Category: Medical Practice

There Are Three Kinds of Primary Care, Not to Be Confused With Each Other

Apr 2, 2026

By HANS DUVEFELT

(Note: Hans is rerunning some of his greatest hits. This one is from 2014 and leans right into my current and future obsession with fixing primary care-Matthew Holt)

Primary care doctors, the way things are organized in this country, perform three kinds of services. If we don’t recognize very clearly just how fundamentally different they are, we risk becoming overwhelmed, burned out, inefficient and ineffective. And, if we think about it, should we really be the ones doing all three?

SICK CARE

Historically, people called the doctor when they were sick. That service has, at least in this country, become more or less viewed as a nuisance in primary care offices. We keep a few slots open for sick people, in part because the Patient Centered Medical Home recognition process requires us to. But our clinics may worry that those slots go unfilled and lead to lost revenue.

Instead, sick people scatter toward emergency rooms with crowding, high overhead and liability driven testing excesses or to freestanding walk-in clinics that only sometimes are integrated with the primary care office but universally staffed by providers who don’t know the patient. These providers, due to staffing cost strategies, are sometimes the least experienced clinicians within their organizations, doing what I feel is the most challenging work in health care – sorting the very sick from the only moderately ill or even completely healthy but worried patients.

In the worst case scenarios, the walk-in clinic is freestanding, operating without any access to primary care or hospital records, starting from absolute scratch with every patient. Some of these clinics are well equipped, with laboratory and x-ray facilities and highly skilled staff. But some are set up in a room in the back of a drug store and staffed by a lone nurse practitioner with minimal equipment and no backup.

Because health care in this country has no master plan, this is what has emerged. If we had a national strategy for health care services, does anybody think it would look like this?

CHRONIC DISEASE MANAGEMENT

More and more people suffer from chronic diseases like diabetes, hypertension and autoimmune conditions. This is where the bulk of primary care work is done. Much of it is straightforward and predictable: Diabetics get their glycosylated hemoglobin checked every three months, hypertensives get their blood pressure logs and blood tests reviewed at certain intervals. And, sadly, much of it is ineffective. Few people lose weight, improve their blood sugars or change their lifestyles. Our visits follow the same tired routine from one time to the next – “I’ll do better this time, Doc”.

The more our country’s chronic disease burden increases, the more clinician time and effort this kind of work will consume. And the more we need to question whether there isn’t a better way to deliver chronic disease management.

Healthcare’s Quiet Dependence on the “Possimpible”

Mar 31, 2026

By GANESH ASAITHAMBI

In an episode of the sitcom How I Met Your Mother (HIMYM), Barney Stinson introduces a fictional word: possimpible. The possimpible combines “possible” and “impossible” and describes the extraordinary achievements by people who refuse to accept conventional limits. In modern healthcare, the possimpible is no longer a joke; it has quietly become an expectation.

Clinicians are expected to provide care that is safer, faster, and more compassionate despite rising administrative burdens, workforce shortages, and an increasingly complex patient population. These expectations often extend beyond what existing systems were designed to accommodate. The distance between what the system can provide and what patients need is increasingly filled by clinicians.

Picture this example at the end of a clinician’s day. A physician takes a seat to call a patient’s family. The phone conversation takes longer than expected with questions about their loved one’s prognosis and hesitancy about what to do next with fear about what is to come. The physician provides reassurance and guidance. The physician hangs up, only to find that note dictations are not complete and messages are still unread. None of this shows up as productivity, but it is needed to provide quality care. There are thousands of scenarios like this that take place every day in American health care.

These moments appear routine. However, they reflect something more consequential: healthcare has become quietly dependent on clinicians to stretch beyond the boundaries of the systems they work within.

Lauren Ranalli, Town Square Health

Mar 6, 2026

Lauren Ranalli is the VP of Patient & Community Engagement at Town Square Health, a brand new medical group setting itself up for the senior population. There have of course been a lot of attempts to create new primary care medical groups. Town Square has its roots in Oak Street but is adding immediate visits (during primary care visits) with specialists which the believe will close the care loops and provide better care. Their goal is to be efficient on staffing, use AI and then take risk. Personally I’m not sure that’s the best tactic…so Lauren and I had a good chat about their strategy, and how the heck we fix primary care in America–Matthew Holt

The Vocabulary of Survival

Feb 26, 2026

By GEORGE BEAUREGARD

From 2018 to 2022, I served as a physician executive in a large health system on Long Island. During that period, I became acquainted with the Provost and Executive VP of the New York Institute of Technology. One of the university’s divisions is the New York College of Osteopathic Medicine (NYCOM), one of the largest osteopathic medical schools in the country. I saw an opportunity to provide medical students with a high-level introduction to “population health”—something not typically offered in medical school curricula and something they would certainly be dealing with in some shape or form upon completing their residencies and fellowships. With the support of the Provost and the medical school Dean, I designed an elective course for fourth-year students at NYCOM called ‘Population Health 101’, a four-week rotation through my Population Health Management division. The course was very popular amongst the students, and my staff enjoyed having students shadow them.

More recently, an opportunity arose for me to return to NYIT and present at a NYCOM’s ‘Clinical Practice Reflections’ session, a bi-monthly assembly where patients share their experiences with health care systems with students. The CPR is not an academic lecture. Its goal is to share the nuances of real patient experiences and their perspectives in their interactions with the health care system. In doing so, NYCOM hopes to highlight the importance of a caring, empathetic physician and aspects of health care delivery that are often overlooked.

After arriving, making my way to the lecture hall, and getting familiarized with how the technology worked, I watched the medical students filing in from the rear doors of the large auditorium.

Some were wearing the short white coats that serve as the indicator of their rank in the hierarchy of medicine. Many greeted their classmates with smiles and warm embraces, suggesting that they hadn’t seen each other for a while. They looked young, energetic, relaxed, and happy.

As someone who is some forty-plus years removed from his medical school days, I felt like I needed to make a connection with this audience at the start. So, my opening remarks were along the lines of the shared experience that is the first couple of years of medical school. Like mine was back in the mid-eighties, their lives are defined by volume. The volume of information. The volume of coffee. And the volume of sheer anxiety about whether they can completely memorize the entire Krebs cycle, the origin and insertion of every muscle in the human body, the Bundle of His, Purkinje Fibers, the Renin-Angiotensin System, the optic chiasm, the corpus callosum, the Loop of Henle, and the hypothalamic-pituitary-adrenal axis. Section members in the beautiful biological symphony that is the human body.

I pointed out that they were learning the vocabulary of medicine. And the vocabulary of survival. The how.

That opening seemed to resonate with the 600-plus students, as many of them were nodding their heads in a manner that suggested “Yep. This guy had to know this stuff, too.”

Shifting Sands Part 3

Jan 28, 2026

By GEORGE BEAUREGARD

Fifteen months ago, I wrote in The Health Care Blog about the “incoming tide” of early-onset cancer.

At that time, the global rise in the incidence of early-onset cancer in younger people that had occurred over three decades had been noticed and was being monitored by researchers, scientists, and other healthcare professionals. Articles on research discoveries in this topic sporadically appeared in top medical journals such as Nature, The New England Journal of Medicine, and The Lancet.

From 2005 to 2011, some early warning articles surfaced in generalist publications in mainstream media outlets like The Wall Street Journal and The New York Times. Those stories were framed as tragic “one-offs” or medical mysteries. Following a landmark study published by the American Cancer Society (ACS) in 2017 (1), the narrative shifted from “anecdotal” to “epidemic”. In 2020, the death of actor Chadwick Boseman, who was diagnosed with colorectal cancer at the age of 43 catalyzed mainstream media reporting on the situation. Chadwick died one month before my son, Patrick, who was 32 years old. Patrick was featured in a WSJ article in January 2024.

Since then, other reputable national publications like Time magazine and The Economist, and major media news outlets have featured stories about the growing situation. Stories about it have even appeared in some popular supermarket tabloids.

Over the past year, articles about the potential causative roles of diets high in ultra-processed foods, obesity, environmental factors, sedentary lifestyle, and a gut bacterium’s genotoxin remnant mutagraph, so-called Colibactin, have appeared.

The recently released ACS report Cancer Statistics, 2026, presents a jarring “good news, bad news” dichotomy and has garnered wide attention. The good news: overall, five-year survival rates for people with cancer have increased from 50 percent to 70 percent since the mid-70s. A 40 percent increase. Certainly a cause for celebration. (Mary Lasker would be smiling.)

But a dark reality persists.

The Dartboard Toss and the Algorithm

Dec 16, 2025

By GEORGE BEAUREGARD

How A.I. could have personalized my 2005 cancer journey

I don’t think I’m in the minority of Baby Boomer physicians when it comes to my curiosity and ambivalence about the progressing application of A.I. in medicine. But that curiosity isn’t just prospective, it’s retrospective too. In 2005, I became an outlier who perhaps needed something other than the standard of care for a disease.

During the fall of 2005, I first saw a single drop of blood hit the toilet water while I was urinating in my bathroom. After hitting the water, the rose-colored bead slowly sank, twisting and contorting, dissipating like a puff of smoke. The evidence was fleeting—gone in seconds. If I were a spectator rather than the source, I might have admired its visual artistry. There was no associated pain.

A single thought ran through my mind: Did I just pee blood? I thought I had perhaps imagined it.

I was 49 years old and didn’t have what were considered risk factors for kidney or bladder cancer: smoking, obesity, advanced age, high blood pressure, or exposures to cadmium, trichloroethylene, or herbicides. But I was adopted and lacked any knowledge whatsoever about my family history. Did I have a grim genealogy? What was perhaps significant, however, was that both of my adoptive parents had developed different types of urogenital cancer. That led me to speculate that environmental factors related to materials in our house and/or the land it sat on or around it had perhaps played a role.

I tried to dismiss any concerns, but the adage “painless hematuria is cancer until proven otherwise” ran through my mind in chyron-like fashion.

The episodes continued and worsened, prompting an ultrasound, the report of which read: “…a soft tissue density is seen in the base of the bladder toward the right. While this could represent thrombus, I cannot rule out a primary mucosal lesion. The lesion measures approximately 4 X 5 cm in diameter.”

I consulted a urologist colleague, who performed a cystoscopy. His comment about what he saw: “As you know, you have a mass in your bladder. I got a very good view of it. It’s pretty angry-looking, so I suspect it’s not benign. I tried to remove as much as I could. It would’ve been pretty risky to scrape deeper and risk puncturing your bladder. I know I didn’t get all of it.” A TURBT soon followed. The pathology showed a high-grade urothelial carcinoma extensively invading the lamina propria and muscularis propria. There was multifocal lymphovascular invasion, so I probably had a more advanced subgroup than the localized SEER stage.

At that time, the relative five-year survival rate for stage II muscle-invasive bladder cancer was about 45 percent.

Overwhelmingly, bladder cancer is an age-related malignancy. So, there I was, 49 years old, with a cancer whose median age of incidence—septuagenarians— was much older than mine. A WTF moment.

One that started me thinking about how much time I had left.

So, I had cancer, but in some ways felt cautiously optimistic. I had access to Boston-based academic centers and specialist colleagues who were willing to see me quickly, and good insurance.

But getting the diagnosis was only the beginning. I saw three expert urologists, each of whom recommended a radical cystectomy, small bowel resection, and construction of an orthotopic ileal neobladder. Convergence. Certainty for me.

Let’s get moving on AI-discovered treatments

Dec 11, 2025

By STEVEN ZECOLA

Recursion Pharmaceuticals announced results today for one its AI-discovered treatments. I was pleased to see the large, sustained reduction in polyps attributable to its treatment for Familial Adenomatous Polyposis. Recursions’ oral medication will be viewed by the traditional scientific and regulatory community as “promising”.

On the other hand, I was disappointed not to see/hear any reference to the savings of the cost to society from this treatment and a vague reference to working with the FDA in 1H2026. Quite frankly, the urgency seemed to be lacking.

Currently, treating FAP is an expensive, lifelong endeavor for the 50,000+ survivors. Early detection strategies cost $10k+ and late detection $37k+. The cost to treating metastatic colorectal cancer (for which FAP predisposes) can be extremely high, up to $300,000. Overall, the cost to society from FAP easily exceeds $1 billion per year, or more than $15 billion on a present value basis.

This medication should not be subject to any further regulatory delay. There is enough information now on efficacy and safety to have Recursion more forward with a broad application of this treatment, while continuing test dosage levels and stratifying the patient population. The alternative is more needless cost and suffering.

Steve Zecola sold his web application and hosting business when he was diagnosed with Parkinson’s disease twenty three years ago. Since then, he has run a consulting practice, taught in graduate business school, and exercised extensively

Waiting for Codman: 100+ Years of Profits > Patients

Nov 6, 2025

By LEONARD D’AVOLIO

I’m in the waiting room of the New England Baptist Hospital. They just wheeled my father to the OR. It’s strange to be back.

Once upon a time, their Chief Medical Officer, Dr. Scott Tromanhauser asked for my help. He was interested in improving the outcomes of total knee replacement surgeries. Nearly 20% of all knee replacements do not improve outcomes. The greatest opportunity for improvement is reducing unnecessary surgeries.

This seems straightforward enough to the casual reader but in the upside down that is US healthcare, very few surgical centers in this country bother to learn if their surgeries make things better or worse. Doing anything that threatens to reduce volume is bad for business.

We pitched a concept to his Board of Directors.

“What if,” we proposed, “we could measure 1 year post-operative outcomes of every total knee replacement? We could share that data with our surgeons and see – for the first time – how our patients fared. With enough data, we could make personalized predictions of outcomes during a pre-operative consult visit. We could give people the information they need to make good medical decisions.”

They supported the idea. Yes, it might lead to fewer surgeries – but these were the surgeries that shouldn’t be conducted. Plus, it might be an edge during price negotiations with payors. Beyond that, they concurred, it was the right thing to do.

Scott and I celebrated the approval with a walk through the Mount Auburn Cemetery to visit the grave of Dr. Ernest Codman. It was his idea after all.

Dr. Codman, was a surgeon at Mass General Hospital in 1905 when introduced his “End Results System.” In it, he proposed that every hospital capture data before, and for at least one year, after every procedure. This was to find out if the procedure was a success and if not, to ask “why not?” Codman wanted patients to have this information. How else would outcomes improve? How else would patients make good medical decisions?

Now, more than 100 years later, we would bring his idea to life, just miles down the road from where he introduced it.

The ‘After Phase’ Is Missing: Why Every GLP-1 Prescription Needs an Exit

Nov 4, 2025

By HOLLI BRADISH-LANE

I’ve seen clients start GLP-1 medications full of hope—and stop them feeling betrayed by their own biology.

Some reached their limit with side effects: relentless nausea, fatigue, or the quiet loss of joy in eating. Others simply couldn’t afford to stay on. A few never saw the promised results at all. But for nearly all of them, the story ended the same way—one step forward, five steps back.

We celebrate the success stories of GLP-1s, but we rarely talk about the crash that follows when treatment stops. And it’s not just psychological. The body rebounds fast—hunger, weight, and metabolic chaos rush back in.

The problem isn’t the medication itself. It’s that we’ve built an elegant on-ramp for GLP-1s—and almost no off-ramp at all.

The Evidence Is Already Warning Us

The data couldn’t be clearer. In the STEP-1 extension trial, participants who stopped semaglutide regained roughly two-thirds of the weight they had lost within one year. Their blood pressure, cholesterol, and blood-sugar levels slid back toward baseline.

A nearly identical pattern appeared in the SURMOUNT-4 trial for tirzepatide: those who continued therapy maintained—or even deepened—their weight loss; those who stopped rapidly regained.

Meanwhile, the SELECT cardiovascular outcomes trial showed semaglutide reduced major cardiac events in people with overweight and obesity. That’s a major win—but also a reminder that stopping abruptly can erase much of the benefit.

Both the American Diabetes Association 2025 Standards of Care and the American Gastroenterological Association guidelines now emphasize continuing anti-obesity pharmacotherapy beyond initial weight loss goals.

The implication is simple: for most patients, GLP-1s are not a 12-week intervention—they’re chronic therapy.

Yet in real life, chronic use isn’t always realistic.

Why So Many Will Stop Anyway

Insurance coverage ends. Supplies run short. A job changes, or a deductible resets. Some patients plan a pregnancy, experience intolerable side effects, or simply want to know who they are without the injection. Others plateau despite perfect adherence and feel the drug has stopped working.

In each case, the result is the same… withdrawal without a plan.

The Nobel Prize’s Amazing Track Record in Immunology

Oct 27, 2025

By MIKE MAGEE

With the announcement of the 2025 Nobel Prize in Physiology or Medicine last week, the American Association of Immunologists (AAI) took an understandable victory lap, stating: “This Nobel Prize demonstrates how immunology is central to medicine and human health. The ability to harness, modulate, or restrain immune responses holds promise across a vast range of diseases — from autoimmune conditions to cancer, allergies, infectious disease, and beyond.”

This year’s award went to Mary E. Brunkow, Fred Ramsdell and Dr. Shimon Sakaguchi, and it couldn’t have come at a better time as our nation’s scientific community and their governmental, academic and corporate science leaders push back against vaccine skeptic RFK Jr.

As the AAI proudly exclaims, “Since 1901, Nobel Prizes have been awarded to 27 AAI members for their innovation and achievements in immunology and related disciplines.” Make that 28 with the addition of Dr. Sakaguchi, a Distinguished Fellow of AAI.

The field of Immunology and the Nobel Prize in Physiology or Medicine have grown side by side over the past century.

Immunity has Latin roots from the word immunitas which in Roman times was offered to denote exemption from the burden of taxation to worthy citizens by their Emperor. Protection from disease is a bit more complicated than that and offers our White Blood Cells (WBCs) a starring role. These cells are produced in the bone marrow, then bivouacked to the fetal thymus for instruction on how to attack only invaders, but spare our own healthy cells.

WBC’s are organized in specialized divisions. WBC neutrophils engulf bacterial, fungi, and fungi as immediate first responders. Monocyte macrophages are an additional first line of defense, literally gobbling and digesting bacteria and damaged cells through a process called “phagocytosis.” B-cells produce specific proteins called antibodies, designed to learn and remember specific invaders chemical make-up or “antigen.” They can ID offenders quickly and neutralize target bacteria, toxins, and viruses. And T-cells are specially designed to go after viruses hidden within the human cells themselves.

The first ever Nobel Prize in Physiology or Medicine went to German scientist, Emil von Behring, eleven years after he demonstrated “passive immunity.” He was able to isolate poisons or toxins derived from tetanus and diphtheria microorganisms, inject them into lab animals, and subsequently prove that the animals were now “protected” from tetanus and diphtheria infection. These antitoxins, liberally employed in New York City, where diphtheria was the major killer of infants, quickly ended that sad epidemic.

The body’s inner defense system began to reveal its mysteries in the early 1900s. Brussel scientist Jules Bordet, while studying the bacteria Anthrax, was able to not only identified protein antibodies in response to anthrax infection, but also a series of companion proteins. This cascade of proteins linked to the antibodies enhanced their bacterial killing power. In 1919 Bordet received his Nobel Prize for the discovery of a series of “complement” proteins, which when activated help antibodies “drill holes” through bacterial cell walls and destroy them.

Victories against certain pathogens were hard fought. In the case of poliovirus, which had a predilection to invade motor neurons, especially in children, and cause paralysis, it required a remarkable collaboration between government, academic medical researchers and local community based doctors and nurses to ultimately succeed. The effort involved simultaneous testing in children of two very different vaccines.

Current vaccine skeptics like RFK Jr. argue against historic facts.