Monday, March 30, 2009

Immigrant and Refugee Health

The New York Times (March 29, 2008) has a front-page story about the challenges faced by clinics caring for large numbers of immigrants and refugees.[1] It focuses on the International Clinics at Hennepin County Medical Center in Minneapolis, MN, and particularly emphasizes issues confronting Somali refugees and their caregivers.

Many of these issues, including language and cultural difficulties, and the problems of poverty that often afflict people in these groups, are not new to the United States. Our multi-cultural, multi-ethnic (and sometimes “melting pot”) society has long tradition of immigrants arriving from other countries and cultures and presenting “new” challenges to the social service and health care systems. Each group of new arrivals has been seen as “different”, and many that were previously seen as outsiders, such as Jews, Italians, and Irish, have become insiders[2][3],[4][5] One obvious exception has been African-Americans, whose ancestors were brought here as slaves, and who have never (unlike the ethnic groups in the books referenced above, have never “become white”; indeed, that very term derives from the special place of oppression that has been reserved for black people in this country.

One point not really addressed by the Times article is the difference between immigrants and refugees. While the US has had both over its history, immigrants have always been the dominant group. Refugees came after WW II, and after the Vietnam war, and after every war. Immigrants are searching for a better life for their families, and despite the hardships, they have chosen to make the change. They are, historically and currently, different people from those who stay, more willing to take risks, more buoyed by hope. Refugees, on the other hand, are fleeing often horrific situations; they are not coming by choice but by lack of choice. Life in their homeland is intolerable. Thus, while both groups may hold onto their cultural values, beliefs and habits, for refugees this may be all that they have.

The Times notes that, largely in response to pressures from Somali refugees who will not allow themselves to be delivered by male physicians, the obstetrics staff at Hennepin County has become almost entirely female. This decision has been made, de facto or de jure, but many other issues also exist that are not as easy to resolve? When does respect for the culture of someone else (a good thing, generally) become limited by the implications? Providing interpreters is good but very expensive; providing female obstetricians and midwives is probably good, and may be part of an overall transition in obstetrics. But what about “female circumcision”, genital mutilation, also common among Somali women? If this is a core “cultural” tradition, highly desired by a refugee (or immigrant) group, does this mean it should be provided? I think not. A similar example (though not specific to Somalis, let me be clear): If a woman is battered by her partner and this is explained as “part of their culture”, would this make it any more ok? Again, I think not, but these examples illustrate the continuum of decisions that have to be made in delivering health care to refugee and immigrant (as well as “native”) people.

Refugees are also much more likely than immigrants to have experienced terrible personal tragedy; the deaths of friends and family members, often in violent and gruesome ways, rape, mutilation. Post-traumatic stress disorder (PTSD) is common. On the “plus” side, once having been granted refugee status, they are legal in the US, and eligible for certain benefits. Many of our immigrants are “illegal”; they do not have papers and are increasingly denied access, as the Times article points out, except in certain “safety net” venues, or until they come in to the emergency room very ill. Our increasingly restrictive laws see limiting access to health care as both a way of saving money (“why should we pay for these illegals?”) as well as being a punishment.

Which, as it often does on these pages, brings us back to money. Why does Hennepin County Medical Center bear the burden of this care? Why are there not other medical centers and doctors throughout the Minneapolis area taking equal responsibility for poor and uninsured immigrants and refugees? Why is this also a problem in every other major city, including my town of Kansas City and my state of Kansas, in which there are no publically funded hospitals? Everyone wants the best of care for themselves and their families, but the definition of “best” is very open to question (not only for cultural, but for medical reasons as well, as I have often discussed). In addition, the costs may become untenable. There is only so long that honorable people can say “Do for me (and mine); save the money on you (and yours).” Eventually we need a comprehensive and rational care system, which deliveries necessary care to all before there are frills for any.

[1] Grady D., “Foreign Ways and War Scars Test Hospital”, New York Times, March 29, 2009.
[2] Roediger DR. Working Toward Whiteness: How America's Immigrants Became White: The Strange Journey from Ellis Island to the Suburbs. Basic Books. New York. 2005.
[3] Ignatiev N. How The Irish Became White. Routledge. New York. 1995
[4] Brodkin K. How The Jews Became White Folks And What That Says About Race In America. Rutgers University Press. Piscataway, NJ. 1998
[5] Guglielmo J. Are Italians White?: How Race is Made in America. Routledge. New York. 2003.

Thursday, March 26, 2009

Medicare Costs in Rural America: A case of reaping what we haven't sown?

This guest column is by Donald Frey, MD. Dr. Frey is Professor and Chair of the Department of Family Medicine at Creighton University in Omaha, Nebraska, and an expert in rural primary care. He is also the accomplished author of the fiction book "Medicine: a Novel"

The recent New England Journal of Medicine article by Elliot Fisher describing the latest data release from the highly respected Dartmouth Atlas Project[1] underscored what many have known for some time—Medicare costs are soaring.

The study compared state and regional growth in Medicare costs between 1992 and 2006. But in addition to the overall rise in costs, the continued marked variance among costs across all states/regions was particularly disturbing. These cost discrepancies, as in previous studies, were independent of patient severity and disease status. In some instances, states that had previously been low on the cost index had jumped significantly. Others showed relatively moderate increases. None showed cost reductions.

The figures for Nebraska are particularly interesting. Sitting squarely in the center of the country, Nebraska has two metropolitan areas (Omaha and Lincoln) and a large region of rural and frontier counties. In 1992, Nebraska was at the top of the heap when it came to efficient use of Medicare dollars, ranking 51st out of 51 states and territories in Medicare costs per enrollee.

But something funny happened on the way to the 2006 survey. Costs per enrollee skyrocketed 5.3 % and Nebraska soared to 39th in Medicare spending. Interestingly, the greatest cost increases were in the most rural portions of the state.

What happened? The authors offered very little in the way of specificity. Undoubtedly, further analysis of these data may result in significant insights into why costs are rising more rapidly in specific areas as opposed to others. But at present, it is important to note what the extensive earlier work of the Dartmouth Atlas project has already shown.

Repeatedly, the Dartmouth researchers have shown the positive correlation between the percent of state physician workforce comprised of primary care physicians and lower costs and improved outcomes. States with higher concentrations of specialty physicians tended to have higher costs and poorer outcomes. Such findings are right in line with the international data generated by Dr. Barbara Starfield at Johns Hopkins.

All of this would be consistent with Nebraska's status in 1992. At that time, Family Medicine was the backbone of health care delivery in the state, particularly in rural areas. Even in the metro areas of Omaha and Lincoln, primary care was readily available and widely utilized. Four residency programs, all with a strong rural component, produced 32 residency graduates per year, many of whom remained in state to practice following graduation.

But in the ensuing years, Nebraska's urban centers began investing heavily in developing overlapping and competing subspecialty services. The number of medical students entering Family Medicine plummeted, and urban hospital systems found that a cost effective way to cover their primary care needs was to loot rural areas of their physicians. Rural communities began to experience increasing difficulty meeting their workforce needs. Some towns saw workforce reduced by more than 50%, with some 4-5 doctor communities reduced to only 2 Family Physicians.

Physicians in these communities suddenly found themselves overwhelmed. Local systems that previously were highly organized with respect to call coverage, division of labor, procedural practice, etc., were now finding it impossible to continue providing the same level of service in the face of such huge demand simply for basic care. Thresholds for referral began to lower. In order to manage the most basic community needs, cases that previously would have been readily handled locally by community Family Physicians had to be referred out to regional centers. These centers, specializing in more intensive—and more costly—care, began to manage these patients instead.

As the demand for more intensive (and more lucrative) care increased, urban health system recruitment of sub-specialists intensified, with an all-too-willing crop of medical graduates flooding local sub-specialty training programs, compromising even further the availability of Family Medicine graduates to "backfill" rural areas.

The result? Care that was more costly, further removed from the community, with no discernable improvement in quality.

Whether changes in workforce alone can fully explain Nebraska's explosion in Medicare costs is certainly open to question at this time. Hopefully, further analysis of state-wide Medicare costs, along with comparative data from other states will more fully illuminate this issue. In the meantime, given the exhaustive data regarding primary care and Medicare costs already produced by the Dartmouth Atlas project, the notion that Nebraska's significant rise in Medicare costs could be best explained by a statewide shift away from primary care remains a disturbingly plausible possibility.

If this is the case, rural states like Nebraska, where Family Medicine has traditionally provided a greater percent of overall care, may turn out to be harbingers of even greater increases in overall healthcare costs for the nation, as even those states that traditionally have relied less on primary care for health care delivery shift an even greater percent of their workforce to sub-specialties.

Regrettably, the influential Association of American Medical Colleges (AAMC) remains steadfast in its opposition to restructuring residency training positions to reflect the growing national need for Family Physicians, instead advocating for an increase only in total medical school student enrollment, with the seemingly blind-faith position that “the market” will drive graduates to where they are needed most.

An unregulated market that’s supposed to make everything work out fine? Certainly sounds familiar in 2009.

If the planned expansion of medical school enrollment by 30% occurs as planned, along with a continued insistence that market forces will auto-correct physician workforce, the work by Fisher, Starfield, Wennberg, Shi, and so many others[2] would predict that health care outcomes in this country will actually worsen because of the AAMC’s actions. If this occurs, it will reflect a perverse twist on one of the oldest principles of agriculture known to everyone here in Nebraska—rather than reaping what we sow, the outcomes we inherit will instead be due to what we haven’t sown.


[2] Many of these articles are previously referenced on this blog. See especially December 11, 2008.

Tuesday, March 24, 2009

Mexican Murders and US Guns

The “drug war” violence in Mexico has been getting an increasing amount of press in the last few days. Over 1600 murders in Ciudad Juarez, Chihuahua, across the river from El Paso, Texas, last year alone; more than in Baghdad. Now the “spillover” into the US is big news. In the New York Times on March 22, 2009, Randal Archibold’s article “Mexican Drug Cartel Violence Spills Over, Alarming U.S” [1] talks about the increasing murders in many US cities linked to that violence; today, March 24, 2009, Enrique Krauze bemoans the characterization of Mexico as the being primarily the home of drug cartels and murderers, describing the work Mexico has done and the work of its democracy, noting that “…Nor, for that matter, did anyone ever see Al Capone and the criminal gangs of Chicago as representative of the entire country.” [2] Mr. Krauze has a point.

But, whatever the injustice of characterizing Mexico by the drug cartel murders, the big news in the US is its "spillover" here. What no one is talking about is the fact that the US gun laws (or lack thereof) is at fault; the US is an open shopping market for automatic weapons for the drug lords – not to mention home-grown criminals like Lovelle Mixon who killed 3 (may soon be 4) police officers in Oakland, California on March 21, 2009.[3] In this same week, an Arizona judge threw out a case against a gun dealer in Glendale accused of selling over 200 guns to arm cartels.[4]

Let’s get right down to it. Guns don’t kill people, people with guns kill people. And the US is a candy store for weapons that have no place in hunting. A large part of the blame belongs to the National Rifle Association’s intransigent stance against any regulation of firearms, including automatic weapons, and even more to the federal and state legislators who either because of their own beliefs or fear of the power of the NRA continue to do its bidding. And if they act on those beliefs, or on that fear, they have to accept the results, intended or not. Any one of those legislators or congressmen who bemoans these murders but has opposed gun control regulation should look at the blood on his/her own hands.

[1] Archibold R, Mexican Drug Cartel Violence Spills Over, Alarming U.S, NY Times, March 22, 2009
[2] Krauze E, The Mexican Evolution (Op-Ed), NY Times, March 23, 2009
[3] Healy J, 3 Officers Are Dead After Shootings in Oakland, NY Times, March 21, 2009
[4] McKinley JC, Prosecutors Seek Appeal in Dismissal of Gun Case, NY Times, March 19, 2009

Saturday, March 21, 2009

PSA Screening: What is the value?

Two studies published in the New England Journal of Medicine on line on March 18, 2009 regarding the use of prostate-specific antigen (PSA) screening for prostate cancer have been getting a lot of coverage in the popular media, including NPR and the New York Times. The reason is that these studies do not, overall, indicate that such screening saves significant numbers of lives. In the US study of 77,000 men, the PLCO trial, there was no significant difference in mortality in the group receiving PSA screening (92 deaths in the study group vs. 82 in the control group),[1] while in the European study of 182,000 men, there was a very small reduction in mortality, barely achieving statistical significance.[2] Dr. Allan Brett, summarizing the article in “Journal Watch: General Medicine” notes that “To prevent one prostate cancer death, 1410 men had to be screened, and 48 additional cases of prostate cancer had to be diagnosed and treated. All-cause mortality did not differ in the two groups”.[3]

In fact, the US Preventive Services Task Force, the committee that evaluates prevention strategies including screening tests, has long indicated that there is insufficient evidence to recommend for or against prostate cancer screening using PSA, and recently amended that statement to recommend against screening in men over 75:

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of prostate cancer screening in men younger than age 75 years..
The USPSTF recommends against screening for prostate cancer in men age 75 years or older.”

So what is the fuss? Why does the Times have a front page article entitled “Studies show prostate test saves few lives”.[5] Well, mainly because, despite the lack of recommendation by the USPSTF, doctors have been ordering PSA tests for men over 50 for years. The American Urological Association has recommended it: Regarding early detection of prostate cancer, the expert panel concluded that routine PSA testing should be offered in men when:

“Age is 50 years and greater, unless the man has increased risk factors, such as genetic predisposition via family history or African-American racial status. In these "at risk" men, PSA testing should be offered between 40 - 50 years of age.”[6]

That is to say, there were conflicting recommendations. Perhaps unsurprisingly, the urologists, who are the people who see the prostate cancer and operate on it, had a different sense of both the prevalence of the disease and its bad outcomes, and their ability to alter those outcomes through intervention. But mainly, it is the issue of looking at intermediate variables rather than the outcomes of significance. In this case, looking at whether the PSA can diagnose prostate cancer, rather than whether diagnosing (by any means) and treating prostate cancer saves lives.

What? How can finding a cancer early, and treating it, not save lives? “Why,” you might well say, “I have a friend who had a routine PSA screening, and it was high. He had a biopsy, they found cancer, they operated on him, and now he is alive. Isn’t that a good thing?” Well, it’s certainly good that he’s alive. The question is: Would he not be alive, or would he be suffering the pain of metastatic prostate cancer, if he hadn’t had the cancer found and treated? And that is the question we do not know the answer to. And that is why the recent studies are so important.

Simplistically, there are two kinds of prostate cancer: the bad kind that will kill you after probably creating very painful metastases to bone, and the kind which will be lying indolently and asymptomatically in your prostate when you die of something else. But we have no way of distinguishing between these by any of our diagnostic tests. And, more important, we have no idea whether treatment makes a difference – that is, whether the people who die without treatment would have died even if treated, and if the people who survive with treatment would have survived even if not treated.

This is a really big thing. Why would we want to screen lots of men to find a relatively few cancers that we can treat when we don’t even know if treatment makes a difference in death? In the US study, it didn’t. In the European study, it made a small difference in death from prostate cancer, but it took screening 1410 men and treating 48 to save one life from prostate cancer. And the overall death rate, from all causes, was no different.

Better safe than sorry? Maybe, but what the studies did not look at was the side effects from treatment. What about those other 47 men who were treated and whose lives were not saved? The fact is that, while there are many treatments for prostate cancer, all have a significant “side effects”. Treatments such as radical prostatectomy, external beam radiation, radioactive “seed” implants, and newer procedures such as “green laser” very frequently lead to varying degrees of impotence and incontinence, not minor inconveniences! Hormone therapy, whether by removal of testosterone production by removal of the testicles (orchiectomy) or by administration of anti-androgens, have other effects including “cosmetic” ones such as feminization (weight redistribution, breast enlargement) and serious weight gain that can lead to greater morbidity and mortality. So treatment is scarcely benign. And, because we should not forget cost, the cost of the massive screening by PSA, followed by the further testing and procedures and treatment that follow it, is enormous. These studies demonstrate that even without considering cost-effectiveness or the morbidity of treatment, there is little or no benefit to screening in terms of lives saved.

However attractive the idea of screening and early detection is, both to public-health focused primary care physicians like me and to people in general, screening is only of value if it can not only identify disease in the pre-symptomatic phase, but if there is effective treatment that has a patient-important outcome: lower mortality or greater quality of life. PSA screening, at this point, does not meet this criterion.

The NPR segment covering this issue ended with a primary care physician emphasizing that the answer was not just looking at a single PSA value, but rather looking at the change over time. He noted that the ability to do this, as well as to complement monitoring the trend in PSA with serial rectal examinations, was one of the strengths of the primary care relationship. But, with all due respect, and with the great respect I have for primary care, this misses the point. Such a relationship, with its ability to monitor trends, may increase the likelihood of an accurate diagnosis of prostate cancer (i.e., a PSA of 10 that does not change over time may be less likely to mean cancer than one that goes from 2 to 4 to 6) but this still considers a positive outcome to be an accurate diagnosis rather than a decrease in mortality. Absent our ability to distinguish between “good” and “bad” prostate cancer and to know that treatment makes a difference in patient-important outcomes, greater accuracy in diagnosis may just lead to greater cost and greater morbidity.

[1] Andriole GL et al. Mortality results from a randomized prostate-cancer screening trial. N Engl J Med 2009 Mar 26; 360:1310. published on line at
[2] Schröder FH et al. Screening and prostate-cancer mortality in a randomized European study. N Engl J Med 2009 Mar 26; 360:1320. published on line at
[3] Brett, A, Journal Watch General Medicine March 18, 2009
[5] New York Times, Thursday, March 19, 2009, p.1

Sunday, March 15, 2009

Bargaining down the medical bills

A recent article in the New York Times health series, March 13, 2009[1], discusses the ways in which patients, particularly those who are uninsured and without adequate resources, can and do bargain with doctors and hospitals for reduced charges and payment plans. At one level, it is very distressing. As one of my closest and wisest friends says: “How sad--a ‘how-to’ guide for bargaining over medical expenses”.

At another level, given the horrific situation in which so many people find themselves when facing medical expenses, I’m sure that this “how-to” guide can be very useful and important. It is not only the poor and uninsured that are affected; many, many people who thought that they had adequate health insurance find themselves very unpleasantly surprised when actually confronted with medical bills. Remember, all of the people featured in Michael Moore’s film “Sicko!” had health insurance!

But it remains true that one of the most nauseating facts about the “business” approach to medical care is that it leaves those who are least able to pay with the greatest bills. The norm in business is to give discounts to large purchasers, but when this is applied to the health care of people, it is bizarre and offensive – large purchasers get big write-offs, poor people get charged full price! And this is not just a “little” more. I told the story of my hernia surgery – outpatient, in at 7 am, home by noon – and the $10,000 hospital (not doctor) charge. My insurance company paid $1,600, told me to pay $400, and the hospital wrote off the $8,000 as “contractual adjustment”. But if I was uninsured I would have gotten a $10,000 bill! How wrong is that? And, if I couldn’t pay and the hospital (after dunning me, sending me to collection agencies, and ruining whatever credit I might have left) finally wrote off my bill, they would claim $10,000 in “uncompensated care”, even though the insurance company would have only paid the $2,000. And our federal government exacerbates the situation by forbidding providers to charge anyone less than they charge Medicare. Charge Medicare; not what Medicare will pay. This is meant to ensure that Medicare is getting the “best rates” compared to private insurers, but it is the uninsured patient caught in the middle. If we charge $100, and Medicare will pay $45, it is illegal to charge the uninsured patient less than $100.

Therefore, I applaud the Times for showing how most hospitals and doctors are willing to negotiate rates and payment plans for needy patients. It is a small tool for the individual person to have in dealing with giants. Of course, the greatest beneficiaries will be the educated New York Times reader who has lost her job, lost his insurance, fallen on hard times through illness, but still has the skills to engage in such negotiation. I suspect that the vast majority of people who need these special arrangements are unlikely to read the New York Times, and often are poorly educated, non-English-speaking, and generally disempowered, making them both unaware that such “deals” can be struck, and without the skill sets necessary to negotiate successfully.

The whole system of charges, contractual adjustments, allowables, payments, is a nightmare maze of “gaming” between providers (e.g., hospitals and doctors) and payers, catching actual people in the middle. I have used “horrific”, “nauseating”, “bizarre”, and “nightmare” above to try to describe the current system, but feel as yet unsatisfied. “Indignity” doesn’t begin to describe it; “insane stinking mess” comes to mind. People should not have to learn how to bargain to get the best deal on their health care. When Michael Moore, distinguished health economist Uwe Reinhardt of Princeton, and director of the Health Insurance Association of American Karen Ignani appeared on “Oprah!” some months ago, Oprah asked Ms. Ignani (and I paraphrase, I don’t have the transcript): “So if I need a $200,000 procedure, why don’t you just pay it?” Flustered, Ignani said, “Well, you presume that the $200,000 is in fact what the procedure is worth; other hospitals may chart less …” – Oprah interrupted her: “I’m sick!”, she said, “I don’t have time to go shopping around to six different places to see where I can get the best deal!” Unsurprisingly, the audience, made of of regular people, not pundits, applauded wildly.

Clearly, we need a way out, and the way out is universal health care, where everyone gets a covered, for the same amount for the same services, preferably (mainly because of the cost savings it allows) by a single payer. As in civilized countries. Where hospitals are globally budgeted and physicians know what they will be paid for a particular service to a patient, whether s/he is a millionaire or a homeless person.

[1] Alderman L, “Patient money: Bargaining down the medical bills”, New York Times, March 13, 2009.

Wednesday, March 11, 2009

“Conservative” Drug Prescribing

While Victor Fuchs in his (somewhat pessimistic) commentary on “Reforming US health care” in a recent JAMA observes that one problem with the Clinton-plan era was that the public focused on “…`greedy drug companies’ and ‘overpaid’ physicians rather than on systemic problems in funding, organization, and delivery of care.”[1], there can be little doubt that the pharmaceutical industry has an enormous influence on the delivery of health care, much of it negative. The Association of American Medical Colleges (AAMC) issued a recent report expressing serious concern about the influence of the pharmaceutical industry on medical education[2], while recent media coverage of researchers’ ties to the drug companies has been widespread. Any number of books and articles documenting the influence of the pharmaceutical industry on physician choice of drugs have been published.[3] Gordon Schiff, MD, co-author of a recent Commentary in JAMA entitled “Promoting more conservative drug prescribing”,[4] has said that while the pharmaceutical industry promotes the idea that it works in “partnership” with physicians in the care of patients, and thus that the 3 groups have the same interests, the fact is that the wider use of many of the principles he promotes would not be in the interest of the drug companies.

Schiff and William Galanter, his co-author, provide a list of 25 principles for more conservative prescribing, grouped under 6 larger headings that are discussed at greater length in the article. Unsurprisingly, several of them would result in the use of fewer and cheaper drugs, and they would thus, in fact, decrease drug company profit. These include:

Think Beyond Drugs: to first consider the use and effectiveness of other, non-pharmacologic approaches to treatment of a person’s symptoms, such as diet, exercise, physical therapy, stress reduction, and “…even surgery where appropriate.”. This is exactly what virtually all review articles about treating most conditions suggest, and yet physicians frequently see these as pro forma, not to be seriously considered except as adjuncts to drug therapy, as they reach for their prescription pads.

More strategic prescribing:
“Too often clinicians reflexively prescribe for each symptom a patient experiences.” Sometimes this may be appropriate, but it clearly increases the risk of drug-drug interactions, as well as the possibility that drugs prescribed for one symptom may make another worse (requiring yet a third drug?). This leads to:

Heightened vigilance regarding adverse effects. Drugs have adverse effects. Some of them are less common, and less known by physicians, but no less serious for the patient who experiences them. Many of these effects are not discovered before mass marketing because they are relatively uncommon – or worse they are discovered or suspected by the manufacturer and the information is suppressed. Vioxx®, anyone?

Caution and skepticism regarding new drugs is my personal favorite, violated every day, and the most important place where the interests of drug companies diverge from those of physicians and patients – though the latter two groups often miss this. The marketing of new drugs is where pharmaceutical companies make their money; it is these drugs that are heavily advertised in the medical journals (including JAMA), and to consumers in popular magazines and on TV. It is these new drugs that fill the sample closets of physicians, drugs still under patent and highly profitable. If patients respond to the samples, then they will want the doctors to prescribe them. Rarely are they the first “drugs of choice” and never are they low-priced or generic. Cost may well be the less important issue of prescribing generic drugs – the fact that their patents have expired means that they have been out long enough for us to know how well they work and what their side effects are, something we well may not know about the newer, highly-promoted drugs. “Although many payers stress prescribing generic medications for cost savings,” Schiff and Galanter write, “another important value of generics is the greater safety knowledge inherent in their longer track record compared with more newly marketed brand name products.”

The other two broad headings that they identify:
Shared agenda with patients, and
Weigh longer-term, broader effects
are also both very important. Regarding the latter, many drugs that seem to work initially may lose their effectiveness (relief of the undesired symptom) but perhaps not their side effects (undesired effect) over time. This can also affect the broader community, with emerging resistance to antibiotics being a prime example.

The idea of a “shared agenda with patients” seems to be redundant to the practice of medicine – after all, shouldn’t all of our work be to enhance the well-being of our patients? However, there are many times when, because the agenda is not made explicit to and by both parties, and negotiated between physician and patient, they may end up not working effectively together. Some physicians still believe in the “miracle, mystery and authority” of the physician, exemplified by the title character in “The Chief of Medicine”, chapter 1 of Howard Brody’s classic book “The Healer’s Power”.[5] Others, less authoritarian, are often frustrated by the patient’s lack of “compliance” (or “adherence”, a newer term that seems to me to be no less judgmental) to the doctor’s “orders”. In reality, most of the time the physician (unless actively performing surgery, giving an injection, etc.) is an advisor or consultant to the patient; even the ritual of giving a piece of paper with writing on it (a prescription) is only advice, until the patient takes it to a pharmacy, exchanges it and money for a drug, and then takes the drug. Some of the lack of understanding by patients may be from the above-noted authoritarianism, but much more is cultural (differences in the culture of the doctor and the patient, which includes although it is not limited to, ethno-cultural and language differences), abetted by the lack of time for adequate communication in the typical short visit required by the fee-for-service system. Inadequate communication about drug therapy may be part of this.

The patient may be most interested in relief of a symptom, while the physician, with a longer term teleological view of illness, is more worried about downstream effects of an untreated disease; thus they may not share an agenda. Patients, while perhaps not getting the “full-court press” that physicians do about new drugs, certainly see the advertisements, and they (at least in the US) are often enamored by the “newer is better” view we have of most things (technology, etc.). When we see the lists of medications some patients are on, we may begin to believe that the main reason they don’t have more drug interactions is because they don’t take all the medication prescribed; as physicians, however, we must be concerned that the ones they don’t take may be the ones that we think are more important. Thus, limit, to the extent possible, polypharmacy.

Finally, there is the issue of cost. Generic drugs may be good for most conditions because they are the best known, safest, and first-line choices, but indeed they save money as well. And with the increasing cost of medicine being driven at least in part by drug costs, this is no small matter. Schiff and Galanter’s principles are well-worth implementation by all physicians, and indeed consideration of these issues should be demanded by knowledgeable patients.

[1] Fuchs VR, “Reforming US Health Care”, JAMA 4Mar09;301(9):963-4.
[2] Association of American Medical Colleges. “Industry funding of medical education: report of an AAMC Task Force”. AAMC. Washington DC. June 2008.
[3] E.g., Angell, M. The Truth about drug companies: how they deceive us and what we can do about it. Random House. New York. 2005.
[4] Schiff GD, WL Galanter, “Promoting more conservative drug prescribing”, JAMA 25Feb09;301(8):865-7.
[5] Brody H. The Healer’s Power. Yale University Press. New Haven. 1992.

Saturday, March 7, 2009

“The Feminization of Medicine and Population Health…”

…is the title of a Commentary in the Feb 25, 2009 issue of JAMA, by Susan Philips and Emily Austin from Queens University in Kingston, Ontario, Canada.[1] It is a very interesting piece, citing data and also speculating on the implications of the increasing number of women in medicine. They note that there has been a steady increase in the number of women in medical school for the last 50 years, and that women now comprise 43.5% of graduates of US schools. They enter primary care specialties, however, at much higher rates than their male counterparts. In 2007, 33% of female Canadian graduates chose family medicine as opposed to 22% of males; while either of these numbers (and certainly the mean) would be great by US standards, it demonstrates a “gender gap” even in Canada, where many of the forces discouraging entry into primary care in the US are much lower (there is much less medical debt, income differentials between primary care doctors and specialists are less, there is a system built around primary care, and there is a national health insurance program), there is, apparently, great incentive for medical school graduates, especially men, to choose non-primary care specialties. “Women account for a minority of currently practicing Canadian physicians (37.9%) but a majority of that country’s family physicians (58.6%).” In the US, similarly, “fewer than half of medical school graduates are women (43.5%) but they account for the majority of residents in primary care programs”. The authors indicate that data from the UK, most of Europe, and Australia show similar trends.

It is a good thing that women physicians enter primary care at higher rates than men, because we need more primary care physicians, as demonstrated by much data that has been previously presented in this blog (Dec 11, 2008, and others). However, the authors also note that “Recent reports identifying lower productivity among female physicians have debated whether more women in medicine will exacerbate a shortage of physicians by limiting patient access to care….In general, women are less likely to work excessive hours or to work past the typical age of retirement. Female physicians see fewer patients per hour…”. The impact of this can be understood in terms of Robert Bowman’s Standard Primary Care (SPC) year (“10 myths regarding primary care in the future”, Jan 15, 2009), and suggests that the lower number of SPCs generated by NPs may also be in part associated with gender. In addition, a recent report from the Robert Graham Center cites data showing that while women enter primary care at higher rates than men, they are much less likely to enter rural practice, thus not helping to resolve the rural/urban health disparity problem.[2]

But Phillips and Austin go further. Finishing the sentence above, the write (and cite references for) “Female physicians…demonstrate better communication skills and include more preventive care than their male counterparts.” They note that the issue is health outcomes, not simply access to health care, a point I have repeatedly made. They note that:
“In developed countries, the number of physicians per capita, alone and separated from any analysis of the nature of care provided, has no association with mortality rates. In 1978, Cochrane examined how a number of proximate factors, including gross domestic product, physician density, sugar consumption, and cigarette smoking, were associated with mortality
rates in 1960 and 1970 across 18 developed countries.
[3] He found no association between physician density and any of the standard mortality rates and concluded that health service factors were relatively unimportant in explaining differences in mortality among developed countries.”

They go on to note that in comparing physician densities and life expectancy, Canada has the lowest density among developed countries but life expectancies comparable with the Netherlands, the highest density, and better than the US, which is intermediate in density, and that the highest life expectancy is in Japan, with a physician density just higher than Canada’s. They note the work of Macinko and Starfield, which I have referenced before, showing that the strength of a country’s primary care system is most associated with good health outcomes[4], not physician density. Again, as I have discussed before, having more doctors working at the tertiary point of the health workforce pyramid does not improve health outcomes. It is important to note that this is referring to highly developed countries with large physician workforces; clearly there is a threshold (not reached in much of the world, and even in many rural areas of the US) below which there are too few physicians to meet health care needs. But there is also a density at which outcomes plateau, and even, at the highest levels, decreases because of the effect of unnecessary interventions.[5]

This does not, however, mean that having more women physicians will improve the quality of health care, not to mention compensate for their lower number of patients seen and SPC years. It clearly will not meet the needs of those people who live in rural areas, where women, even in primary care specialties, are less likely to practice. Phillips and Austin hope it will:
Seeing more patients more frequently may not increase the life expectancy of those patients, but spending more time with each patient, hearing and listening more effectively, and including
more preventive measures (all characteristics identified in studies of female physicians) may result in fewer but more effective clinical encounters rather than a greater volume of encounters.”

Perhaps this will be true, I would certainly hope so. They are more certain that the benefit from women becoming primary care doctors will have benefit:
“Because women across time and place tend to become primary care physicians, the feminization of medicine may well have beneficial health outcomes possibly attributable to the nature of the care they provide irrespective of women’s lower volume output relative to that of men. Such an improvement in outcomes may occur because of the practice styles of women, who outnumber men in primary care, or because of the nature of generalism. Either way, as women increasingly enter medicine and become generalists, rather than being a liability by
not working excessively long hours or abandoning parenting, the quality of the care they provide may result in improved population health.”

So to the extent that having more women in medicine leads to more primary care physicians, and because of the convincing evidence that a system built upon primary care leads to improved health outcomes, this is a convincing argument (except for rural areas). The concept of “population health” is critical here, because it includes all people, not a sum of the individual people who have seen doctors.

The degree to which the practice “style” (more time spent with each patient, better communication) will enhance outcomes is more speculative. However, it certainly may, and there are few in the community who would not like to have their physicians spend more time with them and communicate with them better. I hope that this practice “style”, more characteristic of women, becomes more dominant, and I look forward to studies demonstrating that it does improve health outcomes.

[1] Phillips SP, Austin EB, “The feminization of medicine and population health”, JAMA Feb25,09;301(8)363-4
[2] Robert Graham Center, “Specialty and Geographic Distribution of the Physician Workforce: What Influences Medical Student & Resident Choices?”, pp. viii, 20. Accessed 3/4/09,
[3] Cochrane AL, St Leger AS, Moore F. Health service “input” and mortality “output” in developed countries. J Epidemiol Community Health. 1978;32(3): 200-205.
[4] Macinko J, Starfield B, Shi L. The contribution of primary care systems to health outcomes within Organization for Economic Cooperation and Development (OECD) countries, 1970-1998. Health Serv Res. 2003;38(3):831-865.
[5] Goodman DC, Grumbach K. Does having more physicians lead to better health system performance? JAMA. 2008;299(3):335-337.

Wednesday, March 4, 2009

Quote of the Day (with apologies to Don McCanne)

From the New York Times, March 4, 2009.

“David Rifkin Jr., an associate White House counsel under the first President Bush who is scheduled to testify at the hearing on Wednesday, said he planned to urge Congress not to move forward with that proposal, which he said would violate the rights of Bush administration officials and set them up for prosecutions by foreign courts.

“’They want to pillory people,’ Mr. Rivkin said. ‘They want to destroy their reputation. They want to drag them through the mud and single them out for foreign prosecutions. And if you get someone in a perjury trap, so much the better.’"

Well, all I can say is: Duh. If the shoe fits. Do you think Mr. Rifkin feels the same way about prosecution of more conventional murderers, thieves and con men?

Tuesday, March 3, 2009

Kathleen Sebelius as Secretary of HHS

As a citizen of Kansas, I probably know more than the average American about the new nominee for Secretary of HHS, Governor Kathleen Sebelius. On the whole, I think that she is a good choice who will be effective as well as honest, without the baggage ($128K tax and close relationships with lobbyists) that Sen. Daschle had. However, Sen. Daschle gave a great speech at his confirmation hearing, pointing out that every other country with decent health outcomes starts from a base of primary care, moving up through secondary and tertiary care if they can afford it. The US, on the other hand, starts with funding tertiary care, and runs out of money before providing comprehensive primary care (see picture; this is an unstable format!)

I hope that Governor Sebelius can be as articulate at her confirmation hearing, but hope much more that she will press for such important change as Secretary. While she is not a single-payer advocate, she has advocated coverage for all, which is a good start; indeed, “Cover Everybody!” should be our mantra, although there is a lot of bad and overpriced coverage out there – so Rep. Conyers’ assertion that “what we want is access to high quality health care for everybody” is really the goal.

While Gov. Sebelius, the daughter of former Democratic governor of Ohio John Gilligan and daughter-in-law of a prominent long-time Republican congressman from Kansas, was early in her career Executive Director of the Kansas Trial Lawyers Association, and as such not popular with physicians, her subsequent tenure as a legislator, state Insurance Commissioner, and Governor has been very positive regarding health care, and even healed many of the wounds with physicians. Her most important decision as insurance commissioner was blocking the sale of Blue Cross/Blue Shield of Kansas to a private company, Anthem, in 2002, saying it would raise costs for Kansans. This was a good decision, occurring during a time when the insurance industry was, across the country, consolidating its hold on health care. It gained her great popularity and was a major reason she was elected Governor later that year.

She is seen as a Democrat who is able to work across party lines, a necessary characteristic in a very “red” state, where both houses of the legislature have become increasingly dominated by the what is known as the “conservative” wing of the Republican party; whether “conservative” or not, they are ideologically driven in much the same way as the increasingly marginalized national GOP is, except here in Kansas they are in control.

I would also add, if we want to know the kind of person she is, that in 2005 I was headed down to New Orleans for a conference. Waiting at SW Airlines, I looked up from my book and saw her sitting across from me. Someone else recognized her and razzed her for not taking her state "jet". She replied, "First, it's not a jet, and second, this is not state business. I'm taking a few days to meet my husband down in New Orleans for the Jazz and Heritage Festival".
So she waited in line with everyone else, and as I helped her put her bag in the overhead rack, remember thinking "I can't imagine Arnold Schwarzenegger or George Pataki (then Gov of NY) doing this - flying with the hoi polloi on SW, personal business or not." Or, for that matter, Tom Daschle.

She has some excellent health advisors in Kansas, and if they accompany her to DC, I would be optimistic about effective change.

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