Friday, September 24, 2010

Capability: understanding why people may not adopt healthful behaviors

In Social Determinants, Personal Responsibility, and Health System Outcomes, I discussed the limitations of the potentially attractive (at least to the empowered) concept of “personal responsibility”. In its more malignant form, personal “accountability” as put forward by John Mackey of Whole Foods, there is the implicit – sometimes explicit – suggestion that people might be denied care if they had not personally taken on the behaviors that might have helped prevent the condition. Of course, which behaviors, for which conditions, and how much remains unspecified. Aerobic exercise 60 minutes daily? Or would 30 minutes 3 times a week qualify? No sweets, or cookies only on Sunday? How many? I am reminded (well, I’m old) of former North Carolina senator Jesse Helms who was against funding the treatment of AIDS as it came from inappropriate and immoral behavior (MSM sex and IV drugs were, I think, what he had in mind). Of course, he strongly supported both tobacco and funding the treatment of heart disease (such as he, a heavy smoker, had).

Of course, I’m sure that, today, smoking is on John Mackey’s “no-no” list, but it is the concept of “your bad habits are worse than my bad habits” that is emblematic of the “different from me is bad” phenomenon that ebbs and flows in world history, and has become increasing common both in this country and around the world. The Tea Party movement is one domestic example; at the “Values Conference” recently held in Washington, Christine O’Donnell, the newly-elected Republican candidate for Senate in Delaware, wowed the crowd with the line "We're not trying to take back our country. We ARE our country." Except, of course, for those who are not part of “we”. Me, for example. And those other ‘others’: those who believe in brotherhood, caring, and diversity.

But surely John Mackey is not embracing racism or prejudice? Classism, maybe; certainly discrimination against those who don’t adopt the health behaviors that he endorses. One might ask: why don’t they? And, if one does, we can get a good answer from a wonderful article that appeared in the recent Annals of Family Medicine, “Capability and clinical success”, by RL Ferrer and AV Carrasco (disclosure: Dr. Ferrer has previously been a guest-author on this blog.) Going beyond the “social determinants of health”, which is a relatively passive model in that it mainly just describes them, Drs. Ferrer and Carrasco discuss the concept of “capability” of health behaviors. They draw upon the work of Nobel Prize-winning economist Amartya Sen, who introduced this concept, and that of Jennifer Prah Ruger of Yale, who has developed its use in health (e.g., “Health capability: conceptualization and operationalization” in the January, 2010 issue of the American Journal of Public Health). The concept of “capability” goes beyond simply evaluating people’s behaviors, and looks at opportunity to perform those behaviors, which is not equally available to all:

“What distinguishes the capability framework from other approaches to evaluation is its emphasis on opportunity as well as achievement. Turning raw capacity (e.g., the ability to walk) into action (walking for 60 minutes a day) to achieve a goal (being physically fit) requires that there be real opportunities to do so. Examining the set of potential opportunities that are viable for a given person (a capability set) helps to define what goals are attainable. For instance, a capability set for physical activity would encompass the various modes and durations of physical activity that are realistically achievable given a person’s constraints of time, money, support from others, physical abilities, and what is locally available.”

Capability is influenced by individual, social, psychological and environmental factors, as well as by income. Money – or lack of it – is a major component, but not the only one, because other features can mitigate or exacerbate financial issues. The concept of “social capital” developed by Robert Putnam (“Bowling Alone[1]) and others is one formulation of this. In his book Heat Wave[2], Eric Klinenberg describes how the deaths in the 1995 Chicago heat wave, while associated with age, illness, poverty and availability of air-conditioning, were also associated with the availability of social supports. He notes the differential death rates in two adjacent low-income communities. In one, the decimation of the commercial sector and fear of crime had people locked in hot apartments, while in the other neighbors checked on the old, sick, and poor, and merchants on the vibrant shopping street allowed them access to their air-conditioned stores. “A capability perspective,” write Ferrer and Carrasco, “implies that poverty should not be defined primarily by income but by scarce opportunity to pursue valued activities and goals. Strong external supports create opportunities that enable people with limited income to pursue their goals for healthy living. Capability is thus a key mediator of the relationship between socioeconomic position and outcomes.”

What Ferrer and Carrasco add to the discussion is the clinical component, discussing how the clinical relationship can take account of capability, and how the clinician can play a role in enhancing the health of patients through understanding and acting to help ameliorate its impact on those who have little. They suggest an example of a series of questions (their Table 2) that a clinician can ask in order to assess an individual’s capability of adopting different healthful behaviors. They also provide suggestions for how the clinician or practice can access help through social service agencies, public health departments, programs of connectors or promotores, and grass-roots agencies. Clinicians may be able to assist in helping people gain access to wholesome food or places to exercise, and to groups that would support their activities.

Of course, in some cases, maybe often, these programs will not already exist. In that case, it could become the role of the clinician or the practice, or even better the health system (or, to use the terms of the new ACA law (PL 111-148), the 'Accountable Care Organization') to help develop such programs in the interest of promoting the health of its patients. Indeed, we should and must if we are interested in promoting health and not just casting blame.

[1] Putnam, Robert D., 2000, Bowling Alone: The Collapse and Revival of American Community, Simon & Schuster, New York, NY
[2] Klinenberg, Eric., 2002, Heat Wave: A Social Autopsy of a Disaster in Chicago, University of Chicago Press, Chicago.

Saturday, September 18, 2010

Shared Medical Decision Making: Between Autonomy and Authoritarianism

One area that has been a “hot” topic of conversation in the medical literature, among “patients”, and even among physicians, is “shared decision making”. This means that decisions about a person’s health are made with input both from the person (or their decision makers, if they are unable as in the case of children and people with dementia) and the physician. An initial response might be “Why shared? Why should not the patient make the decision?” A physician may be involved in explaining the options, discussing the positives and negatives, risks and benefits and costs, of each alternative, try to put the issues and words into “lay” language, even suggest what s/he (the physician) would do (or thinks s/he would do!) in the same situation, but should not the decision, ultimately, be up to the person?

Alexander Kon, in a recent article in the August 25, 2010 issue of JAMA, “The shared decision making continuum”,[1] helps us to understand this. He begins by describing the trajectory of decision making, moving from a long-standing “paternalistic” physician-centered model to, in the 20th century (and I would say late 20th century) a patient-centered “autonomy based” standard in the US. He notes that in the US the pendulum is swinging back toward the middle, to shared decision making, and that it is also moved in this direction in many other countries that never moved from paternalism to autonomy. Kon, as promised, presents a continuum, from 100% patient-driven (autonomy) through “physician recommendation”, “equal partners”, and “informed nondissent”, to 100% physician-driven decision making. This makes sense, as rarely, even in the most paternalistic systems, and certainly even in the most “autonomous” that have developed, is the decision making truly at either extreme. Kon goes into some detail about each option, which are best understood as stages; however, “informed nondissent” may require some further explication. In this model, the physician takes on the bulk of the decision making, and explains it to the patient, who has the right to demur (dissent). Given that information is required to be able to dissent, for this to be different from the extreme of “physician decision”, the patient has to be in possession of all pertinent information, and also has to be aware of the ground rules – that “nondissent” (silence) implies tacit agreement. “Patients must understand that they are welcome to veto the decision and if so, their wishes will be honored and they will receive excellent care.”

Kon further discusses the uses of different approaches in different settings for the same patient-physician relationship. He suggests that “physician responsibility” may be appropriate for “value-neutral” decisions, but goes on to caution that what seems value-neutral to the doctor may not be to the patient and provides several examples of this. He suggests that a very narrow definition be applied – such as “what size endotracheal tube* to use.” Kon diverts a bit from the framework he has developed when he says “Patient preferences must guide the approach used,” for in saying this he is taking a stand against a truly physician-centered approach. I agree with him, but it must be acknowledged that there are many settings and many physicians, both in the US and abroad, who use a physician-centered model, and to whom the question of “what is the patient’s preference?” never occurs.

Of course, even in these settings “patient preference”, and indeed “patient decision making” plays a major role. Kon’s examples of the size of the endotracheal tube used, the hand in which an IV might be inserted in a child, and even decisions regarding end-of-life, are understandable given that he is in the field of pediatric critical care. However, for the primary care physician – or indeed any physician or practitioner caring for “outpatients” (the medical term for “people who are not in the hospital”), it is clear that patients all make decisions all the time.

Some part of ambulatory care, in which a “procedure” of some type is to be performed (an immunization, a Pap smear, a minor surgical procedure, even an x-ray or lab test) resembles inpatient (hospital) care in that it is done by the health care provider and the role of the patient is to agree or not agree to it. However, in most of ambulatory care the physician acts solely as a consultant, suggesting behaviors that would be beneficial, suggesting what medicines to take (and not take) and how often and for how long. The advice, for medication at least, is transferred to a prescription that serves the shared conception that the doctor is actually doing something. In fact, of course, it requires the patient (or their agent) to take the action of bringing that paper to a pharmacy, paying money to fill it, and taking it – as prescribed – for the suggestion to be turned into an action that might improve the person’s health. Even in the most physician-centric model: “Here,” says the physician, writing a prescription, “take this three times a day,” without any discussion of whether the patient wants to, has questions, is concerned, or anything else, the patient has autonomy and ultimately makes the decision. This may be because the patient has a different understanding of what “three times a day” means (up to three times a day? Every day? When I have a symptom? What symptom? For how long?). Or it may be because the patient is getting different advice from someone else (family member, friend, other health provider), or because the patient sees, correctly, the physician as advisor rather than dictator.

None of this gets to the issue of cost, and who pays, which further complicates the question. Sometimes there are treatments that the physician, or the patient, or both agree, is necessary and/or appropriate, but which the patient cannot afford. Sometimes the physician, or the patient, or both agree to because it is affordable (or the insurance company is paying for) when it is not necessary and/or appropriate (or even because the physician will be reimbursed for it). Thus, well-insured people may get treatments they don’t need (and may even harm them), because the doctor, patient or both want to try it, while others may not get treatments they definitely need despite doctor, patient or both recognizing that need.

I agree with the concept of shared decision making, not because I am opposed to patient autonomy, but because of the risk that physicians will, under the rubric of autonomy, not fulfill their obligation to make sure that the patient has the benefit of all the physician’s knowledge and understanding in making their decision. To say “here are the choices, it is your decision” about something as complex as many health decisions are, may seem a more efficient use of the physician’s time, but it is irresponsible. In addition, there are many circumstances (in addition to cost) in which a patient decision to have a treatment should not be honored (when the likelihood of benefit is small or nil, and/or the likelihood of harm is significant). Ultimately, people should make the decision on whether or not to take a recommended treatment, but it is the responsibility of the provider to ensure that they have all necessary information that makes the process “shared.”

*This is a tube inserted through nose or mouth into the airway to help someone to breathe, usually attached to a “breathing machine”

[1] Kon, A, “The shared decision making continuum”, JAMA 25Aug2010;304(8):903-4.

Sunday, September 12, 2010

Social Determinants, Personal Responsibility, and Health System Outcomes

Whole Foods, Inc., CEO John Mackey has been both an outspoken critic of the Obama administration's health reform plan and an advocate for “personal accountability” suggesting that people’s health behaviors – including such things as smoking, poor diet, obesity, and lack of exercise -- account for much of their health risk, and thus people should be held responsible for the poor choices that they make, receiving fewer health benefits if they have not taken the steps to maintain their own health. He has recently made this argument in an op-ed piece in the Wall St. Journal, “The Whole Foods alternative to Obamacare” (August 11, 2010). Subtitled “Eight things we can do to improve health care without adding to the deficit”, Mackey runs through a list of proposals that feature inequity, maintaining and increasing the health and wealth of those who already have the most of it; that would create enormous increases in insurance company profit, would not meet the health needs of those who have needs, and would end up costing a fortune. The “controls” are all on services that would benefit people, the “freedom” is all for corporations to continue to have unfettered access to excessive profit.

All countries with socialized medicine ration health care by forcing their citizens to wait in lines to receive scarce treatments,” he writes. Of course, his definition of “socialized” includes the health systems of every single developed country in the world outside the US, whether they have a National Health Service (e.g., UK), single-payer insurance (e.g., Canada) or a mixed system that includes private insurers that are regulated (e.g., Switzerland, Germany). What is unsaid by Mackey is that the system he proposes (much like the current one in the US) does not eliminate lines for everyone but rations by wealth and insurance status. CEOs like him do not have to wait in lines, but the further down the socioeconomic ladder you are, the longer the line becomes, until, at the end, unlike in those other countries, there are tens of millions of people who can’t get on the line at all. Unsurprisingly, these proposals are likely to resonate with and please the readers of the Wall St. Journal’s editorial pages. The US health system is not only incredibly expensive (not because it covers everyone, which it doesn’t, but because of the huge profits taken out of the system by Mackey’s fellow CEOs) and unfair, but it performs poorly on virtually all dimensions (see the Commonwealth Fund’s 2010 report, “Mirror, Mirror on the Wall”, with results summarized in the attached figure).

More insidiously, however, some of these arguments can appeal to many others, who see sense in expecting people to take “responsibility” for their health and act in healthful ways: “Unfortunately many of our health-care problems are self-inflicted: two-thirds of Americans are now overweight and one-third are obese. Most of the diseases that kill us and account for about 70% of all health-care spending—heart disease, cancer, stroke, diabetes and obesity—are mostly preventable through proper diet, exercise, not smoking, minimal alcohol consumption and other healthy lifestyle choices.” Eat nutritious food, exercise, don’t smoke or take illegal drugs or drink to excess, etc. This is good advice, and all of us should try to take it. I’m sure that it is advice that many of the employees of Whole Foods – the ones who are young and healthy – appreciate, because it validates what they do, and see – the “outcome” is that they are young and healthy. It is possible that there are other Whole Foods employees, not young and healthy but older and/or with chronic disease – who many not find his advice, or the company’s health plan, to be of such great value. His essay may be a call to action for those who, given some combination of youth, genetic luck, good health, and socioeconomic opportunity, are still not doing all they can.

But health behaviors – and the health care system – are not the only determinants of health. Indeed, the Determinants of Health model from Healthy People 2010 (see figure) make clear that there are m any factors that impact health, most of which are ignored by Mackey and his ilk. They are also not all going to be addressed by health system reform, whether that in the current “Obama” plan or even in a more extensive change, advocated by people like me and the Physicians for a National Health Program to be more like the other, much higher performing systems in other countries. That system change is necessary, but not, in itself, sufficient. The environment, both physical and socio-economic, have tremendous impact. In addition, issues not specifically on this model, such as the impact of race (racism, not perhaps overt but in terms of the impact of “perception of race” on those of color). These are the Social Determinants of Health, and have been written about extensively, in a literature that is either unknown to or rejected by Mackey and his friends. Perhaps the clearest exposition of the Social Determinants is by Camara Phyllis Jones, MD, MPH, PhD, of the Centers for Disease Control and Prevention (CDC), who has written extensively on this topic. However, she has also developed a cartoon depicting how the social determinants of health intersect with the health care system as well as how the different levels of the health care system (primary, secondary, tertiary prevention, and treatment) interact with each other. Her slide show, “Social Determinants of Health and Equity, the Impacts of Racism on Health” is available on line and contains these cartoons. They demonstrate, through the use of a cliff analogy, the role of these different factors. Although very useful for teaching children, their clarity is also of great value for teaching health professionals. And they might even be understood by CEOs.

With Dr. Jones’ permission, Neal Palafox, MD, of the University of Hawaii, produced slides based on her model, one of which is reproduced here. It represents health risk as a cliff. If someone falls off, we can provide medical care (the ambulance); however this is variably available for people (access to care). If we can identify diseases and treat them before they require expensive care, this is secondary prevention (the net also represents “safety net” health services). Better yet, we can provide primary prevention – keep people from falling off the cliff (the fence). Some of this is achieved through the individual behavior changes like those advocated by Mackey. The social determinants, however, which he ignores, are represented by the distance that people are from the edge of the cliff; some folks are at greater risk. As Dr. Jones also develops in her slides, many of those same people are those who have less protection by the fence, or the net, or for whom, when they do get sick (fall off the cliff) the ambulance is not there, or even “going in the wrong direction”.

Most of the discussion of these issues are among those of us who are relatively privileged. We may not be wealthy CEOs like John Mackey, but we are educated, literate, and consumers of ideas. Most of us are at least middle-class; even those who may say “no, I don’t have money” are usually in that status temporarily (e.g., from being students), but have the values and self-efficacy that comes from our class, socioeconomic, and educational background. This group certainly includes all the politicians, pundits, academics and successful businesspeople – and medical students. It may be hard to believe, but the vast majority of people are not in that group. Check out income demographics: according to the US census, in 2000 only 12.29% of households – not individuals – had incomes over $100,000 a year, and only 2.37% over $200,000; 2008 estimates indicate household income >$100,000 is the top quintile, and the top 5% is >$180,000.

We absolutely need health reform, real reform, that will begin to move us in the direction of the high-performing health systems in other countries. We also need to encourage healthful behaviors. However, rather than penalizing others whose circumstances – genetic, socioeconomic, social, racial, physical – make that more difficult, we need to develop programs, that require, as Dr. Jones notes, “…collaboration with multiple sectors outside of health, including education, housing, labor, justice, transportation, agriculture and environment.”

And we need to get started.

Tuesday, September 7, 2010

Drugs, Tobacco, Doctors and the Health of the Public

Drugs (the legal prescription type) and drug safety seems to continually return to the news, most recently with reports of serious side effects from a new oral contraceptive pill (OCP), featured on NPR’s "Morning Edition”. With regard to OCPs, it is important to note that virtually all the side effects of oral contraceptives, including the serious ones, are the same as the ones women are at greater risk for from being pregnant. The fact that pregnancy is a “natural” event does not make it risk free; complications such as clots in the veins of the legs (deep venous thrombosis, DVT) do occur, associated with the higher levels of estrogen in pregnancy, and occur more frequently than they do for women taking oral contraceptives. Whatever one’s level of risk for OCPs, a risk that increases with increasing age and dramatically if one smokes, that risk is greater from being pregnant.

However, because the probability of getting pregnant (and thus having serious “side effects” from it) decreases with increasing age while the risk of serious side effects from OCPs goes up, it makes sense for older women who are still fertile to use alternative types of contraception – but, unless they are actively trying to get pregnant, to use contraception. The fact that OCPs can have significant benefits (mainly: preventing unwanted pregnancy) does not make them benign, but neither is pregnancy itself.

The choice to use or not use drugs for any condition (or for prevention of a condition), whether they are prescribed by a health care provider or, in the case of many nonprescription drugs, chosen by the person him/herself, is influenced by number of factors. The best one is that a person has a condition that puts them at risk for bad health outcomes (the “patient important outcomes” of premature death or decreased quality of life; see Calcium, Heart Attack and Osteoporosis, August 2, 2010; Rosiglitazone and the "Holy Grail" July 16, 2010; Statins and scientific integrity, July 6, 2010), and the probability that a drug will decrease that risk is significantly greater than the probability that the drug’s effects will cause a problem. There are sometimes other reasons; a person (patient) will hear from a friend that a drug worked for them, or see on it advertised on television or elsewhere, and decide to try it (if non-prescription) or ask their doctor for it (as so often urged on TV commercials). Depending on a number of factors (whether the drug is in fact useful or potentially useful for something the person has, whether it might create increased risk for the patient, how persistent, or even demanding, the person is) the doctor might in fact prescribe it.

In general, it is fine if you ask your doctor about a medication that you have reason to think might benefit you, but probably not such a good idea to persist/insist if s/he suggests it would not be advisable to take it. A few cautions and things to think about, some of which I have previously discussed (“Conservative” Drug Prescribing March 11 2009):

• Not everything is effectively treatable with a drug. Taking a pill may be easier than changing your diet or exercising or doing other hard or proactive things, but without those other activities it may not work or work as well, and may well be worse;

• Not all drugs are “bad”. Some are really helpful for the right people with the conditions that they are effective in treating, and the potential side effects are far less than the benefits.

• Because some drugs do not require a prescription this does not make them “safe”. They should still only be used when the same criteria are fulfilled: scientific evidence demonstrates that the probability of benefit significantly exceeds the probability of harm. The same applies to any “nutritional supplement”. Because it is not called a “drug” doesn’t make it safe. Everything has potential for harm in the wrong people, the wrong circumstances or the wrong dose (Dietary Supplements can be Dangerous for your Health, October 31,2009)

• If a little is good, more is not necessarily better. Nor is less necessarily better. The right amount is: the right amount!

• Despite our culture’s fascination for the “NEW!!”, new is not necessarily better. Frequently it is worse. Drugs are not cars or cell phones. Newer drugs may have side effects that have not become apparent in the necessarily limited testing that is done before they are marketed, but do manifest when many times more people take them. They sometimes have therapeutic benefit for some people that is greater than old drugs, but often they do not. The only reason to even consider a drug that is new on the market is if your old drug, and the other available old (=”well established”) drugs don’t work adequately or have intolerable side effects, and there is reason (=”evidence”) that the new one will (work better), or won’t (have those side effects).

• Advertising drugs, whether to physicians or to patients, is pretty much a bad thing. As in all advertising, the goal is to sell stuff; it is not (despite pharmaceutical company slogans) improving people’s health. This is highly tied to “NEW!!” because it is the new drugs that are the ones that are advertised. This is because they are the ones that cost the most, that have the highest profit margin, and that the companies need to develop a market for. They also have to amortize their research and development costs, as they will often point out. This would be a less offensive claim if most of the drugs that came out and are heavily marketed were not “me too” drugs – modifications (often quite minor) of existing drugs that are no longer under patent and are being sold generically. Drugs that the doctor may have in his/her “sample closet” will always be these same drugs – the newest, highest cost (and highest profit) options. In health care, if something is being advertised, whether a drug or a procedure available at a local hospital, the meaning is “we would like it if you would buy this because we will make money” and not at all necessarily “this will be good for your health”. By the way, in the case of advertised procedures that you may see on billboards for a hospital or clinic, it means also “if you have insurance”.

The issue of advertising to physicians is addressed in an excellent editorial by Matthew Anderson in the current issue of Social Medicine. It examines the historic and current collaboration by medical organizations with big corporations. In addition to the AAFP/Coca-Cola alliance that I have recently written about, it examines the relationship between the American Academy of Pediatrics (AAP) and infant formula manufacturers and the tight involvement of the AMA with pharmaceutical companies. It is eye opening. In addition, the journal contains a powerful piece by Alan Blum introducing two classic articles about physician activism around tobacco written by the same Dr. Blum when he was, 20 years ago, editor of the New York State Journal of Medicine: “Cigarette smoking and its promotion: Editorials are not enough” and When “More doctors smoked Camels”: Cigarette advertising in the Journal” . The introductory quotation to the first article, from Ira Gershwin of all people, cannot be repeated often enough “One man's death is another man's living”.

And, for those who doubt that, given the current shameful practices, sometimes, given enough time pressure and public awareness, progress is possible, it is worth just looking at the Social Medicine’s cover to see how far we have come, in at least the relationships between doctors and tobacco.

Wednesday, September 1, 2010

Advice for building a new primary care based health system for Armenia: How "knowing the future" can inform our actions now

This is a guest post written by Heidi Chumley, MD. Dr. Chumley is Senior Associate Dean for Medical Education at the University of Kansas School of Medicine.

Recently, my husband and I (both family physicians) and our colleague (a health systems researcher in our family medicine department) visited Armenia as guests of the Kansas National Guard and USAID. Our mission was to learn about the evolving Armenian health care system, develop relationships, and move towards an end goal of providing assistance to Yerevan State Medical University as family medicine continues to develop in Armenia. We knew a little about their health care system before we visited, as our colleagues had made two prior trips.

After the collapse of the Soviet system, the Armenian government endorsed the development of a primary care based health care system and chose family medicine as the discipline to provide that base. We knew they were interested in learning about the family medicine curriculum in medical school, residency, and after residency in the US and specifically at the University of Kansas. So, we prepared our presentations about family medicine training, packed our bags, and worked with the US embassy and YSMU to set up a schedule. We met with officials of YSMU and their department of family medicine, a representative from the ministry of health, and the chair of the department of family medicine at their “NIH”-equivalent. During the course of these meetings, we learned of their two major strategies: 1) retrain "narrow specialists" (their term for physicians who restrict treatment to patients based on age, gender, or organ system) in a one-year program with a national curriculum and 2) begin 2-year family medicine residency programs. Over the past decade, they had retrained 1200 narrow specialists as family physicians. Also, there are 2 government-sponsored family medicine residency programs, training a total of 9 residents per year.

As you might suspect, when there has been no family medicine before in a country seeking to develop family medicine, there are no family physicians to lead the movement. There are narrow specialists who have learned about the value of primary care, endorsed that system, and are working together with other narrow specialists to provide as broad training as possible. This reminded me of what might have happened in the US as family medicine became a specialty. Visiting Armenia was like being granted a rare opportunity: a glimpse into our past, with a known future, poised at an important moment in time. It gave me a chance to reflect on what happened in the US that led us to a specialty-centric health care system and what decisions may affect whether or not Armenia is able to transform to a family medicine based health care system. At our exit meeting with the director of USAID in Armenia, we mentioned that the best way we could help would be to outline pivotal decisions that will either be made or just come to be as if a conscious decision was made. I've scripted those insights into concrete “dos” and “don'ts” based on knowledge of what transpired in the US health care system. Here is my advice, for what it is worth:

· Don't train your primary care doctors in a system where they only rotate with narrow specialists.

· Do train your narrow specialists in primary care settings to help them keep a sense of probabilities.

· Don't make family medicine training shorter or less prestigious.

· Do shorten procedurally based specialty training when possible, creating a system where new narrow specialists continue to develop their procedural skills under a proctoring system funded by private practices seeking new partners instead of the government.

· Do provide a sufficient number of government sponsored family medicine residency positions to produce the physicians needed to provide care for the population.

· Don't provide government sponsored narrow specialty residency positions at a number greater than what is needed for the population.

· Do set goals or metrics for how much a family physician should be able to manage (80% to 90% of what walks in the door).

· Don't enable a system that supports narrow specialist to narrow specialist referral.

· Do a national educational campaign on primary care concurrently with the improvement in the training of primary care physicians.

· Don't pay narrow specialists more than primary care physicians.

· Do follow outcomes and reward improved health of a population.

· Don't financially reward overuse of services.

· Do seek to become a nation in the top 10 of all nations on important health care outcomes.

· Don't spend 8 times as much as the other nations and remain below 40 other nations on health care outcomes.

I was also struck with this amazing reality: only a country as economically blessed as the US could even fathom conducting health care as we do. It is irresponsible of us to hold up our version of western medicine as a model. It won't work except in a society where the people have too much.

In fact, it doesn't work in our society for the people who don't have too much. It often doesn't even work that well for those who do.

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