As a physician, I have to comment. Every day I see patients with high blood pressure, diabetes, ear infections, etc. I see 500 patients a month. I tell all of them about lifestyle modification, holding antibiotics, healthier diets and so forth to avoid medications. About one in every 500 that I see chooses to forgo the antibiotic for their infection, or chooses to cut out the fast food to lower their cholesterol. I prescribe medications because patients are unwilling and unmotivated to change, or to live with their symptoms for more than a couple of days. When society changes their expectations, maybe doctors can stop prescribing so many medications.

Agreed (I am a physician myself). Most patients have the wrong attitude, expecting a quick fix even when this simply does not exist. And many push for scans and other tests that make not much sense.

One has to admit, though, that a lot of physicians don't even try to provide or counselling without treatment (or non-drug treatments).

You make a good point. Still, I *just saw* a patient who was slapped on Lipitor in his late 20s after a single lipid profile demonstrated elevated lipids. No recheck to be sure it wasn't just lab error, no counselling on diet and exercise, and no trial of lifestyle changes.

There is NO primary care physician anywhere who could do literature reviews on every intervention contemplated in a real practice setting. If primary care physicians did what this great cardiology author expects of them they would see very few patients and be bankrupt in no time. This is an absurd article putting an onus on primary care physicians they cannot meet and by a specialist to boot who probably is not up to date in his own field if you scratch his surface hard enough. This is simply another hit job on primary care physicians. Deserved? Theoretically. BUT most of us primary care physicians try hard as noted and DO NOT get reimbursed for the time spent doing contemplation, education, telephone follow-up that is really necessary to practice good medicine. AND, CMS wants to cut the primary care physician's reimbursement by 40 percent!!!!!!

Maybe both you and the author are right. To maintain their incomes in the face of falling reimbursments, primary care doctors ar so busy seeing too many patients in a day they can neither critique the literature nor counsel patients effectively.

But Darshak is right about the lack of critical skills. Here's an example: How many physicians reading the original Vioxx VIGOR paper picked up on the fact that the number of patients in the treatment group who suffered a cardiac event exceeded the number who were protected from a GI bleed? The data were there for everybody to see, but the paper was written in such a way that this essential fact was buried. And that was in the NEJM.

So there are three problems here: 1) the journals are filled with junk science and obscured data; 2) PCPs don't always have the training to pick apart studies; and 3) PCPs are so pressed for time, they don't always provide the coordinated care that patients really need.

Each of those problems has a solution. Better peer review. Higher reimbursements for PCPs. Better training in medical school and getting pharma out of the business of underwriting CME.

Cutting CMS reimbursements is the absolutely wrong thing to do.