Medical Ethics and Social Justice

In a recent JAMA Commentary[1], Darrell Kirch, MD, President of the Association of American Medical Colleges (AAMC) and his colleague David J. Vernon, speak about the “Ethical foundation of American medicine”. They discuss the 4 traditional components of medical ethics: beneficence (do the right thing, or “provide good care”), nonmaleficence (don’t do the wrong thing, “do no harm”), respect for autonomy, and justice. They note that the first two have been the most emphasized in medical ethics and “are foremost in the minds of physicians”. In general, these two are the most obvious ones individual patients, as well as society, would desire to have done, although they can sometimes be very complex and lead to difficult decisions when the line between “do the right thing” and “don’t do the wrong thing” is not perfectly clear.

The authors briefly address respect for autonomy, noting that this includes physician, as well as patient, autonomy, discussing the fact that physicians have “delegated authority” from society, which confers them privileges in return for their using “…their best informed judgment when caring for individuals who need assistance…”. They express significant concern about the degree of physician autonomy in a market-driven system, where “fiscal independence” and the “right to enhance physician revenues” seem to “…have become as important as autonomous decision making in practice…” The result of this, they fear, is that “…attention to social justice [the fourth tenet of medical ethics] may be decreased.” It is this tenet, social justice, to which they dedicate the remainder of their discussion.

They cite Rawls’ theory of justice[2] [3], “often referred to as social justice” as a dominant theory of justice. The two components of this theory, which are also core to the content of this blog, are:

· “People should have maximal liberty compatible with the same degree of liberty for everyone” and
· “Deliberate inequalities are unjust unless they work to the advantage of the least well off.”

Wow. What concepts! The first states that your liberty does not allow you to hurt me, and the second that policies of justice must work to the benefit of the least well off. This is, of course, completely opposite to the trends of the last many years in the US, where the intent of policy has been to be to the advantage of the most well off. This concept is applicable far beyond medicine, prominently including legislative / governmental policy, based on the idea that socially (that is, in addition to issues such as providing for the common defense) the role of government should be to help those most, rather than least in need. The presumption is that those who are “most well off”, are, well, most well off, and least in need of help from the rest of society. Similarly, in regard to health care, it is those who have the least resources – to purchase medication, to take time off from work to see a doctor, to have the most dangerous jobs, to have no job, to have inadequate food or housing – who have the greatest need. Yet, in both cases, governmental and medical, we have not followed this precept; governmentally, it is those with the loudest voices and the most money who have the ears, and service from, government (problem: poor people just don’t contribute enough to politicians!); medically, the greatest resources go to those who have the best insurance, often not those with the greatest need.

Kirch and Vernon look at the difficulties that inhibit physician pursuit of the goals of social justice. They note 3 “interrelated” factors:

“Fundamental human behavior. Physicians, like most individuals, seek and compete for opportunities within their current circumstance to create the best life possible for them and their families.” This means that, while they will (hopefully) offer the best care to their individual patients, they may look first to making more money than expanding to Medicare, Medicaid, or self-pay patients. They observe that the flaw here is that “…for each of the physicians who decide they can no longer care for these patients, the responsibility falls to another clinician.” Perhaps, but that clinician may be in the ER when the patient presents with far-advanced disease because no one in the community will see him/her. (Plus I am always leery of phrases like “fundamental human behavior” and “it’s human nature”; like “I’m sure I speak for all of us when I say…”, there are almost always exceptions!)

Medical student debt. This means not only that students have to make a lot of money to pay it back, but that the socioeconomic background of those going to medical school may become even more imbalanced than it already is (they say “…more than 75% of medical students came from families the top 2 quintiles of family income…”). Facing this debt, maybe those from non-wealthy families will seek other careers.

The US culture of “individualism”. “Specifically regarding health care, many other western nations have some form of universal coverage supported by their government and treat health care as a public good.” Right. And so could we. Especially as we not only spend far more money per capita on health care than any of them, but we actually spend more public money (Medicare, Medicaid, federal, state and local employees, military, VA, and the taxes lost because employer contributions to health insurance are tax deductible) per capita than any other country!

They worry that “…the emphasis on individual responsibility may be deepening,…” citing a study by Lee, et.al. that showed that “…the percentage of Americans who agree that the high the income, the more the individual should expect to pay in taxes to cover the cost of care for individuals who are less well off decreased from 66% in 1991 to 51% in 2003 and to 39% in 2006.”[4] However, this is one study, focusing on the highest cost drugs; study after study has shown that a majority of Americans see the need for a universal health care system and are willing to pay more taxes to achieve it.[5] A majority of physicians support national health insurance.[6] Although, I again note, the taxes for most people would be more than offset by not having to pay for health insurance. And the number of people who have no insurance, inadequate insurance (high deductible, low maximum limit, excluded conditions), sporadic insurance, or think they were insured but still find themselves financially ruined by disease treatment costs – and people who know, work with, and are related to them and thus feel their pain – grows every year.

The 4 principles of ethics are all important, but the emphasis on social justice, in this time and place, is critical. Kirch and Vernon conclude:

“Physicians have a responsibility to ask and answer these difficult questions that are properly viewed as not simply involving politics, but rather as speaking to fundamental medical ethics. The answers in turn may well require personal sacrifices (eg, accepting a lower level of income), professional group action (eg, advocating as much for health care system improvements as current advocacy for the preservation of specialty reimbursement levels), and a commitment to work within the political process (that goes beyond lobbying for maintenance of the status quo). These efforts and corresponding sacrifices are necessary first steps toward creating a society in which everyone has access to appropriate health care.”

Amen. I would add that it is also critical that in medicine, and in medical education, that these are not issues relegated only to special courses in “medical ethics” but are rather core values informing all of what we do.
[1] Kirch DG, Vernon DJ, “The ethical foundation of American medicine: in search of social justice”, JAMA 8Apr2009; 301(14):1482-4.
[2] Rawls J. A Theory of Justice. Cambridge, Massachusetts: Belknap Press of Harvard University Press, 1971. Revised edition 1999.
[3] Gillon R. Justice and medical ethics. Fr Med J (Clin Res Ed). 1985;291(6489):201-202 (This is the reference the authors cite for their discussion of Rawls’ theory of justice)
[4] Lee TH, Emanuel EJ, “Tier 4 drugs and the fraying of the social compact”, NEJM 2008;359(4):333-5.
[5] CNN Poll, May 4-6, 2007, http://i.a.cnn.net/cnn/2007/images/05/09/rel6e.pdf, Question #30, accessed 4/15/09
[6] Carroll AE, Ackerman RT, “Support for national health insurance among US physicians: 5 years later”, Ann Int Med 1Apr2008;148(7):565-7.

Conscientious Objection in Medicine

Julie Cantor, MD JD, has a Commentary in the New England Journal of Medicine, April 9, 2009, titled “Conscientious objection gone awry – restoring selfless professionalism in medicine”,[1] in which she discusses the aggressive content and insidious effect of the “conscious” laws and the more extensive impact of Department of Health and Human Services (DHHS) regulations put into effect in the last months of the Bush administration. Current laws protect providers from being forced to be involved in the performance of abortion or sterilization. If hospitals or other agencies receive federal funds, people cannot be discriminated against for failing to perform, discuss, or refer patients for abortion. “On their face, these laws are quite broad. But the Bush administration’s rule is broader still. It restates existing laws and exploits ambiguities in them”, in ways which will definitely limit patients’ access to health care. “Now everyone connected to health care may opt out of a wide range of activities, from discussions about birth control to referrals for vaccination. As the rule explains, ‘an employee whose task it is to clean the instruments used in a particular procedure would also be considered to assist in the performance of the particular procedure,’ and would therefore be protected. Taken to its logical extreme, the rules could cause health care to grind to a halt.”

Is Dr. Cantor overstating the issue? I don’t think so. The goal of these regulations is to eliminate – by creating as many barriers as possible – abortion, and while they are at it sterilization or anything else that these policy makers and their supporters oppose. It is not really at all to worry about the implications for patient care, or the way that these rules could be interpreted to restrict access to all sorts of care. The rule, Dr. Cantor points out, “…sidesteps courts, which interpret statutory ambiguity and discern congressional intent…” by offering “…sweeping definitions. It defines ‘individual’ as physicians, other health care providers, hospitals, laboratories and insurance companies, as well as ‘employees, volunteers, trainees, contractors and other persons’ who work for an entity that receives DHHS funds”. She also notes that the regulation conflicts with other existing federal law, Title VII of the Civil Rights Act, “…which requires balancing reasonable accommodations for employees who have religious, moral, or ethical objections to certain aspects of their jobs with undue hardship for employers.” The regulation goes MUCH farther, putting the entire responsibility of accommodation on the employer (“ …if an employee objects, for example, to being a scrub nurse during operative treatment for an ectopic pregnancy, subsequently reassigning that employee to a different department may constitute unlawful discrimination….”) But, if we understand that the goal of the regulations is not to protect the employee’s moral objections but to put as many obstacles as possible in the way of anyone doing anything that, while legal, these regulators object to, it is completely understandable.

My remembrance of “conscientious objection” goes back to when there was a military draft and draftees could petition for an exemption based on their religious, ethical or moral objections to killing and war. It was not that easy; long-time members of recognized “peace churches” such as the Quakers had a much easier time making the case than people whose objections were not based in formal religion. And a case had to be made. And the military could reject the petition. In addition, a “mid-range” classification (I-A-O) existed between I-A (draftable) and I-O (conscientious objector), which allowed the individual to be drafted and serve in war, but not be required to kill; many medics came from the I-A-O group. The remarkable difference is that the current “conscientious objector” regulations are both far more sweeping in their “protections” of an individual’s “conscience” and yet require far less investigation – indeed, none – all a person has to do to enjoy all these protections is assert them. Imagine if that had been the case for conscientious objectors in the Vietnam era! Thus, it is clear that the rules are never what the rules say they are about; in the era of the draft it was to get as many young men drafted as possible; in this era it is to block abortions, sterilizations, provision of birth control and other “objectionable” (to someone) procedures as possible.

When these regulations went into place to “protect” pharmacists with such objections from having to dispense emergency (or sometimes any) contraception, access to these legal, and even over-the-counter medications were severely restricted in many communities. There was a “joke” that went around the internet “Did you hear about the Christian Scientist pharmacist? He refused to fill any prescriptions!” Funny? Maybe not. While not their intention, these regulations would actually protect him!

This is all complete and utter nonsense. People should not be forced to perform procedures that they morally or ethically (or religiously) object to; current civil rights law more than adequately protects them. Dr. Cantor suggests that people should not enter fields where their beliefs will prevent them from serving their patients:

“As the gatekeepers to medicine, physicians and other health care providers have an obligation to choose specialties that are not moral minefields for them. Qualms about abortion, sterilization and birth control? Do not practice women’s health. Believe that the human body should be buried intact? Do not become a transplant surgeon. Morally opposed to pain medication because your religious beliefs demand suffering at the end of life? Do not train to be an intensivist. Conscience is a burden that belongs to the individual professional; patients should not have to shoulder it.” If you are a Christian Scientist, then do not become a pharmacist.

”Patients,“ Cantor says, “need information, referrals, and treatment. They need all legal choices presented to them in a way that is true to the evidence, not the randomness of individual morality.” I agree with her, but the fact is that the morality is not random, it is agenda-driven. It is not about protecting the moral beliefs of individuals who are providers, but forcing the choices of others, patients, to conform to those beliefs.

Let’s get right to the crux of the matter: abortion. Despite the proclamations of the virulent anti-abortion movement, it is not about life. While many anti-abortion activists are consistent in their pro-life views, opposing war and capital punishment, most are not. And do not support the living, are not advocating for financial support for the food, clothing and education of the born. The issue is about choice, or more properly, self-determination. No one is “pro” abortion. But people on the “pro-choice” side believe that the decision belongs to the individual, always a “her”, with the counsel of those she trusts and whose opinions she values: family, friends, clergy, physicians, etc. It is perfectly possible to be “anti-abortion”, to never have one for oneself and to do one’s best to talk those one cares about and can influence out of having one, but still believe the decision is ultimately that of the pregnant woman. The “anti-choice” side believes that the decision should be theirs, not the woman’s. And that is what this is all about. How can “we” (in this case, the Bush administration) develop policies that force everyone to do what we believe to be right, whether on abortion, sterilization, stem cells, gay rights, or even having sex for other than procreation within marriage?

Yes, the Obama administration needs to repeal these regulations, post-haste and completely. And yes, the Congress needs to change the actual statutes to be consistent and first protect patients, not providers. And yes, people should choose professions and specialties where they can meet the needs of all patients who come to them, not just those who share their beliefs. And yes, laws protecting health care providers from providing services that they see as morally objectionable should never protect them from not giving patients full information and referral for those services. And yes, we need “truth in advertising laws” so that clinics whose goal is to prevent abortion by withholding information and delaying cannot be advertised as “Crisis Pregnancy Centers” but as “No abortion – Keep your Pregnancy! Centers”. And yes, we need to strip the hypocrisy of these regulations and all these efforts, and to end anti-scientific bias.

But most of all, we need to focus on the health care of the patients. On making sure they are fully informed about issues, have resources to further explain them, helping in making informed decisions, and supported in the decisions they make.

[1] Cantor J, “Conscientious objection gone awry – restoring selfless professionalism in medicine”, NEJM 2009Apr9;360(15):1484-5.

Does the nation need a clear policy on a right to basic health care?

At a recent conference, I was asked to be a “thought provocateur” (!!) on the topic “The nation needs a clear policy on the basic right to health care".

This is an interesting question, since my first reaction is: “Of course, we need a clear policy on the basic right to health care! I mean, I have a pretty clear idea of what that policy should be, but certainly even those who would disagree with me would agree that we need a policy!”

But, on reflection, I don’t know that they do. I think that a great deal of the perseverance of our “non-system” of health care has been a result of a consensus among our leaders to NOT talk about this issue, to NOT grapple with it, to not have to take a position one way or another on whether health care is a basic right.

This is because, if one does take a position, there are implications, and things that we would then have to do.

If health care is a basic right, then we need to provide it to everyone. We can no longer diddle around with partial fixes, tinkering around the edges, covering (maybe) children but not their parents, covering people who are poor – as long as they are children and their mothers and are really poor and not working – but not those who are poor, or nearly-poor, depending on which state you are in. Or, for that matter, working-class, or, in increasing numbers, middle class.
But the problem is most people in power, including most politicians including the President, don’t want to have to take a position against health care being a basic right. It sounds, well, mean. There aren’t many people, except, well, mean people (and maybe some reactionary ideologues), who are willing to defend this position.

So we have shows such as “Sick Around America”, the Frontline “sequel” to T.R. Reid’s “Sick Around the World” (which Reid disassociated himself from). It interviewed insurance company executives who said “sure we can insure everyone”. If we make it mandatory and can make a profit everyone. Hmm. The cost would be ridiculous. And the option of single payer was never mentioned. There is a lot more that has to be decided if we agree that health care is a basic right, like how to provide it, how to pay for it, and what will be and will not be covered. I mean, sure, other countries seem to have solved that problem, and we could model a system on one or more of theirs, but where’s the fun in that?

And if we agree that health care is not a basic right, we solve that problem, but we have other ones – like all these uninsured, and underinsured people.

• And folks not getting preventive care but rather incredibly expensive curative care.
• And companies like our automobile companies going bankrupt in some part because of the cost of health insurance.
• And, oh yeah, people dying in the streets.

For the record, I do believe that we need a policy on health care as a basic right, and my belief is that it should be. Perhaps the most important reason is social justice; we all share in the public good. This is what virtually every other nation of the first world has long realized. When T.R. Reid asked the leaders of the countries he visited for “Sick Around the World” how many of their citizens went bankrupt as a result of health care debts, they all said none. The most dramatic response was from the President of the Swiss Confederation, a conservative who had originally opposed the Swiss program in the early 90s. “No one,” he boomed in his French-accented English, “why, it would be a national scandal!”

The health of our society depends upon the health of all of us.

• When people crowd our emergency rooms, not with minor illnesses, but with serious illnesses that could have been prevented with earlier treatment, that is a scandal.
  
• When parents cannot afford their own health care and their illnesses threaten their ability to keep providing for their children, that is a scandal.
  
• When people stay in jobs they hate, or forego the opportunity to start a new business, because they rightfully fear being uninsured, that is a scandal.
  
• When our friends and neighbors, parents and children, only take partial doses of their medicine because it is a choice between that and not eating, that is a scandal.
  
• When a hard-working man with chest pain can see the billboards advertising the superb heart care available at our local hospitals and know they are not meant for him because he is uninsured, that is a scandal.

When we are all in it together, we all have an interest in making the system be as good as it can be. The efforts of those of us who are more educated, more financially able, more vocal, more empowered will ensure that the needs of those who are less able to lobby for themselves are also met.

Just as our nation cannot survive half-slave and half-free, or with only half of adults having the vote, we cannot survive with only some of us having access to health care.

We need to do this for all of us, for, after all, ultimately, we are our brother’s and sister’s keepers.

"Sick Around America": A little bit sickening

Last week I watched “Sick Around America”[1], the PBS show Frontline. I was greatly looking forward to it as the follow-up to the outstanding show “Sick Around the World” that T.R. Reid, a former international correspondent for the Washington Post and Atlantic did last year. “Sick Around the World”[2] had Reid traveling to 5 countries to look at the way that they delivered health care. Carefully chosen to display a variety of approaches to providing health care to everyone, he visited three long-standing systems, the UK (National Health Service), Canada (single-payer), and Germany (a mixed public-private system), and two rather newer ones, Switzerland (early 90s) and Taiwan (early 2000s). In each country, he probed the people he interviewed, usually health ministers, sometimes prime ministers, and health scholars about the strengths and weaknesses of their programs, but in all he received the message that there was a sense of social responsibility and social justice. In each country he asked how many of their citizens went bankrupt as a result of health care debts, and they all said none. The most dramatic response was from the President of the Swiss Confederation, a conservative who had originally opposed the Swiss program in the early 90s. “No one,” he boomed in his French-accented English, “why, it would be a national scandal!”

The lesson from “Sick Around the World” was that there are many approaches to covering everyone, but that there must be an agreement and consensus to do so, a decision every (other) industrialized country has made. I paraphrase his ending: “For the US veteran in the VA system, healthcare is much like in the UK; for the retiree on Medicare it is like in Taiwan; for the employee with insurance, the US experience is much like in Germany; and, for the 40 million uninsured in the US, it is just another third-world country.” So I looked forward to see what Reid would show us in the US in “Sick Around America”.

The first thing that was apparent was the absence of T.R. Reid, which seemed very strange. The show was ok, I guess, following the trials of some people who had difficulty receiving health care (or not); kind of a watered-down version of parts of Michael Moore's Sicko! without the funny or the punch. There were some good points made, particularly around pre-existing conditions and medical underwriting; for example, when the chairman of one of the health insurance companies noted he had to keep his job because, since he had had cardiac surgery, he would not be able to get insurance on the individual market.

The difficulty and cost of getting insurance in that market was one of the big emphases of the program. The other, surprising, thing was how positively the health insurance companies, and their representatives such as Karen Ignagni of America’s Health Insurance Plans (AHIP), the trade group, are portrayed. The clear message was that our health insurance companies could cover everyone, without problems with exclusions for pre-existing conditions, if only everyone were required to be “in”. The message was that health insurance had to be mandated. The incredible cost of doing this while maintaining insurance company profits was never addressed. Nor was single-payer, the only reasonable alternative that would cover everyone and not cost a great deal more, precisely because it would eliminate the huge profits of the insurance companies.

Indeed, this was the message of “Sick Around the World”; in Switzerland, a country with a grand capitalist tradition and many insurance and drug companies, it turns out that the insurance companies, even before the new system was put in place, were not-for-profit. So how come Reid did not make sure this was pointed out? It turns out, amazingly, that the producers of Frontline dramatically changed the program to make the political point that they wanted to – this nonsense plan to require everyone to have health insurance which would be so amazingly costly that it would never work, and exclude any reference to single payer. And so Reid withdrew from the project. Excellent coverage of this by Russell Mokhiber of Counterpunch, including text of the exchange by the “moderator” and Ignagni[3]. Really disappointing of Frontline. Another effort of the “haves” to exclude a discussion of something that will meet the needs of all of us.

[1] http://www.pbs.org/wgbh/pages/frontline/sickaroundamerica/
[2] http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/
[3] http://www.counterpunch.org/mokhiber04022009.html

More Primary Care Doctors or Just More Doctors?

In a Health Affairs “Web exclusive”, Dr. Richard Cooper of the Wharton School at the University of Pennsylvania has two studies, “States with More Physicians Have Better-Quality Health Care,”[1] and “States With More Health Care Spending Have Better-Quality Health Care: Lessons About Medicare”[2], which have generated a great deal of discussion; in this article I will address the first of these.

Cooper’s study purports to refute a previous study published by Katherine Baicker and Amitabh Chandra previously cited on this blog, “Medicare Spending, The Physician Workforce, And Beneficiaries’ Quality Of Care”[3], a widely quoted study that demonstrated that when states were ranked by either quality of care indicators or by Medicare spending, there was a large difference between those with higher numbers of specialists (costs up, quality down) and generalists (quality up, cost down). Cooper, a long-time advocate of increasing physician production -- but not with an emphasis on primary care or generalists (believing that market demand is an effective way of determining physician workforce) -- argues that increasing numbers of physicians increases quality of care, regardless of whether they are family physician/general practitioners (FP/GP) or specialists, and identifies what he sees as flaws with the statistical assumptions and analysis in the original Baicker and Chandra article. Cooper looks at regions, and notes that the South has low numbers of both specialists and generalists and low quality, the Northeast has high numbers of specialist and low numbers of generalists and pretty high quality, but that the Upper Midwest, Northwest, and Northern New England states, with high quality and high levels of FP/GPs are what creates this result (seeming as if more FP/GPs improve quality). He believes that this is because these states are relatively wealthy, have relatively low numbers of poor and minorities, and perhaps more progressive social policies demonstrated, for example, by the lower rates of incarceration. Some of these are good points; places that have a lot of resources, both in terms of money and social capital, do well; it does not address the issues of the incredibly higher cost of medical care in the Southern New England and Mid-Atlantic states compared to the three areas above, which are very probably the result of the high level of specialists compared to generalists. Cooper does not address cost at all.

Baicker and Chandra respond to this article in the same web issue of Health Affairs,[4] particularly addressing both Cooper’s misinterpretation of their data, and (in their assessment) poor use of statistics in his own study. (I will not try to summarize these issues, which involve the use of correlation, weighting and regression analysis; those of you who are expert enough in statistics can read the article.) They conclude that, properly analyzed, Cooper’s data (as opposed to his conclusions) supports their conclusions in the original 2004 study that higher numbers of FP/GP doctors improve quality measures and higher numbers of specialists do not. They take issue with his title and main theme, ““Quality is better in states with more physicians, both specialists and family physicians”, saying “A more careful statement would be, ‘Quality is better in states with more family physicians, but no significant association was found for specialists.’” They state, in pointing out that correlation shows direction but not in magnitude:

“The numbers of specialists and generalists per capita may have identical correlations with quality, but they have very different size effects on quality. Cooper’s own exhibits suggest that this is the case—and that generalists have a dramatically bigger effect on quality than specialists do....you would have to add roughly ten specialists per capita to move up ten spots in the quality ranking, but you would only have to add one generalist per capita to move up the same ten spots. And, apparently, even the small effect of additional specialists on quality is statistically insignificant.”

Philip Musgrove, deputy editor of Health Affairs, who wrote the Introduction to Cooper’s article, makes this point in the most recent issue of Health Affairs, which contains a series of letters relating to these articles (including letters by both Cooper and Baicker and Chandra). In responding to a letter by John Frey (see below) that asserts that Cooper’s viewpoint is supported by Musgrove, the latter endorses the analysis of Baicker and Chandra, writing “Cooper’s analysis actually agrees with theirs [Baicker and Chandra’s], since his own results show that the presence of more specialists has a much smaller (about a tenth as large) effect on quality than the presence of GPs has.” [5] Of note, Cooper’s response contains no such acknowledgement.

The letter from Dr. Frey, a leading family physician and academic who is Professor and Chair Emeritus in the Department of Family Medicine at the University of Wisconsin, suggests that:

“To test Richard Cooper’s hypothesis that it is simply more doctors, not the mix of specialty/generalists, that makes a difference in access, quality, and cost, why not close down all generalist training programs (which are well on their way toward that goal anyway, with the choices made by U.S. medical students) and see what happens? Managing complex multiple comorbidities, managing urgent and unorganized health complaints, or providing primary and secondary preventive care to large populations of chronically ill patients would be done by an increasing cadre of subspecialty providers.”[6]

Implicit in Frey’s suggestion is that they (the subspecialists, sometimes, to distinguish them from generalists, called “partialists”) would not, and perhaps could not, do so. I absolutely agree. While I do not urge the adoption of such a plan (and I’m sure Dr. Frey really does not either) any more than I advocate closing volunteer safety net clinics to stop “bailing out” government and society from the consequences of their failure to act to meet the basic health needs of all our people, I have no question but that the results would be exactly what Dr. Frey implies. And I have no doubt that the subspecialists would overwhelmingly agree. The “Joint Principles of the Patient Centered Medical Home” developed collaboratively by the American Academy of Family Physicians (AAFP), the American College of Physicians (ACP, representing internal medicine doctors), the American Academy of Pediatrics (AAP), and the American Osteopathic Association (AOA) and endorsed by the Patient Centered Primary Care Collaborative (PCPCC)[7], an industry-led coalition, never specify that these services must be provided by an identified primary care doctor, but it is very unlikely that there are many subspecialists who would choose to have to provide all these services.

However, Frey is correct about the fact that medical students are voting with their feet and running from primary care. Unquestionably, while there are many reasons that medical students might choose one specialty or another, the major issue in the dramatic change away from primary care in recent years ere is expected income combined with medical debt. As I have previously noted, much of this income differential is not “market” driven but simply reimbursement driven. If nothing is done to change the circumstances that have produced this movement, Frey’s ironic suggestion might become de facto true, and we will all suffer for it. Unfortunately, the work of scholars and policy people such as Cooper, advocating simply increase in the number of physicians without attention to the composition of the physicians workforce, may hasten rather than slow, this disastrous outcome.

[1] Cooper RA, “States with More Physicians Have Better-Quality Health Care,” Health Affairs 28, no. 1 (2009): w91–w102
[2] Cooper RA, “States With More Health Care Spending Have Better-Quality Health Care: Lessons About Medicare”, Health Affairs 28, no. 1 (2009): w103–w115
[3] Baicker K & Chandra A, “Medicare Spending, The Physician Workforce, And Beneficiaries’ Quality Of Care”, Health Affairs, 7 Apr 2004;W4.184
[4] Baicker K & Chandra A, “Cooper’s analysis is incorrect”, Health Affairs 28, no. 1 (2009): w116–w118
[5] Musgrove P, “Primary/specialty care: an author responds”, Health Affairs Mar-Apr 2009;28(2):594-5.
[6] Frey JJ, “Test the primary/specialty care hypothesis”, letter, Health Affairs Mar-Apr 2009;28(2):594.
[7] “Joint Principles of the Patient Centered Medical Home”, February 2007, http://www.pcpcc.net/node/14

Immigrant and Refugee Health

The New York Times (March 29, 2008) has a front-page story about the challenges faced by clinics caring for large numbers of immigrants and refugees.[1] It focuses on the International Clinics at Hennepin County Medical Center in Minneapolis, MN, and particularly emphasizes issues confronting Somali refugees and their caregivers.

Many of these issues, including language and cultural difficulties, and the problems of poverty that often afflict people in these groups, are not new to the United States. Our multi-cultural, multi-ethnic (and sometimes “melting pot”) society has long tradition of immigrants arriving from other countries and cultures and presenting “new” challenges to the social service and health care systems. Each group of new arrivals has been seen as “different”, and many that were previously seen as outsiders, such as Jews, Italians, and Irish, have become insiders[2][3],[4][5] One obvious exception has been African-Americans, whose ancestors were brought here as slaves, and who have never (unlike the ethnic groups in the books referenced above, have never “become white”; indeed, that very term derives from the special place of oppression that has been reserved for black people in this country.

One point not really addressed by the Times article is the difference between immigrants and refugees. While the US has had both over its history, immigrants have always been the dominant group. Refugees came after WW II, and after the Vietnam war, and after every war. Immigrants are searching for a better life for their families, and despite the hardships, they have chosen to make the change. They are, historically and currently, different people from those who stay, more willing to take risks, more buoyed by hope. Refugees, on the other hand, are fleeing often horrific situations; they are not coming by choice but by lack of choice. Life in their homeland is intolerable. Thus, while both groups may hold onto their cultural values, beliefs and habits, for refugees this may be all that they have.

The Times notes that, largely in response to pressures from Somali refugees who will not allow themselves to be delivered by male physicians, the obstetrics staff at Hennepin County has become almost entirely female. This decision has been made, de facto or de jure, but many other issues also exist that are not as easy to resolve? When does respect for the culture of someone else (a good thing, generally) become limited by the implications? Providing interpreters is good but very expensive; providing female obstetricians and midwives is probably good, and may be part of an overall transition in obstetrics. But what about “female circumcision”, genital mutilation, also common among Somali women? If this is a core “cultural” tradition, highly desired by a refugee (or immigrant) group, does this mean it should be provided? I think not. A similar example (though not specific to Somalis, let me be clear): If a woman is battered by her partner and this is explained as “part of their culture”, would this make it any more ok? Again, I think not, but these examples illustrate the continuum of decisions that have to be made in delivering health care to refugee and immigrant (as well as “native”) people.

Refugees are also much more likely than immigrants to have experienced terrible personal tragedy; the deaths of friends and family members, often in violent and gruesome ways, rape, mutilation. Post-traumatic stress disorder (PTSD) is common. On the “plus” side, once having been granted refugee status, they are legal in the US, and eligible for certain benefits. Many of our immigrants are “illegal”; they do not have papers and are increasingly denied access, as the Times article points out, except in certain “safety net” venues, or until they come in to the emergency room very ill. Our increasingly restrictive laws see limiting access to health care as both a way of saving money (“why should we pay for these illegals?”) as well as being a punishment.

Which, as it often does on these pages, brings us back to money. Why does Hennepin County Medical Center bear the burden of this care? Why are there not other medical centers and doctors throughout the Minneapolis area taking equal responsibility for poor and uninsured immigrants and refugees? Why is this also a problem in every other major city, including my town of Kansas City and my state of Kansas, in which there are no publically funded hospitals? Everyone wants the best of care for themselves and their families, but the definition of “best” is very open to question (not only for cultural, but for medical reasons as well, as I have often discussed). In addition, the costs may become untenable. There is only so long that honorable people can say “Do for me (and mine); save the money on you (and yours).” Eventually we need a comprehensive and rational care system, which deliveries necessary care to all before there are frills for any.



[1] Grady D., “Foreign Ways and War Scars Test Hospital”, New York Times, March 29, 2009.
[2] Roediger DR. Working Toward Whiteness: How America's Immigrants Became White: The Strange Journey from Ellis Island to the Suburbs. Basic Books. New York. 2005.
[3] Ignatiev N. How The Irish Became White. Routledge. New York. 1995
[4] Brodkin K. How The Jews Became White Folks And What That Says About Race In America. Rutgers University Press. Piscataway, NJ. 1998
[5] Guglielmo J. Are Italians White?: How Race is Made in America. Routledge. New York. 2003.

Medicare Costs in Rural America: A case of reaping what we haven't sown?

This guest column is by Donald Frey, MD. Dr. Frey is Professor and Chair of the Department of Family Medicine at Creighton University in Omaha, Nebraska, and an expert in rural primary care. He is also the accomplished author of the fiction book "Medicine: a Novel"

The recent New England Journal of Medicine article by Elliot Fisher describing the latest data release from the highly respected Dartmouth Atlas Project[1] underscored what many have known for some time—Medicare costs are soaring.

The study compared state and regional growth in Medicare costs between 1992 and 2006. But in addition to the overall rise in costs, the continued marked variance among costs across all states/regions was particularly disturbing. These cost discrepancies, as in previous studies, were independent of patient severity and disease status. In some instances, states that had previously been low on the cost index had jumped significantly. Others showed relatively moderate increases. None showed cost reductions.

The figures for Nebraska are particularly interesting. Sitting squarely in the center of the country, Nebraska has two metropolitan areas (Omaha and Lincoln) and a large region of rural and frontier counties. In 1992, Nebraska was at the top of the heap when it came to efficient use of Medicare dollars, ranking 51st out of 51 states and territories in Medicare costs per enrollee.

But something funny happened on the way to the 2006 survey. Costs per enrollee skyrocketed 5.3 % and Nebraska soared to 39th in Medicare spending. Interestingly, the greatest cost increases were in the most rural portions of the state.

What happened? The authors offered very little in the way of specificity. Undoubtedly, further analysis of these data may result in significant insights into why costs are rising more rapidly in specific areas as opposed to others. But at present, it is important to note what the extensive earlier work of the Dartmouth Atlas project has already shown.

Repeatedly, the Dartmouth researchers have shown the positive correlation between the percent of state physician workforce comprised of primary care physicians and lower costs and improved outcomes. States with higher concentrations of specialty physicians tended to have higher costs and poorer outcomes. Such findings are right in line with the international data generated by Dr. Barbara Starfield at Johns Hopkins.

All of this would be consistent with Nebraska's status in 1992. At that time, Family Medicine was the backbone of health care delivery in the state, particularly in rural areas. Even in the metro areas of Omaha and Lincoln, primary care was readily available and widely utilized. Four residency programs, all with a strong rural component, produced 32 residency graduates per year, many of whom remained in state to practice following graduation.

But in the ensuing years, Nebraska's urban centers began investing heavily in developing overlapping and competing subspecialty services. The number of medical students entering Family Medicine plummeted, and urban hospital systems found that a cost effective way to cover their primary care needs was to loot rural areas of their physicians. Rural communities began to experience increasing difficulty meeting their workforce needs. Some towns saw workforce reduced by more than 50%, with some 4-5 doctor communities reduced to only 2 Family Physicians.

Physicians in these communities suddenly found themselves overwhelmed. Local systems that previously were highly organized with respect to call coverage, division of labor, procedural practice, etc., were now finding it impossible to continue providing the same level of service in the face of such huge demand simply for basic care. Thresholds for referral began to lower. In order to manage the most basic community needs, cases that previously would have been readily handled locally by community Family Physicians had to be referred out to regional centers. These centers, specializing in more intensive—and more costly—care, began to manage these patients instead.

As the demand for more intensive (and more lucrative) care increased, urban health system recruitment of sub-specialists intensified, with an all-too-willing crop of medical graduates flooding local sub-specialty training programs, compromising even further the availability of Family Medicine graduates to "backfill" rural areas.

The result? Care that was more costly, further removed from the community, with no discernable improvement in quality.

Whether changes in workforce alone can fully explain Nebraska's explosion in Medicare costs is certainly open to question at this time. Hopefully, further analysis of state-wide Medicare costs, along with comparative data from other states will more fully illuminate this issue. In the meantime, given the exhaustive data regarding primary care and Medicare costs already produced by the Dartmouth Atlas project, the notion that Nebraska's significant rise in Medicare costs could be best explained by a statewide shift away from primary care remains a disturbingly plausible possibility.

If this is the case, rural states like Nebraska, where Family Medicine has traditionally provided a greater percent of overall care, may turn out to be harbingers of even greater increases in overall healthcare costs for the nation, as even those states that traditionally have relied less on primary care for health care delivery shift an even greater percent of their workforce to sub-specialties.

Regrettably, the influential Association of American Medical Colleges (AAMC) remains steadfast in its opposition to restructuring residency training positions to reflect the growing national need for Family Physicians, instead advocating for an increase only in total medical school student enrollment, with the seemingly blind-faith position that “the market” will drive graduates to where they are needed most.

An unregulated market that’s supposed to make everything work out fine? Certainly sounds familiar in 2009.

If the planned expansion of medical school enrollment by 30% occurs as planned, along with a continued insistence that market forces will auto-correct physician workforce, the work by Fisher, Starfield, Wennberg, Shi, and so many others[2] would predict that health care outcomes in this country will actually worsen because of the AAMC’s actions. If this occurs, it will reflect a perverse twist on one of the oldest principles of agriculture known to everyone here in Nebraska—rather than reaping what we sow, the outcomes we inherit will instead be due to what we haven’t sown.

[1] http://content.nejm.org/cgi/content/full/360/9/849

[2] Many of these articles are previously referenced on this blog. See especially December 11, 2008.

Mexican Murders and US Guns

The “drug war” violence in Mexico has been getting an increasing amount of press in the last few days. Over 1600 murders in Ciudad Juarez, Chihuahua, across the river from El Paso, Texas, last year alone; more than in Baghdad. Now the “spillover” into the US is big news. In the New York Times on March 22, 2009, Randal Archibold’s article “Mexican Drug Cartel Violence Spills Over, Alarming U.S” [1] talks about the increasing murders in many US cities linked to that violence; today, March 24, 2009, Enrique Krauze bemoans the characterization of Mexico as the being primarily the home of drug cartels and murderers, describing the work Mexico has done and the work of its democracy, noting that “…Nor, for that matter, did anyone ever see Al Capone and the criminal gangs of Chicago as representative of the entire country.” [2] Mr. Krauze has a point.

But, whatever the injustice of characterizing Mexico by the drug cartel murders, the big news in the US is its "spillover" here. What no one is talking about is the fact that the US gun laws (or lack thereof) is at fault; the US is an open shopping market for automatic weapons for the drug lords – not to mention home-grown criminals like Lovelle Mixon who killed 3 (may soon be 4) police officers in Oakland, California on March 21, 2009.[3] In this same week, an Arizona judge threw out a case against a gun dealer in Glendale accused of selling over 200 guns to arm cartels.[4]

Let’s get right down to it. Guns don’t kill people, people with guns kill people. And the US is a candy store for weapons that have no place in hunting. A large part of the blame belongs to the National Rifle Association’s intransigent stance against any regulation of firearms, including automatic weapons, and even more to the federal and state legislators who either because of their own beliefs or fear of the power of the NRA continue to do its bidding. And if they act on those beliefs, or on that fear, they have to accept the results, intended or not. Any one of those legislators or congressmen who bemoans these murders but has opposed gun control regulation should look at the blood on his/her own hands.

[1] Archibold R, Mexican Drug Cartel Violence Spills Over, Alarming U.S, NY Times, March 22, 2009
[2] Krauze E, The Mexican Evolution (Op-Ed), NY Times, March 23, 2009
[3] Healy J, 3 Officers Are Dead After Shootings in Oakland, NY Times, March 21, 2009
[4] McKinley JC, Prosecutors Seek Appeal in Dismissal of Gun Case, NY Times, March 19, 2009

PSA Screening: What is the value?

Two studies published in the New England Journal of Medicine on line on March 18, 2009 regarding the use of prostate-specific antigen (PSA) screening for prostate cancer have been getting a lot of coverage in the popular media, including NPR and the New York Times. The reason is that these studies do not, overall, indicate that such screening saves significant numbers of lives. In the US study of 77,000 men, the PLCO trial, there was no significant difference in mortality in the group receiving PSA screening (92 deaths in the study group vs. 82 in the control group),[1] while in the European study of 182,000 men, there was a very small reduction in mortality, barely achieving statistical significance.[2] Dr. Allan Brett, summarizing the article in “Journal Watch: General Medicine” notes that “To prevent one prostate cancer death, 1410 men had to be screened, and 48 additional cases of prostate cancer had to be diagnosed and treated. All-cause mortality did not differ in the two groups”.[3]

In fact, the US Preventive Services Task Force, the committee that evaluates prevention strategies including screening tests, has long indicated that there is insufficient evidence to recommend for or against prostate cancer screening using PSA, and recently amended that statement to recommend against screening in men over 75:

“The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of prostate cancer screening in men younger than age 75 years..
The USPSTF recommends against screening for prostate cancer in men age 75 years or older.”[4]

So what is the fuss? Why does the Times have a front page article entitled “Studies show prostate test saves few lives”.[5] Well, mainly because, despite the lack of recommendation by the USPSTF, doctors have been ordering PSA tests for men over 50 for years. The American Urological Association has recommended it: Regarding early detection of prostate cancer, the expert panel concluded that routine PSA testing should be offered in men when:

“Age is 50 years and greater, unless the man has increased risk factors, such as genetic predisposition via family history or African-American racial status. In these "at risk" men, PSA testing should be offered between 40 - 50 years of age.”[6]

That is to say, there were conflicting recommendations. Perhaps unsurprisingly, the urologists, who are the people who see the prostate cancer and operate on it, had a different sense of both the prevalence of the disease and its bad outcomes, and their ability to alter those outcomes through intervention. But mainly, it is the issue of looking at intermediate variables rather than the outcomes of significance. In this case, looking at whether the PSA can diagnose prostate cancer, rather than whether diagnosing (by any means) and treating prostate cancer saves lives.

What? How can finding a cancer early, and treating it, not save lives? “Why,” you might well say, “I have a friend who had a routine PSA screening, and it was high. He had a biopsy, they found cancer, they operated on him, and now he is alive. Isn’t that a good thing?” Well, it’s certainly good that he’s alive. The question is: Would he not be alive, or would he be suffering the pain of metastatic prostate cancer, if he hadn’t had the cancer found and treated? And that is the question we do not know the answer to. And that is why the recent studies are so important.

Simplistically, there are two kinds of prostate cancer: the bad kind that will kill you after probably creating very painful metastases to bone, and the kind which will be lying indolently and asymptomatically in your prostate when you die of something else. But we have no way of distinguishing between these by any of our diagnostic tests. And, more important, we have no idea whether treatment makes a difference – that is, whether the people who die without treatment would have died even if treated, and if the people who survive with treatment would have survived even if not treated.

This is a really big thing. Why would we want to screen lots of men to find a relatively few cancers that we can treat when we don’t even know if treatment makes a difference in death? In the US study, it didn’t. In the European study, it made a small difference in death from prostate cancer, but it took screening 1410 men and treating 48 to save one life from prostate cancer. And the overall death rate, from all causes, was no different.

Better safe than sorry? Maybe, but what the studies did not look at was the side effects from treatment. What about those other 47 men who were treated and whose lives were not saved? The fact is that, while there are many treatments for prostate cancer, all have a significant “side effects”. Treatments such as radical prostatectomy, external beam radiation, radioactive “seed” implants, and newer procedures such as “green laser” very frequently lead to varying degrees of impotence and incontinence, not minor inconveniences! Hormone therapy, whether by removal of testosterone production by removal of the testicles (orchiectomy) or by administration of anti-androgens, have other effects including “cosmetic” ones such as feminization (weight redistribution, breast enlargement) and serious weight gain that can lead to greater morbidity and mortality. So treatment is scarcely benign. And, because we should not forget cost, the cost of the massive screening by PSA, followed by the further testing and procedures and treatment that follow it, is enormous. These studies demonstrate that even without considering cost-effectiveness or the morbidity of treatment, there is little or no benefit to screening in terms of lives saved.

However attractive the idea of screening and early detection is, both to public-health focused primary care physicians like me and to people in general, screening is only of value if it can not only identify disease in the pre-symptomatic phase, but if there is effective treatment that has a patient-important outcome: lower mortality or greater quality of life. PSA screening, at this point, does not meet this criterion.

The NPR segment covering this issue ended with a primary care physician emphasizing that the answer was not just looking at a single PSA value, but rather looking at the change over time. He noted that the ability to do this, as well as to complement monitoring the trend in PSA with serial rectal examinations, was one of the strengths of the primary care relationship. But, with all due respect, and with the great respect I have for primary care, this misses the point. Such a relationship, with its ability to monitor trends, may increase the likelihood of an accurate diagnosis of prostate cancer (i.e., a PSA of 10 that does not change over time may be less likely to mean cancer than one that goes from 2 to 4 to 6) but this still considers a positive outcome to be an accurate diagnosis rather than a decrease in mortality. Absent our ability to distinguish between “good” and “bad” prostate cancer and to know that treatment makes a difference in patient-important outcomes, greater accuracy in diagnosis may just lead to greater cost and greater morbidity.


[1] Andriole GL et al. Mortality results from a randomized prostate-cancer screening trial. N Engl J Med 2009 Mar 26; 360:1310. published on line at http://dx.doi.org/10.1056/NEJMoa0810696)
[2] Schröder FH et al. Screening and prostate-cancer mortality in a randomized European study. N Engl J Med 2009 Mar 26; 360:1320. published on line at http://dx.doi.org/10.1056/NEJMoa0810084
[3] Brett, A, Journal Watch General Medicine March 18, 2009
[4] http://www.ahrq.gov/clinic/uspstf/uspsprca.htm
[5] New York Times, Thursday, March 19, 2009, p.1
[6] http://www.usrf.org/news/2000PSAguidelines.html

Bargaining down the medical bills

A recent article in the New York Times health series, March 13, 2009[1], discusses the ways in which patients, particularly those who are uninsured and without adequate resources, can and do bargain with doctors and hospitals for reduced charges and payment plans. At one level, it is very distressing. As one of my closest and wisest friends says: “How sad--a ‘how-to’ guide for bargaining over medical expenses”.

At another level, given the horrific situation in which so many people find themselves when facing medical expenses, I’m sure that this “how-to” guide can be very useful and important. It is not only the poor and uninsured that are affected; many, many people who thought that they had adequate health insurance find themselves very unpleasantly surprised when actually confronted with medical bills. Remember, all of the people featured in Michael Moore’s film “Sicko!” had health insurance!

But it remains true that one of the most nauseating facts about the “business” approach to medical care is that it leaves those who are least able to pay with the greatest bills. The norm in business is to give discounts to large purchasers, but when this is applied to the health care of people, it is bizarre and offensive – large purchasers get big write-offs, poor people get charged full price! And this is not just a “little” more. I told the story of my hernia surgery – outpatient, in at 7 am, home by noon – and the $10,000 hospital (not doctor) charge. My insurance company paid $1,600, told me to pay $400, and the hospital wrote off the $8,000 as “contractual adjustment”. But if I was uninsured I would have gotten a $10,000 bill! How wrong is that? And, if I couldn’t pay and the hospital (after dunning me, sending me to collection agencies, and ruining whatever credit I might have left) finally wrote off my bill, they would claim $10,000 in “uncompensated care”, even though the insurance company would have only paid the $2,000. And our federal government exacerbates the situation by forbidding providers to charge anyone less than they charge Medicare. Charge Medicare; not what Medicare will pay. This is meant to ensure that Medicare is getting the “best rates” compared to private insurers, but it is the uninsured patient caught in the middle. If we charge $100, and Medicare will pay $45, it is illegal to charge the uninsured patient less than $100.

Therefore, I applaud the Times for showing how most hospitals and doctors are willing to negotiate rates and payment plans for needy patients. It is a small tool for the individual person to have in dealing with giants. Of course, the greatest beneficiaries will be the educated New York Times reader who has lost her job, lost his insurance, fallen on hard times through illness, but still has the skills to engage in such negotiation. I suspect that the vast majority of people who need these special arrangements are unlikely to read the New York Times, and often are poorly educated, non-English-speaking, and generally disempowered, making them both unaware that such “deals” can be struck, and without the skill sets necessary to negotiate successfully.

The whole system of charges, contractual adjustments, allowables, payments, is a nightmare maze of “gaming” between providers (e.g., hospitals and doctors) and payers, catching actual people in the middle. I have used “horrific”, “nauseating”, “bizarre”, and “nightmare” above to try to describe the current system, but feel as yet unsatisfied. “Indignity” doesn’t begin to describe it; “insane stinking mess” comes to mind. People should not have to learn how to bargain to get the best deal on their health care. When Michael Moore, distinguished health economist Uwe Reinhardt of Princeton, and director of the Health Insurance Association of American Karen Ignani appeared on “Oprah!” some months ago, Oprah asked Ms. Ignani (and I paraphrase, I don’t have the transcript): “So if I need a $200,000 procedure, why don’t you just pay it?” Flustered, Ignani said, “Well, you presume that the $200,000 is in fact what the procedure is worth; other hospitals may chart less …” – Oprah interrupted her: “I’m sick!”, she said, “I don’t have time to go shopping around to six different places to see where I can get the best deal!” Unsurprisingly, the audience, made of of regular people, not pundits, applauded wildly.

Clearly, we need a way out, and the way out is universal health care, where everyone gets a covered, for the same amount for the same services, preferably (mainly because of the cost savings it allows) by a single payer. As in civilized countries. Where hospitals are globally budgeted and physicians know what they will be paid for a particular service to a patient, whether s/he is a millionaire or a homeless person.

[1] Alderman L, “Patient money: Bargaining down the medical bills”, New York Times, March 13, 2009.

“Conservative” Drug Prescribing

While Victor Fuchs in his (somewhat pessimistic) commentary on “Reforming US health care” in a recent JAMA observes that one problem with the Clinton-plan era was that the public focused on “…`greedy drug companies’ and ‘overpaid’ physicians rather than on systemic problems in funding, organization, and delivery of care.”[1], there can be little doubt that the pharmaceutical industry has an enormous influence on the delivery of health care, much of it negative. The Association of American Medical Colleges (AAMC) issued a recent report expressing serious concern about the influence of the pharmaceutical industry on medical education[2], while recent media coverage of researchers’ ties to the drug companies has been widespread. Any number of books and articles documenting the influence of the pharmaceutical industry on physician choice of drugs have been published.[3] Gordon Schiff, MD, co-author of a recent Commentary in JAMA entitled “Promoting more conservative drug prescribing”,[4] has said that while the pharmaceutical industry promotes the idea that it works in “partnership” with physicians in the care of patients, and thus that the 3 groups have the same interests, the fact is that the wider use of many of the principles he promotes would not be in the interest of the drug companies.

Schiff and William Galanter, his co-author, provide a list of 25 principles for more conservative prescribing, grouped under 6 larger headings that are discussed at greater length in the article. Unsurprisingly, several of them would result in the use of fewer and cheaper drugs, and they would thus, in fact, decrease drug company profit. These include:

Think Beyond Drugs: to first consider the use and effectiveness of other, non-pharmacologic approaches to treatment of a person’s symptoms, such as diet, exercise, physical therapy, stress reduction, and “…even surgery where appropriate.”. This is exactly what virtually all review articles about treating most conditions suggest, and yet physicians frequently see these as pro forma, not to be seriously considered except as adjuncts to drug therapy, as they reach for their prescription pads.

More strategic prescribing: “Too often clinicians reflexively prescribe for each symptom a patient experiences.” Sometimes this may be appropriate, but it clearly increases the risk of drug-drug interactions, as well as the possibility that drugs prescribed for one symptom may make another worse (requiring yet a third drug?). This leads to:

Heightened vigilance regarding adverse effects. Drugs have adverse effects. Some of them are less common, and less known by physicians, but no less serious for the patient who experiences them. Many of these effects are not discovered before mass marketing because they are relatively uncommon – or worse they are discovered or suspected by the manufacturer and the information is suppressed. Vioxx®, anyone?

Caution and skepticism regarding new drugs is my personal favorite, violated every day, and the most important place where the interests of drug companies diverge from those of physicians and patients – though the latter two groups often miss this. The marketing of new drugs is where pharmaceutical companies make their money; it is these drugs that are heavily advertised in the medical journals (including JAMA), and to consumers in popular magazines and on TV. It is these new drugs that fill the sample closets of physicians, drugs still under patent and highly profitable. If patients respond to the samples, then they will want the doctors to prescribe them. Rarely are they the first “drugs of choice” and never are they low-priced or generic. Cost may well be the less important issue of prescribing generic drugs – the fact that their patents have expired means that they have been out long enough for us to know how well they work and what their side effects are, something we well may not know about the newer, highly-promoted drugs. “Although many payers stress prescribing generic medications for cost savings,” Schiff and Galanter write, “another important value of generics is the greater safety knowledge inherent in their longer track record compared with more newly marketed brand name products.”

The other two broad headings that they identify:
Shared agenda with patients, and
Weigh longer-term, broader effects
are also both very important. Regarding the latter, many drugs that seem to work initially may lose their effectiveness (relief of the undesired symptom) but perhaps not their side effects (undesired effect) over time. This can also affect the broader community, with emerging resistance to antibiotics being a prime example.

The idea of a “shared agenda with patients” seems to be redundant to the practice of medicine – after all, shouldn’t all of our work be to enhance the well-being of our patients? However, there are many times when, because the agenda is not made explicit to and by both parties, and negotiated between physician and patient, they may end up not working effectively together. Some physicians still believe in the “miracle, mystery and authority” of the physician, exemplified by the title character in “The Chief of Medicine”, chapter 1 of Howard Brody’s classic book “The Healer’s Power”.[5] Others, less authoritarian, are often frustrated by the patient’s lack of “compliance” (or “adherence”, a newer term that seems to me to be no less judgmental) to the doctor’s “orders”. In reality, most of the time the physician (unless actively performing surgery, giving an injection, etc.) is an advisor or consultant to the patient; even the ritual of giving a piece of paper with writing on it (a prescription) is only advice, until the patient takes it to a pharmacy, exchanges it and money for a drug, and then takes the drug. Some of the lack of understanding by patients may be from the above-noted authoritarianism, but much more is cultural (differences in the culture of the doctor and the patient, which includes although it is not limited to, ethno-cultural and language differences), abetted by the lack of time for adequate communication in the typical short visit required by the fee-for-service system. Inadequate communication about drug therapy may be part of this.

The patient may be most interested in relief of a symptom, while the physician, with a longer term teleological view of illness, is more worried about downstream effects of an untreated disease; thus they may not share an agenda. Patients, while perhaps not getting the “full-court press” that physicians do about new drugs, certainly see the advertisements, and they (at least in the US) are often enamored by the “newer is better” view we have of most things (technology, etc.). When we see the lists of medications some patients are on, we may begin to believe that the main reason they don’t have more drug interactions is because they don’t take all the medication prescribed; as physicians, however, we must be concerned that the ones they don’t take may be the ones that we think are more important. Thus, limit, to the extent possible, polypharmacy.

Finally, there is the issue of cost. Generic drugs may be good for most conditions because they are the best known, safest, and first-line choices, but indeed they save money as well. And with the increasing cost of medicine being driven at least in part by drug costs, this is no small matter. Schiff and Galanter’s principles are well-worth implementation by all physicians, and indeed consideration of these issues should be demanded by knowledgeable patients.

[1] Fuchs VR, “Reforming US Health Care”, JAMA 4Mar09;301(9):963-4.
[2] Association of American Medical Colleges. “Industry funding of medical education: report of an AAMC Task Force”. AAMC. Washington DC. June 2008.
[3] E.g., Angell, M. The Truth about drug companies: how they deceive us and what we can do about it. Random House. New York. 2005.
[4] Schiff GD, WL Galanter, “Promoting more conservative drug prescribing”, JAMA 25Feb09;301(8):865-7.
[5] Brody H. The Healer’s Power. Yale University Press. New Haven. 1992.

“The Feminization of Medicine and Population Health…”

…is the title of a Commentary in the Feb 25, 2009 issue of JAMA, by Susan Philips and Emily Austin from Queens University in Kingston, Ontario, Canada.[1] It is a very interesting piece, citing data and also speculating on the implications of the increasing number of women in medicine. They note that there has been a steady increase in the number of women in medical school for the last 50 years, and that women now comprise 43.5% of graduates of US schools. They enter primary care specialties, however, at much higher rates than their male counterparts. In 2007, 33% of female Canadian graduates chose family medicine as opposed to 22% of males; while either of these numbers (and certainly the mean) would be great by US standards, it demonstrates a “gender gap” even in Canada, where many of the forces discouraging entry into primary care in the US are much lower (there is much less medical debt, income differentials between primary care doctors and specialists are less, there is a system built around primary care, and there is a national health insurance program), there is, apparently, great incentive for medical school graduates, especially men, to choose non-primary care specialties. “Women account for a minority of currently practicing Canadian physicians (37.9%) but a majority of that country’s family physicians (58.6%).” In the US, similarly, “fewer than half of medical school graduates are women (43.5%) but they account for the majority of residents in primary care programs”. The authors indicate that data from the UK, most of Europe, and Australia show similar trends.

It is a good thing that women physicians enter primary care at higher rates than men, because we need more primary care physicians, as demonstrated by much data that has been previously presented in this blog (Dec 11, 2008, and others). However, the authors also note that “Recent reports identifying lower productivity among female physicians have debated whether more women in medicine will exacerbate a shortage of physicians by limiting patient access to care….In general, women are less likely to work excessive hours or to work past the typical age of retirement. Female physicians see fewer patients per hour…”. The impact of this can be understood in terms of Robert Bowman’s Standard Primary Care (SPC) year (“10 myths regarding primary care in the future”, Jan 15, 2009), and suggests that the lower number of SPCs generated by NPs may also be in part associated with gender. In addition, a recent report from the Robert Graham Center cites data showing that while women enter primary care at higher rates than men, they are much less likely to enter rural practice, thus not helping to resolve the rural/urban health disparity problem.[2]

But Phillips and Austin go further. Finishing the sentence above, the write (and cite references for) “Female physicians…demonstrate better communication skills and include more preventive care than their male counterparts.” They note that the issue is health outcomes, not simply access to health care, a point I have repeatedly made. They note that:
“In developed countries, the number of physicians per capita, alone and separated from any analysis of the nature of care provided, has no association with mortality rates. In 1978, Cochrane examined how a number of proximate factors, including gross domestic product, physician density, sugar consumption, and cigarette smoking, were associated with mortality
rates in 1960 and 1970 across 18 developed countries.[3] He found no association between physician density and any of the standard mortality rates and concluded that health service factors were relatively unimportant in explaining differences in mortality among developed countries.”

They go on to note that in comparing physician densities and life expectancy, Canada has the lowest density among developed countries but life expectancies comparable with the Netherlands, the highest density, and better than the US, which is intermediate in density, and that the highest life expectancy is in Japan, with a physician density just higher than Canada’s. They note the work of Macinko and Starfield, which I have referenced before, showing that the strength of a country’s primary care system is most associated with good health outcomes[4], not physician density. Again, as I have discussed before, having more doctors working at the tertiary point of the health workforce pyramid does not improve health outcomes. It is important to note that this is referring to highly developed countries with large physician workforces; clearly there is a threshold (not reached in much of the world, and even in many rural areas of the US) below which there are too few physicians to meet health care needs. But there is also a density at which outcomes plateau, and even, at the highest levels, decreases because of the effect of unnecessary interventions.[5]

This does not, however, mean that having more women physicians will improve the quality of health care, not to mention compensate for their lower number of patients seen and SPC years. It clearly will not meet the needs of those people who live in rural areas, where women, even in primary care specialties, are less likely to practice. Phillips and Austin hope it will:
“Seeing more patients more frequently may not increase the life expectancy of those patients, but spending more time with each patient, hearing and listening more effectively, and including
more preventive measures (all characteristics identified in studies of female physicians) may result in fewer but more effective clinical encounters rather than a greater volume of encounters.”

Perhaps this will be true, I would certainly hope so. They are more certain that the benefit from women becoming primary care doctors will have benefit:
“Because women across time and place tend to become primary care physicians, the feminization of medicine may well have beneficial health outcomes possibly attributable to the nature of the care they provide irrespective of women’s lower volume output relative to that of men. Such an improvement in outcomes may occur because of the practice styles of women, who outnumber men in primary care, or because of the nature of generalism. Either way, as women increasingly enter medicine and become generalists, rather than being a liability by
not working excessively long hours or abandoning parenting, the quality of the care they provide may result in improved population health.”

So to the extent that having more women in medicine leads to more primary care physicians, and because of the convincing evidence that a system built upon primary care leads to improved health outcomes, this is a convincing argument (except for rural areas). The concept of “population health” is critical here, because it includes all people, not a sum of the individual people who have seen doctors.

The degree to which the practice “style” (more time spent with each patient, better communication) will enhance outcomes is more speculative. However, it certainly may, and there are few in the community who would not like to have their physicians spend more time with them and communicate with them better. I hope that this practice “style”, more characteristic of women, becomes more dominant, and I look forward to studies demonstrating that it does improve health outcomes.

[1] Phillips SP, Austin EB, “The feminization of medicine and population health”, JAMA Feb25,09;301(8)363-4
[2] Robert Graham Center, “Specialty and Geographic Distribution of the Physician Workforce: What Influences Medical Student & Resident Choices?”, pp. viii, 20. Accessed 3/4/09, http://www.graham-center.org/online/etc/medialib/graham/documents/publications/mongraphs-books/2009/rgcmo-specialty-geographic.Par.0001.File.tmp/Specialty-geography-compressed.pdf
[3] Cochrane AL, St Leger AS, Moore F. Health service “input” and mortality “output” in developed countries. J Epidemiol Community Health. 1978;32(3): 200-205.
[4] Macinko J, Starfield B, Shi L. The contribution of primary care systems to health outcomes within Organization for Economic Cooperation and Development (OECD) countries, 1970-1998. Health Serv Res. 2003;38(3):831-865.
[5] Goodman DC, Grumbach K. Does having more physicians lead to better health system performance? JAMA. 2008;299(3):335-337.

Quote of the Day (with apologies to Don McCanne)

From the New York Times, March 4, 2009.

“David Rifkin Jr., an associate White House counsel under the first President Bush who is scheduled to testify at the hearing on Wednesday, said he planned to urge Congress not to move forward with that proposal, which he said would violate the rights of Bush administration officials and set them up for prosecutions by foreign courts.

“’They want to pillory people,’ Mr. Rivkin said. ‘They want to destroy their reputation. They want to drag them through the mud and single them out for foreign prosecutions. And if you get someone in a perjury trap, so much the better.’"

Well, all I can say is: Duh. If the shoe fits. Do you think Mr. Rifkin feels the same way about prosecution of more conventional murderers, thieves and con men?

Kathleen Sebelius as Secretary of HHS

As a citizen of Kansas, I probably know more than the average American about the new nominee for Secretary of HHS, Governor Kathleen Sebelius. On the whole, I think that she is a good choice who will be effective as well as honest, without the baggage ($128K tax and close relationships with lobbyists) that Sen. Daschle had. However, Sen. Daschle gave a great speech at his confirmation hearing, pointing out that every other country with decent health outcomes starts from a base of primary care, moving up through secondary and tertiary care if they can afford it. The US, on the other hand, starts with funding tertiary care, and runs out of money before providing comprehensive primary care (see picture; this is an unstable format!)

I hope that Governor Sebelius can be as articulate at her confirmation hearing, but hope much more that she will press for such important change as Secretary. While she is not a single-payer advocate, she has advocated coverage for all, which is a good start; indeed, “Cover Everybody!” should be our mantra, although there is a lot of bad and overpriced coverage out there – so Rep. Conyers’ assertion that “what we want is access to high quality health care for everybody” is really the goal.

While Gov. Sebelius, the daughter of former Democratic governor of Ohio John Gilligan and daughter-in-law of a prominent long-time Republican congressman from Kansas, was early in her career Executive Director of the Kansas Trial Lawyers Association, and as such not popular with physicians, her subsequent tenure as a legislator, state Insurance Commissioner, and Governor has been very positive regarding health care, and even healed many of the wounds with physicians. Her most important decision as insurance commissioner was blocking the sale of Blue Cross/Blue Shield of Kansas to a private company, Anthem, in 2002, saying it would raise costs for Kansans. This was a good decision, occurring during a time when the insurance industry was, across the country, consolidating its hold on health care. It gained her great popularity and was a major reason she was elected Governor later that year.

She is seen as a Democrat who is able to work across party lines, a necessary characteristic in a very “red” state, where both houses of the legislature have become increasingly dominated by the what is known as the “conservative” wing of the Republican party; whether “conservative” or not, they are ideologically driven in much the same way as the increasingly marginalized national GOP is, except here in Kansas they are in control.

I would also add, if we want to know the kind of person she is, that in 2005 I was headed down to New Orleans for a conference. Waiting at SW Airlines, I looked up from my book and saw her sitting across from me. Someone else recognized her and razzed her for not taking her state "jet". She replied, "First, it's not a jet, and second, this is not state business. I'm taking a few days to meet my husband down in New Orleans for the Jazz and Heritage Festival".
So she waited in line with everyone else, and as I helped her put her bag in the overhead rack, remember thinking "I can't imagine Arnold Schwarzenegger or George Pataki (then Gov of NY) doing this - flying with the hoi polloi on SW, personal business or not." Or, for that matter, Tom Daschle.

She has some excellent health advisors in Kansas, and if they accompany her to DC, I would be optimistic about effective change.