and being readily available for visits on a same- or next-day basis. If you’re considering a change to this rewarding practice model, we welcome your call.

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Health Studies: Expert Insight

Understanding Health Studies

Why Today’s Health News Often Becomes Tomorrow’s Retractions

We’ve all seen it played out hundreds of times, as a drug, food or habit is trumpeted as the way to lower the risk of cancer or heart disease only to be walked back the next month in another study. The reasons can be diverse, including a flawed hypothesis, bad data or misleading conclusions, but at the center is the study design itself. A longitudinal trial may yield very different findings from an observational one, while the gold standard – a randomized controlled trial (RCT) – can be extremely costly and difficult to design. The resulting patchwork of research requires professional analysis and a wait-and-see approach until confirmation is received via follow-up studies. We share some expert insights to help you view new health studies with both a healthy skepticism and the realization that some of the most important medical breakthroughs of recent years have been discovered in just this way.

Fast Facts on Health Studies

1,400

Number of scientific papers retracted each year
Sources: Vaccine Journal August 2018, Centers for Disease Control, Harvard Health

50%

Percentage of scientific studies confirmed in follow-up studies
Source: Healthy Aging Project, University of Colorado, Boulder

Researchers agree that a randomized, controlled trial is the best way to learn about the world. In a drug study, for instance, a population is randomly divided into groups who receive the drug and those who don’t. If properly controlled and designed, any difference in outcomes between the groups can be measured and credibly attributed to the effects of the treatment. The methodology is highly valued in evidence-based medicine, proving that associations are causal, and not just by chance. The approach has powerful real-world applications, as seen in the Women’s Health Initiative (WHI), one of the nation’s largest-ever health projects.

Begun in 1993, with more than 161,000 women enrolled, the randomized, controlled clinical trial was designed to test the efficacy of long-term hormone therapy in preventing heart disease, hip fractures and other diseases in post-menopausal women over 60 years old on average. Previous observational studies had strongly suggested the preventive benefits of hormone therapy, and it was routinely recommended for women years after menopause. What happened next was stunning.

In 2002, the trial was halted three years earlier than planned as evidence mounted that the estrogen plus progestin therapy significantly raised a woman’s chances of developing cardiovascular disease, stroke and breast cancer. Millions of women stopped taking hormone therapy, and the trial has since been credited with reducing the incidence of breast cancer by 15,000-20,000 cases each year since the results were made public. Numerous follow-up studies were conducted to dig deeper into the surprising data, and while they showed that hormone therapy may still be reasonable short-term to manage menopausal symptoms in younger women, it is no longer routinely recommended years after menopause to prevent chronic disease in women.

Similarly, Vitamin E supplements, once thought to reduce risk of heart disease, were found to not have beneficial properties and actually may increase the risk of heart disease in higher doses. Consequently, the American Heart Association now advises that the best source of Vitamin E is foods, not supplements.

The biggest takeaway from both initiatives: the critical need for randomized, controlled trials to prove that associations between an intervention and a disease are causally related.

Nutrition health studies have also come under increased scrutiny, especially with the recent revelation of erroneous data published by high-profile researcher Dr. Brian Wansink, founder of the Food and Brand Lab at Cornell University. Numerous papers have been retracted as the lab’s propensity for data dredging – running exhaustive analyses on data sets to cherry pick interesting and media-friendly findings – came to light. This practice, seen somewhat frequently in food and nutrition research, may be part of why contradictory headlines seem to be the norm.

As the adage goes, data can be tortured until it says what the researcher wants to hear. That’s why your physician will always be the best source for making sense of the tremendous amount of health data released each day…so please ask!

Testing by Design

The most commonly used research models include:

Randomized controlled trial (RCT): carefully planned experiments like the WHI that introduce a treatment or exposure to study its effect on real patients; includes methodologies that reduce the potential for bias and allow for comparison between intervention groups and control groups.

Observational studies: researchers observe the effect of a risk factor, diagnostic test, treatment or other intervention without trying to change who is or isn’t exposed to it. Includes cohort studies, which compare any group of people linked in some way (e.g. by birth year); and longitudinal studies in which data is gathered for the same subjects repeatedly over years or even decades. An example is the Framingham Heart Study, now in its third generation, which has provided most of our current consensus regarding the effects of diet, exercise and medications on heart disease.

Case control study: compares exposure of people with an existing health problem to a control group without the issue, seeking to identify factors or exposures associated with the illness. This is less reliable than RCTs or observational studies because causality is not proven by a statistical relationship.

Meta-analysis:  a thorough examination of numerous valid studies on a topic, which uses statistical methodology to combine and report the results of multiple studies as one large study. This is cost-effective but not as accurate as RCTs as the individual studies were not designed identically.

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