Serving others or self-serving? All generations have both kinds of people

The current generation of young adults, commonly called “millennials”, is often criticized for being self-centered, “spoiled”, the product of “helicopter parents”, showing the signs of having grown up in a culture where “everyone was a winner”. On the other hand, studies also show them to be the most socially conscious, idealistic, and optimistic generation in a long time (despite the evidence that things are not going so well for them, and little reason to think they’ll improve soon). They, as a group, have become politically involved, shocking the established political order with their enthusiasm for the presidential candidacy of an old Jewish socialist from New York City via Vermont, making Sen. Sanders a viable contender

This generation includes most medical students, as well as most residents, so I get to see them a lot. I can say that there are many in this group who are committed, hard-working, idealistic and self-sacrificing. And there are a lot who are not. In short, they are people. Yes, there are those who, for whatever reasons in their personality or upbringing, are “all about me”, argue their grades, have no time for giving to others, seem to have no sense of the collective good, and sometimes make me wonder why they want to be doctors. But you know what? We had those people back in my generation. I was in college in the 1960s, and not pre-med, and there were pre-meds around who had the reputation as narrow, grade-grubbing, and not socially involved. There were also pre-meds who were very involved in the major struggles of the day, anti-war, civil rights, racism. I was in a post-baccalaureate premedical program in the early 1970s, when the Vietnam War, with its extension into Cambodia, was peaking. Many of my fellow students, going to night classes after working all day, could not be seen as privileged, but many, including veterans, were active in those movements. And many were not.

I was in medical school in the mid-1970s, and there were many who were all about themselves and their futures. And many whose futures turned out to be very distinguished and productive. There was also a lot of social involvement. Chicago had a number of medical schools, and students knew each other across schools, even sometimes roomed together. When a physician researcher at one school was discovered to be doing research that targeted poor black women, students there protested; when he planned to leave for a job at another school, students there made an issue of it. I was involved in some of these struggles, and some in medical school. When, at a forum of the whole school to discuss the impact of our 3-year curriculum, the Chairman of Surgery announced he thought our 3^rd-year medical students were ill-prepared because he had heard some of them asking nurses for advice on skills such as starting an IV (“in my day, we would never have asked nurses for advice!”), I stood up and spoke on how we were glad to not be like that, that we wanted to be able to learn from anyone. Maybe not my smartest hour (the chair of another department tried to get my year-old grade in his clerkship changed), but I bring it up because there appeared to be generational differences then, as now. I am not an expert on generational trends (for this I recommend the outstanding book by Paul Taylor, “The Next America”[1]), but looking back I also remember senior faculty who were very supportive of progressive efforts; I think that then, as now, it is people who are different, not really generations.

Our current and recent medical students at KU created and continue to staff and work hard for the Jaydoc Student-run Free Clinic, which provides care for folks with little or no money or insurance in the evenings; succeeding classes, if not generations, have expanded the scope and impact of the clinic. Students frequently volunteer for, and self-fund, trips to provide care in poorer countries – and even sometimes in our own, for those left out of our non-system of health care. (These trips are generically called “mission trips” even when there is no explicit evangelical religious component; however, many are indeed organized by religious organizations, and personed by students, doctors and others motivated by their religious beliefs. I may not be a big fan of religious evangelism, but I am a big fan of people doing good work!) Many of our students are active in the community, in local as well as national programs. They regularly volunteer for the school-based health clinic at a local high school, named the Bulldoc for the school’s teams, the Bulldogs, by the high school’s students (post-milennials?). The clinic itself was created by a collaboration between the school, school district, community groups (particularly pastors), medical school faculty, and students – in particular one medical student, without whose efforts it would never have come to pass.

When I was young, and even in earlier generations, many students, like other people, worked for the interests of others as well as themselves. Many do so now. Others, it is sad (to me) to say, are indeed self-absorbed, and all about themselves. Like other people, like doctors – and nurses and accountants and steelworkers and retail clerks and unemployed people. We can only laud those whose work demonstrates the “better angels” of human nature, and hope that narrow, selfish behaviors will extinguish.

To those who are in medical school, I want to say “No, it is not about you. It is about the people for whom you will be caring. And let’s not forget what ‘caring’ means.” Sometimes I actually do. Maybe we should all say, or at least think, that more often.

---

[1] Taylor, P and the Pew Research Center, “The Next America: Boomers, Millennials, and the Looming Generational Showdown”, 2014.

US Medicine and Medical Education: The Good Part

.
I have often, and I think with good justification, been highly critical of the US health (non-) system, particularly in two areas: the fact that we do not have universal financial access to health care (a completely intolerable situation, which cannot be justified or defended morally, although it often is – always by those who have coverage!), and the fact that we have a great deficiency of primary care physicians. I thought it might be time to address two areas in which I think US medical education and practice is superior to that in Europe and much off the rest of the world.

The first is our medical education system. In specific, I am very happy that our medical schools are graduate schools, entered by students after achieving a bachelor’s degree. This is unlike the situation in most countries, such as Britain, where the medical degree is indeed a bachelor’s degree, MBBS, bachelor of medicine/bachelor of surgery. Medicine as a graduate school is the norm only in the US and in Canada; in virtually every other country, students enter medical school out of high school at 18, and graduate 6 years later. While this still can produce excellent physicians, it is in my opinion less desirable. First of all, they do not have the advantage of the broader education that comes with a bachelor’s degree. Secondly, they are very young. In the US, a student entering medical school right from undergraduate studies would usually be 22, but because many take off for a few years (or have another career first) the actual mean entry age in most US medical schools is about 24 (with the median a little lower). This means a more mature student body, with life experiences – at least the experiences of 4 years of college, if not in another profession, in business, in the Peace Corps, etc. This makes a difference. It also means that US medical students are more likely (and, throughout this piece, when I say “more likely”, that is what I mean – greater probability, not 100%) to really want to be doctors, rather than being there because, at 18, their doctor parents told them that they were going to medical school.

I believe that this greater maturity and life experience lead to greater independent community involvement, creation and management of free clinics, etc. As an example, at the University of Kansas Medical School, the Jaydoc student-run Free Clinic is not only completely student-run, it was student developed, maintained and expanded. There are physicians who supervise at each clinic session, but that is their entire role; the students make the schedules, recruit the volunteers, organize the operation, follow up the results, raise the money (including writing grants and doing benefits). When the clinic was created, a call went out from a student, and over 80 students attended the first meeting. They identified what had to be done: find a venue, decide on frequency, raise money, organize scheduling, on and on. Hands went up from volunteers: “I was an accountant!” “I was a community organizer!” “I was a grant writer!” “I was a teacher!” Even those who had not a previous job or career had their college experiences behind them: “I organized the fund raisers for my sorority!” “I volunteered in the free clinic in the community where my college was located!” I don’t think this happens – could happen – in a school whose students all entered at 18.

Moreover, US medical schools use a variety of criteria for choosing the students to admit. They look for such volunteer work, demographic diversity, achievements in a variety of arenas. While many students are “pre-med”, majoring in biology and chemistry, as we have seen in Medicine, science, and humanities: what is their role in medical education?, August 26, 2010, many are history, English, or art majors. (“What is the course for pre-med?”, a Brazilian medical student, in his 4th year at 21 and still confused about the 4 years US students do before medical school, asked me.) In most countries a cognitive examination is the sole criterion for entry into medical school, and social values are not even considered. Thus, say, in São Paulo (which I know a little) to say that the top 200 scores go to the most prestigious medical school, 201-400 to #2, 401-600 to #3, etc., would not be far off! I have been critical of US medical admissions because they are so skewed to upper-middle-class suburbanites (80% of our medical students come from the top 20% of income), but this skew is even more pronounced in other countries where the cognitive exam is the only criterion, and the greatest likelihood predictor of doing well on these exams is going to the “best” (and most expensive) private preparatory schools. The top 2 medical schools in São Paulo are both public and free – something the socialist government is proud of – but the catch is that it would be virtually impossible for a public school student to get a high enough score on the exam to get into one of them. To get into the free, public medical school requires attending the most elite private prep schools!

The second area in which I think American medical practice – here I am talking about the practice of family medicine – is better is that, to a large degree, our family doctors take care of their patients in the hospital. In Hospitalists, December 4, 2008, I bemoaned the fact that this was changing and that primary care doctors are more and more often choosing to (or being required by their employers to) delegate the care of their hospitalized patients to others. I will not reprise all the reasons why I think this is largely a negative trend, since they are detailed in that piece; what is relevant here is that in most other countries primary care physicians (who are, in most other countries, all family doctors or general practitioners), never cared for their own hospitalized patients, turning them over to internists or pediatricians. In this sense, the trend in the US to hospitalists is emulating practice in Europe and elsewhere; unfortunately, in my opinion, it is emulating one of the more less-desirable aspects of that practice.

Indeed, the trend over the last several decades to increase the proportion of medical students with a broad liberal education is being challenged by a counter-trend, which sees education not as important in itself, but as “job training”-- whether this is in trade school, technical college, professional school, or university. In Medical Student Selection, December 14, 2008, I present my concerns that we will narrow the cohort of medical students rather than broaden it.

Thus, as I take this opportunity to laud some of the aspects of US medical education and practice, I also caution us to continue the positive aspects of our system and guard against adopting the negative aspects of the health system in other countries, as we continue to stand rigidly against adopting their proven effective strategies of providing access to health care for all.
.

Freedom abroad, health at home: experiments in preventive health care

.
First, we must celebrate the victory of the people of Egypt in ousting the 30-year dictator Hosni Mubarak, and we revel in the democratic character of both this peaceful revolution and that in Tunisia last month. We hope that all of the dreams and aspirations of the masses of people involved are realized – freedom of speech, freedom for women and minorities, freedom from hunger. Thinking and reading about it brings tears of joy and admiration for these brave people. It is truly inspiring and encouraging to see this part of the world moving in the right direction. I feel that it may be wrong to have a post that dilutes this excitement with discussion of other topics, but take comfort in the fact that the papers, magazines, and blogosphere are talking about little else.
...

Unfortunately, at the same time it is sobering to think about how much, in the US, we are moving in the wrong direction (see Bob Herbert, “When democracy weakens”, NY Times, Feb 12, 2011). Politicians elected, with money coming from the wealthiest corporations and individuals, on the platform of promising to create jobs, do nothing of the kind (see Robert Reich, “The recession isn’t over until the jobs come back”, Kansas City Star, Feb 12, 2011. At the federal level, to the extent Congress is doing anything, it is giving money away to the richest and taking away from poor and working people. State legislatures are also focused on eliminating support for poor people, as well as oppressing immigrants and banning gay marriage – or any rights for gay people (see Charles Blow, “Repeal, restrict, and repress”, NY Times, Feb 12, 2011). And, of course, on further restricting abortion rights. Indeed, there are those in Congress who wish to eliminate Title X funding for contraception. Given that contraception is the most effective way to decrease the abortion rate, this seems bizarre, but only if you are into “reality-based” policy making.

Where is the good news in our country? We all know that there are lots of good people out there, doing lots of good things. In health care, much of the positive news is people pitching in, volunteering to try to fill the holes left by a health care system that does not, despite the Affordable Care Act (ACA), provide care for much of our population. One example is the JayDoc Clinic, an operation entirely run by students from the University of Kansas School of Medicine, featured in the Feb 12 Kansas City Star (“Student run JayDoc clinic serves the uninsured”). Great work, and a great article, but one result is going to be more people who are in need hearing about it, and further overwhelming the clinic. The JayDoc, like so many “safety net” clinics, is a “finger in the dike”, struggling to survive in providing basic care while billions are spent on what Don Berwick, currently head of the Center for Medicare and Medicaid Services (CMS) and his colleague Brent James at the Institute for Healthcare Improvement (IHI) call “rescue care”.

Meeting the basic health care needs of the really-needy is not only right and compassionate, but is likely to cost less (in dollars and pain) if it prevents serious illness later. Since this does not seem to be a focus of government, which is busy cutting taxes on billionaires like David and Charles Koch and cutting access to contraception, some progressive and thoughtful parts of the private sector have been creating models across the country. Many of these are detailed by surgeon and writer Atul Gawande in his article “The hot spotters: can we lower medical costs by giving the neediest patients better care?” (New Yorker, Jan 24, 2011).

Gawande examines several cities where efforts have been made to identify the sickest, neediest, and highest-cost-users of health care, and intervene to try to reverse or ameliorate the causes. Some of them, like the lead story of the program in Camden, NJ, are the result of hard and extended volunteer work, by Dr. Jeffrey Brenner and friends. Others, such as in Atlantic City, result from partnerships between existing institutions (in this case, a hospital and a union). None are the result of wise governmental leadership investing in these programs to reap a benefit of greater health and lower cost. In Red, Blue, and Purple: The Math of Health Care Spending, Oct 20, 2009, I discussed the implications of the fact that most people use little health care, and a small percent use most of it. Managed care in the late 1990s failed in part because it put major hurdles in the way of receiving health care for the large proportion of the population whose health care use accounted for a small percent of health care spending in any case.

The programs described by Gawande do the opposite; they identify the actual people who account for most of the health costs in these communities and provide services and support to help those people. In Camden, for example, 1% of the population – 1000 people – accounted for 30% of its costs. 900 people in two buildings (a nursing home and a low-income housing project) accounted for more than 4000 hospital visits and $200,000,000 in health care bills over a 6 ½ year period. And, as Gawande points out, Camden is not unique. There is no money for this from the public sector or insurance industry because it is being spent (in addition to insurance company profit and administrative waste) on “rescue care” for people with conditions that advanced so far because they never received sufficient preventive and primary care.

Public funds are also not being spent (indeed, as noted above, they are being cut) to support the myriad other “determinants of health”, social, economic, cultural and linguistic that are necessary for them to take advantage of preventive and primary care, to have the capability (Capability: understanding why people may not adopt healthful behaviors, Sep 24, 2010) of improving their health. Planning to achieve reductions in health care costs by “solutions” such as increasing copayments and deductibles so that people have “more skin in the game” are based on belief but not on facts. Gawande cites the experiences of benefit manager Verisk Health, which showed that such obstacles caused people to use less of all kinds of care – including primary and preventive care – until they finally got so acutely ill that needed to come to an emergency room, get admitted, go into an intensive care unit, so that costs in fact went up. One man “…had badly worsening heart disease and diabetes, and medical bills over 2 years in excess of $80,000. The man, dealing with higher co-payments on a fixed income, had cut back to filling only half his medication prescriptions for his high cholesterol and diabetes. He made few doctor visits. He avoided the ER – until a heart attack necessitated emergency surgery and left him disabled with chronic heart failure. The higher co-payments had backfired…” This outcome has been known for a long time; the RAND health insurance experiment in the 1970s and published in the New England Journal of Medicine in 1983[1] (see also: Joseph P. Newhouse, "Free for all?: lessons from the RAND Health Insurance Experiment", RAND 1993) showed that the opposite strategy – elimination of co-payments and deductibles -- resulted in higher utilization of health care; of both that which might be seen as “unnecessary” (colds) and that which was clearly necessary. And it saved money.

The interventions that have had success in Camden and other places were not “one size fits all”. Different people had different issues that required different interventions. Some were about poverty, some were about substance abuse or mental illness, some were about cultural misunderstandings or about language, and on and on. Interventions required more from nurse case managers for some people, social workers for others, physicians and nurse practitioners for others, and “health coaches” or promotoras for others. A lot of the latter; people who were familiar with the needs of the high-utilizer patients, who spoke their language, lived in their communities, and were often willing to “talk like [my] mother” to them.

And it is not always successful. But it is successful enough, far more successful than just pouring dollars into rescue care, that it needs to move beyond the limits that volunteers and a few forward-thinking institutions are constrained by. It needs to recognize the critical nature of teams, of integrating preventive and primary health care with basic social (and sometimes legal) services, with meeting core needs for food, housing and transportation that are all too often not even considered by policy makers. Funding is key; depending on volunteers in such efforts as these, or the JayDoc student–run free clinic will never come close to being a solution.

About Dr. Brenner’s program in Camden, Dr. Gawande writes “It remains unclear how the program will make ends meet”. In fact, these sorts of programs need to become the mainstream of health care and service delivery, and need to become the priority of federal, state, and local government.

[1] Brook RH, et. Al., “Does Free Care Improve Adults' Health? — Results from a Randomized Controlled Trial”,N Engl J Med 1983; 309:1426-1434.
.