Letters to the editor
HPV Vaccine is Needed
I was pleased that you chose problems of the head and neck as the subject for the November issue. From 1962 until 1992, I operated in this area of the body and was involved in many procedures to remove cancers. During my fellowship at Roswell Park Cancer Institute, I interacted with approximately 150 patients who had oropharyngeal cancers, and only one of them did not use tobacco products. She had a tonsillar cancer (might it have been HPV-related?). During my years in Minneapolis, I saw a 28-year-old teacher with a carcinoma of the tonsil who also did not use tobacco; otherwise, all of the cancers were related to tobacco use and/or poor dental hygiene.
Now, as so aptly brought out in Jeanne Mettner’s article (“A Cancer Gone Viral,” p. 22), the epidemiological spectrum for oral cancer has shifted because of the rising incidence of HPV-related cancers. Fortunately, these relatively new tumors are more responsive to chemotherapy than those caused by tobacco. HPV doesn’t just affect the oral cavity; it’s also found in many anal cancers.
I hesitate to say this, but teleologically speaking, these cavities are not meant for cigarettes, cigars, or snuff, nor for the penis. However, I suspect a call for abstinence will go unanswered. Consequently, it is important that we make use of a workable vaccine—which is available although fraught with problems (such as its cost and when to use it)—if we are to control these devastating cancers.
Harrison Farley, M.D.
Retired clinical professor of surgery University of Minnesota
Neurologist Shortage “Critical”
Last spring, U.S. Senators Amy Klobuchar (D-Minnesota) and Susan Collins (R-Maine) introduced legislation (S. 597) to improve access to specialized care for Americans living with multiple sclerosis (MS) and other neurological disorders. Similar legislation was introduced in the House by Congressman Michael Grimm (R-NY) that also included funding for 1,000 new residents. If enacted, these bills would correct an omission in the Patient Protection and Affordable Care Act that led to the exclusion of neurology from the list of specialties eligible for Medicare payment incentives.
This effort recognizes a critical problem in the United States: a shortage of neurologists. This shortage is so widespread that it is now affecting the military as well. The Army issued a memorandum last March about the “critical shortage” of neurologists for our troops. More than 200,000 men and women who served in Iraq and Afghanistan have suffered head injuries ranging from minor concussions to more severe brain injuries.
One out of six people in the United States—nearly 52 million—has a neurological disorder. More than 400,000, including 10,000 in Minnesota, live with MS. Because of the complex and unpredictable nature of the disease, nearly 75 percent of people who have MS depend on a neurologist to coordinate their care. Often, neurologists serve as the primary care physician for patients with MS throughout their lives.
Today in Minnesota, there are simply not enough neurologists who specialize in the treatment of patients with MS to meet the need. It is not uncommon for a patient in the Twin Cities to wait up to six months to see an MS specialist. In addition, many of the state’s top MS specialists are reaching retirement age, and we are not seeing an influx of new physicians to take their place.
The National Multiple Sclerosis Society and the American Academy of Neurology (AAN) are working to address this shortage by reaching out to medical students and medical schools to gain insight into what motivates students to choose a certain specialty, providing MS specialty fellowships to students, and educating providers at all levels about the shortage.
But there are no quick fixes. A number of factors influence a medical student’s choice of specialty, and compensation is clearly a major one. Our health care system provides significantly lower compensation to certain physicians, including primary care physicians and neurologists.
The majority of neurological care is offered through evaluation and management services. This type of “cognitive care” is time-intensive and is not reimbursed properly by our health care system. A recent AAN survey of 384 neurologists found that 19 percent have either stopped treating Medicare patients or are considering reducing the number they see because of the reimbursement situation. This is an alarming statistic, and it will only get worse as the baby boomers enter the Medicare system unless something changes.
We need to take the neurologist shortage seriously and find new, creative ways to encourage young people to specialize in this critically important area of medicine. We also need to address the systemic issues that inadvertently serve as disincentives to choosing certain specialties for medical students. We commend Senators Klobuchar and Collins and Congressman Grimm for addressing elements of the problem; but much more needs to be done.
Holly Anderson, president of the National Multiple Sclerosis Society, Upper Midwest Chapter, Minneapolis
Catherine M. Rydell, CAE, executive director and chief executive officer of the American Academy of Neurology, St. Paul