Thursday, November 27, 2014

Giving Thanks in a scary world

Let us give thanks.

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

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

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

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

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

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

Oh, yes. Or their children.

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

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

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

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

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

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

Happy Thanksgiving.

Monday, November 17, 2014

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

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

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

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

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

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

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

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


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

Sunday, November 9, 2014

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

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

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

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

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

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

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

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

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

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

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

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