Monday, April 5, 2021

We need more primary care to serve our people: Why do the medical schools lie?

Every year the nation’s medical schools graduate thousands of people with MD and DO degrees. But this is just the start of becoming a practicing physician; they now need to complete residency programs in a specialty area, ranging from 3 to as many as 8 years, to become family physicians, surgeons, radiologists, dermatologists, orthopedists, etc. Indeed, for many physicians this “postgraduate” training (meaning post-medical school, since medical school itself is post-graduate, requiring a bachelor’s degree for entrance) can have two components as well. First there is the primary residency program, say an internal medicine residency of 3 years, and then there is subspecialty training, usually called “fellowship”, where that internist becomes a cardiologist, or endocrinologist, or pulmonary medicine physician. While the internist who completes 3-year residency may practice general internal medicine and thus become a primary care physician for adults, those subspecialists do not. A similar process exists for pediatrics. Family physicians completing their 3 year residencies can also do fellowships in a limited number of areas, and some limit their practices to sports medicine or geriatrics or adolescent medicine, but most add these skills to their primary care practice. And, of course, geriatrics and adolescent medicine are, like general internal medicine or general pediatrics, primary care for a particular population.

This is important. Primary care doctors provide care for their patients that is comprehensive and unrestricted, other than by age for pediatrics, internal medicine, and geriatrics. They meet the World Health Organization (WHO) criteria for primary care, providing continuous, comprehensive, community-and-family-centered care. Distilled down, this means that primary care physicians see their patients for everything, whatever concerns them, referring when needed. They are the doctors for their people, not for a particular disease or set of diseases. The lack of sufficient numbers of primary care doctors has significant negative impact on the health of our people. Of course, it falls hardest on those who are always most disadvantaged – the poor, members of minority groups, and rural residents. But it also has negative impact upon the health of privileged people who see lots of subspecialists, in two ways. One is that the specialist may be expert in their field, but miss appropriate treatments, and especially preventive measures, outside it. The other is that many specialties and subspecialties rely on and extensively use care that is very high-tech and expensive, which can lead to people getting tests and treatments that are not only costly but may not be of any benefit, and indeed may lead to harm.


So, when a medical school claims that it is good at producing primary care physicians, this is serious, and should be accurate. But it usually is not, because schools want to look as good as possible so establish criteria that make them look good, counting a wide variety of specialties that their graduates might enter as “primary care”. The biggest “offender” in this regard is counting all graduates entering internal medicine residency programs as entering primary care. As described above, some of these end up doing fellowships to become subspecialists and do not practice primary care; indeed, “some” is an understatement as it is about 80%. In addition, about half the rest end up practicing as “hospitalists”, taking care of hospitalized patients only, rather than practicing primary care. So an approximation would be to assume about 10% of those entering internal medicine residencies will practice primary care. In pediatrics, continuing as a general pediatrician is much more common; the appropriate multiplier is probably 60%, and for family medicine as much as 95%. There are also residency programs in a combination of medicine and pediatrics (Med/Peds) which can produce primary care doctors, and whose graduates are less likely to pursue subspecialty training; however, they are very likely to choose only one of those areas (adult medicine or pediatrics) and also to become hospitalists.

In addition, some (or many) schools include in the primary care numbers specialties that are simply not primary care at all. Most commonly, they include emergency medicine and obstetrics/gynecology. Emergency medicine does indeed provide first-contact care, but it does not provide continuity. Obstetrics/gynecology can provide some aspects of primary care (and indeed OBGyns may be the only doctors some young women see) but it is limited in that it is not comprehensive; women are more than their reproductive tracts, and they can have a variety of conditions OBGYN does not care for (diabetes, hypertension, heart disease, depression, arthritis, asthma and other lung problems, substance abuse, etc., to name a few). Perhaps the most egregious abuse is counting all students who enter internal medicine “transitional” or “preliminary” years. Such one-year programs, which have replaced the old “rotating internships”, are required for many specialties such as neurology, anesthesiology, radiology, ophthalmology, dermatology, and others, whose practitioners do not do primary care at all.

If we want to know how well a school is doing in graduating students who actually practice primary care at the end of their residency and fellowship training, these inflated numbers do not inform us. Fortunately, one of the most popular sources of information on medical (and other) schools, US News, has worked with the Robert Graham Center, the policy center of the American Academy of Family Physicians (AAFP) to develop and publish a metric that does show which schools actually produce primary care physicians, available at The top of this list is dominated by schools of osteopathic medicine, which consistently graduate higher numbers of primary care physicians, and, among the allopathic schools, the mainly public schools who have been doing well in this area for a long time. The private, largely northeastern, schools that usually top rank lists are nowhere to be found.

It is important to look at this list, not the list of “Top Primary Care Schools”, to get accurate data on production of primary care physicians. The metric on percent of students going into primary care has also been fixed in the “Top Primary Care” rankings, so it is better, but it still only accounts for 40% of that ranking. “Peer Assessment” (subjective rankings) account for 30%, half from medical school deans and other leaders, and half from residency directors. The other 30% is half “faculty resources” (largely faculty ratio) which may be skewed to the advantage of research-intensive schools, because it includes faculty who are mostly in laboratories and not teaching, and half “student selectivity” (based on student grades and MCAT scores), which is actually negatively associated with entry into primary care. This doesn’t mean the students that enter primary care are not as smart; it means that the cachet of attending a research-intensive school makes the competition greater. Unsurprisingly, adding these other criteria does affect the rankings; Harvard, for example, is now #8 in “best primary care schools”, although it ranks #141 of 159 schools in percent of graduates practicing primary care. (In contrast, the University of Kansas, which ranks #9 in primary care, below Harvard, ranks #17 in graduates practicing primary care, at 37.8%). Reputation affects peer assessments in at least 3 ways. One is spillover effect -- well, it’s Harvard, and good in everything so it must be good in primary care. A second is the ignorance of non-primary care deans and residency directors about what kinds of doctors the school produces. Finally, the fact that “good in primary care” can mean things other than what specialties the graduates enter can have an effect; there are schools in which the family medicine and other primary care faculty are well-known for their research and leadership in national organizations, but which do not graduate very many students into primary care disciplines.

The fact remains, though, that the US very short of the primary care doctors it needs to provide quality health care to the American people. The way to begin to change that is to stop deceiving ourselves. Then we can start the process of producing a higher percentage, in every school.

Sunday, March 21, 2021

"Values" based care: Public Health, Primary Care, and Medicare for All

Recently, a class of undergraduate freshmen I teach debated the issue “Health Care is a Human Right”. Although we later determined that most of them personally supported that statement, the “no” team did a good job marshalling the arguments of opponents, often citing those of libertarian think tanks such as the CATO Institute (originally founded as the Charles Koch Institute, in case that helps), which identifies itself as promoting "free markets and individual liberty”. This includes identifying health care as a “commodity” and opposition to health care as a right (and thus to universal health coverage) as an infringement upon individual liberty. Essentially these two concepts boil down to the idea that the individual is free to decide what kind of health care they want, or don’t want, and what kind of insurance coverage they want, or don’t want, and can use their money (or not) to purchase this commodity (health care) as opposed to another (I don’t know, say a bass boat).

The hole in this argument is wide enough, though, to drive a bass boat through. It is that not everyone has such a large amount of disposable income that they have the financial options to make such decisions. An old point about commodities having to do with cars, when most Americans bought American brand cars, is that some folks can buy Cadillacs and others Chevrolets. But of course, even if we update this to Beemers and Kias, there are a huge number of people who are buying used cars – often old “junkers” – to try to get to work and shopping. And there are those who can’t afford to buy, insure, and run any car at all and are reliant on public transportation. If there is any public transportation where they live. People without a lot of money (often despite working multiple jobs, even those making quite a bit more than the federal minimum wage of $7.25/hour -- last raised in 2009 when $7.25 was equivalent to about $9 today) make regular trade-offs on what they will spend their money on. Rent? Food? Clothes for the kids? Heat? Electric bill? Gas for the car to get to work, if they have a car? Health and medical care are rarely right up there at the top unless they are actively ill. Indeed, often even chronic diseases don’t get adequately managed, with medications for common conditions such as diabetes and hypertension stretched out. This family – and to a greater or lesser extent, this is probably true of the majority of families – is trying to figure out how to juggle absolute necessities, not luxury goods. The students arguing the “anti” position gamely tried to respond to such concerns, but learned that, outside the walls of conservative think tanks, Congress, state legislatures, and country clubs, there is a limit to the effectiveness of continually repeating “individual liberty” and “commodities”.

Paying for the cost of health care is a real juggling act for the government, although for a different reason from the one the families above are doing. It is balance between wanting to spend less money and continuing to support the profits of health care corporations such as insurance companies, hospital systems, and drug makers. The rational solution to this problem is to decide that it is not the government’s business to guarantee the often obscene profits of such private corporations, but rather to spend the money on whatever maximally increases the level of health of the American people.

This should include at least two major changes: first, a national health insurance plan (such as “Medicare for All”, recently reintroduced with major improvements by Reps. Pramila Jayapal and Debbie DIngell) that ensures that everyone is covered – everyone, all in one plan, no exceptions by age, disease, etc.), and second, a massive and continuing re-investment in public health, the need for which should have been made clear by the COVID pandemic. Historically in the US, in Democratic and Republican administrations, funding for public health is about 1% of the health budget, with the rest going to individual medical care. When we have a crisis, we bemoan the lack of public health infrastructure for a while, but then it recedes. Yet this is the most important component of keeping us healthy. Fighting an active enemy (like COVID) can garner support, while maintaining programs of prevention absent an obvious crisis gets less. How often do we wake up and say “I’m glad I don’t have cholera today because we have clean water and sewage”? And, yet, recently folks in Mississippi and Texas can count themselves lucky that their lack of water did not come with cholera or another infectious disease.

Instead of such wholesale reimagining we have had programs like “value-based care” for Medicare, adopted with the ACA (“Obamacare) in 2010. When this was first rolled out, I was enthusiastic because I misunderstood it – I thought it was about providing care based upon values, presumably decent human values. Sadly, I was wrong. It was about spending less money. Did it work? To do what? If the goal was spend less, yes, to some degree (see Austin Frakt in the NY Times Upshot Oct 9, 2019, “more singles than home runs”). One of the big goals was to substitute “value” for “volume”. Paying for volume, the number of patients seen, was the accepted way to pay doctors. But what does paying for value mean? This whole issue is reviewed by Dr. Don McCanne in his “Quote of the Day” for March 17, 2021 “Policy community hung up on ‘volume to value’”. Dr. McCanne reviews the recent article “The Future of Value-Based Payment: A Roadmap to 2030” from the University of Pennsylvania on the topic, but in his comments he notes that

“All health care has “volume” – time, effort and resources devoted to health care. Volume varies tremendously depending on the clinical situation. Think of management of a common cold as opposed to management of severe multiple injuries in an accident. Can payment schemes ignore volume? Of course not. Volume is built into the problem.”

Here is a volume/value solution that I have discussed before but will now say clearly: Revise the way that physicians (and other providers) are paid so that family physicians and other primary care doctors make at least as much as those providing subspecialty care. This is the third step to add to universal health coverage and investment in public health. When I go to a shoulder orthopedist for the pain in my shoulder, that is the ONLY PROBLEM they deal with. Not BP, not abdominal pain, not my cold -- not even the arthritis in my knees.  My PCP would deal with every problem on my – and all their patients’ -- problem list (to greater or less extent, depending upon severity and acuity), and thus rarely has enough time for any on person. If you go to the cardiologist, and mention that you have knee pain, they say "I don't do knees; here is a referral to the orthopedist". And you go to the orthopedist, they make a recommendation, you come back to the cardiologist who says "I don't do knees; whatever they said". So, for the subspecialist, referral is a time saver.

But if you come to a PC doc and say your knee hurts, they make some diagnostic and treatment suggestions. After examining your knee, maybe ordering imaging and lab, and thinking about it, if they think it might need surgery, they might refer you to the orthopedist. Then you go and the ortho says "maybe surgery", so you come back and ask your PC doc’s opinion, so they read the whole consult and review the films and think about it and discuss it with you. Result: referral for a PC doc makes MORE work.

And they get paid less.

PC docs need more time with everyone, and thus fewer patients each day/week/year. How much money should they make? I don't care, pick a number, but it should be able to be earned by seeing no more than half the number of visits that they currently do. People's complaint is ALWAYS about not having enough time with the doctor.  

So, increase funding for public health, develop a universal single-payer health insurance system, and pay PC docs at least as much per hour or patient as the highest-paid subspecialist in the outpatient setting. 

Now we begin to have “value”!

Saturday, March 6, 2021

DTC Advertising on TV illustrates the corruption and inequity of the US medical care system

I don’t watch a lot of live daytime TV. (In fact, I don’t watch a lot of live TV at any time.) I do see it several times a week for the 45 minutes I spend on the elliptical at the gym, which requires that the two TVs be tuned to sports. In practice, that means ESPN and ESPN2 and I try to position myself between them so I can look at whichever has the least boring talk. Daytime is not a time for actual sports; it is all sports talk. And mostly I listen to music in my headphones.

But I did seem to notice a really lot of the commercials were medically-related and aimed at my demographic (ie., “old”). Since I was recently in the hospital for several days and had the TV on different stations, I can attest that this pattern is not limited to sports shows; it is absolutely as ubiquitous on CNN, MSNBC, etc. (can’t personally attest to FoxNews, but I bet it is also true there). Sure, there are a few non-medically related commercials aimed at my demographic (e.g., reverse mortgages) and once in a while even something of more general generational interest – I particularly liked a half-hour infomercial for the NuWave Bravo air fryer/convection oven. But the medically related dominate.

Such commercials include those related to insurance (Medicare supplements and in particular Medicare Advantage – which seems a bit odd, since open enrollment doesn’t start until October), those advertising medical treatments for disease of the age-challenged, and lots of commercials for incredibly expensive recombinant DNA (anything ending in “-ab”) for relatively uncommon diseases. This last group is in the traditional (if your idea of “tradition” is 40 years) mode of direct-to-consumer (DTC) advertising first legalized under the Reagan administration: “ask your doctor if this is right for you”. The implication is that it probably is, although the litany of unpleasant side effects that always starts with bloating, and moves to serious infections, and ends in death, should give us pause. It is certainly right for the drug manufacturer, who – shock! – makes HUGE HUGE HUGE amounts of money on these things. Some of these drugs cost $100,000 a year. There are neurologic drugs that cost $30,000 a MONTH. Or more. Thus it is worth advertising to lots of people in the hope that even a small percentage will “bite”.

NOTE: Most doctors hate this DTC advertising. Yes, it is in part because of how irritating and time consuming it is for patients to come in and keep asking about whether they should be on these drugs. But more important, it is because they are trying to take care of you, to best manage you condition using drugs (when drugs are appropriate) that are the most effective, have the fewest and least dangerous side-effects, and are affordable for you. Why on earth anyone would ever think that a multi-drillion-dollar multi-national drug company would have your health interests at heart more than your doctor? If you think that, 1) you’re wrong, 2) you’ve been watching too much TV.

In addition to the insurance and drug commercials, there are multitudes of miscellaneous others, especially for devices. You can get an app for your phone that will check your EKG. You can get endless numbers of devices that will monitor your blood sugar, many of which apparently come with the added benefit of turning you into a totally fit mountain biker! Indeed, if you have always wanted to play the flute, direct a play, or kayak whitewater, these devices are for you! Also, the you-know-what. And let’s not forget the “mobility devices” like scooters, available at “no cost to you” (although such ads seem a little less common since some of the big operators have been imprisoned). These commercials provide a regular source of income for actors in their 50s playing people in their 70s. Even the ones in scooters look not very old, not very sick, and not very obese. Of course, sometimes they feature a real person in their 70s, if they’re famous. Joe Namath, is, I think, 77.

There seem to be endless ways for the companies to make money off of your Medicare benefit. Medicare Advantage is one issue that deserves a little more discussion, since they often seem to (and may) offer you actual advantage. Medicare Advantage (Medicare Part “C”) takes the money that traditional Medicare would pay, usually has you put in more, and basically puts you in an HMO. You get the benefits of an HMO – stuff not covered by traditional Medicare like maybe eye, ear, dental, or other stuff. Also, the disadvantages, like limited choice of doctors, hospitals, etc., especially if you’re not in your usual geographic area. People with traditional Medicare do not get bills from doctors who are out of network (unless, and this is rare, they have opted out of Medicare altogether), but Medicare Advantage patients do. So, if you never leave your home area, and are happy with the hospitals and doctors in the network, it may be a good choice for you, just as an HMO may be for anyone (disclaimer: probably, however, if you are to choose one, it shouldn’t be the one advertising on TV!)

That’s about you, though. Societally, it is much worse. Medicare Advantage plans, compared to traditional Medicare, have way higher overhead costs (about 12-18% vs about 2%). They also get paid extra by the federal government. Why? Well, you’d have to ask Reagan and his GOP successors; essentially it is part of an effort to privatize as much as possible. And, like most efforts to privatize, actually costs more. And we all, as taxpayers, pay for it.

This is not a benign process, for Medicare, for drugs, for devices. They are selling us very expensive stuff and making a huge profit, while millions of Americans have no health insurance and millions more are grossly underinsured. Discussions about national health insurance proposals often focus on cost, but the stuff being sold in these commercials is part of the structure that causes amazingly inflated costs, making our health system the most expensive (2-3x as much per capita as other industrialized countries) while maintaining among the worst health outcomes of that group of nations. And the burden is not spread equally; those most in need, those who are the poorest, disproportionately minority group members, are the hardest hit. It is inequitable, discriminatory, and immoral.

The bottom line is that all of these commercials propagate a system that is not only vastly inequitable, but is medically inappropriate. A system in which the goal is not to maximize the health of the population, in any fashion but certainly not an equitable one, but rather to maximize the profit for the companies that are advertising, to take money from the rest of the economy and accrue it to themselves. This, of course, is the nature of modern capitalism, but that doesn’t make it good. You have to decide if your health, and the health of your friends, family, community and nation are a core public benefit or a product to be sold, caveat emptor.

The bottom line for the individual is the same as it is for all commercials. They are NOT about YOU. They are about MAKING MONEY for the company sponsoring the commercial. That is all. You are nothing but the vehicle, or perhaps more technically, “sucker”, who will channel that money their way. If you read the fine print it is scary, and that is only the stuff that they are legally required to tell you. Anything that they are not legally required to tell you will not be there. Do not trust them at all. Do not watch them. They are dangerous.

Although I am going to look at see how Consumer Reports rates the NuWave Bravo…

Thursday, February 4, 2021

COVID Vaccine and Privilege: When is it not about you?

Recently, an article from CNN, “A vaccination site meant to serve a hard-hit Latino neighborhood in New York instead serviced more Whites from other areas”, was posted on a medical social justice page of which I am a member. Among a number of others, I expressed my displeasure at this, but I also posted a comment in which I unfortunately said “People are scum”. It did not specifically refer to the white people who had obtained these vaccines, perhaps inappropriately, but certainly could be seen as that. I was called out for that comment, and that was appropriate. People are not scum, for better and worse. Scum is a substance that exists without intentionality. People, however, do have intentionality, and that can make them do things that are very good and very bad and everything in between. Certainly, doing something bad, or wrong, does not make a person bad; many religions have doctrines that are more or less comparable to “hate the sin, love the sinner”.

More to the point is whether the people referred to in the article did anything wrong or objectionable at all. While those quoted in the  article were very critical of this behavior, some of those posting comments on the page felt that these people (presumably people who otherwise met the current criteria in NY for the vaccine, by age or health status) were just trying to do what they could, and not trying to use their privilege to obtain vaccine intended for the minority community. They agreed that the system, and the structure for distributing the vaccine was severely flawed and probably inequitable, but that the individuals pursuing the vaccine should not be condemned. They acknowledged that some people, by virtue of education, wealth, computer-savvy, connections to other family members who may be more computer-savvy, and other characteristics, are more able to avail themselves of benefits. Even when this results in preferentially vaccinating white people rather than the minorities for whom it was intended (by placing vaccination sites in minority communities), it does not mean those individuals (many of whom are sick and elderly) are doing a bad thing, still less are bad people, or certainly scum. Nonetheless, the result is the result; the New York Times on January 31, 2021 reports that “Data showed that while 24% of city residents are Black, only 11% of vaccine recipients were. White New Yorkers received a disproportionate share of the shots.

The CNN report was not the only one critical of people “jumping the queue”. In a NY Times Op-Ed on January 28, 2021, Elisabeth Rosenthal MD, editor of Kaiser Health News, writes “Yes, It Matters That People Are Jumping the Vaccine Line”:

For weeks Americans have watched those who are well connected, wealthy or crafty “jump the line” to get a vaccine, while others are stuck, endlessly waiting on hold to get an appointment, watching sign-up websites crash or loitering outside clinics in the often-futile hope of getting a shot.

She adds, agreeing with some of the points made by the commenters on the site, “I don’t blame the lucky recipients; after all, hospitals would just offer the unused vaccine to the next person on the list,” but also notes that “The problem is that often, people are not really being “offered” the vaccine; in some cases, they are grabbing it through position, influence or deceit.” How often? I don’t know, and probably Rosenthal does not either. Or, for that matter, those who posted comments on the page, although they seem to be from NY and likely to know a lot more about the situation there than I do.

Most likely, the predominantly white recipients of the vaccine being offered in minority neighborhood represent a spectrum of people. They would include those who consciously believe that they are special and privileged and deserve to be at the head of the line, those who believe in equity but let that concern be overcome by their self-interest, and those who are appropriately candidates for the vaccine in the current phase but are desperate, confused, and, with no negative or ignoble intent, found their way to that place and time. Defending the latter, however, does not excuse the former, and there are certainly many of them. Freeman’s Law (which I should probably rename “Freeman’s First Law” so as not to confuse it with Freeman’s Second Law, to which I referred in my blog post of January 28, 2021, “Vitamin D, false nostrums, and conspiracy theories: The world has enough real problems,”) states that in any program designed to help a group of people, no matter how narrowly defined, those with the relatively least need are most likely to benefit. Thus in a program designed, say, to help homeless pregnant teenagers with HIV living under bridges, those who have some greater resources (a bit more education, a slightly less traumatic childhood, etc.) will be the ones who are able to access it first. The larger the universe of people who are targeted, the more people who would qualify for services, the greater the disparity is likely to be. This is of course especially true in the case of COVID vaccine, where the target population is, ultimately, everyone.

Another aspect of the comments posted that was interesting to me was that they referred to those seeking to get the vaccine as “patients”. Perhaps this is understandable on a medical site, and it is quite possible that some of those involved were patients of those doctors who made the comments. I have sometimes been critical of the use of the term “patients”, noting that it was the “medical” word for what in English are called “people”, and that it could tend to diminish their humanity. I am quite sure this was not the intent of those using it, but in this context it has quite another flaw. Calling folks “patients”, especially when they are not your patients, carries a connotation of dependency, needing help from their doctor. Calling them “people” implies more that they have agency, the ability to make decisions, prioritize needs and values, and act on them. While it is often true that many people, particularly the sickest and oldest and least educated and least empowered do need help, it is also true that when the affected universe is the entire population, it includes all of us, all people, adults and children, young and old, Black and White, rich and poor, doctors and “patients”. It includes those who are the wealthiest, most educated, most connected, and most empowered, who are often find ways to get to the head of the line. Thus, prioritizing who should get the vaccine first and enforcing that is critical. Social justice is about promoting equity, which means giving more help to those who have the least and need it the most, and reducing the temptation to give in to those whose privilege or loud voice is most demanding.

Rosenthal writes:

The United States has allowed its public health system to become a hollowed-out underfunded mess, and many vaccination clinics are being run and staffed by contracted private companies. And the private sector has so far proved too vulnerable to private favoritism.

Until the supply is sufficient, the government needs to give the shots to the people and places that need it most, and find ways to ensure that the plan is followed; the system could prioritize ZIP codes that have high Covid-19 infection rates or target low-income populations who might otherwise have a difficult time securing an appointment.

She is absolutely correct, but clearly targeting certain ZIP codes is not sufficient, as the Times describes on February 2, 2021 in ‘Even in Poorer Neighborhoods, the Wealthy Are Lining Up for Vaccines’ (Feb 3 print title: ‘Where poor suffer most, wealthy find vaccines’). And a 52-year old celebrity on-line fitness trainer got the vaccine as an ‘educator’.  Meanwhile the COVID surge most hurts those in the poorest neighborhoods, as in LA. And people behaving as though the doors were opening at a department store the day after Thanksgiving is not just a NY problem. a friend in another city, on seeing the pushing and shoving, both literal and figurative, that went on when they went to get their vaccine, said “I wouldn’t want to be in a concentration camp with those people.”

The problem, if you think it is a problem, of empowered people going to poor neighborhood to get their vaccines is real and ongoing. I think that folks who do so are doing a selfish thing, a bad thing. This in itself does not make them bad people, or certainly scum. However, for the record, I personally believe that there are indeed bad people, and that doing enough bad things often enough, predictably enough, and bad enough does make someone a bad person (see, e.g.,”Nazis”).

We should have compassion for those with need, and the most compassion for the greatest need. And recognize that “me” is not the hallmark of social justice.

Thursday, January 28, 2021

Vitamin D, false nostrums, and conspiracy theories: The world has enough real problems

Near the end of December, Tiffany Hsu, writing in the NY Times, discussed “Dubious COVID Cures”. She compared them to the similar nostrums popularly recommended for the 1918 influenza epidemic, when ‘a spate of ads promised dubious remedies in the form of lozenges, tonics, unguents, blood-builders and an antiseptic shield to be used while kissing.’ She quotes the head of research at MyHeritage, Roi Mandel as saying “So many things are exactly the same, even 102 years later, even after science has made such huge progress.”

Even after all this scientific progress and all the advances in health care, people are still fascinated by over the counter magic drugs, things that seem easy, and are often cheap (although usually very profitable), and somehow better than the treatments being offered by the medical community. This is, of course, even more so when that medical community does not have a whole lot to offer in terms of treatment, a particular issue for virus infection, and mostly talks about prevention, about such things as isolation and physical distancing. Wouldn’t it be better if you could just take something that would cure it or make it better or at least decrease the seriousness of an infection? And, you know, there are ‘studies’ that show it works (although of course I haven’t actually read them and would have no idea how to understand if the research was legit) and, you know, there are doctors who recommend it!  Like ‘Dr. Pierce’s Pleasant Pellets promised that the pills — made from “May-apple, leaves of aloe, jalap” — offered protection “against the deadly attack of the Spanish Influenza.”’ Oh, wait, that was from 1918 – but we have Dr. Oz!

This is not to say that some popular treatments do not have benefit, and this is especially good if they do not harm you, and if they are cheap. One such could be Vitamin D, which has been advocated (most recently for COVID-19, but for a lot of things) by many people, some of whom are actually experts. As with many “natural” remedies, most of the basis for this is in syllogism. You extrapolate from something that is known about a substance (commonly, as in the case of Vitamin D, that it “promotes immunity” – a pretty general, non-specific claim), but such claims are uncommonly backed up by rigorous testing to see if it actually does work. (Freeman’s Second Law: Something that makes sense is properly called a “research question”. You wouldn’t want to study something that didn’t make sense. However, to know whether it is actually true, you have to actually do the studies!)

Recently, The Guardian had an article titled “Does Vitamin D Combat COVID?”. It is very positive about the vitamin, citing many important people (unsurprisingly, being The Guardian, many from England), but does stop short of claiming that it will definitely work. The claims for benefit vary: it makes it less likely that you will get infected, that if you get infected you will get less sick, that if you get sick you are less likely to die. Not really quantified though. The reason is that there are studies that show both benefit and not, and none of them are definitive. There is also concern that people with more melanin in their skin, presumably a genetic adaptation to being from areas with more sunshine (and thus more vitamin D) can become vitamin D deficient when they live in areas in northern latitudes with less sun. Obviously, this is confounded by the existence of a variety of other social and medical health risks accruing to dark-skinned people in northern latitudes. Maybe it is an additional one, but it is unlikely that just taking Vitamin D will solve the problem of inequity.

The actual evidence is summarized in a recent piece in JAMA, “Sorting out whether vitamin D deficiency raises COVID-19 risk”. The first thing that you note here is that it is answering quite a different question – whether people who have low vitamin D levels have greater risk (and, thus, presumably, should take vitamin D supplementation), not whether everyone should be taking vitamin D. ‘Research findings about vitamin D and COVID-19 have been mixed and sparse,’ is the key finding, and the ‘Upshot’ of the pieceis a quote from Dr. Catherine Ross, a nutritionist at Penn State: ‘“Avoiding vitamin D deficiency is always a goal.”

So you should take vitamin D supplements if you are deficient (Dr. Fauci says this also), although knowing if you are deficient would require both your having your level measured, something which is not recommended by the most reliable source, the US Preventive Services Task Force (USPSTF) for asymptomatic adults (although it is by many who are consultants to vitamin D advocating groups), as well as to know what the level below which you are deficient is: 20? 30? 50? You can find all of these in the “literature”. And it is concerning when advocates have industry ties. Nonetheless, vitamin D is available cheaply and generically, is safe if you don’t take too much (as a fat-soluble vitamin you CAN overdose on it), and Dr. Fauci takes it (same article). I took one this morning.

But the really big question is not vitamin D, even if the evidence is not absolutely clear. Overall, it is pretty safe and pretty cheap and has a conceptual justification and at least some studies show some benefit. The really big issue, as put forth early in this piece, is why do people continue to search for magic treatments that are not mainstream? Why do they often trust their friends and neighbors and strangers on the Internet more than doctors? I don’t know for sure, but in Hsu’s article comparing today to 1918 he quotes Jason P. Chambers, associate professor of advertising at the University of Illinois: “Human beings haven’t changed all that much. We’d like to believe we’re smarter, that we’d be able to spot the lies, but the ability of advertising to maintain its veneer of believability has only become more sophisticated over time.” Unfortunately, we’re probably not. That is why advertising is so successful.

This fear is related to not only mistrust of science (it is hard to understand) but to conspiracy theories in general; recently the “political” belief in a “deep state”, that “they” are lying to us and trying to keep important information and benefits from us. Of course, “they” may be; I certainly do not trust the leadership of our country (or any country) to necessarily work in the best interests of the people, except of the richest, most powerful and well-connected people. I absolutely believe that Big Pharma is only interested in making as much money as possible and selling us drugs which may not be any better than cheaper ones, or none at all. But the suspicion that science and medicine are working to harm us often segues into pretty odd stuff (I was recently sent this nonsense about the COVID vaccine being a plan to engender female sterilization!) (On the subject of conspiracy theories, Andy Borowitz’ recent satire – QAnon merging with the Elvis-is-Alive groups -- is, as usual, not far off the mark.)

I am sure that some of this is the fault of the arrogance of scientists and doctors. A good friend was recently diagnosed with breast cancer and was told by her doctors to “not go on the Internet, to not talk to anyone who has had it, because everyone’s cancer is different”. This is ridiculous, although I understand that they probably get frustrated by people coming up with silly or, worse, dangerous treatment ideas that they have heard from someone, or stories from their sister-in-law’s neighbor. This can of course be much better addressed, with something like “You’ll hear a lot from people who have had breast cancer; it is a common disease. You will certainly look things up on the Internet. Listen to them, but remember you are you, and your experience is not likely to be exactly the same as theirs. Please don’t take any treatments without discussing it with us, so we can make sure there is no danger. Welcome the support.” And, I would be wrong to omit, the big reason that doctors feel so pressured and don’t have enough time to talk to and discuss things with folks is in large part because the big corporations they work for (for-profit or “non-profit”) are about maximizing income, not health.

Still, people seem to find themselves drawn to “alternatives”. They like “natural”. OK, keep your mind open, but remember than “natural” is not necessarily better. Any substance that has any effect, positive, negative, or neutral is because of chemicals in it. That they occur naturally does not make them safer than those that are manufactured.

And watch the conspiracy theories and think about what is important. Life on earth could be extinguished by climate change. That is real. War which leads to nuclear war could do it first. People all over the world are starving, are without housing, without basic health care, subjected to natural disasters and man-made ones. They are being killed, often in genocides. In all countries, including ours, there is structural oppression of people based on race, religion, gender. Wealth is being transferred from regular and even poor folks to the richest at an astounding rate. Authoritarian leaders, and even fascists, are proliferating.

These are real problems, that need real concerted efforts to combat. Work on these. Don’t be distracted by non-issues.

Tuesday, January 19, 2021

Emergency services, COVID, and the health system: Your life could well be at risk

I recently had a very unpleasant health event, involving severe abdominal pain for most of a day and night, and many days of recovery. The details of my specific condition are not particularly important, other than to say it is a chronic, recurrent problem, resulting from an event decades ago; it could well need emergency surgery and can have serious results. The point is that I had to decide whether to go to the emergency room that night, and to discuss the issues, both personal and structural, that impacted that decision, and what it demonstrates about our healthcare system, made even worse by the stress of COVID.

Considerations on the side of “go to the ER” were 1) I was in a lot of pain that was lasting longer than it generally has (say twice a year), and wanted to not be, 2) I knew pretty well what was causing it and that, while it had happened before and usually resolved, it could also NOT get better and maybe require emergency surgery, or worse. Considerations on the side of “don’t go to the ER” were 1) it has usually in the past resolved, eventually, on its own, and 2) the idea of getting in the car to go to the ER, and then waiting to be triaged and seen, and maybe imaged, which was likely to take many hours, all while in such pain, was a very negative incentive. If I was going to be writhing in untreated severe pain, I would prefer it to be in my own bed than in the waiting room of an ER. Plus, COVID. Both because it has made the crowding and wait times in ERs and hospitals much worse than “normal”, and because being there increases the risk of exposure and infection. I happen to live in what is currently a “high COVID” state, but nowhere is a really “low COVID risk” area. As it turns out, I didn’t go, and by morning, after about 18 hours, the worst was past. This time. But it will happen again and I will again have to decide what to do.

As do many, many thousands of others, every day, in the US. For many people, a major concern is cost – because visits to the ER are costly for those with no or poor insurance (really a lot of people). Fortunately for me, I’m not in that group. For others, it is because of fear of finding out what the problem is, and that it will be something really bad that they don’t want to know about. That also wasn’t really my issue; as a physician who has dealt with this, I knew what the problem was. Unfortunately, that can make it worse, since my fears and realization of the possible outcomes are based in evidence and not just fear. For yet others, it is the expectation that because of who they are (not White, poor, poorly insured, not well-dressed, have a history of alcohol or drug use or mental illness, or something else that doctors tend to associate with making one of less value) that they will be pushed back in the line, not believed, have their stories discounted, and generally be treated badly. Not really me either, although my physician privilege is decreased now that I am retired in another city, and do not get to go to the ER in the hospital where I work every day and people know me. For a lot of people, it is a combination of these, synergistically making their experience, and expectation of that experience, worse.

In case there may be anyone who is skeptical about my saying it is likely to be hours of waiting even when one presents with an emergency condition and is obviously educated and “respectable” (as a physician or nurse), it happens, and is happening much more continuously in the Age of COVID, when facilities are completely stretched to their limit and resources and people who work there are stressed to the max. Just recently, the last few months, two people who are close to me and are healthcare professionals have been through this experience. One had acute appendicitis, and needed emergency surgery, and after waiting many hours at home before venturing to the ER, waited there for 7 more hours before being seen. Luckily, they are now OK. It was not a positive experience! The other had a similar serious need, a ruptured diverticulitis causing peritonitis. She also waited in excruciating pain for hours, despite the fact that she was accompanied by her husband, a physician from the community who has practiced here for decades who was reduced to screaming at staff before she got her necessary emergency surgery. (For the record, these two people and I are all “seniors”, but these scenarios can and do affect everyone; my initial crisis was when I was 40 years old.)

The best advice anyone can give me is “get an ambulance”; they’ll see you sooner than if you arrive by car. This may well be true, and it may be good advice for me or for any other individual who is not worried about an additional $2000 bill, but in no way addresses the systemic problems that obviously exist.

The first of these is the incredible stress put on the system and the individuals working in it, doctors, nurses, and other healthcare workers, by the COVID pandemic. The burden on hospitals and healthcare workers has been phenomenal. In this sense, doctors and nurses and others on the front line are our heroes, as they are often portrayed. Yes, sometimes they can exhibit inappropriate behaviors. These can even be exhibited by folks in whom they rarely manifested before as a result of the continuous stress of working in the situation that they, and we as patients and as a society, find ourselves in. The governmental response to the pandemic, led by a federal administration who acted as if their intention was to do everything completely wrong, was shockingly inadequate. Yes, building new hospital capacity is possible and usually slow, but some localities did it, and yes, training and equipping more healthcare workers takes time. But there is no conceivable justifiable excuse for not having sufficient PPE, for example, months into the pandemic. This could only happen because of the worst possible management. Remember that this is the country that put a person on the moon 8 years after the first suborbital flight, that built the interstate highway system, that could assemble battleships in weeks during WW II, that has enough money to give trillions of $$ in tax cuts to billionaires and corporations. It only did not happen because of more than ineptitude; it happened because of an intent to do evil. We can hope that at least much of this can be reversed by a Biden administration.

The other big structural issue is our terribly designed and implemented healthcare nonsystem that discriminates against people based upon wealth and insurance status, race and ethnicity, age and pre-exisiting conditions, geographical location, and in appropriate allocation of resources that in the best of (non-COVID) circumstances sends a hugely disproportionate number of true emergencies (medical, surgical, trauma) to some hospitals while others have relatively low, and more mild, usage of their emergency facilities. It is also the fact that many people cannot get into see their primary care physicians promptly, or do not even have primary care physicians (or other providers, such as NPs) so end up waiting until they are severely ill and going to the ER. These are people who, if they get hospitalized, can be considered “primary care preventable” hospitalizations. That is, if they had been able to easily and promptly see a primary care doctor for their illness, and at least as important, had their chronic diseases effectively managed and controlled, would have not needed hospitalization – or emergency care. This needs another set of structural solutions. It needs, first off, a universal national health insurance system. Every single person in the country needs to be completely covered for every medical necessity, without copays, deductibles, etc., and we all need to be in the same program.  The pandemic has clearly demonstrated the vulnerability of employer-based coverage. It is long past time, if it ever was, for ideas of gradual piecemeal expansion of Medicare, ACA, Medicaid, etc. If everyone is not in the same system, it is not a possibility but rahter a certainty that some will get better care than others. Separate, the Supreme Court ruled in 1954, is not equal in education, and separate insurance systems cannot create equality in healthcare.

A universal health insurance system, such as Medicare for All, is not going to fix all of the things that I discussed above. We need to ensure that there are hospitals and ERs available to all people. We need to ensure that all hospitals are welcoming to all patients, and that there is a rational system of referral from smaller to larger hospitals.  We must ensure that there is adequate primary care capacity so that everyone can have a provider that they can see regularly, and promptly when needed, and do not need to access ERs for either primary care or for urgent conditions that could have been prevented by good primary care. And we need to make sure that there is adequate emergency capacity for all emergencies to be cared for emergently, and that ERs, and hospitals, and health systems, are designed and funded and run based solely on what best needs the health needs of the entire community, and not on what makes the most profit for the owners. A universal health insurance system is necessary but not sufficient.

We need all that, and need it yesterday.

Tuesday, December 22, 2020

Protecting the community: Essential workers, nursing homes, and the incarcerated

The COVID-19 pandemic continues, resurging across the US and in many other places. Different strategies have been adopted in different places, with varying degrees of success in slowing the spread of infection and death. This should provide us with information on what works well, and what strategies we should be adopting. For one example, family medicine colleagues in São Paulo, Brazil, report on their experience in nursing homes in the Royal Australian Journal of General Practice. They used public health management techniques including no visitors, rigid use of testing, recommended PPE and isolation, and others, as well as medical management and psychosocial management working with families and patients to help them through this process. They have had only 4 cases in the last 90 days (as of the November publication date), no people in isolation, and a low death rate.

 In Arizona, as in the US, case rates and mortality continue to rise.  We have more cases than ever, and fewer hospital and ICU beds. The state has chosen to address this issue by lifting restrictions on businesses, opening restaurants, bars, salons and gyms. Based on all evidence from everywhere, this is likely to further increase infections and deaths (“Health chief changes benchmarks so no Arizona business will be shuttered in pandemic”.)

Thie new policy is clearly in response to business owners concerned about their livelihoods and the probability that they will even survive. This is a real problem for them, and for us, in the horrific economic downturn that has accompanied the pandemic for most people (for major investors, however, the stock market has done well). Pima County, where Tucson is, has taken a more aggressive and restrictive approach; after more than 320 cases reported among county employees, including the chief health officer, it has furloughed 20% of the work force for 3 weeks. Of course, this will be an economic hardship for those people’s families.

Thus we have the situation where we know what to do to prevent increased infections and deaths, but have to also address the serious financial impact on regular people who lose their jobs and businesses and incomes. Sadly, efforts to reopen have been almost linearly associated with increased infection rates and deaths. The efforts taken by our Brazilian colleagues were effective in an important and high-risk, but ultimately limited, venue, that of nursing homes. The fact that the increased infection and death rate in our communities will take its greatest toll on the elderly and those with chronic disease, not those whose exposure to others in workplaces, schools, and meetings (although they are also at risk, and not immune) makes it even more complicated. The leadership at the federal level, sometimes inaccurately described as “lack of leadership” when in fact it is actively leading us in entirely the wrong direction, is making things much worse, and creating and exacerbating an incorrect understanding of the disease among many people.

Those who work in high-risk occupations, who cannot “phone (or Zoom) it in” but rather have to be present, most often among the lowest paid, those who live in multi-generational and multi-family households, are paying the highest price. These people are not only members of racial and ethnic minority groups, but those groups are far over-represented in their numbers. A recent article in the New York Times again makes the point that Black and Latinx people are hardest hit, not because of any genetic or biologic reason but because of their social and economic situation resulting from centuries of structural racism. Race, it is clear but requires repeating, is a social, not a biological construct. The negative impacts on health, income, longevity, education, and everything else is not from “race” but from “racism”; indeed, the only significance of “race” is that it is the basis for racism.

Now there is a vaccine (actually, two, maybe soon three, vaccines) and administration of them is rolling out, especially in the wealthy countries that have acquired most of the doses (of course, in the US the Trump administration jeopardized this by passing on an opportunity to acquire more doses of the Pfizer vaccine, and this was certainly not to help out the poor parts of the world!) The debate now moves to who should get it first and in what order. In most places in the US, priority is going to health care workers and nursing home patients, which makes sense. They are, respectively, the most likely to contract and transmit the infection and the most likely to die from it. And then? Who? Those with the highest risk or those with the best connections? In many hospitals we hear reports of the C-suite executives (the “front office”) being at the front of the line for vaccine, despite the fact that they do no health care. Nice of them to want to “model” behavior, but the vaccine should go first to those who see patients. The priority should be those who not only interact with the public, but who cannot do their jobs if they don’t actually show up for work, and among those, people who would be the worst off if they lost their jobs (and those who have already been laid off but might be able to come back and begin working again). The last would be those who can continue to work from home, or are retired without major health risks, and can continue to isolate themselves.

Another major group that is finally getting some media attention, even if it is unlikely to get much vaccine, is the incarcerated population. The AP reports that “1 in 5 prisoners in the US has had COVID-19, 1,700 have died”. This could be predicted; it is a group crowded together, unable to isolate, often with pre-existing conditions, and essentially without agency – they have to do what they are told. There are, broadly, two reasons for immunizing them. The first is human – they are human, and they are at very high risk, and they are already being punished; they should not be further punished by getting this disease. The second is practical; prisoners are not, actually, entirely separate from the rest of the population. In addition to guards and others who move between the inside and the outside, many prisoners are released; this is most especially true for jails, where the length of stay is short (usually awaiting a court appearance for those who cannot post bond), and thus is really part of the community from which inmates come – and go back to. Nathaniel Lash makes this case convincingly in the New York Times Sunday Review, “The coronavirus has found a safe harbor”. For example,

Cook County Jail was the site of the largest detected outbreak in the country early in the pandemic. In recent weeks, it has exceeded that — there were 340 active cases among inmates on Dec. 16. The population, meanwhile, has returned to levels typical before the pandemic, about 5,500 people.

We should have fewer people in jail.  It is outrageous that people are incarcerated because they cannot pay bond, overt discrimination against the poor, and cannot afford to support the very politically powerful bail-bond industry. This was true before COVID, and is more true now. ‘“There’s no question with a new peak in infections that we have to be decarcerating now,” said Dr. Emily Wang, the director of Yale School of Medicine’s Health Justice Lab. “If we don’t have larger-scale decarceration efforts, we won’t control Covid.”’ The answer is bail reform that corrects these inequities – vicious inequities with frequently fatal outcomes. But the opposition continues to cloak itself in the mantle of morality rather than greed, public safety rather than racism. ‘“We’re seeing the extent of the opposition to bail reform: They so strongly oppose it they will do it in the face of a pandemic,” said Andre Segura, legal director for the American Civil Liberties Union in Texas.’

The US incarcerates more people than anywhere in the world, a lot for relatively minor drug offenses. This does not prevent crime, especially violent crime, and it continues to rise even as crime rates decrease. In 2020 it is out of control, it is inhumane, and it is a significant cause of the spread of COVID. 

We need to get the vaccine out there soon, especially to those at highest risk of both dying and transmitting it to others. Clearly, the incarcerated population must be included.




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