The role of Primary Care in improving health: In the US and around the world

At the Family Medicine Midwest conference held recently in Milwaukee, the first day’s plenary speaker was Richard Roberts, MD, from the University of Wisconsin. Dr. Roberts has a distinguished history as a health services researcher and leader in Family Medicine, having been president of both the American Academy of Family Physicians (AAFP) and the World Organization of Family Doctors (WONCA). He has extensive experience in international health, and is knowledgeable about the health systems – and their results – in countries around the world. And he continues to practice family medicine.

Some of the issues that Dr. Roberts discussed involve the health care system, and, drawing from the important work of the late Dr. Barbara Starfield, emphasize the importance of primary care to improving the health of a population. I have written about the disproportionate emphasis of medical education on hospital care, advanced disease, and high-cost rescue interventions which often fail to rescue and frequently cause complications, rather than on primary care, prevention, and early diagnosis and treatment. Dr. Roberts reminds us of the “Ecology of Medical Care” (referring to the

setting in which health care takes place), done first by Kerr White in 1961[1] and replicated by the Graham Center of the AAFP in 2003[2] with remarkably similar results. In a community of 1000 adults, in any month about 800 have a health problem or injury, 217seek attention from a doctor, 8 are hospitalized, 5 see subspecialists, and 1 or less is admitted to an academic medical center teaching hospital, which, of course, is where we train most medical students and residents, and where they get a skewed view of the prevalence of disease. They begin to see unusual or even rare things as common, and develop habits of ordering tests that are perhaps appropriate in that setting, but dramatic overuse in ambulatory practice.

In 2005, there were 34 million hospital admissions in the US, but almost 1 billion office visits. Of those, about 53% were to primary care physicians. While much is made of the increase in emergency department usage, from 1995 to 2005 ER visits were up 8% while primary care visits increased 22%. As Roberts notes (medical students should cover their ears!) primary care doctors comprise about ¼ of the physician workforce but see more than ½ of all patient visits and earn about ½ the income of subspecialists (and this is average; a much smaller fraction of the income of the most highly paid subspecialists).

Internationally, the same trends are noted. Countries with a higher “primary care score” (which largely measures the percent of the medical workforce in primary care) had lower rates of premature deaths than those with low PC scores in 1970, and over the last 4 decades, while the rate has gone down in both groups, the gap between them has widened. In an unintended “natural experiment”, the Asian economic boom of the early 1990s allowed Indonesia to greatly increased health spending, mostly in primary care; that nation saw a 70% improvement in health status in all provinces. With the collapse of that “bubble” in the late 1990s, spending on primary care went down, but not on hospital care in the big cities. This was a result not of Indonesian government decisions, but rather of the international community through organizations such as the World Bank saying “your economy is worse, but you need health care – here’s money … to build hospitals”. But health status dropped in most provinces. Not the best use of resources!

In the 1990s, Shi studied socioeconomic, environmental, and health system characteristics of US states and their relationship to health status (mortality, lifespan, deaths due to heart disease and cancer, neonatal mortality, and low birthweight). Access to primary care was the strongest predictor of greater lifespan and was second (to living in an urban area) for lower mortality rates, even ahead of education. Number of specialists and number of hospital beds were far down the list – indeed they were negative predictors![3] None of the changes in the health system since that time are likely to change this; indeed, the increase in specialists, technology, and hospitalizations have probably increased it.

What is it about primary care? Why does it make so much difference. Starfield’s work identified the fact that nations and regions with high levels of primary care have greater self-reported health status and fewer health disparities, and that the presence of primary care tends to mitigate the negative impact of income inequality.[4] This group also demonstrated that an increase of primary care physicians of 1 per 10,000 (20%) physicians decreases mortality by 40 per 100,000 (5% fewer deaths), and 1 per 10,000 (33%) more family physicians decreases mortality by 70 per 100,000 (9% fewer deaths), while an increase in specialists of 1 per 10,000 (8%) increases mortality by 16 per 100,000 (2% more deaths). [5] Dr. Roberts notes 4 features of systems with higher primary care to specialist ratios that might affect this: 1) when there are too many specialist and not enough primary care doctors, specialists may try to manage conditions outside their specialty in which they are not knowledgeable; 2) prevention and early detection save more lives and extend life more than intervention late in the disease process; 3) there is excessive utilization of procedures when there are too many specialists (supply drives demand rather than vice versa) and these often have risks; 4) the more “handoffs” there are between doctors caring for a patient, the more that care begins to resemble an elementary school game of “telephone”, where the final message heard is very different from that which began the communication.

The fact that family physicians specifically seem to improve population health status more than primary care physicians taken as a whole is apparent in the data, but the reason has not yet been identified by studies. Dr. Roberts postulates that it has to do with caring for multiple family members, and using that information to improve their care, such as when a mother’s issues are addressed at a visit ostensibly limited to caring for her child. Primary care (and possibly especially family physicians) acts to achieve all aspects of what has been identified as the “Triple Aim” of health care: greater access, lower cost and higher quality.

Primary care doctors, and especially family physicians, are doctors of “first and last resort”. They care for pregnant women and deliver their babies and care for their children as well as the other adults in the family. They tend to the “grandparents”, older adults, and manage the often complex interplay of multiple chronic diseases. They provide acute care and preventive care and are aware of the individual’s beliefs and preferences and those of the family, and the dynamics that exist between them. They care for people at the end of life, right through the end, not just until “there is no more to do”, and they remain there for the survivors.

The US could do a lot better. We need a health system that is more grounded in primary care, and we need a health system that provides access to everyone. What we don’t need is folks in Congress are committed so committed to preventing that access they will shut the government down!  Another conference speaker, Dr. Cynthia Haq of the University of Wisconsin, quoted the Ethiopian Minister of Health, with whom she had recently met. “Only in the United States,” the Minister said, “could there be discussion about whether access to health care was a human right or not.”

Oh, my. He’s right. I sure wish he were not.

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[1] White KL, Williams TF, Greenberg BG. The ecology of medical care. N Engl J Med 1961;265:885–892.

[2] Green, LA et al., “The ecology of medical care revisited”, N Engl J Med 2001; 344:2021-2025June 28, 2001DOI: 10.1056/NEJM200106283442611

[3] Shi L, "Primary care, specialty care, and life change", Intl J of Health Service,1994; 24(3):431-58

[4] Starfield BA, Shi L, Macinko J, “Contribution of Primary Care to Health Systems and Health”, Milbank Quarterly Sept2005; 83(3):457-502. DOI: 10.1111/j.1468-0009.2005.00409.x

[5] Shi L, et al., “The Relationship Between Primary Care, Income Inequality, and Mortality in US States, 1980–1995”, J Am Bd Fam Med, 1Sep2003;16(5)412-422. doi: 10.3122/jabfm.16.5.412.

Physician Oaths and Social Responsibility

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Most people are familiar with the existence, if not the content, of Hippocratic Oath taken by physicians on graduation from medical school. Whether this was originally written by that Greek “founder of Medicine” or not, it is very old, and has been updated often to be relevant to modern practice. Most medical schools do recite some modification of this oath at graduation, although some use the Oath of Maimonides, written by Moshe ben Maimon, a 12^th century Jewish physician from Spain and North Africa. All are focused on the role of the physician and his or her commitment and implicit pact with his/her patients, including using healing and confidentiality. There is also a fair amount of veneration of teachers. The Declaration of Geneva adopted by the World Medical Association in 1948 after the horrific acts of Nazi doctors were revealed in the Nuremberg trials, and revised many times since then, adds some acknowledgment that the physician also has responsibility to society; it now includes the phrase “will not use my medical knowledge to violate human rights and civil liberties, even under threat”.  

This, I think, is a step forward. In the time of Hippocrates and later Maimonides, there were great limits to what physicians could do as healers. Surgery only became something people regularly survived after the invention of ether as anesthesia and the recognition of the importance of antisepsis (even hand-washing) in the late 19^th century. In his graduation speech to the Harvard Medical School, Cowboys and Pit Crews (which I have cited earlier EMRs and Primary Care: The good, the bad, and the challenges, June 11, 2011), Dr. Atul Gawande refers to Dr. Lewis Thomas describing the work of an intern as recently as 1937 in his book “The Youngest Science” [1]. Those interns worked hard in order to make sure they didn’t miss one of the treatable conditions, because “There were only a few. Lobar pneumonia could be treated with antiserum, an injection of rabbit antibodies against the pneumococcus, if the intern identified the subtype correctly. Patients in diabetic coma responded dramatically to animal-extracted insulin and intravenous fluid. Acute heart failure patients could be saved by bleeding away a pint of blood from an arm vein, administering a leaf-preparation of digitalis, and delivering oxygen by tent. Early syphilitic paresis sometimes responded to a mix of mercury, bismuth, and arsenic. Surgery could treat certain tumors and infections. Beyond that, medical capabilities didn’t extend much further.”

The huge explosion of treatments, and often cures, both medical and surgical, that occurred during the 20^th century far exceeds all that came before. There is an extraordinary amount that we, as physicians, can do for all sorts of conditions as well as much more effective treatments for the conditions Gawande lists above. When I trained in the 1970s, we could do things scarcely dreamed of when Thomas was an intern in 1937, and what we can do today makes the 1970s look like ancient history. We continue to see in the 21^st century explosions of new therapies, some good, some not-so-good, and many unproven before they are released on the market. Our incredibly enhanced understanding of science, such as the human genome, and the amazing engineering capabilities of our technology, make it seem as if nothing is unachievable.

But because we can do things for certain diseases, because we can utilize certain technologies, doesn’t mean that we always should. Even the treatments Gawande describes above, limited as they were, often had devastating side effects that killed when they did not cure. Now we have more treatments that can be absolutely wonderful for some people in some circumstances, but not for everyone in every circumstance. [2] The complexities of these interventions make it even more important to have a physician’s ethic that understands context, understands public as well as individual health, and most important understands the contribution of food, housing, education and other social basics to health.

The “Declaration of Professional Responsibility: Medicine’s Social Contract With Humanity”, adopted by the American Medical Association (AMA)’s House of Delegates in 2001, is a more recent effort to summarize the obligations of the physician. Its title itself understands the role of the physician as more than a commitment to the individual patient but, in fact, a social contract with humanity, to the interconnectedness of all people. Its 9 points re-state many of the basic principles of the Hippocratic and Maimonides Oaths; it then adds several additional critical concepts. These include, in particular, commitments to:

“VI. Work freely with colleagues to discover, develop, and promote advances in medicine and public health that ameliorate suffering and contribute to human well-being.

VII. Educate the public and polity about present and future threats to the health of humanity.

VIII. Advocate for social, economic, educational, and political changes that ameliorate

suffering and contribute to human well-being.”

This is a very big and important step. It is even more important when not just the individual physicians, but the institutions of which they are a part, commit to core social values. Recently, WONCA, the World Council of Family Doctors, convened a conference, in East London, South Africa in October2010, to look at the Social Accountability of Medical Schools. Its final report, issued in December 2010, “Global consensus for social accountability of medical schools”, addresses 10 major areas:

&Area 1: Anticipating Society’s Health Needs

&lArea 2: Partnering With The Health System And Other Stakeholders

&Area 3: Adapting To The Evolving Roles Of Doctors And Other Health Professionals

&Area 4: Fostering Outcome-Based Education

&Area 5: Creating Responsive And Responsible Governance Of The Medical School

&Area 6: Refining The Scope Of Standards For Education, Research And Service Delivery

&Area 7: Supporting Continuous Quality Improvement In Education, Research And Service Delivery

&Area 8: Establishing Mandated Mechanisms For Accreditation

&Area 9: Balancing Global Principles with Context Specificity

&Area 10: Defining The Role Of Society

Each of these has several points listed under it, which are goals/directions for medical schools to achieve. People, and the societies that they comprise, invest heavily in medicine and medical education because they value health, and see this investment as a way to achieve health. But as the cost of medical care rises, absorbing more and more of our GDP and that of the world, it has the opposite effect. As it begins to squeeze out necessary spending on infrastructure, on education, on housing, on nutritious food, it degrades health.

While WONCA represents only family doctors/general practitioners, it is an important international organization and its recommendations will be taken seriously by medical schools around the world. To the extent that they are, it would be a good thing, because medical schools, like the physicians that they educate, need to be much clearer on how they fit into the society that produced and supports them.

Physicians and other health professionals cannot see themselves only as technicians with a bag of tools to use on the sick; they must be the custodians of health, the enablers of health, the advocates for the necessary components of healthy people and a healthy society. The Preamble to the “Declaration of Professional Responsibility” ends with this simple reminder:

“Humanity is our patient.”

[1] Thomas L, The Youngest Science: Notes of a Medicine Watcher, Viking, 1983.
[2] And this does not even touch on the issue of financial cost.