Whence, and whither, family medicine: will it have role in improving our nation’s health?: Part 2

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

Part II: More whence, and some whither family medicine

Family medicine introduced many great things to medical education. We had non-physician faculty in our departments and residencies, psychologists and educators, unheard of then. We valued education, and realized that just being a good doctor was not the same as being a good teacher, so created faculty development programs, including fellowships, often supported by Title VII grants. Our Board required recertification from the beginning, and no one, not even those who created it, were immune, or “grandfathered in”. Many of these innovations (if not the “no grandfathering”) were adopted later by other specialties, although not always crediting the discipline family medicine. And many specialties have not adopted them yet, still to their shame.

But, in the US, family medicine is still somewhat on the margins. It never completely took over as the centerpiece of the health system, not as in Canada or the UK. Much of the opposition has been regional, especially in the NE, and in cities where there were already plenty of doctors who did not want to give up control – or money (remember that word, money, we’ll be coming back to it). Of course, then, as now, most pundits who comment on medicine – actually, on all things – are, at least relatively, well to do. Poor people often adopt such attitudes as “specialists are better”, because they assume that what the rich have is better (bigger houses, better cars, certainly better doctors), although those of us who went to medical school know that that is not necessarily true. Our classmates who wanted to become elite subspecialists caring for the rich did that, and those who wanted to serve the needy did that, and it had little or nothing to do with class rank or skill. Of course, the obstacle to poor people getting what the rich get is, well, they don’t have, and so their doctors wouldn’t make, enough money!!

The small-town white picket fence practice, of Marcus Welby and many fathers and grandfathers (less commonly mothers or grandmothers) of current FPs, such as many of those portrayed in Fitzhugh Mullan’s book ‘Big Doctoring’,[1]

may be mostly gone, but that model was long the darling of the RRC; those of us working in inner-city training settings often felt that the rules were written for someone else. 

Other issues confront us, sometimes divide us. Should the future of family medicine be about “full scope” practice, including caring for children, delivering babies, hospital work, emergency care, musculoskeletal care? Or should it be limited, specialized even (OB, geriatrics, sports medicine)?  Should we be using the term primary care or family medicine? What about general internal medicine? Pediatrics? GIM has pretty much abandoned the field, since 80% of IM graduates become subspecialists and over half the remainder become hospitalists. Should we just stop saying “primary care” and insist on “family medicine”?

Most of us recoil at the oft-heard-from-medical-students idea that GIM is family medicine without the OB and pediatrics. We think that there is a conceptual basis for our specialty that has to do with caring for the whole person and caring for them in the context of their lives, families and communities. Despite the concerns of the young Josh Freeman, this context is critical. The pediatrician cares about the health of the child she cares for, and likely that of the adult that child will become. The family physician also cares for both, but more concretely than the pediatrician experiences the health issues that adults face that often have at least part of their roots in their childhood experiences. In addition, the family doctor cares for that child’s family, and knows, for example, that the child’s mother is not just “mom” (I hate that usage!) but someone with their own problems, maybe a hard job, maybe not enough money, maybe a troubled relationship, maybe caring for her own parents, maybe with her own health issues. I have often said that if clinical sciences have associated basic sciences (like psychology for psychiatry, and anatomy for surgery) then anthropology is the basic science for family medicine because it examines people in the context of their families and communities.

Family medicine is also comprehensive, per se, by its nature. I was once able to recruit an anthropologist to our department because she wanted to work in that comprehensive context, and public health/preventive medicine didn’t really offer it. Preventive medicine is seen by some as holistic, but it segments just as medical specialties do: I do smoking, you do seat belts, she does bicycle helmets, he does violence. But the family physician has to address them all. We can’t say “wear your seat belt” but ignore “stop smoking”! Or, is that what we want FM to become? Geriatricians and sports medicine and women’s health? Hospitalists and ambulists, nocturnists and weekendists? (By the way, that anthropologist went on to help run the AAFP’s national research network.)

Sometimes the issue of how family physicians practice is formulated as a conflict between lifestyle and scope. Is that true? Maybe. Maybe it is good to not take call, or too much call, or have to round in the hospital or have to get up to deliver a baby in the middle of the night. But it may also be true that for a well-trained family doctor, 8-5 clinic patients can become drudgery. Sometimes teaching helps. And what about the issue of lifestyle vs lifestyle? People want to move to and practice in cool places to live, with a lot going on, stimulating cultural events and good educational systems. But these places may pay less money and cost more to live in. Besides your practice, do you want to be San Francisco poor or Nebraska well-to-do? That old white picket fence family doc may have had no conflict, but now young people do.

There have been lots of changes in the health system in my lifetime. Family medicine was created in the 1960s and grew to adolescence in the 1970s. In the 1980s we had lots of promise; Nixon pushed for HMOs, and in the 1990s we had gatekeepers – and different opinions about whether that was good or bad. Our best resident matches were in the late 1990s; no student wanted to be an anesthesiologist because they were afraid of not getting a job. But now ….

One study showed a student entering an anesthesiology residency can expect to make $7 million more in their lifetime than one entering family medicine. In this country. When I was in Denmark a few years ago I visited a rural family practice. In conversation, the doctor mentioned his daughter was married to an anesthesiologist. Tied to my own country’s norms I joked that at least he wouldn’t have to worry about being supported in his retirement. Oh, he replied, in Denmark family doctors make more than anesthesiologists!

Is it all about money?

We have a health system that fails to focus on the health of the people. We have almost abandoned the concept of public health. Indeed, the currency of the term “population health” is more than a semantic difference. Population health can be narrowly defined to be any population – the population of your practice, say -- and it can and does often leave people out. The people who are hard to care for, or don’t make money for us, or mess up our statistics.  Public health requires us to look at the WHOLE public. Eew! How messy!

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[1] Mullan, Fitzhugh. Big Doctoring in America: Profiles in Primary Care. Millbank. 2002.

Prostate Screening and the Public’s Health

For the first time in several years, I am writing about prostate cancer screening. I had hoped that this was sufficiently covered in 2009, with PSA Screening: What is the value? (March 21) and the excellent guest piece by Robert Ferrer, PSA Screening: “One of Medicine's Great Success Stories"? (October 27), and finally a bit of celebration in 2011 with PSA redux: The USPSTF finally recommends NOT getting it! (October 14). However, like the proverbial bad penny (or to use a more au courant analogy, zombie), this issue continues to return from the dead. The most recent effort is “Bring Back Prostate Screening”, a NY Times op-ed piece by Deepak A. Kapoor on July 6, 2015.

What Dr. Kapoor is suggesting is obvious from the title, but the question is “is there some new information, some new research, that now makes such screening more reasonable or appropriate?" The answer, unfortunately (because it makes more work for the zombie hunters) is “no”. Dr. Kapoor suggests that there is. He notes research is this field is “... now paying off.” He says that the decision to recommend against prostate screening by the US Preventive Services Task Force “…didn’t take into account adaptations that urologists have made to help better identify patients likely to develop deadly prostate cancers.” He cites the increased sensitivity of PSA screening, the individualization of it to the risks of different men, and the use of PSA trajectory (its rate of increase, or not), as well as new methods of assessing cancer like MRI. However, his assertion is incorrect; all of this information was available to the USPSTF when it made its recommendations, and was taken into account. It is not new.

“At the time,” Dr. Kapoor notes, “I and many other urologists warned of public health repercussions. Our fears have materialized. Since 2010, fewer biopsies have been performed and fewer prostate cancers found. But studies show an increase in the risk that a cancer, when found, will be more aggressive.” This sounds scary, but it is to be expected; when you stop screening everyone you won’t find the cancers early. A big part of recommending against PSA screening was that so many of the cancers it identified were indolent and not going anywhere; the aggressive cancers will be the ones that eventually show up. Indeed, he actually acknowledges that “No increase in cancer mortality has been observed,” but continues to raise the alarm with “…that may be a matter of time; aggressive cancers are less treatable.” So maybe we should be scared.

Well, in fact all prostate cancer is treatable. All cancer is; in fact all conditions are. The question is how effective is the treatment? Does it cure? Does it prolong life? Does it improve the quality of remaining life? This is the area that Dr. Kapoor and his colleagues do not address, because, for prostate cancer, the answer is basically no. If you have the more common kind of prostate cancer, it is slow-growing (indolent) and may even disappear itself; you will die with it, rather than from it. If you have the less-common aggressive form, you may well die from it, and unpleasantly; prostate cancer metastases go to bone and cause a lot of pain. Sadly, however, treatment does not seem to impact this. The “cures” from treatment of prostate cancer are of the ones that would have “cured” themselves, or at least not have manifested with symptoms. The mortality from aggressive deadly cancers is not changed by treatment. This is the critical point that discussions of the sensitivity and specificity of PSA or any other kind of screening often ignores. Not only can they not reliably distinguish between the indolent and aggressive types of cancer well, even if they could and we had a test to reliably tell which one you had, it is only of importance if treatment can make a difference. And in terms of mortality, it doesn’t. What about the other results from treatment? Improved quality of life? Well, here even Dr. Kapoor notes that “cancer treatment can reduce quality of life.” If you consider impotence, urinary incontinence, and the many unpleasant and painful effects of radiation on the rectum to lower quality of life, you betcha.

We can dismiss Dr. Kapoor’s comments by saying he is a urologist, and they make their money treating prostate cancer; can you imagine the impact on their income if we didn’t treat it? But this misses the far bigger issue, which is that we are enamored with – and, more important, spend huge amounts of money on-- high-technology interventions rather than the prosaic, low-tech interventions that have actually been demonstrated to improve the public’s health. Screening for prostate cancer, and overuse and reliance on mammographic screening for breast cancer, are huge industries which (even in breast cancer) have had relatively little impact on mortality. Providing good prenatal care and preventing unwanted pregnancy, ensuring treatment of common diseases like hypertension and diabetes, ensuring that children are not only immunized against infectious disease but are well-fed, well-housed, and well-educated, and free from poisoning by environmental toxins (including bullets) – the basic components of public health and primary care -- may seem less sexy and stimulate our collective psyches less, but they are the things that actually increase population health.

One of the newer fascinations is genomics, the identification of each person’s sequence of DNA. The promise of “precision medicine” is that we will find out who has the risk gene for which disease, and treat it directly and appropriately; treatment for cancer will be based on the genes you have just as treatment for bacterial infections is based on the organism identified by culturing it in a microbiology laboratory. It is so exciting! It is so “sci-fi today”! The American Board of Family Medicine, for example, is planning to create a new self-assessment module (“SAM”, tests that family doctors have to complete one of each year to maintain their Board certification) on genomics. On the other hand, it doesn’t think we need one on contraception, which is too small an area (isn’t it just part of “women’s health”? Oh, do men have a role in contraception also?), unlike genomics, which could affect EVERYTHING!

Except, so far, it hasn’t and there is little evidence to suggest that it will anytime soon. I wrote a blog on the topic on February 1, 2015 (“Precision medicine, trade policy and the cost of drugs: benefiting people or profit for business?) after the appearance of a Times op-ed by Mayo Clinic cancer expert Michael Joyner (“’Moonshot’ medicine will let us down”, January 15, 2015); Dr. Joyner has more recently contributed more comprehensive articles on the topic to JAMA (“Seven questions for personalized medicine[1]) and The Lancet (“Is precision medicine the route to a healthy world?”[2]) in which he makes the important point that most disease is not the result of a single gene, but rather the result of a complex interplay of different genes and the environment. Indeed, the only cancer-specific genes that have been identified so far are the breast cancer genes BRCA1 and BRCA2, and no treatment has emerged; we simply say “get mammograms more often and consider prophylactic mastectomy”.

Spending all this money on precision medicine, on high-tech interventions, expensive drugs and devices is like blowing your house budget on art for the walls before you have built it. Some art is great, some is mediocre, and some is poor, but none will hang well on a jerry-rigged house made poorly of shoddy materials because there was no money left. Some high-tech, expensive interventions are worthwhile but what we really need to increase the population’s health is public health nurses making home visits to pregnant and recently delivered women, and their children; public health nurses or community health workers or even doctors making visits to people’s homes to assess the real risk factors to their health and reasons that they might not be able to comply with treatment plans. We need more primary care, not more interventionalists. But most important, we need to apply what we know works, what we know how to do, to everyone.

That is how we move the needle on population health.

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[1] Joyner MJ, Paneth N, Seven Questions for Personalized Medicine, JAMA. 2015 Jun 22. doi: 10.1001/jama.2015.7725. [Epub ahead of print]

[2] Coote, John H, Joyner, Michael J. Is precision medicine the route to a healthy world?. The Lancet385.9978 (Apr 25, 2015): 1617.

Medical communication is indeed often "lost in translation"

I often write about the things that I believe make a big difference in the health of people. Some of these are access to the health system, particularly financial access in the US. The bizarre and inappropriate structure of the US health system in terms of overemphasis on high-tech, subspeciality care at the expense of adequate primary care is extremely important. I also believe that the “social determinants of health”, the characteristics of people’s lives that are not usually considered as part of the health system (socioeconomic status, environmental exposures, stress, education, housing, etc.) are major contributors to health.

I have also written about medicine in terms of recommendations for prevention and screening from different organizations (I tend to advocate for those from the US Preventive Services Task Force) and about treatments that are promoted but are often of minimal benefit and sometimes harm to people. Occasionally, I even venture into the area of medical research, trying to help folks understand how science progresses, and how there is rarely a “breakthrough” as big as the news media like to trumpet. As a medical educator, I am very concerned about how we train doctors, and have also frequently written on that topic.

Most of these themes are focused on “population health” rather than the management of individual patients with individual diseases, not because the latter is unimportant but because these issues are extensively addressed in many other outlets, and the ones that I have described are, I think, not as well understood both by the medical community and the general population. I believe that the almost exclusive emphasis in our country on treatment of individuals limits both our commitment to addressing population and system issues, and the resources available to do so.

However, sometimes there is an issue that is mostly about human behavior, something that could be changed, and would make a big difference in the healthcare experiences of most people. One of those I have touched on before (Medical schools are no place to train physicians, January 5, 2014), because I see it as a key part of medical education, is communication between health care providers and their patients. This was addressed in an outstanding “Opinionator” blog that appeared in the New York Times on February 9, 2014, "Lost in Clinical Translation" by Theresa Brown.

Ms. Brown is apparently a nurse, but what she discusses is at least as applicable to doctors and to other health professionals. Starting with a reference to the Gary Larson “Far Side” cartoon here, she gives excellent examples of failures of communication that were disturbing to patients, but did not, apparently, disturb the health professionals who, presumably, thought they were communicating as clearly as Ginger’s human owner does. One story is of her friend's husband, who a heart procedure called a “cardiac catheterization” to look for blockage in the arteries that supply the heart itself, which can cause a heart attack. (That description is, I hope, clear; when I told my residents, however, I just said “he had a cardiac cath”, which was very clear to them but would likely have mystified most patients.) As it turns out the test was completely normal, but this was not clear to the obviously very worried wife who understood almost nothing about what she was being told (for example, that he was being kept overnight in the intensive care unit because this is routine after such a procedure, not because his condition required intensive care!).

This sort of thing happens a lot. Daily. Hourly. There are many reasons for poor communication to occur between health professionals and patients. Some are that people, when they are scared and sick and in a strange place, have difficulty listening to strange words and understanding unfamiliar concepts. They may have to be told again and again, just as, I tell my students and residents, we all had to study to pass exams even though we'd be "told" everything once, in the lecture. But there are a lot of other things that are our fault, and can be remedied by different behaviors.

One, we – doctors, nurses, and other health professionals -- are very comfortable in the hospital, and we take it in stride; it is our "briar patch" and we're at home, but for patients and families it is a scary place full of thorns. I ask doctors and nurses to think about they would feel if they had to go to court, as witness or defendant or plaintiff, and look at how easily the attorneys comport themselves. It is a good reminder of how patients feel in a hospital.

Two, we speak "medical" fluently. We have such familiarity with both words and concepts that we assume that they mean something to regular people (which is, by the way, the correct English term for "patients" and "patients’ families"). But usually they don't; words that mean very different things sound a lot the same; even if people have heard them before they usually have only a vague idea of what they mean, and the difference between "is" and "is not" is, while obviously very significant, not always clear to folks. I point out, just for an easy one, how often we use "negative" when we are describing a normal test. We should ALWAYS use "normal" or "not normal". "Negative" sounds bad. "Positive" (which is often bad) sounds good!

Three, we often use obfuscating words, unnecessarily medical words when regular ones will do fine, and use lots of modifiers and adverbs that make what we are saying even more unclear. The use of such modifiers ("probably", "likely", "potentially", 'possibly") may make what we say more technically accurate, but can obscure the message. Similarly, we are often uncomfortable giving bad news, and when we use such modifiers we may think we are lightening the load a bit for the patient, but really we are being more unclear. When we hide behind medical words, we are protecting ourselves from having a long and perhaps difficult discussion; completely subconsciously, I'm sure, we expect that maybe they won't understand, and thus won't ask hard questions. Also we tend to speak in the third person, kind of distancing both ourselves (first person) and the patient (second person) from what we are saying. All these are illustrated by thinking about how a statement like "The biopsy result showed that the tumor was probably malignant" conveys a very different (and probably incomprehensible) message than "you have cancer".

It is a lot to think about, but the good part is that these behaviors can change. We just have to want to, and work at it.

NOTE: The Medicine and Social Justice blog will appear less often than it has, intermittently or maybe not at all, for some time. I am on sabbatical and will be engaged in writing a book, more or less on the themes described in the first two paragraphs of this piece, the themes that have been the subject of this blog.