Tuesday, December 29, 2009

Quotes for the New Year

The New Year is a common time to rethink, make resolutions, and in various ways commit to leading a better life. We can do this as individuals and as a society. As far as health is concerned, our individual decisions can and do make a big difference in our health outcomes, and it behooves us to learn as much as we can and to be able to distinguish what is information based in evidence from what is opinion, anecdote, or just plain wrong. As a society we can do a lot better in terms of improving health, only one component of which is improving health care. We can, and must, improve access (both financial and geographic) to health care, improve the quality of care and the use of evidence-based (rather than profit-influenced) practices, and the use of cost-benefit ratios to maximize the value per dollar. Maybe we are moving a little in that direction; I will continue to comment on a number of areas surrounding health reform and health care.

One thing that can help us in thinking about ourselves and our societies are the thoughts of others. Epigrams, quotations, can and often do, oversimplify complex ideas, but they can be powerful and pungent. I have frequently used them; on the left side of this blog is a quotation from FDR that I find particularly significant. So, for the New Year, I thought I would provide some of my “favorite” quotations, some more well-known than others. I will also supply the authors, although not attached to the quotations; you can know or guess or look them up, but it can make a difference; a statement by someone who knows about an area can be more powerful than when the same statement comes from one who does not.

My last entry addressed, in part, bigotry, and the attempts of some people to have their beliefs determine the actions of everyone. This is common and recurrent, and does not “get better with time”. Much of Texas’ Hill Country was settled by Germans, a high percentage of whom were Freethinkers. They stood, among other things, against slavery; Confederate troops raided towns like Comfort, TX, killing many and driving others to Mexico. Some years ago a monument commemorating the Freethinker settlers who established the town was proposed for Comfort, but it didn’t happen. The people, conventional “believers”, even descendants of those settlers, found Freethinking too much like “atheism” for them. Of course, people who emigrate, who move to new lands, are different from both those who stay behind. They are bolder, more adventuresome and more independent. They are also, sometimes disappointingly, different from their descendants who are more settled, themselves the “stay behinders”. Many of our “Founding Fathers” were people who were Freethinkers, Deists, and believers in less orthodox approaches to religion. Often they were condemned in their time, but that time was the Enlightenment, when it was believed (wrongly as it turns out) that time would bring increased knowledge of science and the world, and that would leader to broader, not more narrow, thinking. The thoughts of a few:

"I Have Sworn Upon the Altar of God eternal hostility against every form of tyranny over the mind of man."

"Independence is my happiness, and I view things as they are, without regard to place or person; my country is the world, and my religion is to do good."

“It is now no more that toleration is spoken of, as if it was by indulgence of one class of people, that another enjoyed the exercise of their inherent natural rights.”

Not only FDR commented on the inequity of distribution; others also chose to identify what areas, including the determinants of health, might be a better place to spend our money.

"Every gun that is made, every warship that is launched, every rocket that is fired signifies, in the final sense, a theft from those who are hungry and are not fed, from those who are cold and are not clothed."

In a specifically health-related vein,

“Of all the forms of inequality, injustice in health care is the most shocking and inhumane.”

And a few more about our society, government, shadow government and rights:

We the people are the rightful masters of both Congress and the courts, not to overthrow the Constitution but to overthrow the men who pervert the Constitution.”

"Our only hope today lies in our ability to recapture the revolutionary spiritand go out into a sometimes hostile world declaring eternal hostility to poverty, racism, and militarism.”

"Indeed, I think that people want peace so much that one of these days
governments had better get out of their way and let them have it."

And ones I will probably use soon:

"The war on privilege will never end. Its next great campaign will be against the privileges of the underprivileged."

“The potential for the disastrous rise of misplaced power exists and will persist. We must never let the weight of this combination endanger our liberties or democratic processes."

Happy New Year.

Quotes are from (alphabetically) Dwight D. Eisenhower (3), Thomas Jefferson, Martin Luther King, Jr. (2), Abraham Lincoln, HL Mencken, Tom Paine, George Washington

Wednesday, December 23, 2009

Health Reform: The good, the bad, and the bigoted

The New York Times, in a December 22, 2009 editorial, calls the Senate bill “well worth passing” (A Bill Well Worth Passing), and says that it is “worthy of support from lawmakers who care about health care reform.” Whether it is worthy of support by the American people is another question entirely. The Times says that there is “…a lot to like in this bill”, and this is certainly true, as there are many parts of it, that include funding for many good programs. Some of the issues that I have written about in the past, such as primary care extension services and funding for primary care education (“Title VII”) are included in the bill. That makes me happy, and I think that they should be good for the health care of the American people.

A proposal that would expand graduate medical education funded by Medicare by 15,000 slots did not pass, which also makes me happy. Through aggressively supported by the Association of American Medical Colleges (AAMC), it has been opposed by family medicine organizations because the expansion would have been willy-nilly, not giving preference to or even a guaranteed base of funding for primary care. While it is true that there are needs for new physicians in areas other than in primary care, any bill that does not absolutely guarantee primary care slots will result in hospitals allocating them to those specialties that make the most money for the hospitals – certainly not primary care. Moreover, the key flaw of counting all students entering 3-year internal medicine residencies as primary care, despite, as I have discussed (recently November 17, 2009 Primary Care’s Image: A Problem?, October 14, 2009 "War on Specialists?": Wall St. Journal defends the status quo!, October 8, 2009 "Uncomplicated" Primary Care?), the fact that the vast majority of them will enter subspecialty fellowship training. There is an excellent Op-Ed on December 23, 2009, addressing this issue in the Times, "Doctors no one needs", by Shannon Brownlee and David Goodman.

What, of course, is less good (or, as we might say, “bad”) is that 1) it doesn’t cover everyone; 2) it will save some money, maybe, but only a small portion of what might be done by a public option, not to mention a single-payer plan; 3) it will make the insurance companies even richer; 4) it will not guarantee affordable health care for Americans. We have already discussed this (December 6, 2009 Health Care Needs Should Guide Health Reform). It has even eliminated the buy-in to Medicare for people over 55. The core problems with the bill are detailed in the letter to the Senators by the leadership of the Physicians for a National Health Program (http://www.pnhp.org/news/2009/december/pro-single-payer-physicians-call-for-defeat-of-senate-health-bill).

But, as the Times notes in its front-page article on the bill (Democrats Face Challenge in Merging Health Bills by Robert Pear and David M. Herzenhorn), “Democrats were grappling Monday with deep internal divisions over abortion, the issue that most complicates their drive to merge the Senate and House bills and send final legislation to President Obama.” And this is indeed the part of the Senate bill, and in the House bill’s Stupak amendment, that gives free rein to the bigots who feel, literally, that it is their God-given right to apply their moral compass to the most important life decisions of the rest of us. In trying to garner the votes of marginal Democrats (like Ben Nelson in the Senate), the Congress has bowed to the efforts of the Catholic bishops to try to not only control the lives of their own believers, but those not of their religion as well. Make no mistake about this. As much as opponents say that they are opposing abortion, what they are actually doing is choosing to make the decisions about it for other people. All of those people who are affected are women, and most of those making the decision – including all bishops – are men.

Trying to reach a compromise (New York Times, Negotiating to 60 Votes, Compromise by Compromise, by Robert Pear, December 20, 2009), the Senate came up with nonsense. “In what they described as an effort to reduce the demand for abortion, Democrats would provide money to help pregnant teenagers and new mothers so that they could stay in high school and attend college. The federal government would provide $25 million a year for a ‘pregnancy assistance fund.’ The money could be used for ‘maternity and baby clothing, baby food, baby furniture and similar items,’ the proposal says.” If they weren’t politicians, these people would be described as, using the technical term, “lunatics”.

If you really want to “reduce the demand for abortion”, the first step, the necessary step, the sine qua non, is to reduce unwanted pregnancies. Amazing idea! How would we do that? Well, one way would be to tell people, convince people, cajole people, pray for people, and bribe people not to have sex, or not have sex with people to whom they are not married, or not have sex when they are not explicitly trying to have a baby. This is, incredibly enough, a very popular idea and strategy. I say “incredibly” because there is no evidence that it works and no reason to think that it might. For all of human history people have had sex, and the people with the strongest urge to do so are just the young people that we are trying to convince not to (ironically, the potency industry for old men, whom nature has decided do not need to have a desire or ability to have sex, is enormous!).

There is compelling evidence that every program designed to keep young people from having sex is a complete, utter, and absolute failure. Indeed, an unending line of ministers and politicians who preach and pontificate about the issue are having sex outside of their marriages, and proving by their behavior the vapidity of their words. It is of no importance to people outside of their immediate families whether they apologize or feel bad. What is important to the rest of us is that, if they don’t have the common decency to stop being politicians and trying to make policy that affects us all, that they abstain from voting on any issue with any sexually-related dimension.

On the other hand, there are much more effective methods for “reducing the demand for abortion”. They are two: widespread, comprehensive and truthful sex education, and widespread, freely available contraception. Unfortunately, I see no support for these measures in the current bills or in the complete blather coming from the mouths of the hypocrites above.

Friday, December 18, 2009

The trauma of joblessness: who is evil?

On November 8, 2009, the New York Times began its 98th “Neediest Cases” campaign, to raise funds for charities that help New Yorkers who are in real financial hardship. This year, however, the results of the New York Times / CBS News Poll published in the Times on December 14, 2009 as “Poll reveals trauma of joblessness in US” by Michael Luo and Megan Thee-Brenan, document a much more widespread problem, across the US. In addition to the very disturbing data presented, the article, and even more the video clips available on line, put a face on these numbers, and the face is that not only of those in chronic poverty, unemployment and homelessness (who, it must absolutely be remembered, are those who are suffering the greatest negative effects of this “recession”), but of a more traditional working-and-middle class group. Fear of falling out of their social class, whether formerly upper-middle, middle, or working class, is a major concern documented in this poll and discussed on Michael Luo’s Economix blog on the same day.

Some of the data revealed by the poll:
· 60% have taken money from savings and retirement accounts for daily expenses
· 53% have borrowed money from family and friends
· 46% feel embarrassed or ashamed about being out of work

Since this blog is often about medicine, some medically-related data:
69% are more stressed, 55% have trouble sleeping, and 48% have experienced emotional or mental health issues like anxiety or depression.

And they will find it more difficult to receive help for these problems, since:
54% have cut back on doctor’s visits and medical treatments, and
47% are currently without some form of health care coverage.

The Times article says that “Americans struggling with job loss say unemployment has created a crisis in their lives and is exacting a crushing financial and emotional toll.” That seems correct, although not ‘right’, a word I almost used.

It is difficult to not find the contrast with the articles on the huge banks (JP Morgan, Bank of America, Citigroup, Wells Fargo) that are paying back the government’s TARP loans (e.g., “Wells Fargo to repay US, a coda to the bailout era”, New York Times December 15), to free them from the onerous burden of government regulation, such as limits on the outrageous salaries and bonuses that they can pay themselves, or the requirement that they actually loan money to credit-worthy businesses (especially small businesses) and individuals. For the bankers, I guess, the recession is over; the payback, in the word used in the article’s title, is a “coda” (“something coming after or at the end”, from the Latin “cauda”, tail). For those small business and individuals, as well as for the unemployed described in the poll, it is obviously not. And, if the bankers don’t feel secure enough to lend out money, why should they? They had to borrow all that money (“raise capital”) to pay off TARP, and to pay their executives. Sorry there’s none left to loan to you, to keep your business afloat and a few more workers off the unemployment line. (Of course, since the Clinton-era “welfare reform” we no longer have to watch folks on “relief lines”. There are none, because there is no relief.)

David Brooks’ Op-Ed column on December 15, 2009, “Obama’s Christian realism”, suggests that the president, more than his predecessors, has a moral framework that frankly includes “good and evil”. Focusing mainly on the President’s war policy, as enunciated in his West Point and Oslo (Peace prize!) speeches, Brooks essentially calls him a “cold-war liberal”, a label that Mr. Obama may not embrace. But certainly the President’s characterization of the bankers described above, who are not lending money, as “fat cats”, does suggest a good/evil belief system, and reinforces the sense that what we are seeing today is a frank real-world enactment of those old 19th-and-20th century pictures of evil greedy bankers, bosses, and capitalists trodding the working people under their feet. And if they, the bankers, or their apologists and flaks, want to take offense at the “class war” picture, it is their own fault, entirely; the situation, both the initial financial crisis and their current greed in the face of human suffering, is completely of their own making. (Of course, it always has been; the ruling class never complains about class war when they are not only winning, but completely unopposed. They raise the specter, however, when the least challenge to their hegemony is evident.)

Unfortunately, President Obama’s moral judgments do not seem to affect his administration’s policies, which have, molded by the Rubins and Summerses and Geithners, been unabashedly (ok, occasionally slightly abashedly, but certainly pretty completely) based on the critical nature of the success of Wall St., a far from universal opinion. For some data that supports an alternative opinion, the New Economics Foundation, a UK think tank, has a new publication, “A Bit Rich”, in which they look at the economic contribution of different jobs relative to the amount people are paid (h/t Alex Scott-Samuel, on the “Spirit of 1848” listserve). They discovered that hospital cleaners, because they prevent the spread of infection and preserve the health of the public, produce more than 10 times the value of their pay. Bankers earning over £500,000 a year (about $800,000) destroy (based on the effects of the recession on society) about £7 of value for every £1 they create.

So are the bankers evil? Maybe you have to ask the President, or David Brooks, or maybe you have your own opinion. Maybe they are just following their nature, like sharks. The question, however, is much more relevant when looking at members of Congress, especially Senators. The same folks who gave us the Bush-era $4 trillion in tax cuts for the wealthiest Americans, and, in the health arena, a Medicare drug benefit program that was forbidden from negotiating rates with pharmaceutical companies on behalf of consumers, are at it again. They have opposed every effort to rein in the excesses of the bankers (including a proposal to limit credit card interest rates to “only” 18% -- is there any rational human being who cannot identify higher rates as pure usury?), or to extend health care benefits to Americans, who, like those studied by the Times/CBS poll, are unemployed, or the even greater group who are still working but who cannot afford or whose employers do not offer health insurance, or those who have health insurance and find out when they get sick how little it covers.

Fortunately they are now in the minority, which has helped getting some kind of health reform passed in the House. The Senate, however, is a different story; compounding its constitutionally-based unrepresentative nature (remember how the “Gang of Six” Senators formulating the Finance Committee bill represented less than 3% of the US population?*), it has rules (not constitutionally mandated) requiring “super-majorities” of 60% to end filibusters. This has allowed the group of 40 Republicans – plus Joe Lieberman – to prevent single payer from being discussed, to remove the public option from consideration, and now to remove the possibility of people over 55 from buying into Medicare. Kansas Senator Sam Brownback, asked if he will vote for funds to support the troops in the middle east, says “No. I don’t want health care.” They talk about fiscal responsibility, but remember these are the same folks who pushed the enormously expensive tax cuts for the wealthy and restrictions on the Medicare drug plan mentioned above, but have treated single payer, which would not only cover everyone but save LOTS of money, as anathema.

So maybe they are hypocrites. Or maybe they are corrupt, in the thrall of the big corporations, including pharmaceutical and insurance companies, who make big contributions to them. Or, maybe, they are the ones who are evil. After all, the bankers – and insurance company and pharmaceutical company executives – (if you want to buy Milton Friedman economics) are supposed to follow their greed. Congresspeople and Senators, on the other hand, are supposed to work for the interests of the rest of us, and help, through regulation, to protect us from the power of the banks and big corporations.

But who do they actually work for? I’m not sure I want to know the answer.

*The six states that they represent rank 30, 36, 40, 44, 48, and 50 in population!

Monday, December 14, 2009

Tommy Douglas and the Canadian Health System

Five years ago, on November 29, 2004, the Canadian Broadcasting Corporation (CBC) program "The Greatest Canadian" revealed the winner of that designation. According to Wikipedia, this "was not decided by a simple popular poll, but was instead chosen through a two-step voting process. On October 17, 2004 the CBC aired the first part of The Greatest Canadian television series. In it, the bottom 40 of the top 50 "greatest" choices were revealed, in order of popularity, determined by polls conducted by E-mail, Web site, telephone, and letter. To prevent bias during the second round of voting, the top ten nominees were presented alphabetically rather than by order of first round popularity. This second vote was accompanied by a series of documentaries, where 10 Canadian celebrities acting as advocates each presented their case for The Greatest Canadian.” The winner was not a Canadian prime minister, or sports figure, or show business celebrity, or even inventor (like Alexander Graham Bell – did you know he was Canadian?). It was Tommy Douglas.

Who? If you’re American, you probably haven’t heard of him, but that would likely be true of most of the top 10 (except Bell and Wayne Gretzky, who were nos. 9 and 10, and maybe Pierre Trudeau). Douglas, who died in 1986, was a prime minister of the western prairie province of Saskatchewan in the 1940s and 50s. In 1961 he became the first national leader of the New Democratic Party, a post he held for 10 years. I’m sure he was a fine leader in many ways, but what won him this honor was the fact that he was the father of the Canadian national healthcare system, called Medicare. First introduced in Saskatchewan in 1962, the program became federal in 1966 with passage of the Canada Health Act, and was fully implemented by 1971.

Canadian Medicare is a “single-payer” system, such as that advocated by many, including myself, for the United States. It is actually administered by each of the country’s 13 provinces, with much of the funding coming from the federal government through a match. While there are some differences in the coverage in the different provinces, they all must meet five principles: they must be publicly administered, comprehensive, universal, portable (i.e., residents of one province must be covered in other provinces), and accessible. In Canada, doctors and other medical practitioners (mostly in private practice) provide services and submit the bill to the “single payer”, the provincial health ministry, and are then reimbursed at rates annually negotiated between the ministry and the medical associations. Hospitals are provided funding on an annual basis (a “global” fee) rather than fee-for-service, and importantly capital budgets are separate from operating budgets, so that a hospital cannot scrimp on patient care services in order, for example, to build a new building or buy an expensive piece of equipment. Everyone is covered. Everyone can get care. Administrative costs, for both providers and government, are kept down because there is only one payer. Costs for healthcare continue to rise, but at a much slower pace than in the US (see figure).

Are there complaints? Sure. There will always be complaints from people in any system not built specifically around them and their individual needs. Are waiting times sometimes longer than in the US? For elective procedures they might be, provided that you are a person who has excellent health insurance in the US. If you are a person without, or with poor, health insurance you might never get elective surgery in the US. And the waits in Canada, most recently, are certainly not excessive...4 weeks for elective surgery, 3 for an MRI scan. We hear stories of Canadians coming to the US for health care, and undoubtedly there are well-to-do people in Canada who do not wish to wait in line with everyone else (a common characteristic of many of the well-to-do), so come to the US. A 2002 study published in Health Affairs by Katz, et. al. (“Phantoms in the snow: Canadians’ use of health care services in the United States”) revealed, among other data, that in a survey of 18,000 Canadians only 90 had received any health care in the US in the last year and of those, only 20 had gone seeking it (hey, Canadians do go to Florida in the winter and get sick!). And there are many more uninsured Americans who cross the border in search of health care; so many that the Canadian provinces have now put photographs on their Medicare cards so that US citizens cannot borrow them from Canadians.

The system works quite well. Most Canadians (over 80%) are very satisfied with it, and a very small % would wish to trade it for a non-system like that in the US. But this is not what is going to happen with US health reform. Despite the support of nearly 100 representatives for Rep. John Conyers’ “Medicare for All” bill, and the work done in the House by him and others such as Anthony Weiner and Dennis Kucinich, it was not part of the House proposal. And a similar proposal from Sen. Bernie Sanders will likely not be voted on in the Senate. Instead, we are getting sausage – liberally spiced with financial input from the health insurance industry.

Most Americans do not know who Tommy Douglas is, but Canadians do. And they believe that spearheading their single-payer universal health system earns him the title of “Greatest Canadian”. I don’t see any of the leaders of the current effort to “craft” health reform in the US earning a similar honor.

Thursday, December 10, 2009

Free clinics should open our eyes to the real problems

On December 9 and 10, 2009, a massive “C.A.R.E.” clinic, sponsored by the National Association of Free Health Clinics occurred in Bartle Hall, the huge Convention Center in Kansas City. On the first day alone, with temperatures well below 20 degrees and the roads covered with ice from the snow that fell the night before, as many as 1,000 people showed up to receive health care from 1,600 volunteers, including 100 doctors, dentists, and nurse practitioners. It may end up seeing more people than similar events previous held in Houston, New Orleans and Little Rock. There is excellent coverage of the event in an article by Alan Bavley in the Kansas City Star, accompanied online by photos and videos by the Star’s Todd Feeback.

The purpose of these clinics is, of course, to provide some care to the people who attend – often the only care they have gotten in years. People were diagnosed and sometimes treated for acute conditions, such as pneumonia, or diagnosed with chronic diseases such as high blood pressure, high cholesterol, and diabetes. Indeed, most often they were really re-diagnosed; they knew they had these conditions but had been unable to afford medications or medical care. But another, even more important purpose, as Sherri Wood, Director of the Kansas City Free Clinic, says in the video, is to “put a face on the uninsured”. They are not only, or mostly, homeless, alcoholic, completely down-and-out, or even mostly unemployed. Rather, they are employed in low-wage jobs (not infrequently 2 or 3 jobs!) that do not offer health insurance, or they are employed part-time so that their employer does not have to buy their insurance. They are people, American people, our friends and families and neighbors. And they could be us; most Americans are a layoff away from uninsurance, and not too many paychecks away from dire financial straits and even homelessness.

The excellent accompanying editorial in the Star is titled “Massive free clinic at Bartle Hall a great event, but reform is still needed”. The editorial, along with the story, includes interviews with and comments from people who came for services (“Making three dollars an hour plus tips I can’t afford to see a doctor. When you have a house payment and your bills, it’s hard.”), but it also clearly states that “Although impressive, the free clinic clearly is no substitute for reliable medical care”. Yes, indeed. Or rather, No, indeed, it is certainly not. “Charity isn’t a good substitute for justice”, as I have quoted Jonathan Kozol before.

The Star editorial goes further, making the point that I have often made that a solution to the health care problem includes producing more primary care physicians. “Too many medical school graduates gravitate to high-paying specialties partly to pay off burdensome student loans.” We must, it says, “…encourage physicians to take up primary care.” It is appropriately critical of the fact that “The reform bills in Congress contain few incentives to set things right…Expanding access won’t work unless we start now to increase the supply of primary care physicians.”

So the problem is clear. And the solution is clear. Universal health coverage. Based on the principle that we need to ensure that people receive care, not that for profit companies make money. It has been figured out by every first-world (and some not quite first world) countries. It is not tricky, difficult, or even expensive (certainly not compared to what we are spending now). Not that it will happen, or happen easily, as the “debate” in Congress is currently demonstrating.

Maybe some of the opponents of real, meaningful, comprehensive health reform are just mean, evil, selfish people. I don’t rule that out. But more likely they are “blinkered”, like a horse, looking at only one aspect of the problem, such as the Kansas legislator who is proposing that our state refuse to participate in any health reform plan passed by Congress. (I am trying really hard to believe that this is his/her issue, being like the blind men of India with the elephant, not that s/he is mean, evil and selfish.) Plus the campaign contributions from the insurance companies and drug companies and health providers who are doing just fine, thank you, under the current system of literally leaving people out in the cold, help sway their beliefs.

It is time for the leaders of our country to stop compromising on a core need of our people, and ensure that everyone has access to quality health care. And they can do it in a responsible and cost effective manner through a single payer system, although there are other alternatives. The Star editorial says “A compassionate and cost-effective system would provide every American with a medical ‘home’ from which to receive preventive and needed care.”

I hope that most of our congressmen and other leaders are compassionate, and am certain that they wish to be cost-effective. But they need to abandon pandering to big contributors and keep this core value front and center: Quality health care for all.

Sunday, December 6, 2009

Health Care Needs Should Guide Health Reform

As the debate over health care reform proceeds in the Senate, and in the nation, it is important to take stock of the key assumptions of those planning the changes. The Democrats have chosen to combine increased regulation and requirements for insurance companies with economic incentives, in an effort to cover more people and reduce skyrocketing costs. The Republicans have chosen to combine a core opposition to any proposal originating from the Administration or the Democratic leadership (articulated by New Hampshire Republican, and almost-Obama-cabinet-appointee, Judd Gregg) with cynical attempts to portray themselves as the defenders of currently-insured Americans by opposing cuts while criticizing the proposal for not saving enough money. The classic here is John McCain, who campaigned on a platform of quite draconian cuts in Medicare, screaming that the much more modest cuts in the Democratic proposal will, essentially, kill old people.

While the Democratic proposal does resemble an effort to patch the chinks in a leaky old house as winter approaches, leaving lots of holes and at cost greater than fixing the whole thing, the Republican scare tactics should be seen as what they are. Across the board cuts in Medicare would be a bad idea, as are almost all across-the-board cuts in any organization, but cuts which reduce the over- and unnecessary use of expensive tests and procedures, while increasing access to primary care, would save a lot of money. To be sure, the doctors and hospitals who provide those tests and procedures would take a financial hit, but it is unlikely to lead them to food stamps. A colleague who is in the health care field, but not a physician, told me that he had been at a meeting in which a Canadian doctor talked about the structure of their payment system, which pays subspecialists less than they make here, and observed that such change would be opposed by the specialists who would not welcome their income being reduced from, say, $600,000 to $400,000. What is there to say? Life is tough? It is hard to see the American people, worried about their jobs and future, increasingly (as I have recently discussed) on food stamps, fighting to prevent such losses. And, more important, I am sure that we will find doctors in those subspecialties who are willing to work for the $400,000.

The bigger problem with the Democratic proposal is that most of its solutions are based on creating business and economic incentives to try to get insurers to do the right thing, or at least a little more right and a little less evil. This is, I suppose, good insofar as it goes, and seems to be convincing even progressive economists such as Paul Krugman (“Reform or else”, New York Times December 4, 2009). But the idea of patching the house of health care using economics is intrinsically flawed, when the model should be based on social justice, morality, and doing the right thing for our nation and our people. Sophisticated businesses, whether Wall St. banks or health insurance companies, will always find ways to “game the system”, to find profit by reducing service, no matter how the economic incentives are structured (although surely they can be structured better than they are now). Even organizations that are intended to meet the health needs of the underserved can, because of the way incentives are structured, find that they can do better (or even simply survive) by caring for some needy in preference to others.

A case in point is one of our local Federally-Qualified Health Centers (FQHCs), also known as Community Health Centers (CHCs). I discussed these entities nearly a year ago, on December 30, 2008 (Community Health Centers, and more recently on September 3, 2009, Public/Private funding: We’re all in this together). These clinics are financially supported by the federal government largely because, in return for caring for the poor and meeting other federal service and reporting requirements, they receive cost-based reimbursement for Medicare and Medicaid patients, leading to Medicaid payments that are usually several times that paid to private doctors. They also usually receive a federal grant that helps support care provided to the uninsured. However, that money is never enough, and the additional funds from Medicaid and Medicare help subsidize that care for the uninsured.

One branch of the local FQHC located in northeast Wyandotte County, KS, where I live, served a desperately poor neighborhood. Indeed, most of the people are not on Medicare (because they are too young) or on Medicaid (because, while many are unemployed and others work for low wages at businesses that do not provide health insurance, either they are not families with young children or, if they are, they are often undocumented and ineligible). So the clinic was financially unable to support itself, and has solved its problem by moving to another part of the county, where the percentage of poor people with Medicaid is much higher. Still poor, to be sure, and in need of providers, but a good business move for the FQHC.

The problem, of course, is those people living in their old community. They did not go away, become more prosperous, or become more likely to be insured. They just lost their only source of health care. It’s hard to completely blame the FQHC, for all other providers left that community long ago, although the FQHC was specifically designed to fill these gaps. It is possible, and popular, to blame the “illegals” who make up much of this abandoned population, but while this works for propaganda, it is not so smart in reality. These people are here, and absent access to primary and preventive care they will continue to show up in emergency rooms to receive care for advanced disease that could have been treated more cost-effectively.*

Fortunately for this community, an independent, non-federally supported, safety net clinic (disclaimer: I am on its Board) has opened a small satellite in the basement of a church in that community. In doing so, it is not employing a traditional business plan; it is going where the need is, rather than where it can expect to make money. This will be a good thing for the people of that community, but it is no solution to the health care crisis, and cannot be expected to be replicated everywhere as a means of patching those chinks in our system. Not only does it depend upon funding from private foundations to exist, it depends upon enormous “in kind” contributions from its health care providers, doctors and dentists and nurses, who all receive the same wage as every other worker in the clinic, currently $12/hour.

But it could work on a national basis; not the part about doctors and dentists earning $12 an hour (we’re not talking here about $400,000 instead of $600,000!), but rather a national plan for a system that is predicated not on profit but on caring for people. A health care system which did not discriminate among people, but ensured that providers caring for everyone could survive and make a living, so that there would not be big parts of our population left out. Like a single-payer plan. Like Medicare for All.

Our system is upside down. Every other first world country has a health system built upon the idea that everyone is entitled to access to health care. Financial incentives to providers and insurers may work to fill some gaps. Ours uses financial incentives to provide care to a majority of our population, but it is a shrinking percent and even for them the coverage is decreasing and the cost is rising, and volunteerism and sacrifice are relied upon to fill the holes.

A health system for our country should start with ensuring access to high-quality health care for all our people. As I have discussed before, it may actually save money, but the reason to do it is that it is the right thing to do.

*This is not to mention that they work and pay taxes – often payroll, but certainly sales taxes – for low wages. What happens when they really leave – see “Arizona” – is there aren’t enough people to do these jobs, and aren’t enough people to rent housing – causing a major negative financial ripple effect.

Wednesday, December 2, 2009

Food stamp use increases: who should the government be working for?

The New York Times article “Food stamp use soars across US, and stigma fades” by Jason DeParle and Robert Gebeloff (November 29, 2009) details not only the dramatic increase in the number of people on food stamps across the country, but the fact that many people who would never have thought of themselves as candidates for “welfare” now (sometimes ruefully) avail themselves of this “Supplemental Nutrition Assistance Program” (SNAP). In two telling county-by-county maps we are shown, first, which counties have had the greatest increase in recipients of “nutritional assistance” (as food stamps are now called), and then which have the greatest percent of recipients.

The map showing percent increase, calls our attention to the West, Florida, and the North Central States, with Utah, Nevada, Arizona, California, Idaho, Washington, Wisconsin and Florida all darkly colored. As shown on the second map, these are mostly states that previously had relatively low percents of people on food stamps, and are even are now just catching up; they are still below the areas with the heaviest proportions – the Texas-Mexico border; the Appalachian strip through West Virginia, Kentucky, Tennessee, Arkansas, and Missouri; the Mississippi Delta; anywhere there is an Indian reservation. The South as a whole looks bad, but always has, because of the combination of low union penetration resulting in low wages, many people employed in marginal agriculture, and terrible social services. The interactive map feature is “cool” – you can hover over any county in the US and find out what percent of its population is on food stamps, and what the change (almost always “increase”) has been. The result is that “There are 239 counties in the United States where at least a quarter of the population receives food stamps…”, and do, nationally, one in four children.

While there are a number of smaller counties that have almost half (49%) of their population on food stamps, the two with the highest percents among counties with over a half-million people are Bronx County, NY, and Hidalgo County, TX, tied at 29%. Ironically, the last time Hidalgo County (county seat=McAllen) hit the national news it was when it was revealed, in Atul Gawande’s New Yorker piece, the “Cost Conundrum” (discussed in my post ‘Medicare Costs: ‘All Politics are Local’” on June 11, 2009), that it was the region that had the highest Medicare cost per person in the country.

This is pretty sad. It is sad that so many people in this country have to swallow their pride and take food stamps. “’It’s time for us to face up to the fact that in this country of plenty, there are hungry people,’” says SNAP’s director. “The program’s growing reach can be seen in a corner of southwestern Ohio where red state politics reign and blue-collar workers have often called food stamps a sign of laziness,” the Times tells us. But, of course, it is not “laziness” when it is you.

It is hard to think of this without thinking of the multi-billion dollar bailouts given to the bankers and financiers so that they could continue to give themselves huge bonuses. While it may be true that these companies were too big to fail, there is no reason that they had to use our tax money to pay their employees, each of whom is only a person, just like the people who are increasingly in need of food stamps. We are told that some statistics, such as that the rate of job losses are slowing, indicate that “we” as a country may be on our way out of the recession, but that still means that there are fewer people working each month than there were the month before; I don’t think such statistics mean as much to the more of “we” who are out of work each month as the statistics showing the increase in folks on food stamps. I don’t think that it makes the six people looking for each available job feel much better.

I am still marveling at the juxtaposition of the food stamp story with an advertisement in the program for a concern I recently went to. Under the photo of a sultry and glamorous beauty in a gown leaning against an elegant bar with a glass in one hand, the text says: “The glass is half full…of champagne. The more than 97 percent of KC consumers who spend $27,000 , or more, per month on personal luxuries subscribe to one necessity every month – KC Magazine.” I am sorry that it is not online and I can’t reproduce it. I had to read that several times to be sure I hadn’t read it wrong – it is, after all, a tortured sentence. Yes, $27,000. A month. That’s a lot of money. Over half the average annual household income in our region. But they’re not talking about income. They’re talking about luxuries. $27,000 a month on luxuries. $324,000 a year. Or more. In Kansas City, not even New York or LA. I am amazed at the audacity of it.

Paul Krugman’s recent column (“The Jobs Imperative”) calls for a new Works Progress Administration in which the government would directly create jobs. I don’t think this is going to happen because the Obama administration is not bold enough, and has never shown such boldness. It completely kowtowed to the financial sector, and is afraid to take on the right-wing bloviators in Congress who say they represent the American people when in fact all they want to do is to further screw the American people. Most of all it won’t happen because the Congress is owned by wealthy contributors, and doesn’t really work for the American people. It is a very sad situation, but at least we can be confident that few Congressmen, even when they retire, will require food stamps.

We as Americans seem, on so many fronts, to be unable to put ourselves in the position of others, even as we move toward that position. This is true in the area of reproductive rights, where younger women do not realize that if they don’t fight for it now, abortion could not be available when they need it (Sheryl Gay Stolberg, In Support of Abortion, It’s Personal vs. Political, New York Times November 29, 2009). It is true when we fail to realize that without a universal health insurance program, our access to health care can disappear with our jobs. It is also, clearly, true with regard to our basic human needs, such as food. In the Times story, the formerly-employed food stamp recipients of southeastern Ohio say “I always thought it was people trying to milk the system. But we just felt like we really needed the help right now,” and “I always thought people on public assistance were lazy, but it helps me know I can feed my kids.” So would “those people”. Maybe we need to start thinking about how what happens to some of us can happen to us all.

German Pastor Martin Niemöller wrote:
“First they came for the communists, and I did not speak out—because I was not a communist;
Then they came for the trade unionists, and I did not speak out—because I was not a trade unionist;
Then they came for the Jews, and I did not speak out—because I was not a Jew;
Then they came for me—and there was no one left to speak out for me.”

Most of us would agree with the woman in the Times article who said “I like to have a nice decent meal for dinner.” It’s not too much to ask that this be the goal of our national policies, and let the financiers and those people who are spending $27,000 a month – or more! – on “personal luxuries fend for themselves.

Saturday, November 28, 2009

Medicine and Social Justice – the First Year: An Index


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

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

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

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

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

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

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

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

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

Wednesday, November 25, 2009

Breast Cancer Screening and Evidence-based Medicine


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

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

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

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

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

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

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

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

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

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

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

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

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

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

Sunday, November 22, 2009

Health Workers and Our Wars

This guest column is by Seiji Yamada, MD, a family physician, Associate Professor of Complementary and Alternative Medicine at the University of Hawai’i John A. Burns School of Medicine, and one of my mentors. This essay is an expansion of the one that was published in the AAMC journal Academic Medicine, chosen as one of the five best responses to the question put forth by editor Steven Kanter “How can academic medicine respond to peace-building efforts worldwide?”. Dr. Yamada’s original essay, “Academic medicine should start at home”, is at http://journals.lww.com/academicmedicine/Fulltext/2009/11000/Academic_Medicine_Should_Start_at_Home.18.aspx

Health Workers and Our Wars

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

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

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

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

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

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

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

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


[1] Save the Children UK. Iraq sanctions: humanitarian implications and options for the future. Available at: (http://www.globalpolicy.org/component/content/article/170/41947.html). Accessed July 21, 2009
[2] Yamada S, Fawzi MC, Maskarinec GG, Farmer PE. Casualties: narrative and images of the war on Iraq. Int J Health Serv. 2006; 36(2):401-15
[3] Burnham G, Lafta R, Doocey S, Roberts L. Mortality after the 2003 invasion of Iraq: a cross-sectional cluster sample survey. Lancet 2006; 368: 1421–28.

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

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

[6] Parry R. Bush’s death squads. In These Times, Jan 17, 2005. Available at (http://www.inthesetimes.com/site/main/article/1872/). Accessed Jan 23, 2005.

[7] Steinglass M. Vietnam and victory. Boston Globe, Dec 18, 2005. Available at (http://www.boston.com/news/globe/ideas/articles/2005/12/18/vietnam_and_victory/). Accessed Sep 27, 2009.

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

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Tuesday, November 17, 2009

Primary Care’s Image: A Problem?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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