Saturday, November 28, 2009

Medicine and Social Justice – the First Year: An Index


Thanksgiving weekend – today, November 28, specifically – marks the first anniversary of the Medicine and Social Justice blog. I thought I would review the topics I have covered, grouping them generally into several areas. This might enable anyone interested in a topic (particularly one that is not very time-sensitive) to go back and look at old ones that they might not have read. Also, of course, it gives me a way to organize my collected works book. Right! J
I have chosen the groupings: Health Reform and Funding (43), Primary Care (11), Social Justice (21), General Medical Topics (23), Medical Education (6), Other (4) (largely memorials). A few are “double-listed”, and I didn’t list a few small ones, so the total number of columns is 110.

Health Reform and Funding
Friday, November 28, 2008: Universal Health Coverage
Monday, December 1, 2008: Medicare "Advantage": Your Gift to the Insurance Industry
Friday, December 5, 2008: Not Getting What We Pay For
Thursday, December 25, 2008: A Rational Health Care System
Tuesday, January 6, 2009: Enthoven: Consumer Choice Health Plan -- Again
Thursday, January 8, 2009: Sanjay Gupta for Surgeon General?
Saturday, February 7, 2009: Universal Health Insurance or Universal Quality Health Care?
Tuesday, March 3, 2009: Kathleen Sebelius as Secretary of HHS
Sunday, March 15, 2009: Bargaining down the medical bills
Sunday, April 5, 2009: "Sick Around America": A little bit sickening
Friday, April 10, 2009: Does the nation need a clear policy on a right to basic health care?
Wednesday, April 22, 2009: The “Basic Law of Modern Health Care”
Saturday, April 25, 2009: The Social Ethic and Covering Everyone: Reinhardt and Himmelstein
Saturday, May 2, 2009: Health disadvantages of Americans compared to Europeans
Wednesday, May 6, 2009: Health Care Thought Experiments: Mile Long Questions Traveling at the Speed of Light (Guest column by Donald Frey, MD)
Friday, May 8, 2009: What is wrong with the idea of "Consumer Directed Health Care": A "Technical" Answer to the "Thought Experiment" (Guest column by Robert Ferrer, MD)
Saturday, May 16, 2009: Health Care Industry Pledge to Cut Costs: No News at All
Thursday, May 28, 2009: "The Nation"'s Health Care Bottom Line is Bottom of the Barrel
Friday, June 5, 2009: Health Insurers "Balk"
Thursday, June 11, 2009: Medicare Costs: "All Politics are Local"
Monday, June 15, 2009: Health Reform and the "Public Option"
Thursday, June 18, 2009: “No Single Payer”: Sebelius – making policy for the powerful
Monday, June 22, 2009: Government sponsored health coverage: The Good, the Cautionary, and the Ugly
Wednesday, June 24, 2009: Dear Senator Brownback: A letter my Kansas Senator
Saturday, June 27, 2009: Dear Senator Brownback, #2
Sunday, July 5, 2009: European vs. US Health Systems: Which one has the real drawbacks?
Wednesday, July 8, 2009: Proposals to Tax Health Benefits and Institute Individual Mandates
Saturday, July 25, 2009: Integrated Health Systems or Thinking Inside the Box?
Thursday, August 6, 2009: Doctors, their Patients, and Health Reform
Tuesday, August 11, 2009: Health Care Shoutdowns: Liars and Demagogues
Wednesday, August 19, 2009: Advance Directives, not "Death Panels"
Sunday, August 23, 2009: A Modest Proposal: Bribe the Insurance Companies
Wednesday, August 26, 2009: The "Super Rich" and Our Healthcare
Sunday, August 30, 2009: Senator Ted Kennedy, Social Justice, and Healthcare for the People
Thursday, September 3, 2009: Public / Private Funding: We're All in This Together
Tuesday, September 8, 2009: Will the President turn the “health reform” discussion around to real reform? Can he?
Monday, September 21, 2009: Medicare for All: Moran's logic, not the idea, is flawed
Wednesday, September 30, 2009: Some good, but a lot still wrong, in health reform bills
Sunday, October 4, 2009: Seniors and Medicare: Beware not simply "Scare Mongers" but lying hypocrites
Tuesday, October 20, 2009: Red, Blue, and Purple: The Math of Health Care Spending
Wednesday, November 4, 2009: Poverty and Uninsurance Diverge: So let’s solve the problem!
Sunday, November 8, 2009: Celebrating the Defeat of the Opponents of Health Reform
Thursday, November 12, 2009: HR 3962 is still a bad bill, and Stupak-Pitts is a scandal

Primary Care
Thursday, December 11, 2008: A Quality Health System Needs More Primary Care Physicians
Friday, January 2, 2009: Student Debt, Resident Hours, and Primary Care Redux
Thursday, January 15, 2009: Ten Biggest Myths Regarding Primary Care in the Future (Guest Column: Robert Bowman, MD)
Friday, April 3, 2009: More Primary Care Doctors or Just More Doctors?
Wednesday, April 29, 2009: Primary Care Shortage makes Times Front Page
Thursday, May 21, 2009: Primary Care, Pediatrics, and Physician Distribution
Sunday, July 12, 2009: The Primary Care Extension Service
Thursday, September 3, 2009: Public / Private Funding: We're All in This Together
Thursday, October 8, 2009: "Uncomplicated" Primary Care?
Wednesday, October 14, 2009: "War on Specialists?": Wall St. Journal defends the status quo!
Tuesday, November 17, 2009: Primary Care’s Image: A Problem?

Social Justice
Saturday, November 29, 2008: Mumbai, Valley Stream, and the Economic Meltdown
Wednesday, December 17, 2008: Notes on Diversity
Sunday, December 21, 2008:The financial sector, for a change…
Tuesday, January 27, 2009: Social Justice: Economic Stimulus and Bailout
Sunday, January 11, 2009:Mr. Bush’s Legacy: The Global Gag Rule
Friday, January 23, 2009: President Obama rescinds Global Gag Rule
Monday, January 19, 2009: Martin Luther King, Jr. Day and the Inauguration
Monday, February 9, 2009: Masters of the Universe: They need a long fall
Sunday, February 15, 2009: New Orleans: Have we still no shame?
Wednesday, March 4, 2009: Quote of the Day (with apologies to Don McCanne)
Tuesday, March 24, 2009: Mexican Murders and US Guns
Saturday, April 18, 2009: Medical Ethics and Social Justice
Wednesday, July 1, 2009: Stonewall: 40 years Later
Sunday, August 2, 2009: Not "Special Interests": The Wealthy and Powerful
Sunday, August 16, 2009: Should it be a crime to be poor, or, instead, to criminalize poverty?
Sunday, August 30, 2009: Senator Ted Kennedy, Social Justice, and Healthcare for the People
Wednesday, September 16, 2009: Joe Wilson: Racism in America rears its ugly head
Monday, October 12, 2009: Lessons from World War I
Saturday, October 17, 2009: The actions of criminal settlers in Israel cannot be allowed to define the Jewish people
Friday, October 23, 2009: "Wall St. Smarts"? Maybe the smart people should be doing something productive
Sunday, November 22, 2009: Health Workers and Our Wars (Guest column by Seiji Yamada, MD)

General Medical Topics
Thursday, December 4, 2008: Hospitalists
Monday, December 8, 2008: Physician Conflict of Interest
Tuesday, December 30, 2008: Community Health Centers
Thursday, January 22, 2009: The "Neurontin Legacy"
Monday, February 2, 2009: Prevention and Cost
Friday, February 13, 2009: Economics and Disease Prevention
Thursday, February 19, 2009: Performing procedures: Who is capable and how should we pay?
Tuesday, February 24, 2009: Quality and Chronic Disease Management
Thursday, February 26, 2009: Defining "Streetlight" Research
Saturday, March 7, 2009: “The Feminization of Medicine and Population Health…”
Wednesday, March 11, 2009: “Conservative” Drug Prescribing
Saturday, March 21, 2009: PSA Screening: What is the value?
Thursday, March 26, 2009: Medicare Costs in Rural America: A case of reaping what we haven't sown? (Guest column by Donald Frey, MD)
Monday, March 30, 2009: Immigrant and Refugee Health
Tuesday, April 14, 2009: Conscientious Objection in Medicine
Saturday, April 18, 2009: Medical Ethics and Social Justice
Tuesday, May 12, 2009: Clinical Guidelines and Technology Assessment
Wednesday, May 13, 2009: Addendum: Medtronic back in the news
Thursday, July 16, 2009: Fetal Monitoring: Why it will continue
Wednesday, July 29, 2009: Prevention and the “Trap of Meaning”
Tuesday, October 27, 2009: PSA Screening: “One of Medicine's Great Success Stories"? (Guest column by Robert Ferrer, MD MPH)
Saturday, October 31, 2009: Dietary Supplements can be Dangerous for your Health
Wednesday, November 25, 2009: Breast Cancer Screening and Evidence-based Medicine

Medical Education
Wednesday, December 3, 2008: Medical Resident Work Hours
Tuesday, December 9, 2008: Resident Work Hours: Addendum
Sunday, December 14, 2008: Medical Student Selection
Monday, May 25, 2009: Funding Graduate Medical Education
Saturday, September 12, 2009: Are we training physicians to be empathic? Apparently not.
Friday, September 25, 2009: Rankings of Medical Schools: Do they tell us anything?

Sunday, November 30, 2008: Steven B. Tamarin, MD
Sunday, May 31, 2009: In Memoriam George Tiller
Monday, June 8, 2009: More on Dr. Tiller
Sunday, November 22, 2009: Health Workers and Our Wars (Guest column by Seiji Yamada, MD)

If you have been following Medicine and Social Justice since early on, or are a new follower, or an occasional visitor, you may want to see if there are any that you missed and are of interest to you.

And, in the spirit of the season, I thank you very much for your time and attention, and hope that it has been worth the investment.

Wednesday, November 25, 2009

Breast Cancer Screening and Evidence-based Medicine


In case you’ve been in a coma for a while, the US Preventive Services Task Force (USPSTF), a federally-funded-but-independent group of scientists who evaluates the evidence regarding preventive care, has announced new guidelines on screening for breast cancer. It has generated an amazing amount of comment, from physicians, patients, advocacy groups, politicians, and journalists. Every possible position on the issue, from thoughtful and balanced to alarmist and opportunist, has been taken and published by someone. For a quick review of articles just in the New York Times in the last few days we have:

November 17:
Panel Urges Mammograms at 50, Not 40”
November 18:
New Mammogram Advice Finds a Skeptical Audience”,
Many Doctors to Stay Course on Breast Exams for Now”
November 19:
Screening Policy Won’t Change, U.S. Officials Say
Columnist Gail Collins: “Breast Brouhaha
November 20:
Kevin Sack, News Analysis: “Medical Science and Practice in Conflict
Mammogram Debate Took Group by Surprise

Therefore, the wise course might be for me to stop here, let you read everyone else, and not get involved. Of course, I won’t. Let me start by discussing the discovery, use, and application of evidence in medicine, and in particular with the USPSTF.

Disclaimer: I don’t work for, or have any relationship, financial or otherwise, with USPSTF, but I do believe that the responsible practice of medicine requires keeping up with the evidence and changing practices as new information becomes known; it should not be a “faith-based” effort.

Medical evidence for anything, including appropriate preventive services, gathers slowly. Studies are first done on high-risk populations, then later on average or low risk. Depending on the variables looked at, and the population studied, different information can emerge. Rarely (but sometimes) is the data from one good study on the same population directly opposite that of previous studies; more likely it will be similar, but might be of a greater or lesser degree of magnitude. Or just different enough to tip the risk/benefit balance. Because virtually never is anything – a treatment, a diagnostic test, a preventive activity – all good or all bad. There are benefits, real or potential, and risks, of varying degree. As new evidence accumulates, it tends to move the scales, or the seesaw, more down or up on one side or the other. Usually not enough to drop one end to the ground, but sometimes enough to tip the balance. And new studies are being done all the time, and it is not only hard to keep up, it is hard to assess the changes in risk. But it must be assessed, because it would be wrong to just keep doing what you were doing when the evidence changes.

That is the incredibly valuable service that the USPSTF has been providing since it was first convened in 1984. Evaluating, the existing studies and making recommendations – to clinicians – on what they should discuss with their patients. They are not really for patients, although this seems to be where much of the confusion is. Much of the coverage is about individual women trying to decide what to do – or reacting “against” the recommendations. The Times article cited above, “Many Doctors to Stay Course on Breast Exams for Now”, includes this: “Patients are already trying to figure out what the recommendations mean.” It means they should discuss them with their health care provider.

USPSTF assigns both a grade and a level of certainty to its recommendations. The grades are A, B, C, D, and I, and the levels of certainty are high, moderate, and low, and are described at the USPSTF website, at When the grade is A or B, the procedure is recommended to clinicians in practice; when the grade is C it is generally not recommended, but there may be individuals or situations in which the benefit would exceed the risk; when it is D, it is not recommended. A grade of I means there is insufficient evidence to assess whether there is net benefit.

USPSTF is not the only group that makes recommendations. Many medical professional organizations and advocacy groups (such as the American Cancer Society and the American Heart Association) also make recommendations. However, the USPSTF is independent and has no “dog in the fight”, no financial or emotional attachment to an outcome. For example, after these recent recommendations were announced, suggesting most women start receiving mammograms later, and have them less often, the American College of Radiology (ACR) announced its disagreement with them. I’m sorry, but the fact that radiologists have an obvious financial stake in doing more mammograms has to make their opinion more suspect.

Certainly doing fewer mammograms will save money for insurers (including the government, for Medicare patients). In the current climate of our debate on health reform, some have seen these recommendations as an effort by these insurers to save money, and others have noted that, because of this, the timing of the announcement was “unfortunate”. However, unlike the ACR, the members of the USPSTF have no financial stake in their truly independent recommendations. I, for one, absolutely consider them to be the most valid source of independent analysis and advice.

What about these specific recommendations? They make sense to me, and are supported by the evidence. The recommendation that mammography begin at 40, rather than 50, only dates back to 2002, and was controversial at that time.
“In 2002…,” reports the Times in Panel Urges Mammograms at 50, Not 40, “When the group recommended mammograms for women in their 40s, some charged the report was politically motivated. But Dr. Alfred Berg of the University of Washington, who was the task force chairman at the time, said ‘there was absolutely zero political influence on what the task force did.’ It was still a tough call to make, Dr. Berg said, adding that ‘we pointed out that the benefit will be quite small.’ In fact, he added, even though mammograms are of greater benefit to older women, they still prevent only a small fraction of breast cancer deaths.” In the last 7 years more studies have come out, which have weakened the relative benefit to risk ratio for women between 40 and 50 who are at average risk for breast cancer.

In addition, the body of evidence does not suggest that there is significant additional benefit to screening every year rather than every two years. It also recommends against teaching self-breast examination (not against women doing it) – a “D” recommendation -- because there is good evidence from large population studies that it offers no advantage death or morbidity from breast cancer. Continuing screening of women over the age of 74, and doing clinical breast examination (by a physician or other clinician) in addition to mammography get “I” – insufficient evidence recommendations.

In the news analysis cited above, “Medical Science and Practice in Conflict
Mammogram Debate Took Group by Surprise”, Kevin Sack notes that “The backers of science-driven medicine, with its dual focus on risks and benefits, have cheered the elevation of data in the setting of standards. But many patients — and organizations of doctors and disease specialists — find themselves unready to accept the counterintuitive notion that more testing can be bad for your health.” But it certainly can be.

More, it should be obvious, is not always better, not only with fatty foods and salt, but with screening. The risks of unnecessary (read: too often for the risk level of the woman under consideration) mammograms is more than anxiety for false positives. It is also biopsy for false positives. And sometimes complications. And radiation exposure, which is not insignificant, and is, as we know, linked to causing cancer. Think: men get breast cancer also, but not at the rate that women do (about 1%). We do not screen men, because the risk/benefit ratio is way over to risk. Let me make clear that all of this discussion is about screening; by definition, someone who has NO symptoms. No lump, no discharge, no skin dimpling. They are not about diagnostic mammograms – examining someone with symptoms or physical findings, or a previous abnormal mammogram, and certainly do not apply to follow-up of people who have had breast cancer.

In “Many Doctors to Stay Course on Breast Exams for Now”, Dr. Annekathryn Goodman, director of the fellowship program in gynecological oncology at Massachusetts General Hospital, says “It’s kind of hard to suggest that we should stop examining our patients and screening them….I would be cautious about changing a practice that seems to work.” I hope that is not what she meant. What “seems to work”, while intuitively attractive, is not always correct. That is why we have independent bodies such as USPSTF continually examining the evidence.

Sunday, November 22, 2009

Health Workers and Our Wars

This guest column is by Seiji Yamada, MD, a family physician, Associate Professor of Complementary and Alternative Medicine at the University of Hawai’i John A. Burns School of Medicine, and one of my mentors. This essay is an expansion of the one that was published in the AAMC journal Academic Medicine, chosen as one of the five best responses to the question put forth by editor Steven Kanter “How can academic medicine respond to peace-building efforts worldwide?”. Dr. Yamada’s original essay, “Academic medicine should start at home”, is at

Health Workers and Our Wars

What is the responsibility of American health workers with regard to our nation’s wars in Iraq, Afghanistan, and Pakistan? As Americans, our primary responsibility should be to influence the actions of our own government. As health workers, our expertise is in the realm of morbidity and mortality, encompassing the direct effects of violence as well as the indirect effects arising from the collapse of health services, poor access to water and food, and damage to infrastructure, economies, and societies. Thus, we should monitor our government’s actions, apply the scientific methods at our disposal, apply the moral and ethical principles to which we subscribe, formulate and recommend policy, and disseminate our findings to the people. In a democracy, the citizenry would then determine the course of action.

During this decade, our nation has been responsible for invading and occupying two countries halfway around the globe—Afghanistan since 2001 and Iraq since 2003. In the case of Iraq, the invasion of 2003 was preceded by comprehensive economic sanctions, which hampered the rebuilding of its infrastructure after the Gulf War of 1991. The consequences included childhood deaths, mental illness, juvenile delinquency, begging and prostitution, as well as cultural and scientific impoverishment.[1]

In 2002-03, the American people were not convinced by the Bush administration that war on Iraq was justified. However, despite massive demonstrations against the war prior to its launch, the intellectual classes, the corporate media, and our elected representatives went along with the administration. Democracy failed us in this respect. Prior to the war, we health workers should have been recounting the health toll of the First Gulf War and the sanctions regime. With its onset, we should have been disseminating the images and recounting the narratives of casualties of the war.[2] As it progressed, we should have been acutely interested in the number of casualties caused by the war. The best estimates for deaths among Iraqis are those of the July 2006 epidemiological survey that reported 655,000 deaths as a consequence of war.[3] This study did not distinguish among civilians, military, and irregular combatants. While its authors have been criticized for breaches in the non-identification of participants, the study is nevertheless considered the most accurate estimate.[4]

Insofar as we have failed to pay attention to such findings, American health workers have failed its constituents.

At the mention of history or political economy, many health workers groan. We are not interested in politics, they say. But unreflective citizens repeat the blather that they are fed by the corporate media. We need advocate for the cause of health—in particular for the health of those whose voices are otherwise unheard, whose deaths are otherwise uncounted, unmourned, unopposed, and unorganized against. In order to do so, our analysis must be geographically broad and historically deep, as Paul Farmer urges us.

As the United States pulls its troops out of Iraq and sends them to Afghanistan, as our military wields drones called Predator and Reaper in Pakistan, we should concern ourselves with whether the cause of peace is thereby served by such acts. Our commander-in-chief is apparently now reflecting upon whether to double down (again) in Afghanistan and pursue counterinsurgency, as urged upon him by his general in the theater.[5]

Apparently, “counterinsurgency” no longer connotes Vietnam or Central America.[6] But the “clear and hold” strategy utilized late in the Vietnam War was characterized by indiscriminate shelling and bombing of villages[7] and ran concurrently with the Phoenix program of torture and assassination.[8] Extrajudicial killings in the Federally Administered Tribal Areas of Pakistan are now being carried out by the CIA by missile attacks by drones, with the deaths of many innocents.[9] Of 701 people killed in 60 attacks in FATA between January 2008 and April 2009, fourteen were suspected militants.[10]

The British and the Soviets failed in their attempts to militarily control Afghanistan, while inflicting untold casualties on the populace. The Soviet Union’s invasion of Afghanistan proved to be its Vietnam. One would think that our own country would not repeat its mistakes in Vietnam, but our wars in Iraq and Afghanistan’s go on. As American health workers, we must concern ourselves with the morbidity and mortality caused by our own government’s actions. Let us get to work.


[1] Save the Children UK. Iraq sanctions: humanitarian implications and options for the future. Available at: ( Accessed July 21, 2009
[2] Yamada S, Fawzi MC, Maskarinec GG, Farmer PE. Casualties: narrative and images of the war on Iraq. Int J Health Serv. 2006; 36(2):401-15
[3] Burnham G, Lafta R, Doocey S, Roberts L. Mortality after the 2003 invasion of Iraq: a cross-sectional cluster sample survey. Lancet 2006; 368: 1421–28.

[4] Tapp C, Burkle FM, Wilson K, et al. Iraq War mortality estimates. Conflict & Health 2008;2:1-13.

[5] Filkins D. Stanley McChrystal’s long war. New York Times Magazine, Oct 18, 2009.

[6] Parry R. Bush’s death squads. In These Times, Jan 17, 2005. Available at ( Accessed Jan 23, 2005.

[7] Steinglass M. Vietnam and victory. Boston Globe, Dec 18, 2005. Available at ( Accessed Sep 27, 2009.

[8] Chomsky N, Herman ES. The Washington connection and third world fascism. Boston, MA: South End Press, 1979.

[9] Mayer J. The predator war. New Yorker, Oct 26, 2009. Available at ( Accessed Nov 15, 2009.

[10] Ahmad MI. Pakistan creates its own enemy. Le Monde Diplomatique. Nov 2009. Available at ( Accessed Nov 5, 2009.

Tuesday, November 17, 2009

Primary Care’s Image: A Problem?

Pauline Chen, a transplant surgeon and respected author of “Final Exam: A surgeon’s reflections on mortality” (Vintage Books) also write a “Doctor and Patient” column for the New York Times. On November 12, 2009, the topic was “Primary Care’s Image Problem”, in which she talks about the decreasing interest in primary care among medical students, and the perception among many, increased by many faculty members, that primary care was a backup to more “prestigious subspecialties…like dermatology, orthopedics, plastic surgery or radiology.” In particular, she talks of Kerry, one of her classmates, who wanted to (and did) enter primary care “despite” being at the top of her class, and how this amazed her friends. Dr. Chen addresses the attractions of the “ROAD” (radiology, ophthalmology, anesthesiology, and dermatology) to financial success as well as greater prestige, and the challenges it presents for having an adequate supply of primary care physicians.

While scarcely optimistic (“But even with current legislative efforts to address educational debt, payment discrepancies and lifestyle differences, many medical educators worry that the results will not be enough….Why? It is due to an issue deeper than money and paperwork. While the frisson of continually advancing treatments and approaches to patient care seem to envelope most other specialties, the image of primary care remains one of a vaguely anachronistic practice — a group of doctors who do not stand on the forefront of creative change and who are continually left holding the biggest bag of administrative expectations and clinical care coordination and demands.”), she also notes that “That image, however, may be changing”.

Dr. Chen attended a meeting of the Association of Deans and Directors for Primary Care, held in conjunction with the annual meeting of the Association of American Medical Colleges (AAMC) in Boston on November 9, 2009, where the discussion focused largely on changes in the type of practice, particularly in the creation of a “medical home” and a team approach to care. She quotes organization chair Bruce Gould, MD, of the University of Connecticut: “In a patient-centered medical home, I would not be the sole proprietor. Sometimes I would be the leader because of my specific skill set. But if we were dealing with adherence to diabetes care, the team’s social worker might be the leader….With a team approach each of us is freed up to practice at the top of our scope of training. And that leads to better patient outcomes and more job satisfaction.”

I admit that I found it somewhat frustrating, having been in the room, that the 3 physicians Dr. Chen quotes are all general internists, despite the fact that at least half the participants in the meeting and 2 of the 5 speakers were family doctors. I agree with the general theme expressed by many that it is important for primary care doctors to work together and not fight, but there are important differences in these specialties. In addition to the fact that family doctors care for adults and children and often pregnant women, the breadth of their practice makes them more suitable for rural practice, where there may be only a few doctors. While most family doctors do not practice in rural areas, about 20% do, which is comparable to the percent of the overall population; indeed, family medicine is the only specialty that “distributes” according to where people live.

More important for this discussion is that virtually all family physicians practice primary care, thus it is the primary care “bellwether”, going up more when student interest in primary care is up, and down more when it is down. Internal medicine, on the other hand, offers those who complete its 3-year residency the option of entering primary care / general internal medicine practice (or hospitalist practice, which is not primary care) or continuing into a subspecialty fellowship (cardiology, gastroenterology, pulmonary medicine, etc.); it is thus less sensitive to these ups and downs. As I have discussed previously (most recently in “Rankings of medical schools: do they tell us anything?” on September 25, 2009), the trend for general internal medicine is definitely down. General pediatrics, the third primary care specialty, has not seen a decrease, although the distribution and career trajectories are an issue, as I have discussed in “Primary care, pediatrics, and physician distribution” on May 21, 2009. Indeed, facing a shortage of pediatric subspecialists, many pediatrics groups are trying to encourage subspecialization.

Dr. Chen’s article ended with some guarded optimism, and an invitation to join the discussion on Tara Parker-Pope’s “Well blog”, “Giving primary care more respect”. With 180 responses (by November 16), it is clear that there are a lot of opinions out there, from physicians, medical students, other health professionals, and the general public. I admit to adding my comments, and “plugging” my October 8, 2009 blog piece “`Uncomplicated’ Primary Care?”, where I argue that primary care is anything but uncomplicated.

I thought that some comments on this from medical students on this issue might be welcome. The following comments are from students who spent 6 weeks with rural family physicians in Kansas between their first and second years of medical school, from quotes they gave to a reporter from the Kansas Family Physician, publication of the Kansas Academy of Family Physicians:

This summer, I learned that people don’t choose family medicine because they want an easy profession. They choose it because they want to be life-long learners and truly want to help the community. Their knowledge base and diagnostic ability is no less than any specialist. The only difference they think ‘big picture’, and don’t focus on any one organ system.”

“A young man in his mid-30s came into the clinic. He was a partial quadriplegic of 15 years from a car accident. He was not there complaining of any acute symptoms or any problems; he was just there because he wanted to find a new doctor…Out of curiosity, I asked him what he was looking for in a physician. His only reply was: ‘I want someone who cares about me, not for me.’”

“I could not help but be impressed with the enormity of information family physicians are expected to ideally know. We are talking about working with every organ system of the body and also understanding the procedures and diagnostic tests that go along with these systems.”

“I learned family medicine is not simply caring for patients with chronic health issues or diagnosing and treating the common cold. While family physicians do both of those things almost every day, they also provide a variety of other care. They can deliver babies, provide women’s health, perform EGDs and colonoscopies, manage chronic pain, and diagnose extraordinarily well in the acute setting, just to list a small amount of what they do weekly.”

“Nothing compared to the feeling I got watching a family physician take care of the mother during delivery, perform an emergency C-section, and then treat the infant all within the same day. The ability of a family doctor to care for both mother and child simultaneously made me truly appreciate the rich complexity of family medicine.”

“A family physician should be held in the highest regard among physicians, for he or she must have the patience of a geriatrician, the gentleness of a pediatrician, the courage of an ER physician, the steady hand of a surgeon, and a knowledge base of every medical specialty.”

There are more, and many of them – which maybe I’ll post later – specifically talk to the role of the rural family doctor. Remember, these are not a random sample of students; they elected to do this experience. Many of them are from rural backgrounds and many are also planning careers in family medicine. All of them, having just finished their first year of medical school, have a long way to go before deciding on their specialty, and undoubtedly some will take some variant of the “ROAD”. We know from recent research that empathy takes a nose dive in the third year of medical school (“Are we training physicians to be empathic? Apparently not”, Sept 12, 2009).

However, it is great to hear these attitudes and know that at least among some students family medicine and primary care do not have an “image problem.” We can only hope that it persists in them, and in their peers. Hope, and do everything we can to foster it.

Thursday, November 12, 2009

HR 3962 is still a bad bill, and Stupak-Pitts is a scandal

After the House of Representatives passed HR 3962 recently, I celebrated the defeat of the opponents of health reform. I tried to make it clear, and I will emphasize here below, that the bill is not only far from perfect, it is bad. I just think it would have been worse, a victory for those who wish to keep the status quo (for example, virtually all the Republicans). To my knowledge, Ohio congressman Dennis Kucinich is the only representative who voted against it from a progressive perspective, and I applaud him for that.

I was at a conference recently at which former Senator Tom Daschle spoke. He invited us to envision a huge stadium with the 300,000,000 Americans in it, and the President at the center asking “what should we do about health reform?”, and the huge multiplicity of opinions that would come. He then suggested that the Congress, with its 535 representatives and senators, was a microcosm of those people, expressing all their multiple beliefs. Well, maybe the multiple beliefs, but not in the same proportion. I feel quite certain that, while there would have been a lot of opponents, the 300,000,000 Americans would have been a lot more supportive of health reform, much more meaningful health reform, than the 535 representatives. This is because they don’t get huge contributions from lobbyists from the insurance industry, pharmaceutical industry, hospital industry, and other big corporations, as well as doctors and lawyers and other rich people. Congress does, and it definitely affects their way of seeing things.

HR 3962 is a bad bill that will finance insurance companies, not save money, and not cover all people. I think, I know, we can do better than that. A single-payer plan, for example, such as that proposed in the Medicare for All bill sponsored by Rep. John Conyers (D, MI), and almost voted on by the house in an amendment by Rep. Anthony Weiner (D, NY) to include single payer. This is actually quite a victory, that it came so close, given the efforts of both the Administration and the Congressional leadership to keep it “off the table” from the beginning of this debate. We can hope that, at least, the amendment sponsored by Rep. Kucinich permitting states to pilot single-payer plans, that passed out of committee with bipartisan support, will be considered. It would be a scandal to not allow those states that wished to to try to model a single-payer program.

Speaking of scandals, HR 3642 is further poisoned by the inclusion of the “Stupak-Pitts Amendment”, named after its sponsor, Michigan Democrat Bart Stupak, which not only continues the Hyde Amendment’s ban on the use of federal funds for abortions, it expands on it, by forbidding any plan that may have anyone getting a federal subsidy from offering coverage for abortion care. No “public option” can offer abortion coverage. This will mean that virtually no insurance policy will offer coverage for abortions, including the ones that do at the current time. Companies could offer two separate policies, so that portion of the population not getting subsidies (above 400% of poverty) could buy the other policy, but there is no evidence that they will do so. Under current state laws, five states offer the possibility of insurance companies offering “abortion riders”, allowed under Stupak-Pitts, but there is no evidence that any of them do. Women do not anticipate that they will need an abortion; like other medical care that may come unanticipated (such as the need for emergency surgery, or a diagnosis of cancer) it needs to be covered in the “regular” policy. See the excellent analysis by Jodi Jacobson, “The ‘Real Life’ Effects of Stupak-Pitts: An Analysis by Legal Experts at Planned Parenthood”, or at the Planned Parenthood site,

The only exceptions allowed under Stupak-Pitts are for abortions resulting from rape, incest, or danger to the life of the mother. Note that this would not only include danger to the mental health of the mother, but would exclude terminations for fetal anomalies, even those incompatible with life. Thus, as is already the case in states such as Mississippi and Louisiana, which have such laws, women can get prenatal testing with ultrasound and amniocentesis, but have no legal access within their states for terminations if something is demonstrated to be wrong. They cannot even be referred. Luckily, at this time, they can go to other states. The Stupak amendment would make the current situation worse.

A group of at least 40 women in Congress, led by Diana DeGette of Colorado, have signed on to a letter demanding that Stupak-Pitts be removed from any final health reform bill. They deserve all the support that they can get, from other members of Congress, from their constituents, and from those who are residents in districts with representatives who voted for Stupak-Pitts. Note that this effort is led by women in Congress. This, obviously, is not a coincidence. Women are the people who get pregnant, including when it is not planned, including when the fetus has anomalies incompatible with life. There are many women, as well as men, who oppose abortion in the sense that they would not have one, that they might counsel friends and relatives not to have one, but also believe that the ultimate decision about what happens to a woman is hers, not theirs. There are also many women, as well as men, in Congress and in the public, who support the concept of Stupak-Pitts and Hyde and other restrictions on abortion, who believe it is their right to make decisions for other women. But none of the men will ever get pregnant themselves. There are many women who were strongly opposed to abortion who have had abortions because their circumstances were special. No men have had to. The role of men, including, obviously, the Catholic Bishops – who, amazingly, are all men! – in fighting for restrictions on abortion, is grossly immoral and offensive.

President Obama has indicated that he will seek some revision of Stupak-Pitts, as described in the New York Times article “Obama seeks revision of plan’s abortion limits”, but even his position would continue the Hyde Amendment restrictions. This has to stop. Women’s lives and health need to stop being the pawns of politicians.

Sunday, November 8, 2009

Celebrating the Defeat of the Opponents of Health Reform

Last night, late on November 7, 2009, HR 3962, the health reform bill jointly worked out by 3 House committees, passed the House by the narrow margin of 220-215. All Republicans but one (Anh "Joseph" Cao of Louisiana) plus 39 Democrats voted against it. This is reason enough to be glad that it passed, despite the limitations of the bill itself. It did not come so close because of progressives concerned about those limitations voting against it; it came so close because there are so many in Congress who are opposed to any improvement in the access to health care for the American people. It is important that they were defeated, even if by a slim margin, because they are voices for an untenable and unjust status quo.

The bill that passed the House is not a good health reform plan on the face of it. It will leave millions of Americans uninsured. It will not provide a significant limit on the ability of insurance companies to profit from the health problems of our people. A wise and clear analysis of the limitations of the bill is provided by John Geyman, MD, Professor and Chair Emeritus of Family Medicine at the University of Washington and author of the official blog of Physicians for a National Health Program (PNHP). In his piece Health Care Reform 2009: No Bill is Better than a Bad Bill, he makes the case that it should not pass. PNHP’s official position before the vote was: “We have been asked how to tell members to vote on the House bill. Our response is that the bill is ‘like aspirin for breast cancer’.” I agree with their analysis of the bill, and still hope (but am not optimistic) that a better bill will eventually emerge from conference, but have to disagree that it would have been better for it to have been defeated, because that would not have been seen as a victory for progressives, but rather have been a victory for the forces of darkness.

Herb Freeman, a long-time social activist and observer (and a close relative), writes:
Because of the tenor of the health bill discussion in the House today [November 7] on C-span, and after receiving an e-mail showing what cost of living and earnings were in the US 100 years ago, I started to Google how and when other changes were made. In looking up information on other federally-mandated social modifications (or improvements), such as abolition of child labor (1938), compulsory public education (early 1900s), fair labor standards (especially the 40-hour week, 1938) and food standards and examination, I came across some surprising things:
Wikipedia mostly quotes libertarian approaches to public education as destructive to the "educable" and wasteful to the "others."
The impact of the 40-hour week is largely negated by 12-hour work days, elimination of overtime after an 8-hour day, partially because of the lack of a national health plan, which makes insurance too expensive for employers and partially from lost vacations to compensate from static wages.
I reviewed the arguments made, both at the time of passage and to this day, against 68 or more laws that protect people from gross exploitation as workers, and they are exactly what I heard today on C-Span for several hours on the health bill from these dinosaurs from Texas, Mississippi, Wisconsin and Utah, etc.”

The cruel and vicious racist and classist arguments that were made against child labor laws and a 40-hour week and fair wages, that were based in ideas that some people were “educable” and others were not, that exploitation was ok, are the same ones we heard in the health care debate. They were evil and wrong back then, and they are evil and wrong now. The laws that Mr. Freeman refers to, which offer some protection for workers, have indeed been eroded, but to the extent that they exist, and that there is a strong belief on the part of most people that they are good things, help to protect against the worst of exploitation. Many of them also passed, in their day, by narrow margins. I think that the importance of passing HR 3962 was that, by a narrow majority in the House (representing, of course, a much larger majority in the country, that of the people who are not rich or corporations to give money to congresspeople), is that it rejected the narrow-minded selfishness and toadying-to-their-wealthy-benefactors of its opponents

I am not optimistic that the Senate bill will be better (Professor Leonard Rodberg, PhD, Chair of Urban Studies at Queens College/CUNY, describes in Don McCanne’s Quote of the Day how the current plan is bad (he calls it a DOG, but I like my dogs!) or that there will be much improvement in the bill that comes out of conference. It is very unfortunate that there is not a single-payer plan, and that Rep. Anthony Weiner’s single-payer plan was not brought to a vote. I still hope that the proposal by Rep. Dennis Kucinich to allow states to pilot single-payer programs (which passed the committee with support from even some Republicans) may yet happen. Single payer got much further along in the debate than the administration and leadership, which tried to kill it at the beginning of the debate, hoped.

But the most important point is that, whatever, the content of the bill, on this one night, by a narrow margin, a bill passed that says the American people should have access to health care, whatever its limitations in actually providing for it, passed, and it passed over the opposition of those who only support legislation that benefits the privileged minority, and opposed, as they have always opposed, programs that benefit all of our people. I celebrate their defeat.

Wednesday, November 4, 2009

Poverty and Uninsurance Diverge: So let’s solve the problem!

Wyandotte and Johnson counties form the Kansas side of the Kansas City metropolitan area. Wyandotte, mainly Kansas City, KS, where I live, is an old “rust-belt” inner city, packing-house industrial city, and is the poorest county in Kansas. Johnson, to its south, consists of older inner suburbs and newer, were-recently-farmland suburbs, and is the richest and most populous Kansas county, with more than 3 times the population of Wyandotte. In Johnson County, only 14% of the population is below 200% of the poverty level, compared to Wyandotte County’s 44%, but it actually a slightly larger absolute number (73,200 to 67,400) because of Johnson County’s larger population. More interesting is the uninsured rate; while it has fewer than 10% more people under 200% of poverty, Johnson County has 2.5 times as many uninsured people as does Wyandotte County.

This means, obviously, that there are many non-poor uninsured people, and this is a national phenomenon. For most of this century, poverty and uninsurance rates tracked together. But in the late 1990s, with poverty rates decreasing, uninsurance rates continued to rise. With the recent recession, both have climbed, but uninsurance is rising at a higher rate. (See graph).

This dissociation between poverty and uninsurance is a very troubling phenomenon; while it is bad enough for poor people to not have financial access to health care, more and more of the uninsured are not poor.

Thus the case for health reform: let’s do something about this. Let’s dissociate the “privilege” of having health insurance from being employed by an entity large enough to afford to provide it, and make sure everyone has financial access to high quality care. Unfortunately, the current plans in the Congress will not do so. The recent assurance by Senate Majority Leader Reid that the Senate bill will contain a “public option”, as will the House bill, obscures the fact that the public option it contains will be weak; in an ostensible effort to not give the public option an “unfair advantage” over private insurance plans, it has been given an unfair disadvantage – it will not be able to use its public status to set rates for provider compensation, as does Medicare, or for drug prices, as Medicare (under the bad restrictions of Part D) also does not.

This is, of course, bizarre: why should anyone, other than the insurance companies themselves, care that they can continue to make money hand over fist while providing inadequate coverage, and not be held accountable by having to compete with a public option that provides comprehensive coverage and does not have to make a profit? Oh yes, the senators and congressmen who get contributions from those insurance companies, yes, but the rest of us? Why should we care? And why should we not insist that our representatives represent our interests, and not those of the insurance companies?

Much of the opposition – not only to single payer, but to a “public option” has been based on, not to put too fine a point on it, lies spread by opponents who are mostly on the payroll of insurance companies. These lies have led people to think that they will lose the excellent medical care, and extensive freedom of choice that they have under the current system (oh, whoops, forgot, they don’t!) if we have a government program. Writing in the Oct 28, 2009 issue of JAMA, Joseph S. Ross and Allan S. Detsky look at “Health care choices and decisions in the United States and Canada[1], choosing Canada specifically “…because the Canadian health system, with much greater government involvement, is often publicly portrayed in the United States as limiting choice.” They review the restraints on choice of insurance plans, hospitals and doctors, and diagnostic testing and treatments, and conclude, modestly that “…there is clear evidence that for Canada’s health care system, less choice in insurance coverage (although guaranteed) has not resulted in less choice of hospitals, physicians, and diagnostic testing and treatments compared with the United States. In fact, there is arguably more choice.” More than “arguably”, I’d say, based on the evidence provided in their piece.

The fewer obstacles that are placed in the way of services to people, the more efficient they are, the more they are appreciated, and the less they affront the dignity of the people receiving them. When comprehensive services are provided to everyone, there is no need to put people through rigorous screening to see if they are poor enough, or don’t have other insurance, or are deserving enough to receive them.

Ironically, or maybe not, the same legislators who decry government bureaucracy are those who demand that bureaucracy through establishing restrictions on programs that help people. This includes, of course, income and citizenship verification for those seeking help with health care; after all we wouldn’t want people to “cheat” and avail themselves of public services when they didn’t “need” them, when their incomes exceeded the 200% of poverty, or 100% of poverty, or 38% of poverty* that we require. If there were one program for everyone, a single-payer or Medicare-for-all program, then all this bureaucracy could be eliminated. We wouldn’t have to screen people, because everyone would be eligible. It would be everyone’s program.

I have written before about the enormous administrative cost involved in both insurance companies (payers) and providers having huge teams of people to try to deny payment or get paid; in one more way, a single-payer plan would eliminate administrative waste and bureaucracy. Funny that those anti-government-bureaucracy folks can’t – or won’t – see it this way.

*38% of poverty was what one's income used to have to be to get financial assistance in Kansas if you were a childless adult -- and it was $100/month. Now it is not available at all.

[1] Ross JS, Detsky AS, “Health care choices and decisions in the United States and Canada”, JAMA, Oct 28, 2009;302(16):1803-4.

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