Sunday, July 31, 2011

Training Rural Doctors: The KU Salina Program


Among the many forms of disparity in access to health care, the imbalance between rural and urban/suburban areas in terms of physician and other healthcare provider workforce is one of the most obstinate. The problem has been well-documented and been discussed by myself and others on a number of blog posts (e.g., Primary Care, Medical School Debt, and US Health Needs: Analysis from the Graham Center, May 31, 2001, Training rural family doctors, November 5, 2010). While the latest data from the Census Bureau show that the percentage of Americans living in rural areas has dropped from the 20% I have often cited to 16% in the 2010 census (as reported by Hope Yen for the Associated Press in Rural US disappearing? Population share hits low), 16% is not yet “disappeared”. In addition, the percent of doctors working in these areas (which I have previously cited at 9%) is almost certainly lower as well, given both retirements of older doctors and the low level of interest in entering even primary care (requisite for rural practice), not to mention rural practice itself, among graduating medical students and residents.

The problem of lack of availability of health care in many rural areas is further complicated by the aging of the rural population, which is associated with increased need for health care. There are wider reasons to fear the loss of rural doctors. Rural medical practices not only enhance health directly, they provide income and economic development for a community (jobs), and may indeed be one of the key determinants (along with schools) of why some rural communities will survive while others slowly disappear. We need strategies to increase the number of students matriculating in medical schools who are interested in rural practice, and strategies for encouraging and supporting them to enter family medicine (which is the main medical field that works in rural areas, although there are also roles for other primary care doctors such as general internists and general pediatricians, and some specialists, particularly general surgeons).

This is why the fact that the University of Kansas Medical School (KUSoM) is opening a 4-year medical school campus in the small central Kansas city of Salina is big news, not only in the state (as in reports from the Kansas Health Institute [KHI]) but nationally (as demonstrated by front-page coverage in the New York Times and on NPR). Like many state medical schools, KUSoM has long had a regional campus, in Wichita, where a portion of medical students have done their third and fourth (“clinical”) years of training. That campus will be expanded to have 8 new first-year students this year, and 28 beginning next year, who will spend 4 years in Wichita. But the bigger news is in Salina, a north-central Kansas city of just under 50,000 whose previous opportunity for fame as the place where Bobby McGee “slipped away” in Kris Kristoffersen’s song itself slipped away when Janice Joplin, in the most widely-known version, sang it incorrectly as “Salinas” (well, she was from Texas and lived in California!) [OK. I HAVE IT ON GOOD AUTHORITY THAT I AM WRONG AND IT WAS ALWAYS SALINAS. OH WELL, IT WOULD HAVE BEEN A GOOD STORY.]. Eight students per year will spend their entire 4 years in Salina, making it the smallest city to have a 4-year campus and making the “New Salina med school campus unique in US” according to Dave Ranney of the KHI. Or almost unique; Indiana University School of Medicine has done something similar, expanding a first-two-years campus in Terre Haute to 4 years. The KUSoM Wichita campus has done a good job of producing primary care doctors who practice in rural Kansas compared to most places, but Wichita is the largest city in Kansas, not in itself at all rural.

A.G. Sulzberger notes in his piece, “Small town doctors made in a small Kansas town” (NY Times, July 23, 2011) that “when one visitor from the Liaison Committee on Medical Education, an accrediting body whose approval was considered a major hurdle, [s/he]remarked with surprise that the area was not just cornfields.”  Of course not! Kansas is the Wheat State! That aside, Salina, on the banks of the Saline River in the Smoky Hills, does sit in the middle of an agricultural region. Indeed, it is the home of the Land Institute, a wonderful organization dedicated to developing a perennial prairie grass that will produce an economically-usable grain, that I take every opportunity to direct people to. 

The perspective of New Yorkers aside, Salina is not really a small town. A 4-year curriculum equivalent to that in KC or Wichita would be impossible in too small a town because the community must have at least the “core” specialists of internal medicine, pediatrics, surgery, obstetrics-gynecology, and psychiatry as well as family medicine. Salina is a prosperous town with a large enough medical community to support all the “core” clerkships that medical students need to take in their 3rd year, as well as faculty to lead the small groups for Problem-Based Learning (PBL) sessions, and to support the basic biomedical science education. All of the materials for the modular curriculum for the first two years of medical school is available on-line, and the fact that all lectures are podcast means that Salina students will have the option of emulating many Kansas City-based students and not attend them all. But if they do, they will be directly tied in via high-quality, high-resolution interactive TV, and will even be able to ask questions of the KC-based lecturer just as if they were in the room.

The CEO of Salina Regional Medical Center, Micheal Terry, is quoted by Sulzberger as saying “When they go off to the ritz and the glitz and pick up a spouse from the big city, it’s always hard to get them back to small-town America.” Even if you think that the ritz and glitz of Kansas City and Wichita do not make them New York or Paris (but you should visit these cities before judging), it is not just “how you gonna keep ‘em down on the farm after they seen Paree”. Medical students are usually in their 20s, at the age where they often meet their spouses, and they meet them where they live. If that is in Kansas City or Wichita, it is more likely that the spouse will be from that area and unwilling to move to a rural area, or have a job that precludes them from doing so. If the Salina program is successful, it could be a model for decentralizing even more of the KUSoM curriculum to other Kansas cities, and of course for other states.

But how will we know if it is successful? In the very short term, we will see how the students and their teachers assess the experience, as well as student performance on exams. In the relatively short term (4 years), we will see whether they mostly enter primary care programs, and some years after that, whether the indeed enter rural practice. We don’t know, of course, whether, even if they do, it will actually increase the number of students entering rural practice, because some already do. Since the students were admitted first and then those who wanted to go to a rural site chose Salina, there is at least a possibility that 8 students who would have entered rural primary care practice anyway are matriculating in Salina, and we just took 8 additional suburban students in Kansas City who will not. We hope this is not the case, and look forward to expanding the program.

In any case, it will be extremely important if it demonstrates that medical education can be decentralized and effectively taught in smaller communities, and that it can be done with high quality and in a setting that does not demand relocation to major metropolitan areas. With this new setting, we have to make sure that our admission process favors students who are most likely to become rural primary care physicians. If we do that well, we may really have something here!

Monday, July 25, 2011

Evaluating the Communications Skills of Potential Medical Students: Looking at the "Whole Person"


As US medicine is becoming increasingly seen as more impersonal and technological, there is an unsurprising reaction among the people it serves. While Americans unquestionably value the benefits of high-tech interventions (at least for themselves and their loved ones – maybe not so much for others), they also want doctors who will listen to them, understand them and care about them. There is a definite sense that technical skill is great but the decision about how and to whom to apply that skill requires understanding the person, not just the disease and the potential intervention.

Most people are not in a good position to evaluate physician skill on a technical basis. Most studies on this topic have found that in general people assume quality – they assume the knowledge and skill of their doctors, and of the hospitals in which they practice. This is why hospitals and practices often compete on the basis of “hotel” services -- is there a nice lobby, is the place modern and impressive, are the rooms big, is the food good -- as well as issues such as “are complaints addressed”. When people are unhappy with their medical provider, doctor or hospital or other, it is usually because they had a bad outcome or because they didn’t get the “service” that they wanted. All of us can relate to that, but these are not always the result of “bad medicine” being practiced. Not getting the service you wanted may be medically appropriate if that service was not indicated or even potentially harmful. The bad outcome may be because the provider didn’t do a good job, but it could just as well be because there was inherent risk in both the procedure done and the underlying disease that it was intended to treat. Indeed, it  may be that the potential benefits of the procedure were oversold and the risks minimized; when people are suffering they are often likely to look at potential benefits and not so much at risk. It is therefore the job of the provider to make clear what the benefits are most likely to be (not just “best case scenario”). A cure? How often? An improvement? How much? A longer life? How long? And in what condition? And what are the risks? And costs? This, of course, gets back to communication.

On the whole, medical students have not been selected for communication skills. Sure, admissions committees value them, but they are not “make or break” the way test scores are. Most medical school faculty have a variation on the (true) story I heard from a colleague; the interviewer, a high tech physician, wrote on the applicant’s interview form “Great scores, zero interpersonal skills. Admit.” Unfortunately for the applicant, arguably more fortunately for his/her future patients, those interpersonal skills were so poor s/he finally failed out when s/he moved from the test-taking years to the actual patient care years.

A new medical school in Roanoke, VA, the Virginia Tech Carrilion School of Medicine, is formally integrating assessments of communication skills into its admissions process, as described in the NY Times July 11, 2011, New for Aspiring Doctors, the People Skills Test. The particular method that they are using is the “Multiple Mini-Interview”, or MMI, in which applicants have a series of 8-minute discussions with an interviewer who presents them with a problem – an ethical issue, a values conflict, a team dynamic – and looks for how well the interviewee is able to approach the problem, to think about, and to express their concerns. There is no “right answer”; “Candidates who jump to improper conclusions, fail to listen or are overly opinionated fare poorly because such behavior undermines teams.” This is not the traditional model for selecting doctors, who are classically opinionated, the “boss”, and so sure of themselves as to often be accurately characterized as arrogant. The article indicates that many other medical schools are looking at this system, originally developed at McMaster University in Ontario, Canada, or another similar one.

Of course, there was a response to this article and not all of it was positive. Most of the letters published in the Times on July 18 were critical in one way or another. Several were from physicians, but I will not mention the specialty for fear of feeding stereotyping (if you are interested in knowing, following the link above). While one writer set up a straw man to attack: “Charm won’t save a patient’s life,” which confuses (presumably on purpose) the ability to communicate and work with others as “charm”, other letters suggested that their authors had familiarity with the specific test, the MMI. They perceived flaws in the test, suggesting that it might overselect extraverts compared with introverts and be disadvantageous for the applicant “…with less ‘real world’ experience or an applicant with fewer resources who may have less experience navigating ethical discussions,” or that it “may ‘weed out’ talented applicants who have the compassion and capacity for great “people skills” but have not had the time or opportunity to nurture them.”  Another worried “that the stressful mini interviews might screen out not bullies, but mildly awkward people who would be fine when dealing with real patients and nurses.”

Another writer was generally supportive, but worried that “…while speed ethics tests are at best an intriguing experiment, at worst they are the latest gimmick”. This person suggested that “Medical schools might try looking at the whole person.” Of course, “looking at the whole person” is exactly what Virginia Tech Carilion and other medical schools are trying to do, whether using the MMI or other methods of assessment. They are trying to get instruments to measure that “whole person” beyond the ability to score well on multiple-choice tests, which have, after all, long been the cornerstone for deciding who gets into medical school. Our “charm” writer suggests that the answer is to “select brilliant students, and then cultivate their social skills.” Of course, all the data suggests that “brilliance” aside, it is much easier to teach knowledge and technical skill (the whole point of the medical education experience) than it is to teach social skill, as demonstrated by the elegant work of Dr. Robert Sade and colleagues, “Criteria for the Selection of Medical Students”[1], published in the Annals of Surgery in 1985.

Much other research has demonstrated that the traditional methods of selection (high test scorers, mostly from privileged backgrounds) predict success in the first two years of test-based education but not at all in the clinical years or in practice. MMI also has a research basis; Dr. Harold Reiter, the McMaster professor who developed it says “…candidate scores on multiple mini interviews have proved highly predictive of scores on medical licensing exams three to five years later that test doctors’ decision-making, patient interactions and cultural competency.”  

Perhaps the MMI is not the best tool for assessing communication and teamwork skills, but it is a good one, and those are important skills. Those skills, as Dr.Sade identified, are among those we should be selecting for. If the applicant has “less ‘real world’ experience”  but has “…not had the time or opportunity to nurture them,”  maybe it is important for them to do that and find out if they are capable before they are accepted to medical school.

The correlations we will ultimately need to have to see if our methods of medical student selection are good or not will not be with performance on multiple choice tests. They will look longer term at specialty choice, practice location and at the benefit to the health of the patients they care for. Most important will be the overall health of our population. In the meantime, we should at least accept medical students who have the basic interpersonal skills to communicate effectively with another human being.

[1] Sade RM, et al. Criteria for selection of future physicians. Ann Surg. 1985 February; 201(2): 225–230

Tuesday, July 19, 2011

"Reforming" Medicaid, or Cutting Medicaid: No shortage of folks to cast the first stone


Jeff Colyer, MD, the Lieutenant-Governor of Kansas, has been leading an effort for Governor Sam Brownback to “reform” Medicaid for the state. This is of concern because the state faces the same budget crunches that are faced by most states and the relatively high cost of Medicaid as a percent of the state budget (about 22% in Kansas). Gov. Brownback wants to cut $200-400 M in Medicaid expenditures and is looking for ideas on how to do so. In the Fiscal Times, Blair Briody’s piece Medicaid’s Ticking Bomb Could Wipe Out State Budgets discusses the challenges states face with increased enrollment in Medicaid (6.5% in 2009) because of job losses resulting from the same economic crisis that has state revenues down. Of course, there is another solution, but (like most new Republican governors) Gov. Brownback and his legislature are firmly opposed to increasing revenues (ie, taxes)

Dave Ranney, reporting for the Kansas Health Institute, covered the second of two (so far) public forums, held in Wichita and led by Lt Gov. Colyer and attended by Secretary of the Department of Health and Environment Bob Moser, MD (Moser is a family physician; Colyer is a plastic surgeon). In Medicaid forum generates long list of reform ideas Ranney lists many of the ideas identified by working groups. They include:

• Enact policies that discourage non-emergency visits to emergency rooms.
• Remind families of their moral obligation to at least share in the costs of caring for frail elders.
• Reward behaviors that improve health. Discourage those that do not.
• Increase the numbers of nurse practitioners in the state’s rural areas.
• Let Medicaid beneficiaries know how much their services cost.
• Do more to promote “living wills” and hospice care, less to promote nursing home care.
• Limit families' ability to switch managed care providers more than once a year.
• Do more to encourage businesses to hire disabled people.
• Approach companies like Home Depot and Lowe’s about helping people with disabilities make their homes accessible; installing wheelchair ramps, for example.
• Foster home-like homes for frail seniors or disabled people who might otherwise move to a nursing home.
• Reduce the potential for fraud and abuse by not allowing family members to be paid for caring for elderly relatives.
• Close one or both of the state hospitals for people with severe developmental disabilities.
• Find ways to better coordinate patient care.

Something is missing from this list. That would be any suggestion that the state has a responsibility to provide quality health care to Medicaid recipients. Of course, that might cost a lot more, not less money. Some of these ideas are reasonable, like asking Home Depot and Lowe’s to help people, encouraging businesses to hire the disabled, and developing “home-like homes” (I love that; as opposed to ‘non-home-like homes’, or ‘home-like non-homes’?) for frail seniors and disabled people. They might even help some folks, but they are unlikely to save Medicaid much money.  Others, such as increasing the number of nurse practitioners in rural areas, are good ideas, but without a strategy that addresses how are of little use. Nurse practitioners do not locate in rural areas for the same reasons that physicians do not: because they are often from urban areas and can make more money in urban areas, particularly working in subspecialties rather than primary care. Paying them more to work in rural areas might be effective, but that also would cost more money.

Closing the state hospitals for people with severe developmental disabilities would probably save money, but only if adequate services can be provided for them in the community. Whoops, that will also cost more money. And that money will be vulnerable every year, especially when there is a budget shortfall. We have experience in this area. Several decades ago, across the country, we closed state mental hospitals because we could provide better mental health care in community mental health centers while giving the patients a better shot at a higher quality of life. Unfortunately, after “de-institutionalization” (as it was called), federal and state governments ratcheted down funding for community mental health services. The result? Lots of homeless, under-treated, mentally ill people. It is not clear to me that those with severe developmental disabilities will even do as well.

Doing more to promote “living wills” and hospice care might be good for many people, Medicaid or not, as would finding ways to better coordinate patient care. Of course, nursing homes are businesses, and state government wants to be business-friendly.

The most obvious characteristic of the list is that most of the suggestions fall squarely in the category of “blaming the victim”. They are mean-spirited and reflect a definite sense that the people who are receiving Medicaid are, by and large, irresponsible, manipulative, and wasteful. Certainly they are not anything like the people making the suggestions! Thus, we should limit their ability to change providers and we should emphasize the importance of families taking care of their elders (whether those families have any resources or not; whether they have families or not). In the cases where they do have families we need to reduce the potential for fraud and abuse by not allowing family members to be paid for caring for elderly relatives, enact policies that discourage non-emergency visits to emergency rooms, let beneficiaries know how much their services cost. How these would save money without hurting the health of beneficiaries is not made clear. What if the providers are not meeting the patients’ health needs? What if the frail elders (and here I assume that we are talking about people who receive both Medicare and Medicaid, known as “dual-eligibles”) do not have families, or if their families are without resources? What if they do have families and now those family members cannot go out and get a job because they are caring for frail elders but we won’t pay for it? And what is the point of reminding them what their benefits cost? It is presumably health care providers who order the tests and treatments, and these are based, presumably, on medical need.

It is actually, by and large, a pretty ugly list. Maybe we should remind the members of these citizens’ panels what their benefits cost. Are they paying out of their pockets for their health care, or do they have insurance? Is there anything more morally acceptable about receiving inappropriate, medically unjustified, non-evidence-based health care if one is insured by something other than Medicaid? Or is not receiving appropriate, medically justified, evidence-based health care more acceptable if one is on Medicaid? In my last post I cited the June 28, 2011 NY Times article, “New prostate cancer drugs extend lives but raise costs”, in which Andrew Pollack notes that Medicare is going to look into whether to pay for drugs that may extend life for a few months but cost upwards of $90,000 per course of treatment, but that “…some patient advocates and politicians portrayed the review as a step toward rationing.”  I hope that these are not the same people who are advocating rationing for those who are poor.

Because that is what Medicaid patients are. Poor. Not all poor people get on Medicaid, of course. In most states, including Kansas, only poor people who are children and their mothers, severely disabled people, or people in need of long-term care, are on Medicaid. Not undocumented people, not childless adults no matter how poor or in need of health care. But everyone on Medicaid is poor. If there were any poor people on these panels, whether or not they were Medicaid recipients, you can be sure that these suggestions did not come from them. There is not a single working-class, middle-class, professional or upper-class member of any of these panels who would want to change places with these poor people so that they can get Medicaid. It is so much easier to judge others.

The reality is that the most useful suggestions will not save much if any money, and most of the rest are mean. In an Op-Ed in the Wichita Eagle, state Rep. Jim Ward (D-Wichita) suggests that the cuts first “Do no harm”. He states it is from the Hippocratic Oath, which it is not really (see Physician Oaths and Social Responsibility, July 7, 2011), but it is a good idea. Another really good idea is close management of the sickest, highest-cost, highest-risk patients using health coaches or promotoras (such as those described by Dr. Atul Gawande in The hot spotters: can we lower medical costs by giving the neediest patients better care?” and discussed by me in Freedom abroad, health at home: experiments in preventive health care, February 13, 2011).

The necessary step to both maximizing health and minimizing cost is to have a single-payer system so that we are all in the same program, so that cutting your benefits cuts mine. Then we can make wise decisions on the most medically appropriate, as well as cost-effective, way to spend that money.

Wednesday, July 13, 2011

Direct-to-Consumer Advertising and the Role of Advocacy Organizations: Two Threats to Evidence Based Testing


Two recent “Commentaries” in the same issue of JAMA address different challenges to the implementation of evidence-based practice guidelines. One, “Direct-to-consumer cardiac screening and suspect risk evaluation” by Lovett and Liang[1] addresses the challenges posed by the potential for profit that occurs when companies market screening tests direct to the consumer (DTC) that may not be indicated, may not be indicated for the people who it is marketing to, or may even be harmful to the recipients of such screening. This harm can, of course be physical, as in untoward events, or in risks inherent in the further procedures for those who “screen positive” but turn out to have been “false positives”. The harm is also financial, for there is a cost to doing these tests – to the individual (sometimes) or to their insurer; in the latter case, whether that insurance is public (e.g., Medicare, Medicaid) or private, the cost is to all of us. And, of course, that cost is the reason for such marketing, as it is what translates into profit for the company selling the test.

In the case of cardiac screening, Lovett and Liang, using the recommendations of the US Preventive Services Task Force (USPSTF), the American Heart Association/American College of Cardiology Foundation (ACCF/AHA), describe heavily-marketed tests that can cause more harm than benefit to the many people who are not in the narrowly-targeted group for whom the tests are indicated; other tests which have valid indications although, again, in the appropriate populations; and finally tests for which there is little or no evidence. The marketing of these tests can incur anxiety or fear in people who have no reason to be worried about these conditions and may occur outside the physician-patient relationship, thereby not allowing people to get the physician’s analysis of the results even when the test is indicated, and cost a great deal of money. This is particularly true when a possibly-positive test needs to be followed up with a number of other tests to rule it out, this time covered by insurance. They make several suggestions for how DTC companies should be regulated. They conclude that, “DTC cardiac testing may pose more harm than benefit to many consumers. Oversight efforts are needed to protect the public from inappropriate testing and to ensure that the health care dollar is spent on care promoting health in an evidence-based fashion.” I would say that is a mild suggestion!

The issue raised by the other article is probably more insidious;  because it lacks the obvious profit motive present in DTC marketing, we may be less wary.  In “Health advocacy organizations and evidence based medicine[2], Sheila Rothman examines the tendency for groups that are created around a single disease (e.g., breast cancer, epilepsy, autism, etc.) to push for screening tests, diagnostic tests, and treatments for “their” disease whether or not there is evidence to support their use. In response to an Institute of Medicine (IOM) survey that sought to identify what tests and treatments should be included in a basic benefits package, “They contended that EBM [evidence-based medicine] should serve merely as an aid in medical decision making, not as the basis for it. Outcome data, they insist, should not limit patient choice or restrict available services.” This is truly remarkable. These groups are basically saying “our disease is so important we should screen everyone, everyone who screens positive should have diagnostic tests, and everyone who has it should be able to get any treatment that they want, even if there is weak or no evidence for its efficacy. And, of course, someone else should pay for it.” This would probably be unreasonable if there was only one such disease, but there are hundreds and each is the “most important” for its advocacy organization. The reason that this is more insidious is that these groups are not seeking to make a profit on these tests and treatments (usually); they are (usually) functioning as advocates for people who are truly suffering.

However, the fact that people are truly suffering does not mean that society should screen large numbers of low-risk people for all of these conditions. There are, of course, some things that we should and do screen everyone for. We screen all newborns for a set on genetic or congenital conditions for which identification makes all the difference. Two good examples are congenital hypothyroidism (in which the newborn thyroid doesn’t function) and phenylketonuria (in which the newborn lacks the enzyme to break down a certain protein). Undetected (and thus untreated) these lead to serious disease, mental retardation and death. Detected, and easily treated (by thyroid hormone replacement and avoidance of phenylalanine-containing foods, respectively) the child can lead a normal life. But every condition with an advocacy organization is not one of these, nor are the screening, diagnostic tests, and treatments so straightforward.

Sometimes, these advocacy groups may indeed have a financial interest in a test or treatment, but even when they do not, they may push for policies that allow physicians to prescribe expensive brand-name drugs even when generic drugs have not been tried. Or to demand the availability of expensive but unproven treatments: “’Autism Speaks’ criticized insurance companies that refused to pay $300 000 for 4 years of applied behavior analysis therapy for toddlers, despite a lack of evidence of effectiveness.” That is a lot of money even if we know a treatment is effective, but it is an awful lot when we do not. The issue is that this organization is focused only on people with “its” disease, and has no concern for what the money could otherwise be used for to treat other people with proven therapies. Maybe this is their role, but there is no reason that the rest of society must buy into this logic.

Cancer, of course, has the strongest set of advocacy organizations, and breast cancer is far and away the leader. I wrote about the issue of advocacy versus evidence regarding the most recent USPSTF recommendations for screening in Breast Cancer Screening and Evidence-based Medicine, November 25, 2009. More recently I looked at these issues, including both breast and prostate cancer screening, in Men’s Health? Women’s Health? Valid screening opportunities or “Hallmark Holidays”?, March 15, 2011. In this context, the Food and Drug Administration recently approved several new drugs for metastatic prostate cancer. The cost can be over $90,000 for each treatment cycle and might exceed $500,000. In the June 28, 2011 NY Times article, “New prostate cancer drugs extend lives but raise costs”, Andrew Pollack notes that Medicare is going to look into whether to pay for these drugs, but that “…some patient advocates and politicians portrayed the review as a step toward rationing.” Excuse me? Don’t we already have rationing based on whether or not one has money or insurance? I recently addressed this in my recent post The real face of lack of access to health care, June 19, 2011. It is not ok for “patient advocates” to advocate for some people to get any kind of treatment paid for by someone else (e.g., Medicare) when everyone who has that medical need is not able to get care. And since there will be more things to spend money on than there is money, there needs to be a more rational system than “Me first!” This system is the use of evidence-based guidelines.

Rothman concludes her commentary:
However valuable independent advocacy organizations are for a democratic society and however important their services provided to targeted populations, their advocacy positions and the related underlying assumptions must be scrutinized with the same diligence as those of other stakeholders. There should be no automatic assumption that all health advocacy organizations deserve special standing or represent the common good.” 
And for good reason, because they probably do not.

[1] Lovett KM, Liang BA, “Direct-to-consumer cardiac screening and suspect risk evaluation “,JAMA  2011Jun23/29;305(24):2567-8.
[2] Rothman SM, “Health advocacy organizations and evidence based medicine”, JAMA  2011Jun23/29;305(24):2569-10.

Thursday, July 7, 2011

Physician Oaths and Social Responsibility


Most people are familiar with the existence, if not the content, of Hippocratic Oath taken by physicians on graduation from medical school. Whether this was originally written by that Greek “founder of Medicine” or not, it is very old, and has been updated often to be relevant to modern practice. Most medical schools do recite some modification of this oath at graduation, although some use the Oath of Maimonides, written by Moshe ben Maimon, a 12th century Jewish physician from Spain and North Africa. All are focused on the role of the physician and his or her commitment and implicit pact with his/her patients, including using healing and confidentiality. There is also a fair amount of veneration of teachers. The Declaration of Geneva adopted by the World Medical Association in 1948 after the horrific acts of Nazi doctors were revealed in the Nuremberg trials, and revised many times since then, adds some acknowledgment that the physician also has responsibility to society; it now includes the phrase “will not use my medical knowledge to violate human rights and civil liberties, even under threat”.  

This, I think, is a step forward. In the time of Hippocrates and later Maimonides, there were great limits to what physicians could do as healers. Surgery only became something people regularly survived after the invention of ether as anesthesia and the recognition of the importance of antisepsis (even hand-washing) in the late 19th century. In his graduation speech to the Harvard Medical School, Cowboys and Pit Crews (which I have cited earlier EMRs and Primary Care: The good, the bad, and the challenges, June 11, 2011), Dr. Atul Gawande refers to Dr. Lewis Thomas describing the work of an intern as recently as 1937 in his book “The Youngest Science” [1]. Those interns worked hard in order to make sure they didn’t miss one of the treatable conditions, because “There were only a few. Lobar pneumonia could be treated with antiserum, an injection of rabbit antibodies against the pneumococcus, if the intern identified the subtype correctly. Patients in diabetic coma responded dramatically to animal-extracted insulin and intravenous fluid. Acute heart failure patients could be saved by bleeding away a pint of blood from an arm vein, administering a leaf-preparation of digitalis, and delivering oxygen by tent. Early syphilitic paresis sometimes responded to a mix of mercury, bismuth, and arsenic. Surgery could treat certain tumors and infections. Beyond that, medical capabilities didn’t extend much further.”

The huge explosion of treatments, and often cures, both medical and surgical, that occurred during the 20th century far exceeds all that came before. There is an extraordinary amount that we, as physicians, can do for all sorts of conditions as well as much more effective treatments for the conditions Gawande lists above. When I trained in the 1970s, we could do things scarcely dreamed of when Thomas was an intern in 1937, and what we can do today makes the 1970s look like ancient history. We continue to see in the 21st century explosions of new therapies, some good, some not-so-good, and many unproven before they are released on the market. Our incredibly enhanced understanding of science, such as the human genome, and the amazing engineering capabilities of our technology, make it seem as if nothing is unachievable.

But because we can do things for certain diseases, because we can utilize certain technologies, doesn’t mean that we always should. Even the treatments Gawande describes above, limited as they were, often had devastating side effects that killed when they did not cure. Now we have more treatments that can be absolutely wonderful for some people in some circumstances, but not for everyone in every circumstance. [2] The complexities of these interventions make it even more important to have a physician’s ethic that understands context, understands public as well as individual health, and most important understands the contribution of food, housing, education and other social basics to health.

The “Declaration of Professional Responsibility: Medicine’s Social Contract With Humanity”, adopted by the American Medical Association (AMA)’s House of Delegates in 2001, is a more recent effort to summarize the obligations of the physician. Its title itself understands the role of the physician as more than a commitment to the individual patient but, in fact, a social contract with humanity, to the interconnectedness of all people. Its 9 points re-state many of the basic principles of the Hippocratic and Maimonides Oaths; it then adds several additional critical concepts. These include, in particular, commitments to:

“VI. Work freely with colleagues to discover, develop, and promote advances in medicine and public health that ameliorate suffering and contribute to human well-being.
VII. Educate the public and polity about present and future threats to the health of humanity.
VIII. Advocate for social, economic, educational, and political changes that ameliorate
suffering and contribute to human well-being.”

This is a very big and important step. It is even more important when not just the individual physicians, but the institutions of which they are a part, commit to core social values. Recently, WONCA, the World Council of Family Doctors, convened a conference, in East London, South Africa in October2010, to look at the Social Accountability of Medical Schools. Its final report, issued in December 2010, “Global consensus for social accountability of medical schools”, addresses 10 major areas:

&Area 1: Anticipating Society’s Health Needs
&lArea 2: Partnering With The Health System And Other Stakeholders
&Area 3: Adapting To The Evolving Roles Of Doctors And Other Health Professionals
&Area 4: Fostering Outcome-Based Education
&Area 5: Creating Responsive And Responsible Governance Of The Medical School
&Area 6: Refining The Scope Of Standards For Education, Research And Service Delivery
&Area 7: Supporting Continuous Quality Improvement In Education, Research And Service Delivery
&Area 8: Establishing Mandated Mechanisms For Accreditation
&Area 9: Balancing Global Principles with Context Specificity
&Area 10: Defining The Role Of Society

Each of these has several points listed under it, which are goals/directions for medical schools to achieve. People, and the societies that they comprise, invest heavily in medicine and medical education because they value health, and see this investment as a way to achieve health. But as the cost of medical care rises, absorbing more and more of our GDP and that of the world, it has the opposite effect. As it begins to squeeze out necessary spending on infrastructure, on education, on housing, on nutritious food, it degrades health.

While WONCA represents only family doctors/general practitioners, it is an important international organization and its recommendations will be taken seriously by medical schools around the world. To the extent that they are, it would be a good thing, because medical schools, like the physicians that they educate, need to be much clearer on how they fit into the society that produced and supports them.

Physicians and other health professionals cannot see themselves only as technicians with a bag of tools to use on the sick; they must be the custodians of health, the enablers of health, the advocates for the necessary components of healthy people and a healthy society. The Preamble to the “Declaration of Professional Responsibility” ends with this simple reminder:
Humanity is our patient.”

[1] Thomas L, The Youngest Science: Notes of a Medicine Watcher, Viking, 1983.
[2] And this does not even touch on the issue of financial cost.

Wednesday, July 6, 2011

New blog and post

Yesterday, I posted a blog about "Religion and the YMCA of the Rockies".
I have moved this post from this blog, "Medicine and Social Justice", to a new, more personal, blog I have created called "Life, the Universe and a Few Things"


Friday, July 1, 2011

Medicare: We need to expand it, not cut it!

Medicare is big news lately. Saving Medicare, cutting Medicare, reforming Medicare. Medicare has become a part of the political right’s effort to roll back all programs that were implemented in the 20th century to help provide any safety net for Americans. I was going to say “most vulnerable Americans”, but actually many of these are programs for all Americans. The prime examples, of course, are Medicare and Social Security, often seen as the “third rail” of American politics which cannot be touched because they are so wildly popular. They are particularly popular with those who most benefit, primarily seniors who vote in very high proportions. These “entitlements” (a word that is often used by those who oppose them as a negative, but it is not) are considered so core by their recipients that they “forget” they are government programs (as in “keep the government’s hands off my Medicare!”).

So the proposal of Paul Ryan, the chair of the House Budget Committee, to essentially privatize Medicare by giving out vouchers for recipients to purchase private insurance, was heralded as “bold” by many commentators. Perhaps it was, although Ryan himself is backing away from this “bold” stand, as are most other Republicans.  Sure, sometimes “bold” is stupid, leading a charge into impossible odds (“into the valley of death rode the 600[1], but it has the implication of “heroic”, doing the right thing even in the face of certain defeat. Ryan’s plan wasn’t heroic. It was mean and callous and another part of the effort to make sure that our national policies benefit only the wealthiest among us.

The Ryan plan is terrible because it does not ensure health care but (and only in its most positive formulation) insurance coverage – it would provide vouchers to purchase private insurance. But the vouchers won’t cover any reasonable health insurance plan (remember, all health insurance is not good health insurance), certainly nothing compared to the current benefits covered by Medicare. And as any health insurance purchaser (employer or individual) knows, the cost of health insurance keeps going up. When Medicare was passed in 1965, it was because our society finally recoiled in horror at the reality of older Americans, who had worked all their lives, finishing out those lives in sickness and indignity and bankruptcy without health coverage. That need has not changed.

But Rep. Ryan’s plan, designed to gut Medicare, isn’t the only bad one. Senator Joseph Lieberman of Connecticut has proposed raising the age of eligibility for Medicare from 65 to 67, again to save money. This plan was debunked by Paul Krugman (“Medicare saves money”, NY Times June 12, 2011), who cites the work of “… the health economists Austin Frakt and Aaron Carroll [who] document, right now Americans in their early 60s without health insurance routinely delay needed care, only to become very expensive Medicare recipients once they reach 65. This pattern would be even stronger and more destructive if Medicare eligibility were delayed. As a result, Mr. Frakt and Mr. Carroll suggest, Medicare spending might actually go up, not down, under Mr. Lieberman’s proposal.” This is exactly the point I made in the recent blog “The real face of lack of access to health care”, June 19, 2011; not covering people for a period of time doesn’t save money because those people “save up” their health problems for when they are covered, and often need more expensive care.

Needless to say, Senator Lieberman took umbrage and responded with a letter to the Times which did not effectively address any of Krugman’s criticisms. His position was supported by a letter from the Executive Vice President of America’s Health Insurance Plans, the health insurance company trade group. Krugman’s criticism was supported by all the other letter-writers, including Harvard Medical School Professor and former New England Journal of Medicine editor-in-chief Marcia Angell, MD. More recently, in the Times’ “Opinionator” blog, Notre Dame philosopher Gary Gutting (“Medicare facts and convictions”, June 22, 2011) analyzes the method of argument (rhetoric) being used by the “two” sides of the debate, Ryan’s and President Obama’s (accepting Ryan’s concept that these are the only two sides). He decides that the key difference between them is one of beliefs, not data; that is, what you believe is the right thing or the way to do things determine how the problem should be addressed, not the facts, which seem to Gutting not to be really where the disagreement lies. “We can and should argue about convictions,” he says, “but this can seldom be done fruitfully in the context of specific policy disputes.  Once we’ve pushed the debate on Medicare or any other policy matter to the point where convictions become the sole basis of disagreement, it is time to vote.”

I agree that the issue is one of convictions, or belief systems. It is about whether we want to live in a society where there is come collective social responsibility or a society in which everyone is on their own.  Republicans tend to state their convictions in the language of “big government is bad”. As an abstract concept, this can resonate with working people who are struggling to support their families and feel that their taxes are too high. But this misses the fact that only through the action of government can the collective interests of the vast majority of us begin to have any weight against the vast wealth of those who fund Ryan and his colleagues (well, for some of us there are unions, but there is a nationwide campaign, well-funded by a few billionaires such as the Koch brothers, to gut any strength they have; “exhibit one” being in Rep. Ryan’s home state of Wisconsin). The Supreme Court has been a huge enabler of this movement through its decisions in Citizens United, making corporations “people” with unlimited ability to use their money to influence the political process, and the recent Walmart sex-discrimination suit in which they have severely restricted the ability of regular people to join cause to oppose those big corporations through class-action lawsuits.

The critical flaw in all of these discussions is that the core issue for Medicare is financial: that it costs too much and those costs need to be controlled by some means – whether privatization (Ryan), increasing the age eligibility (Lieberman), finding fraud (whether real, as the organized crime groups stealing billions of dollars for completely fake claims, or inadvertent minor mistakes made by doctors and hospitals “uncovered” by bounty hunters), or some other plan. Yes, it is true that the costs of Medicare are rising, maybe too high (depends on your “convictions”), and it is likely, under its current funding mechanism, to go bankrupt. This, however, is not a problem with Medicare but rather with health-care costs overall. They are rising, in this country and all over the world, as the availability of new technologies allow us to do many more things – very expensively.

 As Krugman points out, relative to other forms of health coverage Medicare is cost-effective, with much less overhead than the private sector. Cuts to Medicare alone only limit the access of those non-high-income seniors who are dependent upon it and skirt the need to address rising medical care costs. Indeed, the ways to do that (having boards that can evaluate the evidence to permit Medicare to pay only for effective procedures; limiting insurance company and drug and device maker profit; reducing the enormous payments to the highest-income medical specialists and to many specialty hospitals) have been opposed by those same colleagues-of-Ryan who propose cutting benefits to the elderly.

Rather than raising the eligible age for Medicare, or providing vouchers to buy private insurance, the right answer, fiscally as well as morally, is to expand Medicare to include everyone. It would decrease costs as people no longer put off early diagnosis, prevention and treatment. It would allow, through a single insurer, regulation of the excessive costs addressed in the paragraph above. Sure, it would cost the government more, but most of that would be covered by the money currently going to buy private insurance, and the waste engendered by the administrative structures of providers seeking to get paid and insurers seeking to avoid paying (see A Modest Proposal: Bribe the Insurance Companies, August 23, 2009). And a rise in taxes, not for most people but for those wealthiest who saw their taxes cut in the Bush years by trillions of dollars so that now the top tier and biggest corporations pay less than 15% in taxes, way lower than the middle class.

If someone complains that they do not have enough money to feed and house their children, most of us would at least feel sorry for them. But if we then find out that the reason is because they are spending almost all of a good income on alcohol, drugs, and gambling, that sympathy pretty much disappears. As a society we have done the same thing. We have dropped tax rates, especially on profits from stocks (capital gains) and bailed out the financial industry so their titans would not lose much on their gambling debts. This has led to millions of job losses and home foreclosure – people not having enough money to feed their food and children. We need to fix it, and use that money to provide health care for our people rather than profits for the gamblers.


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