Whence, and whither, family medicine: will it have role in improving our nation’s health?: Part 3

The 25th J. Jerry Rodos Lecture, presented at the 30th Annual Conference of Primary Care Access, Kauai, April 8, 2019:

Part III: Whither Family Medicine and Our Health?

So, in the end, is it all about money? Is it about the primacy of profit? We have seen massive consolidation of health systems, all focused upon making money, even if not “for profit”. Doctors as employees, are “pawns in the game” (remember the Dylan song?). PAs and NPs added not because better but because cheaper. FPs are only good because they are cheaper. Do the key principles of family medicine really make a difference? Barbara Starfield said yes, but she is gone and so is the control FPs had of their practices. We are ambulists (some of us hospitalists), few of us deliver babies. How many even care for families?

Perhaps the variety is why we become family doctors. We have variety in our patients, not just limited to one kind of disease or organ system, and we have variety in our day. Well-child, older person with chronic diseases, sports injury, pregnant woman, substance user, minor surgery. Maybe it is this variety that keeps us going, and makes us different from the sub-sub-specialist who needs to know all there is to know about very little. It is challenging because it is more complex, much as that might grate on the specialist; what they do maybe difficult but it is the same thing over and over. A Graham Center one-pager (by me!) looked at complexity in terms of how many different diagnoses, ICD-9 codes, it took to account for 50% of all codes by specialty.  For family medicine, it took 23 codes, for IM 18, for pediatrics 11, for cardiology 6, and for psychiatry 3![i]

We often hear about family physicians being replaced by NPs and PAs, but what about other specialists? Their practices are often more routine, more all-the-same, and in fact easier for NPs or Clinical Nurse Specialists to replace, as we see daily in hospitals. The Clinical Nurse Specialist in Heart Failure knows all there is to know about a narrow practice. But they – both the physicians and non-physicians -- make more money than FPs or FNPs. Is that all it is about?

There are many other challenges that face us, and face other specialists as well. One of the things that my colleagues in other disciplines complain about, and I agree with, is the apparent attrition of critical thinking among many of our trainees. This probably has many intellectual, educational, and social causes, but a big one seems to be the electronic health record (EHR), and the fact that our employers, health systems, have designed them to maximize reimbursement, not truth (is it all about money?). Much of the EHR is about filling in boxes and checking the ones that make our employers the most money. It is about cutting and pasting rather than thinking. The patient had a chest x-ray? Just paste in the whole radiologist report. This creates a huge long note, is a bear to read, is available elsewhere in the record (under, like, ‘radiology reports’, where it was cut-and-pasted from!) and requires no judgement! A simple “normal chest x-ray” (or ‘chest x-ray with interstitial infiltrates, possible pneumonia vs congestive heart failure’) required at least some thinking and judgement. The old “SOAP” note is entirely unbalanced, with not too much in “S” (patient history), bloated “O”s (cut-and-paste) and then – Plan! Almost no “A”, no assessment, no taking the information provided above and reflecting on it and thinking about what it means, or might mean, or might be if it doesn’t mean the first thing. It may be this that is the greatest threat to the role of doctors, any doctors, except as technicians.

But it is not just residents and students and practicing doctors that are being co-opted into a world of rote. Our family medicine leaders – program directors and chairs -- must help contribute to the “needs” of their health system –that is to make as much money as possible. We may, as individuals, care very much for the individuals who are our patients and for good practice, and I think we do, but our institutional role can overwhelm that. For caring for selected populations, mainly those who we get reimbursed for. I remember in the early 1990s, in the days of the Clinton health plan, seeing a version of this cartoon: R. Dolan, MD. “Specializing in the diseases of the insured”.

Our organizational leaders should – and do not always -- guard against the seduction of being part of the “in group”, getting to go to meetings (especially if paid for) being named to policy-making committees and commissions, hobnobbing with other “leaders”. Or maybe I’m wrong, maybe it’s just me, maybe this is really the good part about being a leader, not providing effective advocacy for your faculty, residents, students, and most of all patients? One need not be José Baselga, the former head of Sloan-Kettering who lost his position over graft and lack of disclosure, to lose one’s way – but that is the end of gradual moral and ethical compromise.

Over a decade ago the discipline undertook a major study and marketing program, the Future of Family Medicine. What do you remember from it? I remember that 2/3 of those who thought they had a family doctor really did and 2/3 of those with a family doctor knew it. I remember that when presented with the idea of a doctor who had the characteristics we associate with a family physician – the “Starfield” characteristics of comprehensive, continuous, compassionate, and personal care in the context of family and community – there was terrific resonance among the American people. I remember that specialists valued family physicians almost more than we valued ourselves. But what came of this? Is our health system more oriented to those values and characteristics than it was?

Now we have another project that cost the discipline $20 million, the Family Medicine for America’s Health (FMAHealth) project. Will it change the way the discipline practices and is structured, or will it be more of the same? How many of you have read the reports of the “tactic teams” in the recent February issue of Family Medicine? What do you think? As my friend John Saultz, editor of Family Medicine, notes that if FPs don’t define themselves, their roles, and their scope of practice, others will. It is happening and we as a whole are buying into it.

Is there hope? This is where I always say “a national health system”. I still say it. It is true that a national health system will not solve society’s problems – people will still need homes and food for health. It will not ensure quality of care. It will not mean that family medicine gets its due as the centerpiece of healthcare.

But it provides the context and mechanism for all of these. Most important, and of course this will be the challenge – it will change the focus of the health system from making money to be about delivering health care. It would provide a context for truly measuring quality. It would provide a reason to emphasize critical thinking. It would provide an impetus for health professionals to demand societal changes that will make a difference for people’s health. It would provide a way to make population health really be public health by not excluding anyone.

There will always be those who say we need to compromise, we cannot go too fast; it is something we are commonly hearing now as the campaign for the 2020 Democratic presidential nomination goes forward. But compromise is not always a good thing. Stephen Covey notes it is often lose-lose. We need win-win.

We need completely universal health care. 90% covered won’t do. “99-1/2 just won’t do” (Mavis Staples) because those are real people who are left out. Compromise means real people will not have health care. So the advocates of compromise need to specifically identify who those left out will be. I’m pretty certain they don’t think it will or should be themselves. Unless they are suggesting that we are going to leave them out, leave out the politician, pundit, wealthy, and their friends relatives and neighbors, then the people who need it most should get it most.

In the 1970s the British GP and epidemiologist Julian Tudor Hart put forward the “inverse care law”: the availability of care is inversely proportional to the need for it.[ii]

Let us correct that.

Health care for all!

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[i] Freeman J, Petterson S, Bazemore A, “Accounting for Complexity: Aligning Current Payment Models with the Breadth of Care by Different Specialties”, Am Fam Physician, 2014 Dec 1;90(11):790.

[ii] Hart JT, “The Inverse Care Law”, Lancet. 1971 Feb 27;1(7696):405-12.

Justice, Social Justice, Health and Health Care: Part II

This is the second of what will be 4 parts comprising the Henry A. Withers lecture I gave at the University of Texas-Houston Department of Family and Community Medicine. When they have all been posted, I will attach them as a "GoogleDoc".

The Social Determinants of Health

A key measure of Social Justice are the Social Determinants of Health, and manifests, in the negative, as health disparities. Some of the most important  work on disparities was done by the British physician, Julian Tudor Hart. Practicing in the Welsh coal-mining town of Glyncorrwg, Tudor Hart was able to identify who got sick from what, and as the physician for this community, he could identify how it related to their economic and social standing. As an epidemiologist he gathered this data in the pre-computer era, and then expanded it by looking at access to health care across Britain. The result was a 1971 article in Lancet called “The Inverse Care Law”,[1] in which he demonstrated with empiric data that “the availability of health care services is inversely proportional to the need for it.”

A corollary of this law is that the “higher” the level of medical involvement, in terms of both complexity and cost, the lower the overall impact on the health of the population, as demonstrated in this graphic from Dr. Steven Woolf. The greatest determinants of health of the populations are those that come before medical care. This incontrovertible truth is integrally tied to the concept of social justice. The role of social determinants in the health of the population and the production of health disparities was developed as an outstanding cartoon by Camara Phyllis Jones and colleagues, “Addressing the social determinants of children’s health: a cliff analogy.”[2]

A link to a powerpoint presentation of these, developed by Neal Palafox and colleagues at the University of Hawai’i Department of Family Medicine, can be found here, and is definitely worth reviewing. In brief, it pictorially demonstrates that all people are at risk for injury or illness, but some live a little closer to the “edge,” which puts them at greater risk of falling off. The same is obviously true for populations who live “closer to the edge”, who are at higher risk for disease – because of genetic risks, environmental risks, and behavioral risks – but also because they have less money, or social support, or greater stress in their lives. Things that, at the best of times, mean they are just able to get by and keep from falling off.

So, what can we do?

·    We can pick up the person, or people, who “fall off the cliff”, who get sick. This is known as “tertiary prevention”, because the bad thing has already happened and we are hoping to prevent complications, prevent it from getting worse. This is where we spend almost all of our “healthcare” dollars.

·    Or maybe we can put up a safety net. You’ve heard of “safety net clinics” and “safety net hospitals”. This can be thought of as a form of secondary prevention – they have already fallen, their high blood pressure or diabetes has become uncontrolled and they are at risk for something really bad, but we intervene. In the nick of time.

·   Or we could actually put a fence up on the edge of the cliff, preventing people from falling off. This is a kind of “primary prevention”.

But there is something else that might even be more effective. We can move these people further from the edge. This “pre-primary” prevention actually involves intervening on the core risk factors for health – addressing the social determinants of health. It is not a major component of our current medical model.

This is what health disparities are about. They are about differences that we could control. About some people living closer to the edge. And maybe the ambulance doesn’t come as quickly; that is, high tech medical care is less available. Or there is no safety net. And not even a fence, primary prevention. All these three are characteristics of access to medical care. Social determinants address health disparities by asking the questions that Dr. Jones asks:  why are there differences in who is found at different parts of the cliff, and why there are differences in resources along the cliff face?

Earlier I mentioned the work of John Rawls, and tried to distinguish between the concepts of intrinsic equality (as in the Declaration of Independence, “All men [sic]  are created equal”), and people actually being equal in all things (including intelligence, wealth, physical ability, genetics, etc.) I noted Rawls speaks of distributing societal goods equally, which is a different thing. I also noted that the principle of “justice” in medical ethics, which I said implies that people with the same conditions be treated the same. This concept is equity. What is the difference between equality and equity? Which should we strive for?

The Declaration of Independence, for example, also states that all men [sic, again] are entitled to “life, liberty and the pursuit of happiness”. It doesn’t guarantee happiness, but suggests some degree of equity, of equality of opportunity. What about when people start, as the folks on the cliff do, from such different places? What are the implications? For example, we have all heard politicians rail against inheritance taxes as “death taxes”, but what does it say about someone who is raised with all the advantages of money – good food, education, support, tutoring – but still cannot compete with a person raised with nothing? Are inheritance taxes good or bad? For myself, I’d say it depends on what we are going to spend the money on. Bombs? Feeding people? Bailing out banks? Housing people?

A key concept, going back to Rawls, is that the exception to the general rule of distributing all social goods equally is when not doing so is to the benefit of the least advantaged. This is also the basis for why for it is a different thing for the underprivileged or oppressed to band together to relieve that oppression or lack of privilege than it is for the privileged or oppressors to band together to maintain it. This is the flaw of the concept of “reverse discrimination”. Is it discrimination if we take away all of the advantages that one group had that another did not? I suppose that it is still a matter of perspective. While I do not know the source of this quotation, I believe it speaks very well to the issue of perspective: “If you’ve spent your whole life with the wind at your back, a calm day seems unfair!”

(to be continued)

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[1] Tudor Hart J, “The inverse care law”, Lancet. 1971 Feb 27;1(7696):405-12.

[2] Jones CP, Jone CY, Perry GS, “Addressing the social determinants of children’s health: a cliff analogy”, Journal of Health Care for the Poor and Underserved, 2009Nov;20(4):supplement pp 1-12. DOI: 10.1353/hpu.0.0228