Sunday, February 22, 2015

Cuba: A health system designed to serve to health of the people, not the profit of a few

I just returned from a week’s visit to Cuba with a group of medical journal editors and public health people. We met with many people in the medical professions including family doctors and nurses and people from highly specialized referral centers in pediatric cardiac and hepatobiliary surgery, nutrition, and diabetes, and with faculty and leaders from the school of public health and some of Cuba’s medical journals, including the Cuban Journal of Public Health. We met with US students from ELAM, the Latin American Medical School that trains (for free) students with social commitment and economic need from not only Latin America (and North America) but the entire world.

Much has been written on the Cuban medical system, and how it is structured. One of the best recent articles is by C. William Keck and Gail Reed in the American Journal of Public Health in 2012, “The Curious Case of Cuba”.[1] Keck and Reed are, respectively, Editor-in-Chief and Executive Editor of MEDICC Review, an academic journal that publishes research and commentary from both Cuban and US (and other international) authors about the Cuban health system and health status, and is part of MEDICC (Medical Education in Cooperation with Cuba). They were also leaders of our MEDICC-sponsored trip. I will not try to provide yet another in-depth description of the Cuban health system, with which many readers may be familiar, but will rather highlight some aspects of it that struck me as particularly important, and explain why.

First of all, the medical system in Cuba is a national priority. As a socialist country, its centralized nature exceeds that seen in the more-commonly described wealthy Western European nations, and it provides care for everyone. This is a positive, obviously, but also (of course) limits the access to some elective procedures for those who would be rich enough to afford it in another society. It also, of course, limits the ability of those people to be at the front of the queue, which is a particular irritation to the privileged, high-income people who are often those most critical of any type of equitable health system. The health statistics are excellent; several indicators, including infant mortality rate (4.8/1000 in 2013) are much better than in the US.

It is also very primary-care based. Teams of family doctors and nurses are in every neighborhood (in the densely populated parts of central Havana where we were, actually every few blocks) and are responsible for the health of a geographically defined population of 800-1800 people (depending on percent of older, high need people). They spend half their day seeing people in the office, and the other half making home visits, most frequently to those who are high-need because of chronic disease or recent mothers (the nurse sees almost daily). They also live in the neighborhood, frequently in or over the clinic, and are expected to be available 24-7 for any of the patients in their community who needs urgent help. Some of the doctors in these settings are residents in the second of their two-year FM residency, and they include those from other countries whose governments permit residency training in Cuba (we met a resident from Ecuador, who would be returning to his own country).

At the next level are polyclinics, also very neighborhood-based and serving a number of family medicine practices. Staffed with a family medicine professor as well as other specialists (pediatrics, IM, OB-Gyn, etc.) they see patients referred to them by the FM practices (and send them back for continuing care) as well as provide some procedural and imaging services. All physicians complete the 2-year FM residency, and then do residencies in other specialties; about 40% of doctors are FM. There are also hospitals, emergency / urgent care settings, and several levels of referral centers. The ones we visited in Havana for pediatric specialty surgery (including transplants of livers, although not yet hearts for children), nutrition, and diabetes were the most high-level referral centers in the country. At every level the centrality of the family medicine community practice for ongoing follow-up was emphasized. Specialty doctors have great respect for this system. In addition, although they make earn more than family doctors, the difference is small, and all earn far less in relation to the income of others in society than in the US. Doctors are not in it for the money. Public health is a much more prominent part of the health system in Cuba than it is in the US, and there are strong centralized efforts to integrate it more with the medical care, and particularly primary care, system. It remains underfunded relative to medical care delivery, but the inequity is significantly less than in the US where public health receives about 3% of the health care dollar compare to 97% for medical care.

In addition to the medical care that they provide to their own people, the Cubans provide care all around the world, and train doctors (as indicated above) from all around the world. Many poor nations have their health facilities staffed by Cuban physicians, and their human resource commitment to fight the Ebola outbreak in West Africa dwarfs any comparable effort by the US or other nations (see the article “Cuba vs. Ebola” on the MEDICC webpage). As noted above, ELAM graduates several thousand physicians from other countries every year, including the US. The students from the US, selected by the organization Pastors for Peace, are typically from lower-income families and ethnic groups under-represented in US medicine. The US students are required to have at least 2 years of college, and spend at least 6 years in the medical school, plus an extra one before if they are not fluent in Spanish. They are provided free tuition, room, and board. Life is not easy, and like most Cubans – even those working in the most advanced centers, including the National Medical Library – have limited and slow Internet access, a result, apparently of the lack of access to satellites resulting in the “low bandwidth” we heard about constantly. But the graduates are expected to enter primary care and work in communities of need that are like those they come from, and despite the inability of Cuba to enforce this, most of them do. Many have completed residencies in the US and others are currently training, predominantly in primary care. They tend to bring excellent history-taking and physical examination skills, although need time to adapt to the electronic medical record and the ability to “just order a CT scan”.

The hardest part for me about the US medical students at ELAM is that they are exactly the kind of students that every medical school in the US should be aggressively recruiting: from families and communities that have not typically produced physicians, from underrepresented groups, and with a passion and commitment to provide care for those communities. It embarrasses me that they have to go to Cuba to school, while our medical schools are filled with “more of the same”: privileged, generally majority, students with much more interest in high-specialization than primary care, and much more commitment to themselves than to the needs of society.

There are a lot of problems with Cuba, and even with their health system. It is very expensive, very dependent upon physicians, and upon paying relatively low salaries to health workers. It is handicapped by limited resources in a relatively poor country, even though the largest portion of that nation’s resources are spent upon health care and education. Its poor access to the Internet and lack of money for international travel limit the ability of its health professionals to collaborate and stay on top of what is happening in the rest of the world. But what the Cuban model shows is that it is possible to have a health system based on trying to provide needed health care, relatively equitably, to everyone in the society. It starts with primary care, and everyone gets that before anyone gets more; as time and resources progress, more people get more, but still equitably. The emphasis is that health and healthcare and medical care are for everyone, not for a portion of the population. It is based upon the presumption that everyone should get what they need before anyone gets what they do not.

Advocates of a market-based model for health care in the US may insist that they are not mean or selfish, but that the market is the best model for organizing everything, including health care. Their mantra is that “the market will provide”, presumably not just profit for the providers of services, but health to the people.

How’s that working for us?







[1] C. William Keck and Gail A. Reed.  The Curious Case of Cuba. American Journal of Public Health: August 2012, Vol. 102, No. 8, pp. e13-e22. doi: 10.2105/AJPH.2012.300822

Sunday, February 8, 2015

Medicaid expansion and uncovered lives: are people meaner in the South?

I have lived in a number of places, from New York City to Texas, Illinois to Kansas. Politically and socially there are very different norms that prevail, which are demonstrated by the difference in who we elect and what policies we choose to legislate. And, yet, in all of these places people are people. They can be kind and generous or mean and selfish. As individuals, they love and care for their children, or sometimes don’t. They are respectful of others, or not. In all places. And yet it is clear that there are major regional tendencies to policy that must reflect the local and regional values even though people are not necessarily nicer or meaner. I think that my blog posts have made clear my positions on many issues, particularly those related to health and to social justice.

Obviously, self-interest has a lot to do with what people believe, what policies they support, and which politicians they vote for to implement those policies. To a large degree, it is economic – what is good for me and my family, as illustrated in the old Clinton campaign mantra “It’s the economy [stupid]”. Of course there is more than that. If people voted mostly for their economic self-interest, we would have a very different set of national policies because there are so many more poor and middle-class people than rich, and in the last decade especially so many more middle-class people descending toward poor than ascending toward rich. Many of the policies we have would only be supported by those who are both rich and selfish, the latter being only a portion of the rich. And yet, so many of our policies only benefit the very richest. When it is “the economy”, it is usually good for the wealthy and big business, but not necessarily for all of us. And it is more so in some states and regions. We are, not individually but as a group, meaner some parts of the country than in others.

Access to health care and the means to be healthy (having the opportunity to have a home, and good food and a job and a reasonable opportunity to care for the needs of yourself and your family) is one important arena in which we are meaner in some places than others. We know, for example, that expansion of Medicaid under the Affordable Care Act has varied not only by state but largely by region. Since the ACA intended people under 133% of poverty to be covered by this expanded Medicaid (paid by the federal government, 100% for 4 years and then 90%), they are not eligible for health insurance exchanges. Thus, if their state did not expand Medicaid, they are unable to get coverage. This is the map of states that have expanded Medicaid; clearly, it there is a strong regional difference:


This figure from the Kaiser Family Foundation, showing the regional focus of non-expansion of Medicaid in the Southeast, South Central, Plains and Mountain states, is included in a very interesting piece in the Huffington Post by Harold Pollack of the University of Chicago, “Martin Luther King wouldn’t be very happy with this map”, posted on King’s Birthday holiday, January 19, this year. What he is referring to is that the South, the area King was from and spent most of his time working in (much of which is shown in the movie “Selma”) is one of the areas most affected. But Pollack makes the point that it is actually much worse, and that the South has the vast majority of uncovered people because some of those geographically-large Mountain and Plains states haven’t got very many people. Other states that have not expanded Medicaid, like Wisconsin, have other programs covering a large number of those who would be eligible for an expanded Medicaid. We have seen maps of the US re-drawn to make the size of states proportional to their population, where California and Texas and Florida and New York are huge, and Mountain states tiny. Pollack asked Harvard researcher Laura Yasaitas to show the states re-drawn to have their size proportional to the number of uncovered people. The results are even more amazing:

Because of their larger population, Southern states now obviously account for the vast majority of uncovered people, with the most populous states – Texas, Florida, Georgia, and North Carolina seeming huge. The two states Kansas City borders, Kansas and Missouri, are pretty big (Missouri is the one above Arkansas, the blue keystone in the middle, and Kansas is to its west, over Oklahoma which is recognizable because of its panhandle). Montana, Wyoming, and Utah fade not because they are covering people but because of their small populations. California and New York only show up because the mapmakers artificially pretended there were a couple of thousand uncovered people so they wouldn’t drop off the map altogether.

As Pollack points out, the two states that have benefited the most in terms of fewer people being uninsured are Arkansas, the keystone mentioned above, and Kentucky, the dark blue state above and to its east. This is because these two, southern/border states, had very large proportions of uninsured as did the rest of the South, so showed the greatest increase in covered people when they expanded Medicaid. Arkansas’ expansion created poignant stories in places like Texarkana where the poor folks in the Arkansas half were now able to get coverage, while those in the Texas half were not (see the NY Times In Texarkana, uninsured and on the wrong side of the state line”, June 8, 2014). The lesson is that Medicaid expansion could benefit even more people if it were implemented in these large-population states, with real significant changes in the actual and potential health status of lower-income people there.

But they haven’t done it and are unlikely to. The political will is not present. There are anti-ACA crusaders in many states, but they are particularly prominent in the South, which already has the highest proportion of poor and needy people and the lowest levels of social services. Clearly, this has a lot to do with race – that historically and in the present many of the poorest people in the South are African-American (and, especially in Texas, Latino). This makes Dr. Pollack’s invocation of Dr. King particularly relevant. And particularly poignant. Racism has been one of the dominant themes in America, and while it certainly exists in all parts of the country, it has never been as institutionalized as in the South (remember slavery? Jim Crow?). And to those who say it is not like that anymore, we don’t have Bull Connor, or the bridge in Selma anymore, we are the New South, look at the map above.

I really don’t think that the people in the South, any more than in Kansas or Missouri—or Montana and Wyoming—are meaner than they are in other parts of the country. So why do they elect people who institute policies to make it look like they are?

Sunday, February 1, 2015

Precision medicine, trade policy and the cost of drugs: benefiting people or profit for business?

In a recent (January 29, 2015) New York Times Op-Ed, Mayo Clinic anesthesiologist Michael Joyner writes that “’Moonshot’ medicine will let us down”. What Dr. Joyner is referring to is what is now most commonly called, particularly in the large academic medical centers that have bought into it in a big way, “precision medicine” or occasionally “personalized medicine”. This is the concept that, by knowing your individual genetics, medicine can devise targeted treatments for diseases (most of the emphasis is on cancer) that will work for you, but maybe not for other people. Maybe the treatment most commonly used for the disease isn’t right for you; this would find it out.

It is a very attractive concept, and one that has clearly gained traction since the first complete sequencing of the human genome in 2003, moving from a science fiction idea to a mainstream investment by many institutions. As Dr. Joyner notes, “President Obama’s new budget is expected to include hundreds of millions of dollars for so-called precision medicine. The initiative, which he introduced last week in his State of the Union address, has bipartisan support and is a bright spot in the otherwise tight funding environment for medical research.” That is the “moonshot” part – hundreds of millions of dollars. When other funding for research is stagnant or being cut. Because it sounds cool, exciting, really like something cutting edge, a step toward the day when disease will no longer bedevil the human race. However, Dr. Joyner adds: “Unfortunately, precision medicine is unlikely to make most of us healthier.” Bummer.

Maybe he is wrong. Maybe the medical centers investing heavily in precision medicine, and the federal government which will fund it (of course, the “investing heavily” is not unrelated to the “hundreds of millions in federal funding) are right. “Star Trek” here we come! But let us look at the evidence that Dr. Joyner presents. He notes that most common diseases that affect people, even those with clear association with families and thus likely genetics, such as Type II diabetes, are not the result of a single or even a few genes that could be targeted if they could be fixed. There are multiple genetic characteristics that impact whether someone has a tendency to get DM2. Moreover, whether it actually occurs is a result of a complex interplay between those genetic risks and actual behaviors such as diet and exercise. He argues that it is obesity, caused by behaviors but certainly abetted by social changes in our lives, jobs, and easily availability of cheap high-calorie food leading to obesity, that has been the major culprit, given that DM2 (and obesity) is an epidemic of the last half-century, therefore not a result of any genetic change. In addition, even when there are genetic factors for differences between people in their response to treatment, it turns out that these do not explain most of the difference (“missing heritability”), such as in response to the anticoagulant warfarin (a so-far failed effort to use precision medicine to choose treatment). Treatment of chronic diseases like cystic fibrosis by genetic intervention has been unsuccessful, and cancer (like microbes) mutates a lot faster than genetically normal cells.

Joyner also raises the very real concern that people’s behaviors will change in ways that work against their health when they learn their genetic risk. Some people will use the information that they are at lower genetic risk to adopt risky behaviors. This has been described in many areas, everything from people with negative cardiac tests continuing to smoke and overeat to men who have had negative HIV tests and circumcision to decrease their risk of spreading HIV increasing their unsafe sex practices. He also notes that the opposite test result, finding yourself to be at greater genetic risk, can also lead to unsafe practices because you figure you’re doomed anyway. In addition, he notes that there are some people (“worriers”), “…who might embark on a course of excessive tests and biopsies ‘just in case.’ In a medical system already marked by the overuse of diagnostic tests and procedures, this could lead to even more wasteful spending.”

The main message here is only in part that “precision medicine” is something whose time has not yet come and may or may not ever come. More important thing is that, despite this, the government is planning to invest hundreds of millions of dollars in it. Most important is that money is not being spent on implementing treatments for conditions that we do know how to treat. People who are poor or uninsured cannot access many already available – and often incredibly expensive – treatments for diseases like cancer (see my piece “Squeezing the needy: a truly flawed financing system for healthcare”, March 2, 2013) or hepatitis C or many neurologic diseases. “Precision medicine” treatments are certainly going to be even more costly. In addition, we do not spend the necessary money to address the social determinants of health--housing and food and warmth and education--that make more of a difference in health than all of health care.

Indeed, we invest large amounts of money, public as well as private, in programs that effectively make our health worse. Sometimes this is in subsidies to major environmental polluters (BP, anyone? How about fracking and the Keystone XL pipeline?), and sometimes it is more direct, when we actually invest government funds in making treatments more expensive and less accessible to people, albeit to the benefit of the drug companies? Noted economist Joseph Stiglitz takes this on in another recent Times Op-Ed, “Don’t trade away our health” (January 30, 2015). He describes how the US Trade Representative, who negotiates trade agreements “supposedly on behalf of the American people”, is in fact consistently working on behalf of big corporations. In the case of the Trans-Pacific Partnership, this will mean increased obstacles to lower-cost generic drugs by making competition more difficult.Just the availability of generics drives prices down: In generics-friendly India, for example, Gilead Sciences, which makes an effective hepatitis-C drug, recently announced that it would sell the drug for a little more than 1 percent of the $84,000 it charges here.”  This competition should be encouraged; it is the essence of capitalism. But our trade representative is representing big business, not people.

Of course, high drug costs are already a reality. On January 28, 2015, the Times’ Business Section previewed a study coming out in the New England Journal of Medicine from Harvard. “Study finds HIV drugs priced out of reach”. Much of the great advance made against HIV in the last few decades come from effective and more tolerable drug regimens. Atripla, for example, is a once-daily combination of 3 drugs (2 made by Gilead, one by Merck), that is extremely effective. But this study shows that the “flexibility” available to insurers under ACA will mean that folks with worse insurance (usually poorer people) will have to pay $3,000 a year more for Atripla than those with better policies. Again, the poor pay more.

Precision medicine may sound good, and certainly cool, and sexy. It may even benefit some people, if at very high cost, in the future. But right now, today, there are lots of conditions we know how to treat and lots of people who are not getting that treatment because they don’t have the money, are not desirable, have diseases not in the most preferred “product lines”. And we are spending federal money on making some of the drugs that we have that we know are effective less available.

Despite publicity about or funding for precision medicine or any other “new idea”, the fatal flaw is that our health system is not about improving our health, it is about profit. This is intolerable.

Sunday, January 25, 2015

Our health is going downhill: poor public health and poor attention to the social determinants

“Our health is going downhill” shouts a headline in the Kansas City Star, January 4, 2009. The local take of this article, by Alan Bavley, was the poor performance of Kansas and Missouri, the two states served by the Star, on the 2014 report on America’s Health Rankings, published by the United Health Foundation, the longest-running ranking of public health status in the nation, since 1990. Bavley emphasizes that both states have dropped significantly in those rankings; Kansas was 12th in 1990 and is now 27th; Missouri was 24th in 1990 and is now 36th.

This leads to a lengthy discussion of why both states have dropped, mainly attributed to a lack of investment in public health, and how there is a geographic disparity, with states on the coasts doing overall better than those in the Midwest: “What explains this dramatic difference between the coasts and the Midwest is broad investments on the coasts in things that make communities healthy,” Bavley quotes Patrick Remington of the University of Wisconsin. What this misses, however, is the even worse news that is hidden by “rankings” data. While in rankings of states there will always be a #1 (in this case, Hawaii) and a #50 (you guessed it, Mississippi) this hides the fact that, overall, states have gotten worse over this 25-year period. The graphs in the print edition of the Star (not included in the on-line edition) show the decrease in rankings noted above for the two states over time. However, on the “America’s Health Rankings” website one can not only look at the map showing relative state rankings but also click on each state and see how its absolute health ratings have changed over time.

Hawaii, ranked #1 in 2014 (Vermont is ranked #1 for the whole 25-year period), has nonetheless had its health status drop quite dramatically since 1990, while Mississippi, #50, has actually slightly improved. Locally, Kansas’ health status has dropped significantly consistent with its slippage in the rankings, but Missouri’s, after a big dip in the intervening years, is about the same as it was in the mid-1990s, despite its lower ranking. How can this happen? How can Missouri drop 12 places in the rankings despite having about the same health status if the top-ranked states are getting worse? The only explanation is that the gap was even greater in the past, and that some states in the middle, such as Illinois (#30) and Pennsylvania (#28) have gotten better while Missouri has stayed the same. Hawaii has dropped from a rating of +0.7 to +0.3, while Mississippi has gone from -0.4 to -0.3. Dr. Remington’s comments may be accurate, but they were more accurate in 1990, and since then states have seen a race to the middle, if not the bottom, in terms of public health.

The rankings above are the “all outcomes” rankings from the United Health Foundation studies. They are composed of several subcategories. One component lowering these overall outcomes is the obesity rates, which have risen nationally from 11.6% in 1990 to 29.4% in 2014 (!) as well as in every individual state. Diabetes has risen nationally from 4.4% to 9.6%. Physical inactivity has stayed relatively constant, but distressingly high, at nearly 75%. On the other hand, the last measure, smoking, has gone down nationally from 29.5% to 17.6%, but has tended to stay the same over many years more in lower-ranked states, such as Mississippi, Missouri, and even Kansas.  The study ranks senior health separately, but this tracks pretty well with overall health; Hawaii is the best, Kansas is 25, Missouri is 42, and Kentucky replaces Mississippi (#47) as the worst. The study also examines rankings for a variety of other characteristics, some of which are different for the overall population and for seniors. They include chronic drinking (seniors), binge drink (all adults), depression (seniors), etc., as well as societal measures which might impact or “confound” health status including education level, percent of “able bodied” (no disability) adults and percent of children in poverty.

The study also provides us with information on health disparities, obesity levels by different sub-populations, based on education, race/ethnicity, age, gender, urbanicity, and income. Two non-surprises: the South and South Central regions do the worst, and the problem is greater for those with lower education, non-white race/ethnicity, and lower income; urban status and age have less impact. In terms of educational impact on health disparity (the difference between the highest and lowest educated in terms of health status), things change: Hawaii is still #1 but Mississippi is #2, while California is #50! Unfortunately, for many of the states with both low overall health status and low disparity, it means that even the better-educated have poor health status.

So what do we learn? Yes, as Dr. Remington points out, some parts of the country generally do better than others (although identifying these as the Northeast , West, and North Central  regions is more accurate than saying “the coasts”), and the South and South Central regions tend to be worse. Yes, as Mr. Bavley highlights, both Kansas and Missouri have significantly slipped in the relative rankings. But we also see the whole country getting worse, particularly with regard to conditions such as obesity and diabetes. And we see the most dramatic drops in certain states, not only Kansas but Wisconsin (down from +.38 to barely positive at all, +.07). The people interviewed for the Bavley article in Kansas and Missouri, as noted above, cite inadequate, and decreasing, spending on public health as the reason.

It is certainly one of the big reasons, along with a consumer society that encourages consumption of high-calorie, low nutrition foods. And a car-based society that makes exercise a specialty activity, more available to some than others, rather than part of life. And a terrible economy where a shocking number of people don’t have jobs and others have to hold down two or more to make ends meet so have little time for exercise. The other huge reason are those “social determinants of health”; the impact of poverty, racism, poor education, inadequate housing and food. The social structure and social support for the most needy in the US has never been adequate, and is eroding, more in some states than in others, sometimes on purpose (because of political beliefs) and sometimes by a (possibly) more benign neglect.

Some of it is the chronic problem of public health, that its successes are the absence of disease and thus less obvious. It is easier to feel grateful for treatment of a disease we have contracted than, say (as I have often said before) to be grateful each morning that we don’t have cholera because we have clean water. It is, perhaps for some, easier to think we don’t need to vaccinate our children when diseases that the vaccines prevent are no longer in evidence. But it is a fatally flawed analysis. When a good has resulted from doing effective preventive efforts, the solution is to keep up our efforts, whether vaccination or public health.

And cutting back on our social safety net is a good prescription for worse health.

Sunday, January 18, 2015

Free speech, religious belief, and facts: how does it affect health?

The massacre at the French magazine Charlie Hebdo was shocking and horrible, as are the massacres and atrocities that occur regularly with less immediacy to those in the West, such as those committed by Boko Haram in Nigeria. The most positive result was the massive outpouring of support for free speech, for being able to say and print what you want even if it offends people. And, I would add, particularly if it offends the powerful, which Charlie Hebdo also did. More than a million in the streets of Paris saying “Je suis Charlie” (“I am Charlie”), with more than 40 heads of state in attendance, even if they didn’t actually lead the march, but were photographed together on a protected side street. And even if many of them sponsor severe repression of free speech in their home countries. 

The inclusion of Israeli Prime Minister Benjamin Netanyahu was particularly problematic given the violently repressive policies of his government, but given that the companion attack was on a kosher supermarket where four Jews were killed, the symbolism was important even if a lightning rod for (largely just) criticism of Israeli government policy. Less appreciated was the message from Netanyahu that French Jews should all come to Israel, and more appreciated were the sentiments of French Prime Minister Manuel Valls that ‘France Without Jews Is Not France’, and the demonstrators, most of whom were not, who carried signs that said “Je suis juif” (“I am Jewish”).

But the necessary condemnation of terror, and moves to avert it, along with the necessary condemnation of anti-Semitism and the conflation of Jews with the actions of the government of Israel (or the conflation of Islam with the actions of Islamic terrorists) does not solve the problem of communication, that people see “truth” so differently. I don’t know that I can offer much more insight into the conflict of seeing truth through the lens of religious doctrine (and of course some people and groups’ interpretation of religious doctrine) and a “liberal” concept of the value of free speech. I was interested in the perspective of Maajid Nawaz, a British Muslim who became a radical Islamist at 16, served 4 years in an Egyptian jail where his readings changed his perspective and later founded Quilliam, an anti-jihadist think tank in London, expressed on NPR’s Fresh Air. Asked by host Terry Gross how he saw himself as the same person, given his loss of relationships including family and friends since his “conversion”, Nawaz spoke about commitment to justice. He said it was the blatantly unjust treatment of Muslims that motivated him to fight as an Islamist, and the same commitment to justice that makes him oppose terrorism. Ideologically, I think that this is a good start.

 Most countries, including France and the US, have a mixed relationship with free speech. In the US (which I know much better), many people not only support free speech for positions that they agree with but also positions that they can tolerate listening to. Of course, however, true support for free speech means support for speech you abhor, hate, despise, think dangerous. Not, of course, the same as action (“your free speech stops just short of my nose”), but certainly includes free assembly and demonstrations to express views. If one’s religious views include opposing anyone’s right to criticize your religion (or, even more, as illustrated by the Inquisition or ISIL’s massacres of Yazidis, not adopt your religion), you are clearly endorsing a society antithetical to free speech. And, of course, with the grossly immoral series of US Supreme Court decisions that money is speech and that corporations are people who can exercise that “speech”, the entire concept of free speech in our country is perverted.

Closer to home, and closer to the usual themes of this blog, health and social justice, we see again how beliefs not only threaten free speech but threaten our ability to act as an honorable and just society because groups of people see things so differently. The reasons given are many: our social isolation from groups of people unlike us (residential segregation by race and class and age and educational level), our ability to receive “customized” news, where what we watch on TV or find on the Internet is that which agrees with what we already believe. When people hold views based on their faith, it may be difficult or even unreasonable to expect to change it; this is what “faith” is. However, when people hold views that are not religious and are demonstrably wrong in the face of the facts, and those beliefs are held as firmly as those that are religious, and those beliefs threaten the core well-being of other parts of our society, we would hope that they could change.

I have often written about the Social Determinants of Health. These are the conditions of people’s lives that make them more vulnerable to illness, less likely to be able to prevent it through both health screening and living in places and circumstances in which prevention is possible. For example, not near areas of high pollution, not in poor quality cold housing, not in no housing. To have shelter, and decent food, and the opportunity for education for themselves and their children. All the things that characterize their lives and come before their access, or lack of access, to the health system comes into play. If we are to improve the health of the American people, we must not only provide equitable access to health care geographically, financially, and socially (with language access and caring and actual interest in people’s health) but also address those social determinants that disadvantage so many in the pursuit of their health.
 
And then I read the results of a survey by the Pew Research Center that says a majority of well-to-do Americans think that poor people “have it easy”. Widely reported, including by the Washington Post which leads with “There is little empathy at the top”, and CNN, which reports “54% of those with the greatest financial security believe thatpoor people today have it easy because they can get government benefits without doing anything in return’…Only 36% of the wealthiest say ‘poor people have hard lives because government benefits don't go far enough to help them live decently.’" I want to say this is unbelievable, but I have to believe it is true that they think this. I am, nonetheless, aghast that they could think this. What world do they live in? Is it really true that their only contact with poor people is on TV news, Fox News at that? Have it easy?

Would they want to test that? Live like poor people for a while? Even knowing that – unlike real poor people – they could return to their comfort in a month or a week, would they be able to tolerate it? Not being able to pay their bills, not have heat, not have decent or sufficient food, not be able to afford the doctor, not be able to take off work without losing pay to go to one even if they had health insurance? I think – I know – that if they did they would feel differently about it being easy to be poor. But while there is great value to “walking a mile in someone else’s shoes”, there is a way to know what is going on without even doing that. It is called opening your eyes, looking at the facts.

Even when they are uncomfortable, even when they challenge your beliefs, or more importantly your sense of self-entitled comfort. To not do so is part of no one’s religion. This is the responsibility of free people. 

Sunday, January 11, 2015

Belief vs. "truth": how people often make medical decisions

In a fascinating article in the “Medicine and Society” section of the New England Journal of Medicine, “Beyond belief—how people feel about taking medication for heart disease”[1], Lisa Rosenbaum discusses some of the reasons that people do not take medicines prescribed for them by doctors, really for any condition, not just heart disease. These reasons go beyond the obvious ones of personally experiencing side effects and not being able to afford them; indeed, she starts out discussing the fact that folks don’t use aspirin, a very cheap drug, even after having been diagnosed with coronary heart disease, for which the evidence of benefit is very strong.

Rosenbaum addresses a number of reasons, beginning with simple belief. A friend tells her that “My parents [whom Rosenbaum describes as “brilliant and worldly”] are totally against taking any medication”. Another person she meets, prescribed a “statin” (an anti-cholesterol drug), has no intention of taking it and indeed expresses disdain that is “raw and bitter” (the disdain, not the pill). For him, it is tied to the suffering he saw his sister endure when taking toxic anti-cancer drugs. Her hairdresser suggests another reason: taking medication means acknowledging that you are sick, and people don’t want to acknowledge that. He says that he gives his grandmother her nightly medication by telling her they are vitamins—after all, vitamins are to make you healthier, not treat your sickness.

Rosenbaum tells more stories, relating more reasons, but most come down to a belief, almost to an unchangeable worldview. Some of the issues seem to be semantic. People do not want to take “chemicals”, but will take vitamins. Connotation, and the “frame” that people put around words and concepts (sickness, drugs, natural, chemical, etc.) are very important. Of course, they’re all chemicals, and of course anything (“natural” or produced in a laboratory) that can have a biologic effect (good or bad) can have other effects (good or bad).  People sometimes cite the side effects of drugs even when they haven’t experienced them but have read or heard about them, and credit them with more importance than the beneficial effects. While some people have always made decisions based on creating a parallel to what happened to someone they know, the Internet has probably magnified the universe of people they “know” and stories that they “hear”.

Perhaps the scariest reason Rosenbaum points out is that the success of medical treatment has led people to minimize, in some cases,  the seriousness of the disease. As a cardiologist, she points to acute myocardial infarction (heart attack), which used to require 4-6 weeks of hospitalization, and now often has people out of the hospital in 24 hours. She talks to a person who contrasts it to the flu, which “can knock you down for days or a week or two, [while]the heart attack, once they do the thing, you’re in good shape.” And yet, “once they do the thing”, whatever it is, stents or clot lysing (presumably not yet bypass, which does require a longer hospitalization) and you feel better, you still have the disease; only the use of certain drugs along with diet and lifestyle changes can modify the trajectory of the disease. But the latter are hard, and maybe we don’t want to take drugs. Because, you know, we are feeling better.

I admit to initially feeling anger, hostility, as I read the “reasons” that these people would not take medicine, feeling that they were stupid. I don’t mean that I was angry that they don’t take medicine; this is their decision. In addition, there are lots of important reasons to be wary of taking medicines that go beyond personal experience with side effects. Not the least of these is the fact that they are heavily marketed by drug manufacturers, who are in business solely to make a profit, and regularly invent new “diseases” that “need” treatment in order to market their drugs and make money. In addition, “indication creep” (which I have discussed before, The cost of health care: Prevention and Indication “creep”, drugs, and the Sanders plan, June 25, 2011, particularly citing a piece by  Djulbegovic and Paul, “From efficacy to effectiveness in the face of uncertainty: indication creep and prevention creep”).[2] This means that a drug, which is found to be effective and relatively safe for a certain condition, at a certain severity level, in certain people, starts to be used by physicians (often encouraged by the manufacturers) for other people with less severe levels of conditions, and sometimes for other indications for which efficacy has not been proven. For example, starting drugs for cholesterol at levels below which treatment has been shown to reduce mortality, or putting younger (or older) people on treatments only shown to benefit older (or younger) people, or men or women.

Indeed, this appeals to another system of beliefs common in people (including doctors), that if a little is good, more is better; if reducing cholesterol in people whose level is above “X” is good, why not in people whose cholesterol is a little below “X”; if getting your average blood sugar below “Y” is good, why not a little lower still; if aspirin is good prevention and reduces death in men who have coronary heart disease, why not use it in men who don’t but otherwise look a lot like men who do? This sort of belief may lead to behavior opposite of that described by Rosenbaum (that is, taking medication when it is not of value rather than not taking medication that is likely to be of value) but it stems from same root—making decisions based on beliefs rather than evidence. And it is not uncommon to see both behaviors manifested in the same people: someone who would “never” take “artificial chemicals” (regulated drugs) into their body who ingests large amounts of unregulated chemicals (labeled as “natural”). The apparent contradiction is non-rational to me but makes sense to them.

I often—maybe usually—agree with those who say “less is better”, such as Ezekiel Emanuel in his New York Times op-ed “Skip your annual physical”.[3] But I hope that I do this when, as in the case of the annual physical, the evidence does not demonstrate benefit, and the cost is high, as it is for many heavily-marketed drugs. And, of course, my anger subsides as I realize that I often feel the same things, and maybe even sometimes act on them. I don’t want to be a sick person, certainly not one with a chronic disease (it’s bad enough to have the flu!) and taking a medicine for a condition labels me as such. I don’t want to take medicines just because they “might” help (prescription or over-the-counter, made by traditional pharmaceutical manufacturers or “natural” companies) if there is not good evidence, and I don’t want to experience unpleasant side effects. But I do take the medicines that have been shown to benefit people like me, with the same or similar risk factors, and even put up with some side effects (e.g., mild myopathy from the statin).

I am not going to change anyone’s worldview, no more than Dr. Rosenbaum is likely to change that of the “brilliant and worldly” friends of her parents. And I am certainly not going to become an advocate for treating for the sake of treatment, or being a flak for drug companies. But if there is strong evidence that taking a drug (in the lowest effective dose) for a condition that I in fact have (denial or not) is likely to have a “patient-important” (meaning lower risk of premature death or better quality of life) outcome, and I personally do not experience serious side effects, I will take the drug.

The key issue here is not making decisions to do, or not do something (have a physical or take a drug) because of a general belief that such things are good or bad for you, but rather to evaluate the evidence of how it might benefit or harm you, and to make a decision that balances these filtered through your own value system, how much you value the potential benefit or harm that might come.

To me, this is a rational approach.





[1] Rosenbaum L, “Beyond belief—how people feel about taking medications for heart disease”, NEJM 8 Jan 2015;372(2):183-87
[2] Djulbegovic B, Paul A., From efficacy to effectiveness in the face of uncertainty: indication creep and prevention creep”, JAMA. 2011 May 18;305(19):2005-6..
[3] Emanuel E, “Skip your annual physical”, New York Times, January 9, 2015.

Monday, January 5, 2015

Thursday, January 1, 2015

Direct Primary Care, Scope of Practice, and the Health of the People

One of the relatively new and growing movements in family medicine is “direct primary care”, or DPC. The term seems to have a lot of different meanings, depending upon who is talking about it (or, often, it is talked about in very vague terms, as are many things we want to have only thought about in positive ways; if we get too specific people can criticize!). In general, however, it is about primary care doctors taking direct payment from patients for their services rather than getting reimbursed by insurers (including Medicare and Medicaid). This is touted to be a panacea for doctors tired of “bureaucracy” (often referring to the “government”, but certainly at least as painfully insurance companies); of too many forms to fill out and rules to follow and loss of autonomy. The primary care doctor provides the service that s/he is capable of and the patient pays, just like in the old days (maybe barter is included, but don’t know about paying in chickens – on visit to the vet the other day I saw an old sign on the wall advertising a vet’s services, indicating both cash and barter—but no poultry.)

There is a certain attraction to the simplicity of this arrangement. The doctor provides the services that s/he can provide (presumably not including most laboratory tests or medicines or immunizations) for a fee that is collected in cash. The patient can even apply to their insurance company for reimbursement. Voilà! Everyone is happy! The patient gets the service, the doctor does what s/he likes to do, and is freed from bureaucratic regulations and thus can operate his/her business more efficiently and with lower overhead, presumably (this is not always explicit) passing the savings on to the patient. But there are a few concerns.

The first, obviously, involves people who are too poor to pay. This may not concern some of the DPC doctors, but does others, and should concern our society as a whole. We know these people; we see them regularly in our student-run free clinic (except there they do not pay anything). I have pointed out that this need not be a problem; one of the advantages of not taking insurance is that the doctor is free to charge different people different amounts. The Center for Medicare and Medicaid Services (CMS) requires physicians accepting it to not charge anyone less than the amount they charge Medicare (not the amount Medicare actually pays). Not accepting Medicare means a doctor could charge a well-heeled person $100, and another poorer one $25 for the same service. Or $5. Or a chicken. Or nothing. And those people with Medicare (or another insurer) could still submit a request for reimbursement for what they actually paid. Don’t know if they would be reimbursed or not. And it might be tough for the senior who can barely accomplish their basic functions to submit directly to Medicare. It all depends, as I pointed out to a colleague considering such a practice, on how much you want to make. If you are willing to make less, you can charge people less. I have no idea how many of those physicians currently practicing or planning to practice DPC are charging such a sliding scale, or taking all comers, or are willing to earn less. But it is at least theoretically possible to do this.

A second concern is “what is the scope of care provided by the DPC provider?” Sometimes discussions of DPC seem to focus on treating colds, high blood pressure, sprains, etc., all the things that are currently taken care of by the increasingly common Urgent Care Centers in drug stores and big box stores. Many of these things are problems that do not need to see a provider (your mother can tell you to drink plenty of fluids, rest, and eat chicken soup – perhaps a better use for that chicken than paying the doctor!). Otherwise, it is not clear what advantages DPC offers over Urgent Care Centers, except that the latter are often staffed by Nurse Practitioners, not physicians. If you care. If the services being offered are within the scope of practice of the provider, what difference does it make? And the Urgent Care Center will take your insurance, not a small matter when it comes to the cost of immunizations, for example.

Clearly, this DPC model cannot work for problems that need to be cared for in the hospital, or require facilities. The doctor cannot choose to be DPC only for their outpatient practice but be on insurance for inpatient care, so won’t do it. Or probably deliver babies. Or provide any beyond the simplest of office-based procedures. Including the critical ones of providing long-acting reversible contraception (LARC), IUDs and implants, which have very high up-front costs, except for quite well-to-do patients. Again, it is getting hard to see the benefit of DPC over Urgent Care, except, possibly, the provision of continuity of care with the same provider. Unless, of course, you need something that cannot be done in the office. Metaphors abound; one DPC provider is quoted as saying “you don’t use auto insurance to buy your gas; why should you use health insurance to buy primary care?” I leave this question up to you, including whether the metaphor is apt. However, it clearly minimizes the scope of what primary care doctors can do.

This is a potential challenge for family medicine and other primary care providers, especially as family medicine moves into its “Health is Primary: Family Medicine for America’s Health”[1] campaign. For a long time, other specialists have derided PC for only taking care of simple problems. Many, including me, have argued the contrary, that primary care is difficult and complex (see, for example, my 2009 blog post “Uncomplicated Primary Care”, and my recent Graham Center One-Pager “Accounting for Complexity: Aligning Current Payment Models with the Breadth of Care by Different Specialties[2]), but quotes like the one above seem to indicate a retrenchment, away from “full-scope” practice. Obviously, like DPC, “full-scope” can be defined in various ways, but usually means things like caring for people in the hospital (another thing I have argued is a strength of US family medicine), delivering babies, caring for children, doing a variety of procedures, and even caring for people in intensive care. At the recent North American Primary Care Group (NAPCRG) meeting, several papers from the American Board of Family Medicine (ABFM) and Graham Center indicated that in most cases greater scope of practice of family physicians led to lower cost. The ABFM developed a 0-30 scale for scope of practice, and found significantly lower costs for patients cared for by FPs with 15-16 scores than those of 12-13 (a relatively small difference in scores). Presumably this is because those with lower scope of practice are referring more to higher-cost specialists. The interesting exception was integrated practices (like Kaiser) where the scores for FPs were low (~11.5) but costs were low, as a result of the other surrounding services available to patients from those integrated systems. These would not be characteristic of small DPC practices.

Finally, there is the concern about “who is health care for?” Much of the interest in DPC among residents, it seems, is to make their own lives less stressed, less busy, less frustrating. Not bad things. But the ultimate and only real measure of whether our society should embrace such a trend is whether it enhances the health of our people. All our people. Rich and poor. Rural and urban. White, Black, Asian, Hispanic. Over 150 years ago, Rudolf Virchow (the Father of Social Medicine) wrote “Medical education does not exist to provide students with a way of making a living, but to ensure the health of the community.… If medicine is really to accomplish its great task, it must intervene in political and social life.”

I hope that we still believe this to be true.

Happy New Year!




[1] Phillips RL, et al., “Health is Primary: Family Medicine for America’s Health”, Ann Fam Med October 2014 vol. 12 no. Suppl 1 S1-S12.
[2] 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.

Thursday, November 27, 2014

Giving Thanks in a scary world

Let us give thanks.

Let us give thanks that we are not the parents of Michael Brown. One of the more thoughtful and moving pieces on this subject among the thousands to appear is by Charles Blow, Fury after Ferguson.

Let us give thanks, if we do not live in Missouri, that we won’t see the St. Louis County District Attorney running for Governor. Or, if we are, that we can vote against him.

Let us give thanks that we are not in prison, victims of the four-decade old policy of mass incarceration in the US, addressed as a major public health epidemic by the New York Times, Mass Imprisonment and Public Health”, which details the reasons why

…people in prison are among the unhealthiest members of society. Most come from impoverished communities where chronic and infectious diseases, drug abuse and other physical and mental stressors are present at much higher rates than in the general population. Health care in those communities also tends to be poor or nonexistent.

The experience of being locked up — which often involves dangerous overcrowding and inconsistent or inadequate health care — exacerbates these problems, or creates new ones. Worse, the criminal justice system has to absorb more of the mentally ill and the addicted. The collapse of institutional psychiatric care and the surge of punitive drug laws have sent millions of people to prison, where they rarely if ever get the care they need. Severe mental illness is two to four times as common in prison as on the outside, while more than two-thirds of inmates have a substance abuse problem, compared with about 9 percent of the general public.
Common prison-management tactics can also turn even relatively healthy inmates against themselves. Studies have found that people held in solitary confinement are up to seven times more likely than other inmates to harm themselves or attempt suicide.

The report also highlights the “contagious” health effects of incarceration on the already unstable communities most of the 700,000 inmates released each year will return to. When swaths of young, mostly minority men are put behind bars, families are ripped apart, children grow up fatherless, and poverty and homelessness increase. Today 2.7 million children have a parent in prison, which increases their own risk of incarceration down the road.

Oh, yes. Or their children.

Most of us are not. Some of us are. It is simply not ok. And it is not ok to be selfish, arrogant, so-greedy-it-is-not-to-be-believed multi-billionaires. Be successful, yes. Be rich, yes. Do not be obscenely so wealthy that it requires the destruction of the lives of millions of others.

Blow notes that
Even long-suffering people will not suffer forever. Patience expires. The heart can be broken only so many times before peace is broken. And the absence of peace doesn’t predicate the presence of violence. It does, however, demand the troubling of the comfortable

Nick Hanauer, a multi-billionaire, is less sanguine. He warns his fellow 0.01%ers in a post on Politico.com that “The Pitchforks are coming for us…Plutocrats”. It’s a nice thought, that they would get what is coming to them, but I am less than confident that he is correct. It is a nice thought for Thanksgiving, though.

If we have jobs, let us be thankful. If, even better, they are good jobs, let us be more thankful.

If we have family, let us be thankful. If we have lost family, let us be thankful for the time that we had them. If we can still imagine a world with peace and justice, let us be thankful, although it may be just in our imagination.

And then, let us take a deep breath and realize that it is not just going to come, that we are going to have to work for it. Hard, and tirelessly.

Happy Thanksgiving.

Monday, November 17, 2014

Racism, classism, and who we take into medical school: Who will care for the people?

I work in a medical school. I see and teach medical students. They are a smart group. When measured by grades and scores on standardized exams, they are even smarter. Some of them – but not nearly enough – are members of socioeconomic and ethnic groups or geographic areas under-represented in medicine. Sometimes, these students struggle with grades in medical school. Occasionally, this elicits comments, sometimes smug, sometimes rueful, that this is the result of affirmative action, as if this were a negative thing. Given the alternative, the default of taking all people who look alike, who come from the same background, who want to do the same things – in brief, to stereotype, white 22 year old men who come from economically privileged and professional families (many of them medical) who want to be subspecialists in the suburbs – this is pretty scary.

It is affectively, intellectually, and morally scary, yes, to think that we could accept this kind of regression to an archaic, not to say racist and classist past where becoming a doctor was a privilege limited to only a few. It is also scary in very practical terms, because the people who need health care the most are those least likely to be served by the “default” group. Indeed, in fulfilling their personal goals, the result will be to “serve” already overserved communities, largely in specialties in oversupply. There is good data that shows that students from rural areas are more likely to serve rural communities, that students from underrepresented minority groups are more likely to serve members of those groups, that students from less-privileged backgrounds are more likely to serve needier communities. And that all these groups are more likely to enter primary care specialties, those in most short supply. This is what we want. But they represent a small percentage of our medical students. Why? Because we still, despite all the data showing what predicts service to people most in need, stay wedded to incorrect and outdated ideas of “qualified” for medical school that overwhelmingly bring us the same old same old.

Many (although clearly, given the above, not most) of medical students, from all backgrounds, have some difficulty with the first two years of medical school despite being not only smart but are well-educated from top small liberal arts colleges. There is a relationship here; these colleges emphasize thinking and creativity and problem solving, exactly the skills needed to be an effective physician. They teach largely in small and interactive classes, fostering self-confidence and independence and thoughtfulness and sometimes non-conformity, exactly the temperament needed for an effective physician. They grade largely on the basis of essay tests, requiring integration of information, literacy, and demonstrating an ability to think, not on multiple-choice tests, just what we want from physicians. Unfortunately, this is not the best preparation for the first two years of medical school, overwhelmingly consisting of large lectures characterized by a presentation of a huge number of facts, and designed to reward memorization of those facts using massive multiple-choice tests. Good preparation for this: being a science major at a large university whose courses overwhelmingly consisted of large lectures characterized by a litany of factoids and rewarding successful regurgitation of those factoids on massive multiple choice tests. QED.

Not, of course, the best preparation for being a curious, open-minded, thinking, problem-solving doctor. But this is what we get. Yes, it is certainly true that some of our students from large universities, or from professional or high socioeconomic status, or majority ethnic groups, or suburbs, or all, are incredibly committed to making a difference. Many want to enter primary care, many more want to serve humanity’s neediest, in our country and abroad. They are humble, and caring, and smart. We are lucky to have them in our schools and entering medicine. But they, along with those who are from less-well-off families, and ethnic minority groups, and rural communities, remain a minority among all the sameness. And remain more or less in the same proportions over time. We continue to do the same thing, and have the audacity to wonder why we do not get different results. This is Einstein’s definition of insanity.

On November 16, 2014, Nicholas Kristof published his column “When Whites Just Don’t Get It, Part IV” in the New York Times. He discusses the continuing racism in this country, the legacy of slavery, the fact that “For example, counties in America that had a higher proportion of slaves in 1860 are still more unequal today, according to a scholarly paper published in 2010.” And, of course, he discusses the responses he received (from white people) to Parts I-III, saying it is all in the past, stop beating that drum, it is not my fault, I work hard and don’t get the special privileges that “they” do, and why don’t they take personal responsibility, and our President is Black, isn’t that proof that the problem is gone? I won’t begin to get into the question of how much of the vicious attacks on our President are in fact the result of the fact that he is Black; rather while I observe that the fact that he was elected says “Yes, we have made incredible progress,” I note that this does not eliminate “Yes, we still have lots of racism and it has major negative effects on people as individuals and society as a whole.”

Kristof talks about the fact that he and his Times colleague, Charles Blow, are both promoting books. He notes that while he (Kristof) is white and from a middle-class background, Blow is black and was raised largely in poverty by a single mother. But he also makes clear that this doesn’t prove that the playing field is even, but rather that Blow was very talented, very hard working, and also lucky. That some members of minority groups, or people with very disadvantaged backgrounds (or both) succeed is a testimony to them, to their drive and intelligence and talent and luck, and the support that they have had from others such as family or friends which, while obviously not financial, was significant. It absolutely doesn’t prove that those who are from such backgrounds who have not succeeded are at fault. Indeed, the converse is true; how many of those who are from well-to-do, educated, privileged and white backgrounds, who have had all the financial and educational supports all their lives, who are now in medical school or doctors or professors or leaders of industry would have gotten there if they had started as far down the ladder as, say, Charles Blow, or some of our medical students? Some, for sure, but not most. They are folks born on second, or even third, base, who make it home and look at those who started from home and made it around all four bases, and say “why can’t they all do that”? Most of you, starting in the same place, would, like those who actually did start there, never have had a prayer.

It is common for classes of medical students to develop a “personality”, more self-centered or more volunteering, more intellectually curious or more grinding, more open or more closed. I suspect that this probably has to do with a few highly visible people, because most of the students don’t vary that much. I have heard faculty complain about the inappropriate behavior, the lack of professionalism (especially when they get to the parts of school that involve caring for patients), the sense of “entitlement” that many students have. But this is not true (overwhelmingly) of those who are the first in their families to go to college, who are grateful for the opportunity and hard-working, and committed to making a difference in the world. If we think that entitled, unprofessional students are not desirable, why are we accepting those who fit that mold?


We can do better. We can scale up programs to accept caring, humble, committed, smart people instead of self-centered, arrogant, and entitled ones. Indeed, if we hope to improve the health of our people, we must.

Sunday, November 9, 2014

Uber, pricey doughnuts, and health care: serving the needs of the people or the interests of the rich and powerful?

Two articles in the Sunday Review of the New York Times on November 10, 2014 that are not explicitly about health care seem to me to be very much related to the health care system in the US. “Republicans and the puzzle of Uber”, by Josh Barro, discusses the conflicting interests that affect policy making, particularly at the state level, and create an ideological challenge for that party. On the one side, the libertarian wing of the party lauds “the smartphone based car service” Uber as a wonderful example of deregulation, of opening the market to new ideas that nimbly serve the consumer and meet a real need. On the other side are the existing large and small businesses whose owners not only vote Republican but contribute money to Republican coffers, who want to have their interests protected. In the case of Uber, it is licensed taxi owners, but as Mr. Barro makes clear, this extends to many other businesses where profit margins are protected by legal regulations.

Examples that Mr. Barro cites include everything from licensing of interior designers, auctioneers and ballroom dance studio owners in Florida (run by Republicans) to limiting the sale of coffins to funeral homes (in Oklahoma, also very “red”). He notes that this also occurs in the case of very large businesses at the federal level, citing the controversy about the Export-Import bank, which can protect big companies in the US, but is seen as anti-competitive by some in Congress. Other examples which he does not mention include opposition to the presence of food trucks by local restaurants and “blue laws” in some states requiring car dealerships to be closed on Sunday (hey, if it were legal someone would open and then I’d have to also to say competitive, and I don’t want to work Sunday!)

What does this have to do with the health system? A lot, in a lot of areas, but one that is of great interest to me is the recent initiative begun by a collaboration of all of the major family medicine organizations and newly including osteopathic groups called “Family Medicine for America’s Health”. This effort, with the tag line “Health is Primary”, is good and important, calling attention to the fact (and it is fact) that the creation of a cost-effective health system that delivers high-quality care depends upon a strong primary care base (discussed and with evidence presented many times in this blog). It also emphasizes that family doctors are the central specialty in primary care, given the near abandonment of general medicine by internal medicine graduates. The argument is articulately made in a recent article (ironically called, internally, the “über article” as it will be succeeded by other articles addressing components of the problem) in the Annals of Family Medicine, Health Is Primary: Family Medicine for America’s Health”.

However, there has been less-than-sweeping coverage in the media, and a less than enthusiastic reception by other groups in the medical establishment. A generally positive article in the Kaiser Health News by Lisa Gillespie on October 24, 2014, “Family doctors push for a bigger piece of the health care pie”, quotes Atul Grover MD, chief public policy officer of the Association of American Medical Colleges (AAMC), who says “while primary care is important, taking funding away from specialty training isn't necessarily a solution because an aging population will need more specialty care.” This may or may not be true – we need as much training in different specialties as we need, not more or less. It is almost certainly true that we need more in primary care and less in some others – but it reflects Grover’s (and AAMC’s) role in representing the interests of our academic health centers and all of its components even when this may not be in the best interests of the health of the American people. Just like the Republican party, AAMC has constituents that may reflect different interests.

Thus, there is some irony to another quotation from Grover, that “It’s always a question of what motivates groups to do these kind of campaigns — is it looking out for patients or your own interests, and generally it’s a combination of both,” because this is exactly the position the AAMC is in. However, it is a real caution for the family medicine organizations who are working on “Family Medicine for America’s Health”: to the extent that this campaign keeps to the high ground of America’s health (as it generally is, notably in the Annals article) it deserves strong support. To the extent that the self-interest of family doctors is, or is seen to be, the major driver of the campaign, we risk being lumped with other “special interests”: we could become the funeral homes in Oklahoma selling coffins, or at least the AAMC.

The other NY Times article on November 9, 2014, is from Margaret Sullivan, the Times’ “Public Editor”. “Pricey doughnuts, pricier homes, priced-out readers” addresses common complaints from readers that the Times, not only in its advertising but its articles, seems to be addressing an incredibly wealthy crowd. Anyone who reads the paper is impressed by the lack of accessibility of the homes featured often costing not just millions but tens of millions of dollars, the ubiquity of ads for $10,000+ watches, and articles as well as ads for the highest-end consumer items ($160 flashlights and doughnuts costing $20 for a half-dozen). Sullivan notes that these may seem “aimed at hedge fund managers, if not Russian oligarchs”. She quotes Times executive editor Dean Baquet who, adding insult to injury, says of Times readers “I think we have as many college professors as Wall St. bankers”. This is a double insult; first of all there are way more college professors than Wall St. bankers, and the idea that college professors are the economic “low end” is amazing.

Ms. Sullivan’s article cites mixed reviews of the extent to which the Times covers of poverty (the Pew Research Center says 1% of page 1 articles), but it is clear that appealing to the middle class is missing from the Times. Baquet talks about “balance” as if it were reasonable to balance coverage of issues relevant to the 0.01% with those of the 1% or even only the 10% wealthiest Americans, and only an occasional piece addressing the world of the rest of the nation lives in. This, of course, is what parallels the health care system.

Our hospitals seek to attract well-off and well-insured clients, “balancing” them with poor people. But there are way more poor people, and they tend to be sicker and need more care, so justice, equity, demands that there be much, much more care and attention allocated to them than to the wealthy. If the Times makes money from advertisers who want to reach the wealthiest customers, our hospitals are interested in pleasing their wealthiest customers (oh, I mean patients) in hopes of getting big donations. And those donations are almost never used to provide necessary health care for the sickest and poorest, but rather to open new units (adorned with the donors’ names) to recruit yet more well-off patients. Both our health care institutions and the NY Times are about augmenting their income rather than meeting people’s needs.

Ms. Sullivan ends with “In the end, the upscale doughnut and the penthouse apartment — lofty as they may be — have nothing to do with The Times’s highest purpose.”  Good for her. Maybe Mr. Baquet will get the message, but I doubt it. At bottom, however, if the “balance” of whose interests are addressed by New York Times articles seems off, or offends you, or doesn’t meet your needs, you can read your local paper.

If the balance of who our health care system cares for is way off, we have to work to change it.

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