Breast cancer screening: conflicting evidence? what are the important questions for health?

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Several new, and sometimes contradictory, studies about breast cancer and screening mammography have recently appeared in the medical literature. In a recent study from Norway, published in the New England Journal of Medicine, Kalager et. al[1] looked at the impact of mammography screening of women 50-69 years old in that country by comparing groups of women who were screened and those who were not screened between 1996 and 2005 and comparing them both with comparable groups for the 1986-1995 period. They discovered a significant decrease in the rate of breast cancer detected in women who were screened – but also in women who were not screened. The decrease was greater in the women who were screened, but this only accounted for 1/3 of the reduction in breast cancer mortality in that group; while the reductions in each group were statistically significant, the difference between them was not (quite). Overall the reduction in the death rate in screened women was 7.2 per 100,000 woman-years, and in the non-screened group 4.8 per 100,000 woman-years.

Meanwhile, Cancer published an article from Sweden looking at mammography screening for women who were 40-49 years of age. Because not all Swedish counties screened women that age, they were able to do a retrospective comparison between those counties who began screening at 40 compared to those counties who began at 50. Hellquist, et. al.,[2] found a significant risk reduction (a relative risk of 0.74 for women invited to screening and of 0.71 for those actually screened). Over 16 years of the study “…there were 803 breast cancer deaths in the study group (7.3 million person-years) and 1238 breast cancer deaths in the control group (8.8 million person-years)”, or converting to the same units as the other study, a reduction of 3 deaths per 100,000 woman years, from 14 to 11. The authors note that 1252 women this age would need to be screened to prevent one death.

The Swedish study provides data to support screening women at 40 (although the reduction was greatest in the 45-49 group, which is not surprising as the incidence of breast cancer increases with age). The Norwegian study shows that the rate of breast cancer has decreased anyway. The Swedish study is not a randomized controlled trial, but rather solely a historical comparison, and thus did not control for differences between the women who got screening and those who did not that might have affected breast cancer risk.

So which are we to believe? Both, to the extent that we can understand the methods used. The question is what are we to do? “We”, here, being both women who might choose to undergo mammography screening, and doctors who have to decide whether to recommend it, especially to those under the age of 50. For me, it will involve discussions with each woman, dependent on her individual risks and preferences. The population health benefit is small but significant; while for any woman the risk reduction might be of value regardless of the cost, that woman (and everyone else) has to also bear the cost of screening all those women – 1252 to save the life of one woman 40-49 in the Swedish study. Clearly, women who have a higher risk (family history) will benefit more, since they are more likely to have breast cancer than those without such a family history.

The cost is not only all those mammograms, but the cost of further tests (additional views or ultrasound) in women with questionable results (more common in younger women who on average have denser breasts), in biopsies – not without risk, though low – and pathology reports, discomfort etc. Not to mention what that money might otherwise be spent on. Feeding the homeless? Providing prenatal care? Fighting HIV/AIDS? Building more bombs? Bailing out big financiers? I would certainly agree that there are social programs that could more effectively use the money currently being spent to screen low-risk younger women for breast cancer with far more social benefit; I would also acknowledge the very low likelihood of any saving in mammography screening being used for such purposes rather than other high-tech medical care or further health system profit.

A more important question, perhaps, is why, at any age level, are certain parts of the population – poorer and minority women – less likely to be screened? To the extent that screening does detect cancer in earlier stages, when intervention can be done, and thus make a difference in mortality, why is it not being done as effectively with minority women? For example, African American women are less likely to get breast cancer, but more likely to die from it.

But people do want “answers”, definitives. Newspapers like to publish “breakthrough” research that seems to provide them. When the “answers” seem contradictory, it leads to frustration for many, and a decision to do what they had planned to do anyway, to do what seems to make “sense” (and what they can afford). After all, if sometimes we hear that Vitamin C or E or beta-carotene is a wonder drug to prevent cancer, or Alzheimer’s, and later studies show that it isn’t, and sometimes may even create greater risk, what are we to do?

One thing we could choose to do is to listen to those who are sure that they have the answers, even when these are based upon no data or carefully-selected data. If someone advises people based upon a single study, regardless of the scientific quality of that study and how often its results might have been refuted by later studies, they can be more confident and sure of themselves. This can inspire confidence on those they advise. (I am reminded of the story told by a colleague, fresh out of residency, who was practicing with farmworkers in the Imperial Valley of California. These folks, he said, are used to going to a doctor who listens to their problem, nods, tells them what they have, and gives them a shot to fix it. “I,” he noted, “listen, then tell them to take off all their clothes, examine them for a long time, and then finally tell them I’m not sure what it is, but it probably doesn’t need a shot – and that the shot might even be bad for them – and likely it will go away with time. Who are they going to trust?”). Showing confidence in your opinion is very persuasive. Thus the term “confidence men” (now shorted to “con”).

By the way, I don’t think this is such a good choice. That studies may seem contradictory is part of the nature of science, of how the studies were conducted, on whom, with what controls, using what methods. A future blog will discuss the work of Dr. John Ioannidis, whose work has raised questions about how much of the work published as research is true, made recently au courant by David H. Freedman’s article in the November Atlantic “Lies, damned lies, and medical science,” and some of the important lessons to be learned – and not learned – from his work. Nonetheless, this confusion does not justify complete nihilism – do whatever you want and it’s all the same – or much less undertaking treatments that have never really been studied. (See Drugs, Tobacco, Doctors and the Health of the Public, September 10, 2010.)

In the meantime, remember that there are probably not too many magic shortcuts to better health. A healthful diet and more exercise will make you fitter and stronger and able to do more things; reading and thinking and doing puzzles are interesting, stimulating and fun, whether they prevent Alzheimer’s disease or not.

[1] Mette Kalager, M.D., Marvin Zelen, Ph.D., Frøydis Langmark, M.D., and Hans-Olov Adami, M.D., Ph.D, Effect of Screening Mammography on Breast-Cancer Mortality in Norway, N Engl J Med 2010; 363:1203-1210.

[2] Hellquist BN, et. al., Effectiveness of population-based service screening with mammography for women ages 40 to 49 years, Cancer published online Sept 29 ,2010
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Health and income: "what's new?" or a good resource

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This is a guest post by Kim Kimminau, PhD, Associate Professor of Family Medicine at the University of Kansas School of Medicine and Director of the Center for Community Health Research.

I come from a family where my parents, one a first generation American and the other a child immigrant, and the first in their families to complete high school, would say to me “so, somebody actually pays you to do that?”, and the “that” was my life’s work – the study of human health through time and space (aka, biological anthropology) and to conduct research. For them and so many others, reading the titles of research grants or peer reviewed articles was an exercise in a delightfully sardonic mix of tongue-twisted, mispronounced terms, outright mockery and guessing what and why anyone would want to spend “good money” (as my father would say) to study such things.

Apparently, the time has come. I have become my parents.

In the online Robert Wood Johnson Foundation’s News Digest on public health I learned from a UPI story that a Gallup poll was recently conducted among 200,000 U.S. adults over the span of nine months (http://www.upi.com/Health_News/2010/10/18/US-health-well-being-tied-to-income/UPI-74081287460458/ ). This alone is pretty mind-boggling – a huge poll by almost any standard. I read on. What was learned from the survey was that “the more money Americans make, the better physical emotional and fiscal well being they report.” Really? Who could possibly be surprised at this finding? Using my parent’s lexicon, more importantly, who would waste good money on measuring this?

The article went on to say that poor adults are three times more likely to smoke, eat less healthy options and exercise infrequently. Those with lower incomes are more likely to report having been told they have a chronic disease and, more than their more affluent counterparts, poor Americans report being obese and having twice as many colds and flu. So I braced myself, waiting some intrinsic “blame the victim message” – if only “those people” (and yes, I detest such speech) would stop eating fast food, get a job, stop wasting their money on cigarettes and cell phones, and take care of themselves, these statistics would be very different. But wait, this information was put out by the Robert Wood Johnson Foundation….surely a more valuable lesson about determinants of health was imbedded in the UPI report? But no, the article ended.

So I did some digging. I took some time to learn that Gallup entered a 25-year partnership in 2008 with Healthways (a publicly traded NASDAQ company, headquartered in Tennessee and led by CEO Ben Leedle (who, interestingly, has ties to Wichita, KS)). They conduct a daily nationwide survey that produces the Gallup-Healthways Well-Being Index. Not only is this the largest “behavioral economic database ever created” the Well-Being Index can be used to drill down to associated state, congressional district and city level reports. Eureka! While I was busy dissing the effort, I actually uncovered a fascinating resource that monitors the pulse of the nation on a variety of indicators that I should have been paying attention to over the past two years.

The methodology being used is commendable. Each daily sample includes a minimum quota of 150 cell phone respondents and 850 landline respondents, with additional minimums to ensure representative gender within each region. Using Current Population Survey figures for the 18 year old and older non-institutionalized adult population and including Spanish language interviews, they have a 98% representative adult sample. They measure 6 domains of well-being: emotional health, physical health, healthy behavior, work environment, basic access, and a sixth called “life evaluation” (it includes 2 questions that use the Cantril Ladder scale (Cantril, 1965)). As with any rating system, our first inclination is to look at where we fall on the scale, so in this case, I clicked on “Kansas” to review the most recent summary report (the report includes data collected during 2009. You can also click on “snapshot findings” to see data collected during the most recent 6 months. What that profile tells you is that you should be happy if you don’t live in West Virginia.)

The Kansas report can be found at: http://www.well-beingindex.com/files/2010WBIrankings/KS_StateReport.pdf . (And Nebraska at http://www.well-beingindex.com/files/2010WBIrankings/NE_StateReport.pdf, and you get the drill!) You may be surprised that our state is the last state in the top quintile for overall well-being (up from 22nd in 2008). What’s more, among our three largest cities, Topeka (not Wichita or Kansas City) ranks worst on overall rank. Finally, if I were running for political office in the 1st Congressional District, I’d be worried about the fact that constituents report the worst life evaluation scores compared to the other three districts by a long shot.

But back to the bigger picture. I’d urge you to go to the well-being index home page http://well-beingindex.com/monthlyWBIreport.asp and click on the “daily pulse” tab of the dashboard. I’m a numbers person, but just looking at the daily distance between the orange line of those “thriving” and the green line of those “suffering” should give us all a reason to reflect on why poor people smoke, eat empty calories and at times feel hopeless and helpless. The distance between those doing well and not well is enormous, and the need to close the disparities gap couldn’t be clearer. I plan to return regularly to this page to review how health reform implementation begins to bend these curves, especially on the “basic access” and the “physical health” tabs for the index.

While I’m happy that I inherited the genetic predisposition of skepticism from my parents, I’m equally happy that my training has made me a data dumpster diver and that this superficial article yielded a great return of a new resource for me.

Live and learn. That was another of my parent’s favorite sayings.
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Lower Costs in Grand Junction: More Primary Care, Less High Tech

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Grand Junction, Colorado, and particularly the medical care system in Grand Junction, Colorado, has been getting a great deal of publicity since the health care debate began, because it is a community with lower health-care costs, combined with high health status, compared to much of the country. While well-known to health policy analysts for many years, and particularly featured in the analyses of the Dartmouth Atlas of Health Care, it gained greatest fame when Dr. Atul Gawande published “The Cost Conundrum” in the New Yorker in June, 2009. While the focus of the article was the exceedingly high per capita cost for Medicare in the border town of McAllen, Texas, including how unfavorably those costs compared to the other border town of El Paso, Grand Junction was prominently cited as a community in which Medicare costs, and all health care costs, were exceptionally low. This little town on the western slopes of the Rocky Mountains has become a potential model for those who believe health care costs can be controlled while maintaining or increasing quality, and a bugbear for those (mostly those profiting from medical care, or funded by corporations that so profit) who fear limits on medical costs.

The most recent, and brief and pithy, article, “Low-cost lessons from Grand Junction, Colorado”[1] comes from Thomas Bodenheimer and David West in the October 7, 2010 issue of the New England Journal of Medicine. They cite the statistics on health care and costs in Grand Junction and Mesa County from the Dartmouth Atlas: “…average per capita Medicare spending in Grand Junction was $6,599 in 2007 — 24% lower than the national average and 60% below high-cost Miami”, while maintaining high quality, including high performance on preventive metrics. They note that “…data on mortality and morbidity from the Robert Wood Johnson Foundation and the University of Wisconsin's County Health Rankings database show that the population of Grand Junction's Mesa County is far less healthy than those of some U.S. counties with high Medicare costs (www.countyhealthrankings.org), although it is number one in Colorado in the quality of clinical care provided. One would expect less-healthy communities to have higher costs.”

Bodenheimer and West cite 7 characteristics of the Grand Junction medical system that they believe are responsible for this situation and might be replicable (if “generally not without political battles”):

“These are leadership by the primary care community; a payment system involving risk sharing by physicians; equalization of physician payment for the care of Medicare, Medicaid, and privately insured patients; regionalization of services into an orderly system of primary, secondary, and tertiary care; limits on the supply of expensive resources, including specialists, beds, and equipment; payment of primary care physicians for hospital visits; and robust end-of-life care.”

The payment system is based upon the Rocky Mountain HMO, begun in the 1970s and involving most of the providers in the western slope. This HMO gained the attention of scholars years ago, and was described in a case study by Wellever and Moscovice in the Journal of Rural Health in 1998.[2] One of the key parts of the “Rocky” is that it contracts with both Medicare (via a Medicare Advantage program) and Colorado Medicaid, so that providers, who are largely independent in solo or small groups, are paid more or less a single rate, regardless of the insurance (Medicaid, Medicare, or contracted with Rocky via an employer). This makes costs and reimbursement much more predictable and allows physicians to provide the appropriate care for patients, without trying to figure out what their insurance will pay for. It provides the physicians with the security that would, in fact, characterize a single-payer system.

The other critical component is not only leadership by primary care (and predominantly family) physicians, but an appropriate balance between primary care doctors and specialists, and a limitation on the expansion of procedural services that may not be necessary. The key quotation from Bodenheimer and West here is “Because only one hospital can offer interventional cardiac procedures, there isn't room for many cardiologists in Grand Junction; with such limits on facilities and workforce, the rates of such procedures remain low. The same applies to other types of expensive procedures.”

This is entirely the opposite of what happens in most communities, in which competing hospitals seek to add more facilities and hire or contract with more subspecialist physicians in order to increase the income of both physicians and the hospital. As I have discussed in the past (e.g., Cancer Care and Hospital Advertising, January 16, 2010; Doctors, their Patients, and Health Reform, August 6, 2009) and as the Dartmouth Atlas makes clear, the number of expensive services provided to patients is very different in different parts of the country, and demand is very “elastic”; that is, it is often determined not by need but by the availability of physicians and facilities. That is, supply drives demand, rather than vice versa. Hospitals in other communities compete for doctors and patients (insured patients, let us be clear!) so that they can have a bigger “market share”. This “business” rather than health, approach, can be insidious, destructive, and expensive enough, with overbuilding resulting in overcapacity. More serious, however, as Kelly reminds us,[3] than seeking a bigger market share is the complementary business practice of expanding the market – finding new “customers” for your product – in this case, high cost procedures.

Do I know if the number of interventional cardiac procedures (or any other procedures) done in Grand Junction is the “right number”, or if the system that exists there and limits them means that too few are done? No, of course not. We can look at data cited by Bodenheimer and West that suggest that it is not far off, that health status is not decreasing, and that preventive services on discharge are higher than average. But I do know that there is a “right number” and that it is determined by the health status of the patient population and the risk/benefit ratio from doing procedures, not by the driver of “more is better”. Arguable for other consumer goods (e.g., cars, music, toothpaste), the idea of “expanding the market” for expensive medical procedures – widening the field of those who are “eligible” so that we can have “more business” and make more money, is outrageous and immoral, as well as ridiculously expensive. This is true for procedures which are highly advertised and of little or no medical value as well as for procedures that can be important and lifesaving when utilized appropriately in the right patients. The money not spent on unnecessary high-tech procedures can provide more primary care to more people, and improve health outcomes.

Grand Junction, Colorado may not have all the answers to our health care system, any more than Canada or Britain or Switzerland do. But it is doing a lot of things right, it is saving money, and it is improving the health of the community, and that’s a lot more than most areas in the US are doing.


[1]Bodenheimer T, West D, “Low-cost lessons from Grand Junction, Colorado”, NEJM 7Oct2010;363(15):1391-3
[2] Wellever A, Moscovice I, “Rocky Mountain HMO”, J Rural Health. 1998 Summer;14(3):211-23
[3] Kelly PJ, Personal communication.

"Top Doctors": Who are they -- and who are they not necessarily?

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I have written about the US News and World Report ratings of “Best Medical Schools” (Rankings of Medical Schools: Do they tell us anything?, Sept 25, 2009; A New Way of Ranking Medical Schools: Social Mission, June 20, 2010). Another popular concept is identifying “Best Doctors”. Seems like every local magazine (“Your City’s Name Here!”) has a list of Top Doctors in various specialties. At another level, the airline magazines have full page ads (www.topdoctors.com) where they list 6 or 7 “top doctors” in a given specialty (orthopedics, plastic surgery, cardiology…never primary care!), usually one in each of several major metropolitan areas. The idea here seems to be to attract the business of well-to-do people who are flying, and may need, say, a rotator cuff repair or a breast augmentation. In addition, if you put a doctor’s name into an internet search engine, most of the “hits” will not be links to her/his office, but rather listings – sometimes accompanied by ratings – on a variety of sites. So what does this mean? Are these listings reliable? Should you go to a “top doctor”?

Why not? We all want to go to a good doctor. And isn’t a “top doctor” even better? Of course, if we think about it, we might want to know the basis on which these top doctors are selected; that makes sense. After all, if a site lists the “best cars” and we discover the criteria is which ones are capable of the highest speeds, or hold the largest number of people or cargo, that’s great if what you are looking for is a fast or big car. But if you want, say, a high-mileage car, probably these cars are not the “best”.

Unfortunately, it is very difficult to find out what the criteria are. Even more difficult than finding out how US News ranks medical schools. Some of them are from patient surveys – you are randomly called, or more likely solicited to fill out a survey on what you thought of your doctor. There are problems with this method, although it is nice to know people like their doctors. First, it is not a scientific sample. Maybe people who are happy with their doctors are more likely to fill out such a form. Or (more likely) maybe those who are unhappy with her/him are. Second, people can only evaluate what they can evaluate, and that may or may not be what is important to you. If a doctor listens, shows caring, responds in a collaborative manner – a person can rate that, and maybe that is important to you too (it should be). But maybe you are not interested in collaboration; maybe you just want a doctor who will tell you what to do (probably not if you are reading this site, or reading “top doctor” surveys, but many people are).

Most determinants of physician quality, other than interpersonal skills (and these are very important!) are beyond the ability of patients to assess. Because people really have no way of knowing about many components of the quality of care that they get, much of what they evaluate hospitals (and to a lesser extent, physicians) on is their “hotel services” – are the rooms big? Clean? Well-furnished? Is the food good? More relevant to quality among things people can evaluate are “how are you treated”? Are people attentive? Do they explain things to you? Are your questions answered? (This is, of course, not the same thing as getting whatever you want; receiving medical care is not shopping in a convenience store!) Finally, while a patient can know if they had a good outcome or not, they have no way of knowing if it might have been better – or worse – with a different doctor, or hospital.

If you are, say, having surgery, it might be nice to know how satisfied people are with the surgical results. Or how often people die. It is very hard to get this data, and harder still to control for important causes of variation (we call them “confounders” in research; things that might be associated with both the condition and the outcome). For example, one surgeon might have a very much higher mortality rate than another – until you find out that s/he is operating on the sickest people, the ones who were at highest risk for death, the ones the other surgeons wouldn’t dare to operate on – and that is why a higher percent of his/her patients die; if someone else were operating on the same population, their mortality rates would in all likelihood be much higher.

So what do these ratings mean? Usually not much. One thing that most of the “top doctors”, especially the ones in the airplane magazines, seem to have in common is fancy addresses: Rodeo Drive, Fifth Avenue, North Michigan Avenue. They have their practices in rich neighborhoods and take care of rich people. This may make them the most famous, especially among the folks who the people who write these articles talk to. And, likely, they are among the most financially successful, and thus able to pay to get their names on some of these lists. What it most certainly does not mean is that they are the best doctors, in any of the ways that you might mean it (nicest, best surgical outcomes, best listener, wisest, most highly respected by his/her colleagues, you pick it!). It also doesn’t mean they are not good – or maybe even among the best doctors -- but it is scarcely a guarantee. What they are is doctors who have, for a variety of reasons, chosen to take care of rich people in fancy neighborhoods. The reasons may be ego, a desire for status, a desire for bigger incomes (really a common one) or even a prejudice against or revulsion for poor people.

They are presumed to be the best because they are the ones who take care of rich people, and rich people get the best, right? They have the best cars, and houses, and jewelry, and yachts, and everything else, so they must have the best doctors, right? Wrong. What they have is the doctors who want to take care of rich people. Any medical school has some students who are looking toward such a career, as a prominent rich-people’s doctor, just as others are planning to work in middle class, working class, or poor communities. Or in rural areas. Or in third-world countries. I’ve got news for you – the students in the latter groups are not less smart or less skilled than those in the former group. They probably are more committed and have more developed social values. The densest kid in the class could be on Park Avenue and the smartest practicing in the ghetto, the country, or in Africa.

I don’t know the association of skill as a physician or surgeon and the socioeconomic groups that they care for. I know of both good and not-so-good doctors in all groups. Certainly, every time a celebrity dies of an overdose, we hear of some “Dr. Feelgood” who supplied them with dope, a doctor who was – at least before this adverse publicity – a “top doctor”, a “doctor to the stars” – but not my any measure a good, not to mention “best”, doctor. While elite offices can offer you nicer furniture, less crowded conditions, and more people who look like you (if you are rich), if you are really looking for the “best doctor”, it’s a crapshoot. S/he may be working in the free clinic across town.

So what do you do? Pretty much what you do now. Take recommendations from friends – provided that you think that the friend values the same things as you do in a physician. One who listens. One who is old. One who is young. One who has a nice office or office staff. Maybe one who has – if your friend can tell – helped them to improve their health. Now that would be a good one!
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Primary Care Grants from HRSA: not enough, not wisely done

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In late September, the Health Resources Services Administration (HRSA), a branch of the federal Department of Health and Human Services (HHS) released the funding announcements for its grants support a variety of educational programs for academic year 2010-11. This was long anticipated news by those who had applied for them, since the time period that they cover began in July. The grants cover a wide variety of areas largely involving enhancement of the health professions workforce in primary care, oral health, physician’s assistants programs, minority health, geriatrics, pipeline development, and this year (with ARRA funds) $50 million for equipment. State-by-state funding (very important politically!) can be found here, broken down by state and category here, information on individual grants, by county, can be found here.

Virtually all of the programs supported by HRSA are in important areas that I have written about previously, but I will focus here on those I know best, the “Primary Care Cluster”, part of Title VII. These grants support program innovation in Residency Training, Medical Student (Predoctoral) Education, Faculty Development, and “Academic Administrative Units” (essentially departments of primary care). They have their roots in the development of Family Medicine as a discipline in the 1970s. The feds then, as now, saw primary care (family medicine) as an important need, but one which needed nurturance. Residency programs were being started and needed funding to develop and experiment with different curricula that would be most appropriate to create family doctors. There were no departments of Family Medicine in medical schools, or even academic faculty in the discipline, so the Academic Units grants were created to help support the creation of the former, and the Faculty Development grants the latter. Predoctoral grants helped develop the curriculum for educating medical students in family medicine.

These grants were successful, both in creating programs that trained more family doctors and doctors who went into practice in underserved communities, often through the National Health Service Corps (NHSC), another HRSA program. In addition, another (possibly unanticipated) outcome was that the formal training of family medicine faculty and fellows in educational skills, felt necessary because there were not existing physician educators in this field, created a core cadre of physician medical educators that was far more extensively and formally trained in areas such as teaching skills, curriculum development, implementation, and evaluation, and other education methodologies than faculty in other departments, revealing a large, previously unrecognized need in medical school and residency faculties. In the 1980s, the grants were expanded to a larger pool of primary care programs, primarily General Internal Medicine and General Pediatrics, and later Physician’s Assistants.[1] They became critical supports for innovation in the education of students, residents, and faculty.

While these programs were very successful, reported in numerous articles reporting on general internal medicine[2], general pediatrics, and family medicine (notably in a special issue of Academic Medicine, November 2008) and has been demonstrated to increase the number of physicians practicing in community health centers (Rittenhouse DR, 2008), and have actually enjoyed bipartisan support (after all, both Republican and Democratic legislators have underserved rural and urban areas in their districts), funding has always been threatened. For many years, Presidents of both parties would “zero out” funding for these programs in their budgets, only to have them restored by Congress after significant pressure from their constituents. Even then funding has often been cut; in 2006 there was just enough to fund the existing (usually 3-year) grants and no new ones were funded, and the years since have been marginal.

So there was great anticipation this year, with large (for a small program such as this, compared, say to the NIH funding of biomedical research in the tens of billions) increases from previous desert levels. Much of this was ARRA (stimulus) funding. And the results have been very disappointing. Like much of ARRA, emphasis was placed on projects that would programs that could show quick, tangible results so a good portion went to equipment grants. Some went to specific Congressional earmarks. ARRA funds supporting traditional Title VII Primary Care grants were for 5 years, and were all that was available to General Internal Medicine and General Pediatrics; the relatively small number of programs that were funded thus received relatively large grants. ARRA funds also supported a miniscule number (5) of new Academic Units Grants for Family Medicine. The pot for “regular” funds for grants was smaller than it has been in many other years, and large numbers of faculty development, residency, and medical student education grants that were highly-scored by the peer reviewers did not qualify for funding. The application of ARRA funds made this a particularly crazy year; in the Spring those with existing funding were told that they “might” have to submit new grants, in two weeks, so they wrote them before being told “never mind”. The grant reviews happened late and so funding was late. The staff at HRSA, a highly committed group, must have felt whipsawed by changes in rules from above and urgent questions from potential and current grantees.

So, life is tough. Not all grants get funded. Maybe only a small minority do – talk to those who apply for funds to NIH. And so the money came late – it came (to those who received it.) For grants other than those supporting faculty development fellowships, which would have needed to recruit fellows months before the end the academic year – this is not such a big problem. But with all the talk – justified – about the need to produce more primary care physicians for the US, this is a very small pool of funds to be divided up. Some family medicine leaders have given up on HRSA funding; one writes “Title VII is a dinosaur…it has not effectively funded new ideas for more than a decade…it is no better than a random lottery…” The rigid priority and preferences, good for some reasons, do tend to stifle innovation.

The other issue is the disposition of funds between the 3 primary care specialties, and especially the large 5-year grants to general internal medicine (the leader quoted above continues, “…although it doesn’t seem very random if all the AAU grants went to internal medicine.”) As has been noted on this blog before, the percent of graduates of 3-year IM residencies who enter primary care (general) internal medicine is vanishingly small; most go on to subspecialty fellowships, and most of the rest become hospitalists. The New England Journal of Medicine’s health policy writer, John Iglehart, describes this in the August 5, 2010 issue in an overview of the impact of the ACA law on residency training, “Health reform, primary care and graduate medical education”,[3] in which he indicates 10-20% of internal medicine residency graduates will enter primary care (I think 20% is dreaming; even 10% may be!) From one perspective, perhaps GIM needs a “jumpstart”, but there is little reason to believe HRSA grant funding will change the decisions (largely financial) for most IM graduates. On the other hand, Family Medicine residencies are producing primary care doctors in every study (Iglehart says 91%), so it could reasonably be argued that the funding should go with proven success.

Interestingly, one of the priority criteria for funding was that “90% of students entering ‘primary care’ specialties (FM, IM, Pediatrics) are in primary care practices 3 years later.” Given the large number entering IM, and the low % at almost all schools entering GIM, this is an extremely high bar, even though it generously uses 3 years rather than the 8 years post-graduation used in the study by Mullan and colleagues cited previously (A New Way of Ranking Medical Schools: Social Mission). The social mission of medical education: ranking the schools[4] used 8-year data to account for such things as a delay for a year or 2 between completing residency and entering a subspecialty fellowship as might occur for a 2-year NHSC commitment or a brief stint as a hospitalist to make money. My school, the University of Kansas, was ranked #5 nationally, mostly for its success in getting graduates into primary care and rural practice, but this was almost entirely due to family medicine; when the HRSA criteria are applied, only 70% of graduates of FM, GIM, and Peds were in primary care in 3 years, reflecting the fact that for KU graduates, as those from most institutions, the retention of internists in primary care is abysmal.

In any case, it is critically important to have significant federal funding for education and training in primary care if we are to meet our nation’s health needs, have physicians for rural areas, and staff our community health centers. The funding needs to be much greater, it needs to be reliable year-to-year, it should have consistent criteria, and it decisions should be made well before the start of the grant period. It is the least that Congress can do.

[1] Funds are also available to support nurse practitioner programs, but through a different stream, targeted to nursing.
[2] (Lipkin M, 2008)
[3] Iglehart JK, Health reform, primary care and graduate medical education, NEJM 5Aug2010;363(6):584-90.
[4] Mullan F et. al., The Social Mission of Medical Education: Ranking the Schools, Annals of Internal Medicine, 15Jun2010;152(12):804-10
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The Challenge of Global Health and Primary Care

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I recently attended the 7th American Academy of Family Physicians (AAFP) sponsored Family Medicine Global Health Workshop. Over a period of 3 days, we heard plenary speakers, attended small-group breakout sessions, reviewed a large number of posters, and had an opportunity to talk and share ideas with each other. As one of those in attendance with the least experience in international health (while I have spent some time in Brazil, including a rather short teaching Fulbright, I have never been part of so much as a “medical mission” trip, not to mention spent protracted or recurrent time in providing health care or developing health systems in other countries, either in disaster relief or ongoing care), I felt I had a great deal to learn and I tried hard to absorb as much as possible. The collective experience represented by the attendees was overwhelming. Senior participants had spent decades working in both direct patient care and the creation of clinics as well as in consulting with governments and Ministries of Health on developing health systems based in primary care and family medicine. Some of the participants had returned for years – or for decades – to the same regions, spending months there each year. Family physicians ran or were part of a number of not-for-profit organizations that provided disaster medicine or primary care in countries in need around the world. Others were still residents, or even medical students, who had spent some time in areas of need (most recently, of course, in Haiti) and were planning on making this a central part of their future careers.

There was a breadth of motivations for this work. While many of the participants, and many who work in international health, were inspired by their religious beliefs (and “medical missions” still, in most places including medical schools, is the de facto term for any trip taken by physicians and students even when not sponsored by a religious organization), there were others whose motivation was not, and in particular was social justice. A poster presented by Joanie Baumer, MD, from Fort Worth’s John Peter Smith Hospital Family Medicine Residency (the largest in the country), which has been involved in programs in many countries, surveyed participants on what their main motivations were – and what they perceived those of others to be. Social justice topped the both lists, with “mission” (religious) about 4th, although it was higher in motivations attributed to others.

Plenary sessions from former HHS Secretary and University of Miami President Donna Shalala and others addressed important issues. Fitzhugh Mullan, MD, of George Washington University raised the issue of “brain drain” (see also Primary Care, IMGs, and the Health of the People in this blog, August 14, 2010), in which physicians trained in developing countries, often at public expense, migrated to wealthy Western countries, where they were often welcomed (as in the US) to fill residency and underserved-area-practice positions. While there was some pushback from the (small number) of attendees who had come to the US from other countries, it is hard to argue with Dr. Mullan’s proposition that “the US ought to be able to train enough physicians to care for its population without having to import them from the developing world” (paraphrased). As in so much of policy, there is often a distinction between the individual stories, needs and aspirations of individuals and the overall effect. Cynthia Haq, MD, of the University of Wisconsin, told her own story; one of increasing involvement in international work, from naïve trips to longer stays, to work with WHO and helping other countries develop their health systems, seamlessly intertwined with the story of her own family (“Stepping Stones: Strategies to enrich your life with Global Family Medicine”, posted like many of the other presentations, to the Family Medicine Digital Resource Library, www.fmdrl.org). Steven Spann, MD, of Baylor, presented a superb discussion of ethical issues in doing international work. In a breakout session (and remember, I can only report on those I attended) Gary Morsch, MD, founder of Heart to Heart International, presented the work of that group, which provides opportunities for health professionals to work abroad for shorter periods, a week or two, in settings such as Haiti, in contrast to larger and more famous organizations such as Medecins sans Frontieres, which requires 6-9 month commitments. Dr. Morsch also described H2H’s affiliated group, “Docs Who Care”, which provides locums tenens opportunities in rural parts of the Midwest, both helping those communities with their health needs and the physicians with the opportunity to earn a living in a manner that allows them to spend much of their time doing international work.

Haiti, where the January 2010 earthquake created incredible needs in a nation already living on the edge, with over 300,000 killed outright and hundreds of thousands more severely injured physically, psychologically, and emotionally as well as having every aspect of their lives disrupted or destroyed, was obviously a major focus. Many of the presenters of posters and breakout sessions, and many more of the attendees, had spent some time working in Haiti, in the initial “disaster” phase or the (still disastrous) “primary care” phase. They discussed the good (the people and their resilience, the commitment of the volunteers, the resources pouring in) and the not so good (the historical background of oppression and de-resourcing of Haiti, the lack of coordination between relief agencies, the volunteers who were on occasion self-centered and more often ignorant of the needs and realities of the situation). One of the best sessions I attended was by André Vulcain and Michèle Dodard of the University of Miami Department of Family Medicine. In 1999, they helped to start a family medicine residency program in Haiti’s second city, Cap Haitien, which had graduated 35 family physicians by the time of the quake and is still functioning. Unlike many of the other collaborations described, which are often with private (usually religious) hospitals, this program is sponsored by the Ministry of Health of Haiti and is based in a government hospital. While Dr. Vulcain’s powerpoints are not yet available on FMDRL, Dr. Dodard’s description of the work of the University of Miami’s “Project MediShare”, Rebuilding Haiti’s Healthcare System, is. Rebuilding that system, working with the Haitian government and people, training Haitian health professionals so that they do not need to depend on “mission trips” has also become a key focus of the work of Partners in Health (PIH) (“Zanmi Lasante” in Haitian Kreyol) and many other groups.

One of PIH’s founders, Paul Farmer MD PhD, and his colleagues Vanessa Bradford Kerry MD and Sara Auld MD propose the creation of an “International Service Corps for Health” in an article in a the September 23, 2010 issue of the New England Journal of Medicine.[1] They talk about the work that has been done, particularly that done by academic medical centers, but also address the limitations, especially financial, of these efforts, and suggest that a government-sponsored program, working in collaboration with other US agencies, might be a very effective way of increasing the international reputation of the US as well as helping to meet the staggering needs that exist in the world, such as in Africa, which “…bears 24% of the global disease burden but hosts only 3% of the global health care workforce and is responsible for less than 1% of world health care expenditures.” They describe the enormous impact that the small country of Cuba has had internationally, “…between 1999 and 2004, Cuban foreign-service workers increased doctor visits in resource-poor communities by 36.7 million, provided health promotion outreach for millions of underserved people, and taught 900,000 medical education courses to local personnel.” If carried out reasonably and equitably, an International Health Service Corps (IHSC) might be a major step forward.

There are still great healthcare needs in the US, and very underserved communities (both rural and urban), as detailed in the recent US Census Bureau report “Income, Poverty and Health Insurance Coverage in the United States, 2009”, and it is sometimes distressing to medical educators to observe that many medical students have much greater enthusiasm for “international work” than they they do for helping to meet those domestic needs. However, as Kerry et. al., and the presenters at the AAFP Conference, among others, document, the international needs are staggering.

The interest and commitment of health professionals and students in working internationally, demonstrated not only in the AAFP Global Health Conference but daily in our schools and residency programs, is a wonderful thing. Developing meaningful, useful, and long-term opportunities to serve, such as the existing programs described above and at the conference, or a new “international health service corps”, are very important goals.

[1] Kerry VB, Auld S, Farmer P, “An international service corps for health – an unconventional prescription for diplomacy”, NEJM 2010Sep23;363(13):1199-1201
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