Wednesday, August 14, 2019

"Medicare for All" means ALL -- Accept no substitutes!

Let’s start with the good news. “Medicare for All” is definitely trending. It is the central domestic issue for the Democratic primary. This is because of the absolute crisis in the health system. It is also, let us remember, because of Bernie Sanders, who has supported a single-payer universal health system for decades and made it a central part of his 2016 presidential campaign. He didn’t win the nomination, but he won the battle of ideas, which is why it is so important in this campaign.

People love the idea of being covered for their healthcare needs, and having that coverage untethered from where they work (assuming that where they work provides health insurance), whether they can work if they have been laid off, can’t find a job, or are disabled, or whether they are quite old enough to qualify for Medicare, whether they are quite poor enough to qualify for Medicaid (and let’s be straight, you have to be REALLY poor, even in the most generous states, and in some states it is just ridiculous). This is because the current healthcare system in the US really stinks. A huge percentage of those who are insured have terrible coverage, those who have reasonable coverage pay (often along with their employer) an extremely high amount for that coverage in premiums, deductibles and co-pays, and an unconscionable number of Americans are completely uninsured. The health outcomes in the US are terrible, trailing all other developed countries (discussed here many times). The only thing we lead in is the cost of the system, and of course the amount of profit made by the predatory components of it such as insurance companies, drug companies and some providers – which is of course totally related to why it costs so much.

An excellent example of the insanity of our current profit-driven system is provided by the Kaiser Health Network and covered by CBS Morning News and the medical news site “Medscape”, detailing how a dialysis patient received a half-million dollar bill because the dialysis center he went to, which was closest to his home (70 miles) was “out of network” for him. This particular patient will probably have his bill written off because of the extensive national coverage, but it happens all the time; it is the norm, not the exception. No wonder people are fed up!

The less good news is that, although most of the Democratic presidential candidates (notably excluding front-runner Joe Biden) have endorsed the words “Medicare for All”, their proposals are all over the place. Most of them do NOT guarantee universal coverage, not to mention the necessary expansion of benefits (“Improved and Expanded Medicare for All”) needed to ensure that the American people get ALL the health care that they need (including mental health, vision, hearing, long-term care, substance abuse treatment, etc.) The New York Times, which has made a crusade of limiting coverage of Bernie Sanders and trying to minimize or denigrate him when they do cover him, and is also an opponent of truly, universal, comprehensive single-payer health care, does have a very useful graphic in an article originally from the “Upshot” in February but in the print edition of August 13. It portrays the characteristics of many of the health plans proposed currently, and makes clear that only two, those sponsored by Sanders in the Senate and the bill in the House with Pramila Jayapal (D-WA) as the primary sponsor and over a hundred co-sponsors, actually would provide what we need.  
A clear exposition of many issues, including facts misrepresented about universal single payer, is summarized in an elegant piece in the Washington Post by Rep. Jayapal. It is an excellent point-by-point response to various criticisms and concerns that have been raised, and is well worth the time to read, even if you don’t have time to read the whole bill (Medicare for All Act of 2019).

Two of the most important criticisms to which she responds are particularly telling, since they are deeply tied. One is that people want to be able to keep their private insurance (presumably those who have, or possibly mistakenly think they have – good insurance). The “evidence” provided for this claim is that the percent of people who say that they support “Medicare for All” goes down if the question “even if you have to give up your current insurance” is added. Of course, the question is misleading; when people are told that they would be fully covered for everything, with no co-pays or deductibles or co-insurance, and that they will have completely free choice of providers, this objection goes away. Let’s be honest; no one cares about having a choice of which insurance company will deny them what they need; this is a nonsense concern. And, yet, this is driving the proposals of some presidential candidates and members of Congress to do a less-than-universal solution, some version of Medicare-for-More, or “buy-ins” or expansion of Obamacare.

The other objection, “how will we pay for it”, is also frequently heard, even from those who know how but just don’t want to accept it. The answer is very closely tied to the answer to the question above, because the cost only becomes impractically expensive if insurance companies – and their overhead and profit – are built back into the equation. A comprehensive Medicare-for-All program, when fully implemented, will be funded by the money that Americans and their employers pay for health insurance currently, including all the money spent by the federal government and states on Medicare and Medicaid, supplemented by additional taxes on corporations that do not already provide comprehensive insurance and on the wealthiest Americans. Yes, most people’s taxes would increase, but for the vast majority, the increase would be far less than they pay now in insurance premiums, co-pays, and deductibles, and would “buy” them comprehensive care for all medical problems with no limited ‘panels’ of providers. Those who would pay more can well afford it. But the key here is not having insurance company profit and overhead built into the system; this is one big reason that the US health care system is so expensive, and leaving it in makes it much less affordable. To suggest such solutions is like saying “the cost of business is so high, especially including payoffs we make to gangsters for protection -- but of course it is really important that any new system we develop include those gangster payoffs!”

Why would many pundits and “liberal” media outlets like the NY Times, CNN, etc. want to create such confusion and undermine efforts to create a truly universal, comprehensive single-payer system? I can’t know. I do know that they are all in the upper tiers of income, have good insurance, and are surrounded at work and in their neighborhoods by those in similar situations. Maybe this makes them blind to the needs of most people; maybe they believe that the top 10% of income of which they are a part is in fact typical. Or maybe they realize their privilege and want to keep it, and don’t want everyone else diluting their access.

But including everyone is key, not only for the financial reasons, but for quality reasons. When the upper income and well-educated are in the same system as the poorer and less empowered, they can be depended upon to ensure that the system is of quality, and this benefit then applies to everyone. It is why we cannot let them opt out.

Out health care system is a mess, delivering poor outcomes for lots of money, and is a maze of different programs and eligibility. We don’t need more of that; we need to simplify it and have one outstanding system that covers everyone.

Thursday, July 25, 2019

Opioids, deaths, and capitalism: It's the capitalism, people!

The opioid epidemic is real. Far more opioids (the term that includes opiates, naturally-derived from opium, and synthetic drugs) are consumed than could conceivably be used for medical reasons, whether for short-term use post-surgery or injury, or chronic use for terminal diseases like cancer. The explanation, at one level, is the excessive use of opioids for pain relief for chronic conditions (like back pain, for which other drugs are often more effective) or excessive duration for what should be short-term (acute) reasons, and the fact that they are very addictive. This last has led to the creation of new addicts, who have been placed on prescription opioids for pain, and means that they can be used to substitute for opiates (such as heroin) for those who became addicted to street drugs. This is especially true with the increased availability of extremely potent synthetic opioids, such as fentanyl (50-80 times more potent than morphine), but can go both ways; when those who have become addicted to prescription opioids find the supply drying up, they often move to heroin.

But, like most things, it is complicated. The biggest complication is that many of those who have become “hooked” on opioids are suffering in pain, and opioid withdrawal is, to put it mildly, not fun. The pain relief is greater than that of other pain relievers, for many (but not all) problems, but opioids increase tolerance, so the doses people need to take to relieve their pain, or get their high, continually increases. The “consensus” pendulum has swung, from the message that people are not getting sufficient pain relief (“pain is the fifth vital sign”) to “doctors are creating addicts by overprescribing opioids”. Patients – people -- are caught in the middle.

Another complication is, as is usual in any big issue in the US, race. Opiate addiction and problems were a focus more of criminalization than treatment when it was perceived as mainly a problem for minority populations. The increasing revelation of white, albeit often poorer, less educated, and more rural, white people suffering from the prevalence of opioid abuse, has changed the discussion. Not that this is unimportant – the message that for the first time in a century a portion of the population – middle aged white people – have an increasing death rate (discussed in Rising white midlife mortality: what are the real causes and solutions?, November 14, 2015, and based on the work of Case and Deaton, “Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century”) is shocking. So is the finding that poor white women born in 1950 will live shorter lives than their mothers born in 1920 (“Life expectancy, socialism, and the determinants of health”, February 14, 2016). None of this to deny or ignore the fact that death rates for minorities, although dropping are still higher than those of whites.

The New York Times has had a series of exposé articles on the opioid crisis, and a recent installment completely pulls back the curtain on the marketing and sales practices of opioid manufacturers. “3,271 Pill Bottles, a Town of 2,831: Court Filings Say Corporations Fed Opioid Epidemic” reveals that many manufacturers, not simply Purdue, the maker of Oxy-Contin®, and many pharmacies including all the big chains, have been complicit in the spread of this epidemic. Its content is damning, and the evil acts of these companies are made public, and the information needed to ascertain the reason for the problem is clear.

But the Times does not explicitly call it out. That is because the problem is capitalism, specifically “unfettered” capitalism, essentially unregulated capitalism that not only permits, but encourages, anything that will make more money, regardless of the cost, including (and perhaps especially) the human cost. These corporations are responding to the pressure of Wall St. and their stockholders not only to make more money, but to “exceed expectations”. The value of a stock is not based on whether the company is actually earning a profit, but whether it is earning enough of a profit to please the casino players. This is augmented by the incentives for often huge bonuses for the top management based upon – how much profit the company makes. There are no bonuses for actually helping more people, or even not killing them, or not destroying the world. Sorry, you who die from opioids or suicide, you are collateral damage. Oh, yes, you also, future generations.

To be clear, this is not a result of Republican or Trumpian policies, although they have been both more open about it and have further pushed the envelope with their gargantuan tax cuts for corporations and the 0.1%. It has been the policy of every government at least since Reagan in the 1980s, Clinton and Obama certainly included. Of course, every US government has been pro-capitalist, but for much of the 20th century, starting with (Republican) Teddy Roosevelt, there were both implicit and explicit limits set. Even conservative economic guru Milton (“the only goal of a business is to maximize shareholder profit”) Friedman believed that monopolies were ultimately not a problem because technology and the market would take them down. He was wrong; there are no limits to what they will do for more money.

So we have Americans dying by the tens of thousands from opiate and opioid overdose, and from the “suicides of despair”. We have children being separated from their parents and migrants being housed in prisons because it makes money for the private prison industry, a major donor to politicians. (Kudos to Illinois for being the first state to ban private prisons.) We have the environment being irreparably destroyed for the profit of some companies, with government complicity. We have wars being fought across the globe, killing hundreds of thousands, and each being the potential spark that could destroy the world more quickly through nuclear war. We continue to increase the defense budget although we already spend several-fold more than all our potential adversaries put together, because it is the way that the federal government subsidizes US industries.

Why do we do these things? Our oligarchs (a term the media seems to reserve only for foreigners, especially Russians, even though the US has so many more of them) demand it, and pay for it, essentially through kickbacks. They care not for the future, even for their grandchildren, or for whether there is a world.

They must be stopped. Our health, and our lives, depend upon it.

Tuesday, July 16, 2019

"People will believe anything": Snake oil salesmen and bad health advice

The other day, I took a nephew to see the new Spider Man movie, “Far from home”. No review here; just to say that a big part of the plot revolves around the bad guy using a high-tech virtual reality system to project fake images that everyone takes to be real. Several times in the film he and his henchmen say “people will believe anything”. The parallels to the daily reality of our times, to “fake news” and distrust of science, are too obvious to be coincidental. Of course, in the movie the bad guy loses and the good guy (Spider Man) wins.

It is still far from clear if the “good guys” (and here I speak not of specific individuals, but of those who advocate for truth, a real reality, and science) are going to win in the actual world. The forces of darkness and reaction, wearing the face of Donald Trump and facilitated by the Republican Party, but actually representing and funded by the corporate elite – gangster capitalists – may not wear capes and fly around or use astral projection, but they have enormous resources to control the dialogue, provide misinformation, and serve themselves. They are resilient not only because of their wealth and power, but, sadly, because so many people are happy to try to deal with their own oppression by hating, oppressing, and believing bad things of others.

Health and medicine are clearly not immune from the reach of “fake news” and false beliefs and those willing to exploit our willingness to believe what we want to be true rather than what is. This is often a result of also a logical fallacy, wishful thinking (which is only a fallacy when it is expressed as true; not when it is expressed as a hope or wish) but may be more appropriately called “magical thinking”, a developmentally appropriate stage for young children that is always pathological in adults. Those who promulgate false scientific, medical and health theories and advice can be doing so to make money, to exert power and control, because it derives from a pre-existing belief (sometimes but not always religious). Sometimes it is also self-delusional, especially when the proposed solution is easier, more palatable, less painful, and requires less discipline than the medical alternative (take these simple pills – or snake oil -- and you won’t have to diet/exercise/stop smoking or drinking/have radiation or chemotherapy or surgery and you can be more youthful or beautiful or sexual). I once wrote about a patient who was obsessed with getting mammograms for breast cancer, a condition for which she was not at elevated risk and was far too young for routine screening, but was uninterested in addressing her actual risks resulting from heavy smoking, uncontrolled high blood pressure, and unprotected sex with multiple partners (Healthful Behaviors: Why do people adopt them? Or not?, October 8, 2011). Because, I inferred, it was easier, and would require no real effort or difficulty on her part. This is why it is an attractive option. But it is not a good idea.

The trend toward getting health and medical advice from those who are not medically trained has always been with us, but the same easy dispersion of information (or misinformation) through the Internet that allows us to hear anything we want and, to a large extent, only what we want, impacts health care as well as politics. The “anti-vax” movement is very popular, and promoted by celebrities. (Why should we not get our health advice from those whose qualification is that they are celebrities?) In addition to being wrong, it is very dangerous to the public health. I say that with absolute certainty. The anti-vaxxers are wrong. Period. There is some risk that individuals will have a reaction, very rarely a serious one, but this impact is totally miniscule compared to the benefit of preventing disease through vaccination. Indeed, vaccination is one of the few areas in which we actually can prevent, and thus not have to treat, diseases!

Some celebrities deserve a special call-out for their comprehensive and ubiquitous denial of fact, reason, and science – amazingly, often in conjunction with a profit motive from the brand of snake oil that they are selling; Gwyneth Paltrow is the exemplar. Of course, Ms. Paltrow deserves some credit for being able to convince people that they should do things that are actually unpleasant and painful for the sake of their health and beauty, like getting stung by bees, even though these are of no actual value to her clients. Obviously, they are of financial value to her. And, while I admire much of what she does in the world, Oprah Winfrey is also a big proponent of false health information.

Sometimes, bad policies are advocated by the self-righteous, as is the case with the current Israeli Education Minister, the most recent bigot coming out for “conversion therapy” for gay people. This is an example of falsely medicalizing a condition by suggesting it requires therapy, something that should not be. Sometimes, as in Paltrow’s case and many others, it is at least in part motivated by the opportunity for profit. Often, and this is sad, it is motivated and believed because people do not trust doctors and other health professionals. One reason it is sad is because people eschew treatments that could be of benefit to them in favor of those that will not help and may even hurt. But another major reason is that many doctors and other health professionals have been themselves guilty of pushing treatments that do not benefit, and may hurt, their patients. They do this for the same set of reasons as those I criticize above: to make money themselves, to make money for drug and device makers who pay them directly or in gifts including drug samples, because they are too lazy (or “too busy”) to actually read and evaluate the evidence and so taking the advice of drug or device salespeople is easier, and because they think that because they are doctors everything they think is right. I wish this were not true, but it often is. Holding physicians to a higher standard than non-medical people is appropriate, but this is not an argument for believing people because they are not doctors, no matter how confident. Iit absolutely in no way justifies listening to the advice of non-medical people who know even less!

It is also the case that some “alternative” suggestions for treatment are helpful, and many others are probably benign (except for the cost), even if the evidence is that they are not helpful; one example is taking vitamin supplements. If you can afford them, and don’t take excessive doses, they probably don’t hurt. It is certainly a better way to waste your money than on cigarettes, but if you can’t afford them, skip them. Other medical interventions can be good, and of benefit, but the benefits are often overstated, or reified as totally important. This is especially true when it is promoted as more “natural”, a word so overused as to have almost no consistently definable meaning. One example might be the use of birth attendants, called doulas. For many people, especially those who do not have a support system such as a spouse or parents or siblings or friends (and, likely for some who do) it is very helpful to have a knowledgeable, supportive person during your labor, focused entirely on you. But they are neither magic nor necessary.

Having someone who can help you deliver your baby, like a midwife or physician, is often necessary. A birth support attendant is a nice addition. Nurse-midwives train as registered nurses then do additional years of midwifery training and attend many births, including many doing deliveries under supervision. They can deliver babies as well as support women in labor.  In contrast, becoming a doula, according to requires a total of about 2-3 weeks including the need to attend a few births. So what scientific basis could there be for NY State Gov. Cuomo is advocating the expansion of the use of doulas to decrease maternal mortality, something for which there is not only no evidence, but no rational basis for thinking.

Come on, Governor! Come on, people! Not harmful is good, helpful is even better, not breaking the bank is important, and sometimes natural is nice. But let’s not choose magical thinking over science. That helps no one, except the snake oil vendors.

Sunday, June 23, 2019

The high cost of US Healthcare: It's not mostly the demanding patients!

Did you know that American healthcare is the most expensive in the world? And did you know that health outcomes here are way lower than in other developed countries? Well, since you’re reading this blog, you probably did. But here’s a scoop: one of the main reasons for this high cost is apparently the demanding nature of American patients!

Wow, you’re thinking! I was under the impression that it was greedy drug manufacturers who sell drugs in the US at many times the price they are available in other countries! And insurance companies, making huge profits by collecting high premiums, co-pays, and deductibles and then trying their best to not pay for care! And the health industry itself, providers like hospitals and health systems, who, even when ostensibly “non-profit” act like for-profits trying to make the most money possible and paying their executives in the millions (although maybe less than the C-suites of the drug and insurance companies). You probably thought it was the whole corrupt end-stage gangster capitalist system that never met a dollar it didn’t want, no matter who it hurts.

Well, sorry you’re so naïve! Just read this article by David H. Freedman in the July, 2019 Atlantic, The Worst Patients in the World”. The reason health care in the US is so expensive is the fault of people like his 74-year old father: “An accomplished scientist who was sharp as a tack right to the end, my father had nothing but disdain for the entire U.S. health-care system, which he believed piled on tests and treatments intended to benefit its bottom line rather than his health.”
And yet, Freedman points out, he demanded tests when he was sick! And he not only did nothing medical to try to help his health (like going to get checkups or preventive care), he actively undermined it by
…practically using the list of prohibited foods as a menu. He chain-smoked cigars (for good measure, he inhaled rather than puffed). He took his pills if and when he felt like it. By his late 60s, he’d been rewarded with an impressive rack of life-threatening ailments, including failing kidneys, emphysema, severe arrhythmia, and a series of chronic infections. Various high-tech feats by some of Boston’s best hospitals nevertheless kept him alive to the age of 76.
He also punched a doctor.

Then Freedman goes on to argue that it is both these characteristics, abusing oneself and not taking care of one’s health, including eschewing tests that were “intended to benefit its bottom line rather than his health,” but then demanding that the medical care system provide all the most expensive possible of those tests once he was sick, that typify the behavior and approach of many Americans and account for, in large part, the high costs of health care. While Freedman acknowledges his agreement with the concept of Medicare for All, he suggests that “We ought to consider the possibility that if we exported Americans to those other countries, their systems might end up with our costs and outcomes.”

Wow again! If w. imported US people (“patients” is the medical term for people) to, say, Canada or the UK or Denmark or France, their healthcare costs and outcomes might be, respectively, as high and poor as ours. It is not the first time that this argument has been made, but it is being featured in a major magazine, and written by a presumed progressive (or at least supporter of Medicare for All). Maybe it is worthy of being considered!

Or rejected. Maybe it is a fallacy to presume that it is a flaw in the character of the people who live in the US, compared with those in other countries, that is responsible for the high cost and poor outcomes of our health care system. Or maybe not, considering everything else about us (which I will not now consider in depth), our collective national character illustrated by things like putting migrant children in cages, denying global warming and the climate crisis, supporting the fossil fuel industry with far more money than we spend on education, or maintaining a ubiquitous system of racist law enforcement and imprisonment, just to name a few. I think it is a fallacy, though. I am sure there is a wide range of personality types within the US as well as in other countries; people who are more or less hostile, people who are more or less demanding, people who are more or less suspicious of anything that smacks of authority, and people who are more or less willing to do what they themselves can do to help themselves. So why does it seem like there are so many more in the US, and that this is a major contributor to our health care costs?

Because it does seem as if there are. I have been a doctor for a lot of years, and I have seen lots of people who do little or nothing that should be in their own control to improve their health, and yet are very demanding of expensive resources being used not only when they get sick, but after there is little chance of it benefiting them. People who, like Freedman’s father, contrary to all that “should” happen, are kept alive many years after they “should” have died as a result of the bad genes, habits, environmental factors, and luck that led them to the diseases they had. Yup. Bad behaviors. Shame! And then wanting “everything done” when it is too late, and, oh yeah, you don’t have to pay – the insurance pays. Which raises everyone’s rates. Yup, selfish.

But why would Americans be so selfish, mean, demanding? Why would they be different from other people? Would, in fact, exporting Americans to other countries raise their costs and worsen their health outcomes? That’s not an experiment that we can do easily, although there is no evidence anecdotally of this occurring. The real issue is the one I talked about at the start of this piece: a health system designed to enhance profit for the companies who own it (and the pieces of it). It is their practices that encourage many of the sorts of behaviors that Freedman and others note.

The entire health system is built on high-cost, high-tech interventions. There is far less profit in controlling, say, diabetes, with cheap generic drugs than in the newest high-cost patented drugs. There is enormous emphasis on procedures, diagnostic and therapeutic, that have little evidence of benefit, or evidence of benefit in a very narrowly-defined population. It is absolutely NOT true that a screening test of benefit for a high-risk population, for example, is of benefit for lower-risk people. There is incredible expenditure at the end of life, when often all that can be done is prolonging suffering. It is done because people, and companies, make money on it. And to complain that people behaving relatively rationally in response to these incentives is the problem is to engage, as is all too common, in victim blaming.

And if we blame the victims, we are hardest on those who are victimized in the most ways. The poor, the uneducated, the jobless, the homeless, the imprisoned, the children. Those who “demand” care because, historically, they are members of a class, race, or group that was systematically denied it. You may not feel a lot of sympathy for Freedman’s father (or maybe you do) since he had so much – a scientist, presumably with a reasonable income – who took poor care of himself and then cost the system piles of money to keep him alive until 76. But the system is hardest on those with the least.

And that is why “compromise” solutions to increase health care access rather than make it universal are not only morally wrong but bound to fail. The biggest question about “Medicare for All” is how much it will cost. But the answer is that the cost will be made up for by eliminating exorbitant private-sector profits. Half-measures, “Medicare for More” or “Improved ACA” don’t do that.

Everybody in, nobody out!

Tuesday, May 28, 2019

Growth, Progress, Drugs, and Health Care: All in pursuit of profit

There are times that I worry that I might come across as a Luddite, opposed to new drugs, new technology, progress and change, because I am often critical about how these changes are happening, and also frequently have dampened enthusiasm and expectation for the probability that they will be successful in achieving their stated goals. For the record, I am not against either change or progress, although the definition of “progress” is a loaded one; progress is only good to the extent that it makes people’s lives better. Of course, if it does not it can still be considered “change”, but may well be regress.  Here I exhibit my values: it has to make people’s lives better, and not just those of a few people, but essentially everyone.

I have recently been re-reading John Nichols’ novel “The Magic Journey”, originally published in 1978. While Nichols’ most well-known book is probably “The Milagro Beanfield War”, published in 1974 and made into a film with Ruben Blades in 1988, “The Magic Journey” is his magnum opus. It documents the transformation of Chamisaville, a fictional town that is a thinly-disguised Taos, from a 400-year old subsistence agrarian economy with little cash changing hands, to a “modern” town. A major way this occurs is through the hiring of young people to build things, paying them salaries, allowing them to buy stuff, going into debt, and selling off their families’ land. It is a bit more complex than that, because the “Anglo Axis” controlling this change does far more direct and clearly evil things to move the process along, but the change, the progress (as it were), occurs. It both changes and does not change the life of the people who live there. Yes, they (or many of them) may now have cars and refrigerators and central heating (and the debt that goes with it), but they mostly all still remain poor, and on the edge of desperately poor, often teetering and sometimes falling. Meanwhile, the positive joys of their lives, the music and singing and storytelling and culture fade with each generation, except those that are commercialized for sale to tourists. The Anglo Axis does well, of course, and the one consistency in their decision making is how to make more money and, in order to continue to do so, cement their control and hold on power at every level.

The story of Chamisaville is a story of capitalism – of its triumphs, bringing progress, and its dark, dark side, institutionalizing a continuing oppression and repression. And, in this, it is a microcosm of the US, and much of the world. The health care industry is a big part of that world, and it is run by the same folks for the same reasons. To wit: make as much money as possible, regardless of who (else) gets hurt. And to press forward with the marketing campaign – health is good for you, right? – so that those who control it continue to make money. In capitalism, certainly US capitalism, “progress” is one of the two most commonly used vector words, along with “growth”. Both, the story goes, imply “better”, but this is not always the case.

We know – or should know by now – that “growth” can be terribly bad. With 7 billion people on the planet, most of them in desperate poverty we also have desperate inequality (in India, for example 9 people have as much wealth as the bottom 50% of the population – that’s 600,000,000 people!), we have limited resources. And we spend an enormous percentage of them on war, which continues to compete with the climate crisis generated by our dependence on fossil fuels to see which will be the first to wipe out life on earth, not just our health. The mantra that growth will solve all our problems is not only wrong, it is by now backward.

Yet, in health care, we continue to strive to make progress, and it is not always bad. But one does not have to be a Luddite to note the risks and contradictions. Novartis has just released a new gene therapy, Zolgesma® that treats spinal muscular atrophy, a terrible genetic disease. That is a good thing. But it costs $2.1 million. That is an unbelievable thing. Should it be made available to the children who need it? Yes. Who pays? Not the individuals (unless they are at least multi-millionaires). The insurers? Yes, but then it gets spread to all those with that insurance. The society? Like a national health insurance plan? Sure, but who decides that Novartis should get $2 million for it? This is a big deal. It isn’t that children with this disease should not be treated, but it is the fact that LOTS and LOTS of other people with more prosaic diseases could be treated for that money.

How to allocate resources will always be a difficult decision for health care. More for lower cost services that benefit more people or more for higher cost services than are critical to a few is an ongoing decision made in nations throughout the world because all resources are limited. However, a few things are clear (to me) that should guide these decisions. The benefit of the many should take precedence over the benefit of the few, even if the few are very rich (and I am not saying that the families of SMA children are). This is easy to say, but becomes more difficult when the benefit to the few is great and the benefit to the many is smaller. Or when you are one of the few. Quality of life is important; in the US and some other rich countries, enormous amounts are spent on high-technology care at the end of life. Yes, sometimes it is difficult to know when the end of life will be exactly, but it is often clear that what is being done is protracting existence without quality or hope of improvement. And, in this context, huge profits for the drug manufacturers is not something that should be built into the equation.

It is not only end-of-life care that skews high-technology. Investment in whiz-bang stuff is always, somehow, sexier than providing the care that we already know how to do, already is relatively cost effective, and is not brand new. We need to keep this in mind as we develop, invest in, propagate, and utilize new technologies. Luke Miner’s Op-Ed piece in the New York Times, ”For a longer, healthier life, share your data” argues that the Health Insurance Portability and Accountability Act of 1996 (HIPAA) too extensively restricts data sharing among providers and especially to researchers, who could use this “big data” to identify epidemiologic patterns and link them to genetic profiles within populations, enhancing  both the likelihood of diagnosis and the opportunity to develop treatments. In addition to HIPAA, his big emphasis is on artificial intelligence (AI), and how it could compile and sift through this data to achieve results never before possible. He suggests that, as long as HIPAA prevents sharing this data without your permission, that you give your permission.

This is not necessarily a bad idea, but can never be divorced from the MOST core concept: Who will control that data, and perhaps even more important, who will PROFIT from it. The evidence is absolutely clear: there is nothing so destructive, so evil, so heinous that some people will not do if it makes them enough money. This is lesson #1.

Lesson #2 is that before, or at least while, we invest billions in genetic drugs, personalized medicine, artificial intelligence, high-tech gizmos that will help some people, or maybe (no guarantee!) in some future help a lot of people, we have to be able to disseminate the well-know and cost-effective treatments that we have. Millions die daily from preventable (see: vaccines) or conditions treatable with things we have available to us.

The real magic, the real whiz-bang, the real excitement, will be in ensuring the widest possible implementation of what we already have to care for all the people who need it.

Sunday, May 12, 2019

Requiring TV drug ads to post list prices: a good step from HHS -- but not enough!

"What I say to the companies is if you think the cost of your drug will scare people from buying your drugs, then lower your prices."

Terrific quote from the not-always-terrific Health and Human Services Secretary, Alex Azar. The Department of HHS will require TV ads for drugs to disclose the list price for the drugs they advertise. Sure, they will be at the end in the small print along with the side effects (‘nausea, vomiting, headache, baldness, serious infections, death, etc.’), and thus far there are no plans to require it in print ads, but it is a big step forward. There is so much evil being done by the Trump Administration that it is nice, every once in a (long) while to be able to point out something that is good. The #Trumpenik himself tweeted something very similar to Azar’s quote.

This has been one effort by the Administration to try and control drug prices by a very indirect route that, tellingly, does not include actually controlling drug prices. It does not even include allowing Medicare (the nation’s biggest drug purchaser) to negotiate drug prices with pharmaceutical manufacturers (that ban was built into the GW Bush era legislation that created the Medicare drug requirement, Medicare “Part D”). Still, it is something and something that is not insignificant. You can tell this from the reaction of the drug manufacturers, represented by PhRMA (the Pharmaceutical Research and Manufacturers of America), which said “We are concerned that the administration's rule requiring list prices in direct-to-consumer television advertising could be confusing for patients and may discourage them from seeking needed medical care." It takes some chutzpah to say such a thing; what PhRMA wants is for patients to demand these drugs (some of which cost upwards of $30,000 a year. Or, for some, a month!) from their doctors, and then the doctors to put pressure on insurers to cover them.

Yes, often the price paid by the insurance company will be much less than the list price that the new regulations will require them to put on their TV ads. But there will still be those, the poorly insured and uninsured, the most needy, who will have to go without, who, even if they are not discouraged from seeking needed medical care will find out that it is not really available to them. While PhRMA is the trade group for the most profitable industry in the US, their objection to posting list prices is mirrored by health providers, especially health systems, who argue that posting their prices from their “chargemaster” is deceptive because insurance companies often (usually) pay less. Yeah, so? Why not charge less and let them pay the charge? This is how it is in most other industries, and in healthcare in most other countries.

The pharmaceutical industry has a well-deserved reputation as an evil cabal, and it is not only the “outliers”. Yes, we have the fantastic extremes of Heather Bresch’s Mylan and its Epi-Pen®, and Martin Shkreli and colchicine, but we also have the “mainstream” pharmaceutical companies who have unconscionably raised their predatory pricing on key life-saving drugs, like insulin. NBC reports a doubling of the price of insulin from 2012-2016, and stories on people who are affected abound. In 2017, the pharmaceutical companies were accused of fixing the price of insulin. They deny it, but their actions belie that denial; in March, Eli Lilly agreed to sell a “generic” version of its Humalog® for half price and ExpressScripts, a pharmacy benefit manager (PBM, read either facilitator or middleman, but however you read it, it is “moneymaker”) said it would offer to cap insulin costs at $25/month. Interesting for a drug whose discoverers refused to patent it because they wanted it freely available to the public. (And, interestingly, insulin still does not require a prescription, although the needles and syringes do…) The NY Times recently reported that “Lawmakers in Both Parties Vow to Rein In Insulin Costs”, but we shall see.

Of course, while its reputation as evil is well-deserved, the pharmaceutical industry is not alone in making rapacious profits from our health needs. The entire “industry” is not about making people healthier, or even curing the sick, but on making money. This includes, of course, insurers, but also health providers, hospitals, health systems, nursing homes, doctors, etc. Ever try to get a price on any health care you need, besides drugs? Ever try to figure out a bill? Two stories from my own life I have written about before but will re-tell here:
Some years ago I had outpatient hernia surgery. I arrived about 6:30am and was back home in my bed by noon. Later I got the bill from the hospital for its charges (not including the doctors’): $10,000. Then my insurance company told me that I would pay $400, they would pay $1,600, and the hospital would write off the other $8,000 as a contractual adjustment.

Of course, if I had been uninsured, I would have not been billed for the $2,000 the hospital actually received, but for the whole $10,000! This is why they don’t want to list their charges. This obfuscation is motivated by insurance companies looking to show what a good deal they provide their customers (look! We saved you $8,000!). Of course, this is baloney; since the hospital was willing to settle for $2,000, that is what they should have charged, everyone.

And price lists? Time for the other story.
I live an hour from the border, and, with Medicare but no dental coverage, I go to Mexico to get my teeth cleaned. It costs $35; a lot less that in the US and is done quickly and thoroughly by a dentist. It costs everyone $35. If you have dental insurance (they take it), it costs $35. But say you need more – a filling, a crown, implants. Not only is it a lot cheaper than in the US but they can tell you exactly how much it is going to cost! A friend had several implants, and this cost thousands (but a fraction of the US cost); the point is they told her exactly what the cost would be up front. This, it turns out, is actually possible!

The article I cited at the beginning, from the Associated Press (and read by me in the Arizona Star, shout-out), quotes
‘Leigh Purvis, a pharma expert with AARP's research division, [who] said disclosure will help dispel a "cloak of darkness" around prices and encourage more informed discussions between patients and their doctors. But she cautioned against expecting too much.
‘"The overall idea of reducing drug prices is something for which there is no silver bullet," said Purvis. "This is just one step, one tool in what will have to be a very big arsenal."’]

She is right. I said it was a good step, worthy of praise, but it will not alone be enough to bring down drug prices. Or the cost of any of the health care we are regularly ripped off for. While the burden will continue, as always, to fall heaviest on those who can least afford it and have the greatest need, it is impacting everyone. Let’s start with letting Medicare negotiate drug prices. Let’s regulate insurance company profits. Let’s make everyone in the health industry post their prices.

Indeed, let’s have a universal, single-payer health system. #MedicareforAll!

Breaking News: 

Lawsuit by 44 States Accuses Pharma Giants of 'Multi-Year Conspiracy' to Hike Drug Prices by Over 1,000%

Sunday, May 5, 2019

Whence, and whither, family medicine: will it have role in improving our nation’s health?: Part 3

The 25th J. Jerry Rodos Lecture, presented at the 30th Annual Conference of Primary Care Access, Kauai, April 8, 2019:

Part III: Whither Family Medicine and Our Health?

So, in the end, is it all about money? Is it about the primacy of profit? We have seen massive consolidation of health systems, all focused upon making money, even if not “for profit”. Doctors as employees, are “pawns in the game” (remember the Dylan song?). PAs and NPs added not because better but because cheaper. FPs are only good because they are cheaper. Do the key principles of family medicine really make a difference? Barbara Starfield said yes, but she is gone and so is the control FPs had of their practices. We are ambulists (some of us hospitalists), few of us deliver babies. How many even care for families?

Perhaps the variety is why we become family doctors. We have variety in our patients, not just limited to one kind of disease or organ system, and we have variety in our day. Well-child, older person with chronic diseases, sports injury, pregnant woman, substance user, minor surgery. Maybe it is this variety that keeps us going, and makes us different from the sub-sub-specialist who needs to know all there is to know about very little. It is challenging because it is more complex, much as that might grate on the specialist; what they do maybe difficult but it is the same thing over and over. A Graham Center one-pager (by me!) looked at complexity in terms of how many different diagnoses, ICD-9 codes, it took to account for 50% of all codes by specialty.  For family medicine, it took 23 codes, for IM 18, for pediatrics 11, for cardiology 6, and for psychiatry 3![i]

We often hear about family physicians being replaced by NPs and PAs, but what about other specialists? Their practices are often more routine, more all-the-same, and in fact easier for NPs or Clinical Nurse Specialists to replace, as we see daily in hospitals. The Clinical Nurse Specialist in Heart Failure knows all there is to know about a narrow practice. But they – both the physicians and non-physicians -- make more money than FPs or FNPs. Is that all it is about?

There are many other challenges that face us, and face other specialists as well. One of the things that my colleagues in other disciplines complain about, and I agree with, is the apparent attrition of critical thinking among many of our trainees. This probably has many intellectual, educational, and social causes, but a big one seems to be the electronic health record (EHR), and the fact that our employers, health systems, have designed them to maximize reimbursement, not truth (is it all about money?). Much of the EHR is about filling in boxes and checking the ones that make our employers the most money. It is about cutting and pasting rather than thinking. The patient had a chest x-ray? Just paste in the whole radiologist report. This creates a huge long note, is a bear to read, is available elsewhere in the record (under, like, ‘radiology reports’, where it was cut-and-pasted from!) and requires no judgement! A simple “normal chest x-ray” (or ‘chest x-ray with interstitial infiltrates, possible pneumonia vs congestive heart failure’) required at least some thinking and judgement. The old “SOAP” note is entirely unbalanced, with not too much in “S” (patient history), bloated “O”s (cut-and-paste) and then – Plan! Almost no “A”, no assessment, no taking the information provided above and reflecting on it and thinking about what it means, or might mean, or might be if it doesn’t mean the first thing. It may be this that is the greatest threat to the role of doctors, any doctors, except as technicians.

But it is not just residents and students and practicing doctors that are being co-opted into a world of rote. Our family medicine leaders – program directors and chairs -- must help contribute to the “needs” of their health system –that is to make as much money as possible. We may, as individuals, care very much for the individuals who are our patients and for good practice, and I think we do, but our institutional role can overwhelm that. For caring for selected populations, mainly those who we get reimbursed for. I remember in the early 1990s, in the days of the Clinton health plan, seeing a version of this cartoon: R. Dolan, MD. “Specializing in the diseases of the insured”.

Our organizational leaders should – and do not always -- guard against the seduction of being part of the “in group”, getting to go to meetings (especially if paid for) being named to policy-making committees and commissions, hobnobbing with other “leaders”. Or maybe I’m wrong, maybe it’s just me, maybe this is really the good part about being a leader, not providing effective advocacy for your faculty, residents, students, and most of all patients? One need not be José Baselga, the former head of Sloan-Kettering who lost his position over graft and lack of disclosure, to lose one’s way – but that is the end of gradual moral and ethical compromise.

Over a decade ago the discipline undertook a major study and marketing program, the Future of Family Medicine. What do you remember from it? I remember that 2/3 of those who thought they had a family doctor really did and 2/3 of those with a family doctor knew it. I remember that when presented with the idea of a doctor who had the characteristics we associate with a family physician – the “Starfield” characteristics of comprehensive, continuous, compassionate, and personal care in the context of family and community – there was terrific resonance among the American people. I remember that specialists valued family physicians almost more than we valued ourselves. But what came of this? Is our health system more oriented to those values and characteristics than it was?

Now we have another project that cost the discipline $20 million, the Family Medicine for America’s Health (FMAHealth) project. Will it change the way the discipline practices and is structured, or will it be more of the same? How many of you have read the reports of the “tactic teams” in the recent February issue of Family Medicine? What do you think? As my friend John Saultz, editor of Family Medicine, notes that if FPs don’t define themselves, their roles, and their scope of practice, others will. It is happening and we as a whole are buying into it.

Is there hope? This is where I always say “a national health system”. I still say it. It is true that a national health system will not solve society’s problems – people will still need homes and food for health. It will not ensure quality of care. It will not mean that family medicine gets its due as the centerpiece of healthcare.

But it provides the context and mechanism for all of these. Most important, and of course this will be the challenge – it will change the focus of the health system from making money to be about delivering health care. It would provide a context for truly measuring quality. It would provide a reason to emphasize critical thinking. It would provide an impetus for health professionals to demand societal changes that will make a difference for people’s health. It would provide a way to make population health really be public health by not excluding anyone.

There will always be those who say we need to compromise, we cannot go too fast; it is something we are commonly hearing now as the campaign for the 2020 Democratic presidential nomination goes forward. But compromise is not always a good thing. Stephen Covey notes it is often lose-lose. We need win-win.

We need completely universal health care. 90% covered won’t do. “99-1/2 just won’t do” (Mavis Staples) because those are real people who are left out. Compromise means real people will not have health care. So the advocates of compromise need to specifically identify who those left out will be. I’m pretty certain they don’t think it will or should be themselves. Unless they are suggesting that we are going to leave them out, leave out the politician, pundit, wealthy, and their friends relatives and neighbors, then the people who need it most should get it most.

In the 1970s the British GP and epidemiologist Julian Tudor Hart put forward the “inverse care law”: the availability of care is inversely proportional to the need for it.[ii]

Let us correct that.

Health care for all!

[i] Freeman J, Petterson S, Bazemore A, “Accounting for Complexity: Aligning Current Payment Models with the Breadth of Care by Different Specialties”, Am Fam Physician, 2014 Dec 1;90(11):790.
[ii] Hart JT, “The Inverse Care Law”, Lancet. 1971 Feb 27;1(7696):405-12.

Monday, April 22, 2019

Whence, and whither, family medicine: will it have role in improving our nation’s health?: Part 2

The 25th J. Jerry Rodos Lecture, presented at the 30th Annual Conference of Primary Care Access, Kauai, April 8, 2019:

Part II: More whence, and some whither family medicine

Family medicine introduced many great things to medical education. We had non-physician faculty in our departments and residencies, psychologists and educators, unheard of then. We valued education, and realized that just being a good doctor was not the same as being a good teacher, so created faculty development programs, including fellowships, often supported by Title VII grants. Our Board required recertification from the beginning, and no one, not even those who created it, were immune, or “grandfathered in”. Many of these innovations (if not the “no grandfathering”) were adopted later by other specialties, although not always crediting the discipline family medicine. And many specialties have not adopted them yet, still to their shame.

But, in the US, family medicine is still somewhat on the margins. It never completely took over as the centerpiece of the health system, not as in Canada or the UK. Much of the opposition has been regional, especially in the NE, and in cities where there were already plenty of doctors who did not want to give up control – or money (remember that word, money, we’ll be coming back to it). Of course, then, as now, most pundits who comment on medicine – actually, on all things – are, at least relatively, well to do. Poor people often adopt such attitudes as “specialists are better”, because they assume that what the rich have is better (bigger houses, better cars, certainly better doctors), although those of us who went to medical school know that that is not necessarily true. Our classmates who wanted to become elite subspecialists caring for the rich did that, and those who wanted to serve the needy did that, and it had little or nothing to do with class rank or skill. Of course, the obstacle to poor people getting what the rich get is, well, they don’t have, and so their doctors wouldn’t make, enough money!!

The small-town white picket fence practice, of Marcus Welby and many fathers and grandfathers (less commonly mothers or grandmothers) of current FPs, such as many of those portrayed in Fitzhugh Mullan’s book ‘Big Doctoring’,[1]

may be mostly gone, but that model was long the darling of the RRC; those of us working in inner-city training settings often felt that the rules were written for someone else. 

Other issues confront us, sometimes divide us. Should the future of family medicine be about “full scope” practice, including caring for children, delivering babies, hospital work, emergency care, musculoskeletal care? Or should it be limited, specialized even (OB, geriatrics, sports medicine)?  Should we be using the term primary care or family medicine? What about general internal medicine? Pediatrics? GIM has pretty much abandoned the field, since 80% of IM graduates become subspecialists and over half the remainder become hospitalists. Should we just stop saying “primary care” and insist on “family medicine”?

Most of us recoil at the oft-heard-from-medical-students idea that GIM is family medicine without the OB and pediatrics. We think that there is a conceptual basis for our specialty that has to do with caring for the whole person and caring for them in the context of their lives, families and communities. Despite the concerns of the young Josh Freeman, this context is critical. The pediatrician cares about the health of the child she cares for, and likely that of the adult that child will become. The family physician also cares for both, but more concretely than the pediatrician experiences the health issues that adults face that often have at least part of their roots in their childhood experiences. In addition, the family doctor cares for that child’s family, and knows, for example, that the child’s mother is not just “mom” (I hate that usage!) but someone with their own problems, maybe a hard job, maybe not enough money, maybe a troubled relationship, maybe caring for her own parents, maybe with her own health issues. I have often said that if clinical sciences have associated basic sciences (like psychology for psychiatry, and anatomy for surgery) then anthropology is the basic science for family medicine because it examines people in the context of their families and communities.

Family medicine is also comprehensive, per se, by its nature. I was once able to recruit an anthropologist to our department because she wanted to work in that comprehensive context, and public health/preventive medicine didn’t really offer it. Preventive medicine is seen by some as holistic, but it segments just as medical specialties do: I do smoking, you do seat belts, she does bicycle helmets, he does violence. But the family physician has to address them all. We can’t say “wear your seat belt” but ignore “stop smoking”! Or, is that what we want FM to become? Geriatricians and sports medicine and women’s health? Hospitalists and ambulists, nocturnists and weekendists? (By the way, that anthropologist went on to help run the AAFP’s national research network.)

Sometimes the issue of how family physicians practice is formulated as a conflict between lifestyle and scope. Is that true? Maybe. Maybe it is good to not take call, or too much call, or have to round in the hospital or have to get up to deliver a baby in the middle of the night. But it may also be true that for a well-trained family doctor, 8-5 clinic patients can become drudgery. Sometimes teaching helps. And what about the issue of lifestyle vs lifestyle? People want to move to and practice in cool places to live, with a lot going on, stimulating cultural events and good educational systems. But these places may pay less money and cost more to live in. Besides your practice, do you want to be San Francisco poor or Nebraska well-to-do? That old white picket fence family doc may have had no conflict, but now young people do.

There have been lots of changes in the health system in my lifetime. Family medicine was created in the 1960s and grew to adolescence in the 1970s. In the 1980s we had lots of promise; Nixon pushed for HMOs, and in the 1990s we had gatekeepers – and different opinions about whether that was good or bad. Our best resident matches were in the late 1990s; no student wanted to be an anesthesiologist because they were afraid of not getting a job. But now ….

One study showed a student entering an anesthesiology residency can expect to make $7 million more in their lifetime than one entering family medicine. In this country. When I was in Denmark a few years ago I visited a rural family practice. In conversation, the doctor mentioned his daughter was married to an anesthesiologist. Tied to my own country’s norms I joked that at least he wouldn’t have to worry about being supported in his retirement. Oh, he replied, in Denmark family doctors make more than anesthesiologists!
Is it all about money?

We have a health system that fails to focus on the health of the people. We have almost abandoned the concept of public health. Indeed, the currency of the term “population health” is more than a semantic difference. Population health can be narrowly defined to be any population – the population of your practice, say -- and it can and does often leave people out. The people who are hard to care for, or don’t make money for us, or mess up our statistics.  Public health requires us to look at the WHOLE public. Eew! How messy!

[1] Mullan, Fitzhugh. Big Doctoring in America: Profiles in Primary Care. Millbank. 2002.

Saturday, April 13, 2019

Whence, and whither, family medicine: will it have role in improving our nation’s health?: Part 1

This was the 25th J. Jerry Rodos Lecture, presented at the 30th Annual Conference of Primary Care Access, Kauai, April 8, 2019:

Part I: Whence family medicine, and me

The history of family medicine is familiar to those of us attending this conference. Although most of us were not there “at the beginning” in the 1960s, we have heard, frequently at this conference, about the seminal reports, people, and events that led to the founding of our discipline.

The Willard Report, issued in 1966, was commissioned in 1964 by the American Medical Association’s Council on Medical Education and found that medicine needed a new kind of specialist, the family physician, educated to provide comprehensive personal health care within the nation’s complex healthcare system. It defined a family physician as one who “accepts responsibility for the patient’s total health care within the context of his or her environment, including the community.”[1] The COME also commissioned a report on graduate medical education to achieve this goal, and the Millis Report was also issued in 1966. It contained one of the earlier modern definitions of a primary physician, one who “...will serve as the primary medical resource and counselor to an individual or a family”.[2] The 1967 Folsom Report, developed by the private National Commission on Community Health Services and sponsored by the American Public Health Association and the National Health Council, called for “communities of solution”.[3]
Following these reports, the AMA hired two early leaders in our field, Drs. Leland Blanchard and Lynn Carmichael to “develop family practice”, and they crossed the country doing just that; Carmichael established the first FP residency at the University of Miami in 1965.[4] By 1969 there were 16 residencies. These early residencies were led by major figures in the history of the discipline, including Gayle Stephens in Wichita and Gene Farley at the University of Rochester, and grew to nearly 500 by 2016.[5]

The choice of the term “family doctor” to replace “general practitioner” was not incidental. The ABFM was founded in 1969, but the AAGP did not change its name to the AAFP until 1971, after at least 3 failed efforts. Obviously, people had always referred to their primary physician as their “family doctor” and for marketing purposes the term “family doctor” evoked positive feelings among the American people.

Like everyone here, I am sure, I can tie this to my personal story. Entering medical school in 1973, I did not come from a medical family, and think my parents had only one physician among their friends. I knew what kind of doctor I wanted to be, but not the right word for it. I didn’t even register GP; I wanted to be a “regular doctor”. You know, the kind you can go to with whatever is wrong and not have to diagnosis yourself first, and they can take care of it. As far as specialties were concerned, I guess I had an idea that pediatricians took care of children and obstetricians delivered babies. And maybe from high school friends who had money as well as acne, I knew that dermatologists took care of skin, but that was probably it. Of internal medicine, which played such a huge part in medical school, I had no concept; if anything I would have probably guessed it had something to do with gynecology, as I remember my mother having gone for annual “internal” exams.

My medical school, Loyola, had no family medicine at that time, but as I approached my scheduling for clerkships I found out that there was a physician, Werner Cryns, who ran a family practice clinic at the school. Trained as a pediatrician, Dr. Cryns had gotten private outside funds to establish this small clinic in a corner of the medical school, and I chose it for my elective. It was also my first clerkship, and from then on, I knew that was what I wanted to do. I did my residency at Cook County Hospital in Chicago, under Dr. Jorge Prieto, only the fourth full class to start in 1976. (Little side story: the hospital had always given out an “intern of the year” award, and in the first full class of FP residents, in 1973, it was won by one of them. Everyone else freaked out because “they rotate with everyone; they’ll always win it”, so there went the hospital-wide award. It became departmental.) I wanted very much to work at this public hospital with all of my socially and politically conscious friends from many of the Chicago medical schools, and was thrilled that they had a program in family medicine.

I had interviewed around the country, though, and found out about different programs, including two others that consciously saw themselves as training doctors for the urban inner city populations, Montefiore and San Francisco General. If I had gone to Montefiore, back in New York where I had lived my entire life before medical school, I likely would have had me a different life, but that cannot be known. I wanted to love SF General, as I loved San Francisco and had been unsuccessfully trying to get to California at least since applying to college, but was actually turned off by its emphasis on family dynamics and behavioral science. As someone who loved his own family but saw very much the negative impact that many families had on their children, I wanted to “keep the family out of family medicine”! Suffice it to say, I was wrong, and long since have understood the importance of the interaction of people, families, and communities, on an individual’s health.

At the 1989 Denver STFM meeting, I heard Gayle Stephens talk about “Family medicine as counterculture” (the talk was later published in Family Medicine[6]), and I admit that I was pretty surprised. I felt I had been part of the counterculture, but that doctors, even family doctors, even Dr. Stephens, were a bunch of old white guys in suits representing the establishment. I have to admit that, even though I have long since become an old white guy, and have been frequently known to wear a suit, the faces of those stern corporate-type authority figures from the 1950s and 1960s still make me anxious and a little bit hostile. (Full family disclosure, my father was a worker, not a suit.) But 1989 was a seminal STFM meeting.

I had already been attending STFM for some years, first in 1982 as a fellow at the University of Arizona, and then starting in 1985, when Dr. Prieto shared the educator award, every year since. If I make it to Toronto that will be 35 in a row. Actually, maybe it was 1988, in Baltimore, that was the seminal year, because that was the year Sen. Orrin Hatch received the Leland Blanchard award from the Foundation, orchestrated by Utah department chair and STFM matriarch F. Marian Bishop. I am sure Dr. Bishop did not anticipate, and surely did not appreciate, the antipathy of much of the younger cohort of STFM members to Sen. Hatch. From her point of the senator had been a big supporter of Title VII and family medicine. From our perspective, he was a virulent opponent of not only abortion rights, but ERA and other key issues affecting women. The only organized group within STFM opposing this was the Group on Women, which gathered signatures on a petition that was presented at the business meeting.

So, the next year, 1989, in Denver, there was a conscious effort to make a change. David Schmidt welcomed us with an upbeat and progressive speech. The Blanchard lecturer was Christine Cassel, then a professor of geriatrics at the University of Chicago and later a lot of other things, including head of the ACP Foundation and seminal in developing the “Choosing Wisely” program, speaking on medical ethics. In addition to Dr. Stephens’ talk on counterculture, Dr. Roger Rosenthal spoke about the need to care for underserved people. Several new groups were organized that year, including the Group on Minority Health, which still exists, and the Group on Universal Health Care, which had a shorter life. I felt really good about STFM and Family Medicine – and still do.

I met lots of people through family medicine – at STFM and the Program Directors’ meeting (later AFMRD), and this meeting, who were inspirational, like Frank Dornfest, the South African who was at the time program director in Santa Rosa -- the program our own Rick Flinders has written a history of -- and Gene Farley, who I met when I was a fellow at Arizona and he was chair at Colorado – an inspiration for his whole life. And some who were not old white men – Jorge Prieto, Denise Rodgers, and Carlos Moreno, and Janet Townsend, and others like David Swee and John Frey, white men who were not yet old! And the folks I worked with at Cook County – Pat Dowling, Janice Benson, and Crystal Cash, and many others. And, of course, many of those I have met or gotten to know better at this conference.

Part II: Whither family medicine, and American medicine, will be forthcoming

[6] “Family medicine as counterculture”, Family Medicine, 21(2):103-109, Mar-Apr 1989

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