.
I have written about both the characteristics of medical schools (recently, in A New Way of Ranking Medical Schools: Social Mission, June 20, 2010; also Rankings of Medical Schools: Do they tell us anything?, September 5, 2009) and of medical students, including the people being accepted into medical school, the specialty choice of those graduating, and what aspects of both schools and students are associated with the kind of doctors students become (Who will care for the underserved? The role of off-shore medical schools, June 2, 2010, Primary Care and Residency Expansion, January 7, 2010, "Uncomplicated" Primary Care?, October 8, 2009, Medical Student Selection, December 4, 2008). A recent study, “Primary care specialty choices of United States medical graduates, 1997-2006” (Academic Medicine June 2010;85(6):947-58) by DB Jeffe, AJ Whelan and DA Andriole from the Washington University School of Medicine in St. Louis provides further information to inform this discussion.
The authors used two surveys administered annually by the Association of American Medical Colleges (AAMC) to medical students: the Matriculating Student Questionnaire (MSQ) given when students begin school and the Graduation Questionnaire (GQ) given at graduation. They were able to match the questionnaires of nearly 2/3 (64.9%) of medical students graduating in the 10 years 1997-2006 to look at the degree to which the answers students gave to questions on the MSQ and GQ would predict their choice of specialty. It takes a while to get through the description of how they grouped questions, and “weighted factors”, but there are a number of important findings. Most of them not surprising, but this study provides additional data support for things we have been seeing.
Fewer graduates are entering primary care. For some reason the AAMC’s GQ counts 6 “primary care” areas, including, in addition to the usual family medicine, general internal medicine, and general pediatrics, also obstetrics/gynecology, internal medicine subspecialities (IMSS), and pediatric subspecialties (PdSS). However, this study separates them out. The percent of students entering the first 4 of these dropped from 1997 to 2006 (GIM from 15.7% to 6.7%, GP from 10.2% to 6.6%, FM from 17.6% to 6.9%, and OBG from 8.2% to 6.1%), while the subsubspecialties increased (IM from 6.8% to 11.4%, Peds from 2.2% to 4.4%). This increase in the last 2, however, did not compensate for the decrease in the first 4 so there was a net decrease from 60.7% to 42.1% for all these “primary care” specialties. The increase was in, then, surgical specialties, and more significantly in specialties such as radiology, anesthesiology, and emergency medicine. And the trend continues – although not part of the study, the article reports that the total % of students entering these 6 specialty areas in 2008 was down to 30.3% from the 42.1% in 2006. Remember, this is not just real primary care – it includes medical and pediatric subspecialties!
The more important part of this article is its correlation of certain demographic and attitudinal characteristics with specialty choice. Being female is important: over the 10 years of the study 45.1% of graduates were women, but they were over-represented in each of the 6 fields except IM subspecialties: 77.3% of OBG, 72.6% of GP, 58.2% of PdSS, 50.8% of FM and 49% of GIM. Indeed, the authors suggest that one of the reasons for the continued downturn in entry of medical students into PC fields is that the % of women in medical school, which was increasing during the study period, tended to compensate somewhat for the decreased interest in PC among men. Now that the % of women in medical school has stabilized, at roughly 50%, while interest in PC continues to go down, this is no longer having the same compensatory effect.
Compared to white students, underrepresented minority (URM) students were somewhat less likely to choose the PC specialties of GIM, GP, and FM, while Asian/Pacific Islander (As/PI) grads were less likely to choose FM, OBG, GP and PdSS, according to the text, but there are subtleties to this. For example, white students were 68% of the total but 75.3% of those entering FM; however, the % of URM students in FM (14%) was also greater than in the overall cohort (12.7%). The difference is that As/PI were much lower in FM, 9.9% compared to 18.2% of the overall cohort. In this report URM students include black, Hispanic, and American Indian/Alaskan natives, while the As/PI group includes some groups that are truly underrepresented in medicine and are usually counted by Federal grantmakers as URM, as well as some groups, e.g., South Asian, Japanese, Chinese, that are in fact over-represented in medicine. Many of these are among the 15.7% of students who had one or more parents who was a physician or the 24.1% more who had a non-physician professional parent. This is important because “…a student’s having a physician parent had a pervasive negative effect on graduates’ choice of any generalist-primary care specialty…” while those with non-physician professionals as parents were more likely to choose GIM, GP, and IMSS.
Though highly-touted as a deterrent to entering PC (and, perhaps, of more significance now than in the early part of this study period) debt had only a “modest” effect; students with higher debt were less likely to choose GP, PdSS, GIM, or IMSS, but more likely to choose OBG, and choice of FM was essentially unaffected. The probability of students from public medical schools entering PC was much greater than from private schools, a consistent finding of all studies, presumably reflecting the curriculum and emphasis of those schools as well as the characteristics of the students they select. The authors linked a number of questions to assess students’ “choice of medicine as a career goal” (including the importance of innovation and research, social responsibility, and prestige), and students’ “perceptions about medicine and medical practice” (including altruistic beliefs and the belief that the demands of medicine interfere with family/other interests). All were high, and few led to big differences in specialty choice. Among the most significant of those that did were “intention to practice in an underserved community” (more PC, especially FM), and “interest in academic faculty positions” (very low FM -- the odds of being interested in academic practice compared to full-time non-university practice was only 12% for someone entering FM, compared to GIM’s 86%, IMSS’ 185% and PdSS’ 316%!).
Among areas that the questionnaires did NOT look at was the probability of entering rural practice; other studies have shown that, except for family medicine, essentially no students are entering practice in rural areas (see Primary Care and Rural Areas, April 28, 2010, Medicare Costs in Rural America: A case of reaping what we haven't sown?, March 26, 2009, Ten Biggest Myths Regarding Primary Care in the Future, January 15, 2009 ). Despite their assertion (probably correct) that “…the predictive validity of planning to practicing in an underserved community at graduation has been established,” intention to practice in an underserved community is not a surrogate for intention to practice in a rural area, because practicing in a rural underserved community means living in a rural community, while one can practice in an urban underserved community and live in a more upscale neighborhood. This is particularly true for pediatrics (see Primary Care, Pediatrics, and Physician Distribution, May 21, 2009).
So what does all this tell us that is new? Not much. There is a dramatic decrease in the number and percent of students entering true primary care specialties, combined with some increase in the number entering obstetrics/gynecology, internal medicine and pediatric subspecialties and a large increase in specialties that are in no way primary care. It tells us that students who are interested in and attracted to, and are wooed by, “high-status” research and specialty care medical schools are less likely to enter primary care; that being the child of a physician or having a high family income makes one less likely to enter primary care; that students interested in caring for the underserved and women are more likely to enter primary care (although not rural practice). So what does this mean “we” should do?
Well, that depends on who “we” are. If “we” are the selective, high-status medical schools who are low on social mission (see A New Way of Ranking Medical Schools: Social Mission, June 20, 2010) and “we” value what “we” do, maybe “we” shouldn’t do anything. The same might be said if “we” are the schools that tend to be high on social mission and production of PC physicians. If, however, “we” are the American people, who need more primary care and rural physicians, or the politicians and policy makers who actually can have some influence, “we” need to make policies that reward schools that select the students whose demographic and attitudinal characteristics make them more likely to enter primary care, underserved, and rural practice. And those schools whose curriculum (formal and informal) and faculty attitudes and relative status-within-the-institution favors those same outcomes. And pay, on the back end, more money to those who do what “we” don’t have enough of (primary care, underserved and rural practice) than those who do what “we” have too much of already.
Whether or not “doing the same thing over and over again and expecting different results is the definition of insanity”, it is sure not going to accomplish any change in the physician workforce.
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Monday, July 12, 2010
Tuesday, July 6, 2010
Statins and scientific integrity
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“Statins” are a class of drugs that lower lipid levels, especially low-density lipoproteins (LDL, “bad” cholesterol), and raise high-density lipoproteins (HDL, “good” cholesterol). Since we know elevated LDL levels are associated with higher risk for a number of vascular diseases, mainly coronary heart disease but also stroke, it made sense that these drugs would be beneficial for preventing recurrences in people who had prior heart attacks and strokes (“secondary prevention”) as well as preventing a first attack in those who had the risk factor of elevated LDL (“primary prevention”). Indeed, studies have shown the former; that is, that the use of statins reduced the risk of both a second attack and dying. However, most of the studies that have been done, and showed benefit, studied both groups, people who had already had a coronary event and those with elevated LDL who had not, and combined the results. The first big study that presumed to show benefit of these drugs for primary prevention was the JUPITER study (“Justification for the Use of Statins in Primary Prevention” – all these studies have cute, if often tortured, eponyms). It specifically looked at the drug rosuvastatin, marked as Crestor ® by its manufacturer, AstraZeneca, who also happened to fund the JUPITER trial.
Two articles that just appeared in the Archives of Internal Medicine (V 170, #2, June 28, 2010) raise serious questions about the use of statins for primary prevention. But they also raise serious questions about research ethics, particularly when trials are industry funded, and the strategic manipulation (not falsification) of the data that is presented to make drug therapy look better – this can mean billions of dollars in sales for the manufacturer. They also point out the danger of looking at intermediate, or “surrogate”, outcomes (in this case, lowered cholesterol and LDL) rather than the ones of real interest to patients, which are, essentially, death (mortality) and the quality of life (morbidity). I have discussed this previously (“Quality and Chronic Disease Management,” Feb 24, 2009, and “Physician conflict of interest” Dec 8, 2008; see also the article by GY Gandhi, et. al., “Patient-important outcomes in registered diabetes trials”, JAMA. 2008 Jun 4;299(21):2543-9.)
The first article, “Statins and all-cause mortality in high-risk primary prevention”, by KK Ray, et. al. (Arch Int Med, 28 Jun 2010; 170(12):1024-31) is a “meta-analysis”. This is a type of study that looks at a group of previously-done studies to try to determine if there is a consistent conclusion that is stronger because it includes more patients than any one study, or weaker because the various studies contradict each other. The authors’ goal was to tease out the results for primary prevention from studies that had looked at the use of statins for both primary and secondary prevention. There were 11 studies that met their criteria, which had a total of 65,229 (= “a lot”) of participants. Their Conclusion (verbatim from the abstract): “This literature-based meta-analysis did not find evidence for the benefit of statin therapy on all-cause mortality in a high-risk primary prevention set-up.” This is not to say that the statins did not lower LDL; they did, and significantly, but in the population of people that had not yet had a coronary event or stroke, they did not prevent mortality. It is important to note that they did also, to a small degree, decrease the risk of having a heart attack, although not of dying. The reduction in risk was about 1.5%; that is, if 200 people are treated for 5 years, 3 will not have heart attacks (NNT=67 over 5 years). The previous studies, by mixing up those who did have a prior event and did have lower mortality (secondary prevention), with those who had not, showed, on net, a benefit. This study demonstrates that there is no reduction in mortality from using statins as primary prevention; whether the small reduction in MIs and their associated morbidity and cost is worth the administration of statins in high-risk patients is at least questionable, and may be an issue for each patient to decide with their doctor.
What about the JUPITER trial? This is the subject of the second article, “Cholesterol lowering, cardiovascular diseases, and the rosuvastatin-JUPITER controversy”, by M deLorgeril et.al. (Arch Int Med 28 Jun 2010;170(12):1032-36. In a scathing “critical reappraisal” the authors note a slew of flaws in both the conduct and reporting of the JUPITER study. These include ending the study early, after only 2 years, at a time when it appeared that there was mortality benefit from the patients treated with rosuvastatin but when the curves were beginning to come together (i.e., maybe with more time the apparent benefit to rosuvastatin treatment would have disappeared and there would have turned out to be no difference in mortality rate), publishing reports in which the end of that curve was truncated, to not show the coming together, and publishing “subgroup” analyses that seemed to show benefit (by gender) but not where they didn’t (patients with diabetes). Most surprisingly, JUPITER had what seemed to be an extraordinarily low rate of fatality from myocardial infarction. The authors note that, to be able to get meaningful data to look at, they had to do calculations from the data presented by the JUPITER authors. For example, to know how many people died from heart attacks (myocardial infarction, MI) they had to subtract “nonfatal myocardial infarction” from “any myocardial infarction. This is not falsification, but it is very unusual for authors to present the data in a way that readers are required to make such calculations in order to get very important information. The rate of fatal to non-fatal MI was extremely low compared to studies from the World Health Organization, that show it to be 40-50%; in JUPITER it was 8.8% in the placebo group and 29% in the rosuvastatin group. First of all, it seems, if this data is correct, the fatal to non-fatal MI rate was 3 times as high in the group treated with rosuvastatin as in the group that was not treated (surely not the a point the authors and sponsoring company wanted to emphasize). Moreover, everyone in the study was “…unexpectedly – and inexplicably – highly resistant to acute ischemia and infarction.” The authors of this article suggest that there are many inconsistencies and implausabilities in the JUPITER data.
They then go on to discuss at length the roles of the sponsor (the drug company) and conflict of interest in reporting the data both by the sponsor and the principal investigator, who is co-holder of a patent for a test that is used to show “risk” for coronary artery disease (called “C-reactive protein, or CRP). They refer to other industry-sponsored flawed studies, including those about rofecoxib (Vioxx ®) and gabapentin (Neurontin ®), which I have discussed previously (“The ‘Neurontin Legacy’”, Jan 22, 2009). A superb editorial by Lee Green, “Cholesterol-lowering therapy for primary prevention: still much we don’t know” (Arch Int Med 28 Jun 2010; 170(12):1007-8) summarizes these issues.
Think about this. We have a bunch of studies that seem to show that statins are effective for prevention of cardiovascular events (heart attack and stroke) and prevent death. Turns out that they do this for those who have already had a heart attack, but for those who haven’t, the reduction in heart attack is small and there is no reduction in mortality. The use of statins in the much larger group, people with elevated cholesterol who have not yet had a heart attack, means big money for the drugs’ manufacturers. Studies that mixed the two groups blurred the distinction.
Then we have a big study (JUPITER) that purports to show that statins ARE effective for primary prevention, but that study is funded by the drug company and is seriously flawed. We know elevated cholesterol is associated with heart attack and we presume lowering cholesterol would help prevent those heart attacks, but, amazing and very important, when the study is actually done, the data doesn’t show it. (In studies looking at another such indicator, homocysteine, it was shown that, while elevated homocysteine levels are associated with heart attack, and folate – a cheap drug – lowers homocysteine levels, this did not decrease the rate of MIs. Too bad for the makers of the expensive homocysteine level test.)
I assume that I do not have to review the conflict of interest in the study being funded by the drug company and having the principal investigator a patent holder of a test that is highly used for assessing MI risk. The obvious concern is not that this was a potential conflict in the JUPITER study, but that it in fact led to selective interpretation and presentation of data (and the answers to how they had such a low rate of fatal MIs is still not in). This certainly challenges the claim we sometimes hear that just because there is a potential conflict of interest, it doesn’t mean that there is bad science being done. Of course, intrinsically it doesn’t, but this is one more example – with Vioxx and Neurontin and others – to show that it often does. And it also makes it harder for those who would argue that accepting industry gifts (whether lunch or fancy vacations) is benign. All these issues make a great example for teaching students, about conflict of interest, surrogate measures, scientific integrity, and how, from big issues to small ones, self interest colors our perceptions (see J Dana and G Lowenstein, “A Social Science Perspective on Gifts to Physicians From Industry”, JAMA. 2003;290:252-255).
.
“Statins” are a class of drugs that lower lipid levels, especially low-density lipoproteins (LDL, “bad” cholesterol), and raise high-density lipoproteins (HDL, “good” cholesterol). Since we know elevated LDL levels are associated with higher risk for a number of vascular diseases, mainly coronary heart disease but also stroke, it made sense that these drugs would be beneficial for preventing recurrences in people who had prior heart attacks and strokes (“secondary prevention”) as well as preventing a first attack in those who had the risk factor of elevated LDL (“primary prevention”). Indeed, studies have shown the former; that is, that the use of statins reduced the risk of both a second attack and dying. However, most of the studies that have been done, and showed benefit, studied both groups, people who had already had a coronary event and those with elevated LDL who had not, and combined the results. The first big study that presumed to show benefit of these drugs for primary prevention was the JUPITER study (“Justification for the Use of Statins in Primary Prevention” – all these studies have cute, if often tortured, eponyms). It specifically looked at the drug rosuvastatin, marked as Crestor ® by its manufacturer, AstraZeneca, who also happened to fund the JUPITER trial.
Two articles that just appeared in the Archives of Internal Medicine (V 170, #2, June 28, 2010) raise serious questions about the use of statins for primary prevention. But they also raise serious questions about research ethics, particularly when trials are industry funded, and the strategic manipulation (not falsification) of the data that is presented to make drug therapy look better – this can mean billions of dollars in sales for the manufacturer. They also point out the danger of looking at intermediate, or “surrogate”, outcomes (in this case, lowered cholesterol and LDL) rather than the ones of real interest to patients, which are, essentially, death (mortality) and the quality of life (morbidity). I have discussed this previously (“Quality and Chronic Disease Management,” Feb 24, 2009, and “Physician conflict of interest” Dec 8, 2008; see also the article by GY Gandhi, et. al., “Patient-important outcomes in registered diabetes trials”, JAMA. 2008 Jun 4;299(21):2543-9.)
The first article, “Statins and all-cause mortality in high-risk primary prevention”, by KK Ray, et. al. (Arch Int Med, 28 Jun 2010; 170(12):1024-31) is a “meta-analysis”. This is a type of study that looks at a group of previously-done studies to try to determine if there is a consistent conclusion that is stronger because it includes more patients than any one study, or weaker because the various studies contradict each other. The authors’ goal was to tease out the results for primary prevention from studies that had looked at the use of statins for both primary and secondary prevention. There were 11 studies that met their criteria, which had a total of 65,229 (= “a lot”) of participants. Their Conclusion (verbatim from the abstract): “This literature-based meta-analysis did not find evidence for the benefit of statin therapy on all-cause mortality in a high-risk primary prevention set-up.” This is not to say that the statins did not lower LDL; they did, and significantly, but in the population of people that had not yet had a coronary event or stroke, they did not prevent mortality. It is important to note that they did also, to a small degree, decrease the risk of having a heart attack, although not of dying. The reduction in risk was about 1.5%; that is, if 200 people are treated for 5 years, 3 will not have heart attacks (NNT=67 over 5 years). The previous studies, by mixing up those who did have a prior event and did have lower mortality (secondary prevention), with those who had not, showed, on net, a benefit. This study demonstrates that there is no reduction in mortality from using statins as primary prevention; whether the small reduction in MIs and their associated morbidity and cost is worth the administration of statins in high-risk patients is at least questionable, and may be an issue for each patient to decide with their doctor.
What about the JUPITER trial? This is the subject of the second article, “Cholesterol lowering, cardiovascular diseases, and the rosuvastatin-JUPITER controversy”, by M deLorgeril et.al. (Arch Int Med 28 Jun 2010;170(12):1032-36. In a scathing “critical reappraisal” the authors note a slew of flaws in both the conduct and reporting of the JUPITER study. These include ending the study early, after only 2 years, at a time when it appeared that there was mortality benefit from the patients treated with rosuvastatin but when the curves were beginning to come together (i.e., maybe with more time the apparent benefit to rosuvastatin treatment would have disappeared and there would have turned out to be no difference in mortality rate), publishing reports in which the end of that curve was truncated, to not show the coming together, and publishing “subgroup” analyses that seemed to show benefit (by gender) but not where they didn’t (patients with diabetes). Most surprisingly, JUPITER had what seemed to be an extraordinarily low rate of fatality from myocardial infarction. The authors note that, to be able to get meaningful data to look at, they had to do calculations from the data presented by the JUPITER authors. For example, to know how many people died from heart attacks (myocardial infarction, MI) they had to subtract “nonfatal myocardial infarction” from “any myocardial infarction. This is not falsification, but it is very unusual for authors to present the data in a way that readers are required to make such calculations in order to get very important information. The rate of fatal to non-fatal MI was extremely low compared to studies from the World Health Organization, that show it to be 40-50%; in JUPITER it was 8.8% in the placebo group and 29% in the rosuvastatin group. First of all, it seems, if this data is correct, the fatal to non-fatal MI rate was 3 times as high in the group treated with rosuvastatin as in the group that was not treated (surely not the a point the authors and sponsoring company wanted to emphasize). Moreover, everyone in the study was “…unexpectedly – and inexplicably – highly resistant to acute ischemia and infarction.” The authors of this article suggest that there are many inconsistencies and implausabilities in the JUPITER data.
They then go on to discuss at length the roles of the sponsor (the drug company) and conflict of interest in reporting the data both by the sponsor and the principal investigator, who is co-holder of a patent for a test that is used to show “risk” for coronary artery disease (called “C-reactive protein, or CRP). They refer to other industry-sponsored flawed studies, including those about rofecoxib (Vioxx ®) and gabapentin (Neurontin ®), which I have discussed previously (“The ‘Neurontin Legacy’”, Jan 22, 2009). A superb editorial by Lee Green, “Cholesterol-lowering therapy for primary prevention: still much we don’t know” (Arch Int Med 28 Jun 2010; 170(12):1007-8) summarizes these issues.
Think about this. We have a bunch of studies that seem to show that statins are effective for prevention of cardiovascular events (heart attack and stroke) and prevent death. Turns out that they do this for those who have already had a heart attack, but for those who haven’t, the reduction in heart attack is small and there is no reduction in mortality. The use of statins in the much larger group, people with elevated cholesterol who have not yet had a heart attack, means big money for the drugs’ manufacturers. Studies that mixed the two groups blurred the distinction.
Then we have a big study (JUPITER) that purports to show that statins ARE effective for primary prevention, but that study is funded by the drug company and is seriously flawed. We know elevated cholesterol is associated with heart attack and we presume lowering cholesterol would help prevent those heart attacks, but, amazing and very important, when the study is actually done, the data doesn’t show it. (In studies looking at another such indicator, homocysteine, it was shown that, while elevated homocysteine levels are associated with heart attack, and folate – a cheap drug – lowers homocysteine levels, this did not decrease the rate of MIs. Too bad for the makers of the expensive homocysteine level test.)
I assume that I do not have to review the conflict of interest in the study being funded by the drug company and having the principal investigator a patent holder of a test that is highly used for assessing MI risk. The obvious concern is not that this was a potential conflict in the JUPITER study, but that it in fact led to selective interpretation and presentation of data (and the answers to how they had such a low rate of fatal MIs is still not in). This certainly challenges the claim we sometimes hear that just because there is a potential conflict of interest, it doesn’t mean that there is bad science being done. Of course, intrinsically it doesn’t, but this is one more example – with Vioxx and Neurontin and others – to show that it often does. And it also makes it harder for those who would argue that accepting industry gifts (whether lunch or fancy vacations) is benign. All these issues make a great example for teaching students, about conflict of interest, surrogate measures, scientific integrity, and how, from big issues to small ones, self interest colors our perceptions (see J Dana and G Lowenstein, “A Social Science Perspective on Gifts to Physicians From Industry”, JAMA. 2003;290:252-255).
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Thursday, July 1, 2010
Arrested at the G20: David Wachsmuth
This "Guest Post" is from David Wachsmuth, who was arrested at the G20 event in Toronto. I wanted to share it, and didn't know how else, as it is too long for "Facebook".
Arrested at the G20This weekend I was in Toronto demonstrating against the meeting of the G20 that was taking place there. At 2:45 AM on Saturday night I was arrested for a ‘breach of the peace’. The nineteen hours that followed were probably the most infuriating, frustrating, frightening ones of my life. Unfortunately, from what I now know, my experience was very similar to that of many of the over 1000 people who were arrested over the weekend. So what I'm about to describe, despite being intensely personal, probably speaks for many of us, at least in part.In preparation for the huge number of arrests they presumably planned on carrying out, the police had set up an ad hoc detention centre at an old film studio in the east end of Toronto. On Saturday night, I went with one of my best friends—who was a legal observer at the demonstrations—to the detention centre to join a midnight jail solidarity action in support of those who had been picked up earlier in a violent and arbitrary series of beatings and arrests, including of many people not demonstrating at all but simply in the wrong place at the wrong time. After a few hours of peaceful and spirited demonstration (featuring an excellent marching band), the police ordered us to disperse shortly before 2:00 AM. Like everything else this weekend, that was accomplished by surrounding us on all sides in enormous numbers of cops in full riot gear. (I filmed some video of the demonstration and the arrival of the police, which I have uploaded at http://bit.ly/aEiNaV.) The 150 of us were outnumbered at least two to one. There was some discussion of staying despite the order to disperse, but that only lasted a minute or so, and shortly everyone was filing between the ranks of riot police in the direction we had been ordered to go. A few minutes after we started leaving, and with no warning whatsoever, riot cops cut through the column of protesters and sealed off the two dozen of us at the back. We asked to be allowed to leave as they had just told us we were instructed to do, but we were instead told that we had had our chance to leave and had failed to take it (an odd idea, since we were walking away when they sealed us in). We were all arrested.The arrest itself took about 40 minutes and was uneventful. The only notable thing was how uncomfortable and difficult it is to hold your hands on your head for that amount of time. Since I was nearly the last person to get handcuffed, I had a lot of time for this to sink in. It is much more uncomfortable having your hands handcuffed behind your back, which is what happened next, but I expected that. The cop who dealt with me took me to the edge of where all the arrests were being made, asked me various questions, searched me, and so on. After a minute or two, I realized there was quite a lot of light on me, and it turned out that I was being processed right in front of a television camera, with a reporter making a report. So I asked to be moved to somewhere a little less obtrusive, but the reporter apparently got the footage she was looking for, since various people (including my mother) subsequently told me that they saw me on the news. This had at least the positive effect of letting my loved ones know what happened to me, since I was not allowed a phone call in the 19 hours during which I was detained. My arrest papers say I was arrested at 2:49 AM.We were slowly loaded into paddy wagons to be taken to the detention centre. After various delays, we were stuffed into little miniature jails inside the vans (in my van there were four cells, each of which held two of us) and off we went. We spent the next 30 minutes or so sitting in these tiny little van-jails. Sitting, because the drive was only a minute or so to the detention centre (we had been protesting outside of it). The rest of the time we were parked in what sounded (we couldn't see anything out the tiny little grated windows) like a big room with a lot of prisoners in it. The highlight of this time was the spontaneous round of mass meowing that came from the prisoners outside; the cages we were in really did feel like animal pens. The lowlight was my increasingly aching left arm from being held awkwardly behind my back in the handcuffs (the plastic cable-tie kind, incidentally, not the real metal deal).We were unloaded from the paddy wagons into a set of gender-segregated cages. In the end I spent time in three separate ones, although they were all the same. They were twenty feet by ten feet, with a four-by-four-foot washroom inside. The washrooms had no door, and no toilet paper (some previous inhabitant had stashed a little in our first cage, but it was quickly used up). There were generally 25 or 26 people in my cage, which comes out to just over seven square feet of space each. For the entire time we were imprisoned, we had to rotate between standing, sitting and lying down, since there wasn’t nearly enough room for all of us to do either of the latter two at the same time. Lying down wasn’t a means to actually sleep; at least in my case the combination of the cold temperatures and bright lights (plus the steady ruckus) ruled that out.I don’t know how to describe the way we were treated in those cages except as blatant and probably illegal harassment and violation of our basic rights and freedoms. The list is fairly long. None of us was ever given the opportunity to make a phone call or speak with a lawyer, despite having told that we had the right to do so upon being arrested. Some people (not including myself) were never even read their rights in the first place or informed of their charges. We were kept in handcuffs throughout the day. In the entire time I was incarcerated we were given two tiny little ‘sandwiches’—a single slice of soy cheese and a bit of margarine on a dinner roll. I believe we were given four small styrofoam cups of water, although it may have been five. One of us was a minor, who was never allowed to contact his parents. Two people had serious medical problems that received pathetically insufficient attention. It took us something like 40 minutes to get a medic when one of them was bleeding from under his fingernails and on the verge of collapsing. The guards alternatively taunted us, threatened us, lied to us, or ignored us. Once, when we had been calling for food for some time, a guard deliberately sat down in front of our cell and ate his lunch.And it was not as if we were a bunch of hardened criminals. Of course, even if we had been, the guards’ behaviour would have been completely inexcusable, but in fact not a single one of us had been arrested for anything that resembled just cause. A little under half of the people in my cages had been at the same demonstration as me. About the same number had been arrested en masse outside the Novatel hotel; they were surrounded on all sides by police while engaged in a peaceful demonstration, and then beaten and taken into custody. The rest of the people I met were random passersby. The most egregious was a TTC employee in full uniform, who was jumped by riot cops as he was arriving at his shift. I later found out that he spent 36 hours in custody with no phone call, lawyer, or charges, which I understand to be unequivocally illegal (http://bit.ly/aIXnUG). A few people were arrested for the hitherto unknown crime of dressing in black and going to punk rock shows. One of these was in from out of town, and didn’t even know what the G20 was. Two women we talked to cage-to-cage were trampled by cops on horseback (one, who looked like she was in her 60s, got a broken arm), and were being charged with obstruction of police.It would take far too long to describe all the various forms of harassment we were subjected to, but the major theme was fear and uncertainty. The guards took people from one cage and put them in another, keeping them disoriented and preventing them from getting to know their cage-mates, and keeping the rest of us uncertain about whether they had been released or just shuffled. The police told us on a number of occasions that we were about to be released, only to immediately ignore us for hours and hours. We were repeatedly asked to identify ourselves—twice guards took an inventory of everyone’s name and ID number, and tried to do so a third time—but we were also repeatedly asked if so-and-so was in our cage. He almost never was.While I was in the detention centre, I was inclined to chalk these things up to incompetence and confusion on behalf of the police. Almost 900 people were arrested, and the centre was clearly swamped. But after getting out, talking to others who were imprisoned, and thinking more about it, I now find it hard to escape the conclusion that this confusion and uncertainty was deliberate. We were told too many times to count that the guards were working as fast as they could to process us, but that the paperwork was taking a long time. But when they actually released us, the paperwork they had told us we would need to participate in never happened. They just walked us 50 feet to the exit and handed us our possessions. After talking with a number of people who were arrested, it seems clear that many or most people in my situation were held for 18 to 23 hours—just under the legal maximum—and that therefore the endless promises of impending release were deliberate lies.The result of all this was that we were constantly on edge. We were alternately furious, frightened, depressed, manic, and inert. At some points we were all banging on the cage and screaming at the top of our lungs. At other points we brooded silently. One of us went into shock. By the time we were released, the random passersby were sounding just as radical as the protesters. We had been arrested for different reasons, but the appalling treatment we received was the same, and united us in our outrage.Why did this happen? At the largest scale, it seems clear that the police made extended preparations for mass arrests and an intimidation campaign against people exercising their democratic rights to protest. This is a key component of the ‘Miami Model’ of protest disruption and repression that Toronto police followed so strictly (http://bit.ly/al8eaR). Earlier in the day, the police had strategically abandoned the streets to a group of 'black bloc' protesters, and left a few empty police cars in the middle of the road. This point should be emphasized: there were thousands of police on the streets throughout the entire weekend, but, somehow, when a small group of protesters decided to break off from the main rally and ‘go rogue’, the police simply melted away. The Sun has now reported that this was an explicit order from police central command: http://bit.ly/cnAqIv. The resulting hour or two of smashed windows and burned cars happened with more or less no police presence whatsoever, despite the fact that it happened on the busiest streets in the downtown. The cops didn’t lose track of the protesters; police helicopters were filming the black bloc from above (and passing on the footage to the media). It would have been the easiest thing in the world to simply surround the one or two hundred black bloc protesters with five or six hundred cops and arrest them, if that had been what the police had wanted to do. Instead, the cops left them completely undisturbed until they had smashed their way from King and Bay all the way up Yonge St. to College and then back to Queen’s Park (passing by police headquarters, even!), where they changed out of their black clothing.I can’t figure out an explanation for this other than that the police deliberately encouraged property destruction as a pretext for subsequent repression. The black bloc obliged, and after the cruisers were set on fire and a bunch of storefront windows were smashed, the cops announced that their tactics would have to change in response to this property destruction, and began a violent and arbitrary series of beatings and arrests, including of many people not demonstrating at all but simply in the wrong place at the wrong time.This was the context for all the arrests that filled the cages of the detention centre, and the harassment and intimidation that police inflicted inside the cages is an exact counterpart to the violence that they inflicted outside. At a smaller scale, many of the individual guards chose to taunt, harass, and abuse us, when they could have chosen not to. I’m sure many thought that we deserved it, and others who didn’t found it easier to just let it happen. The abuse was worse because it was completely arbitrary. Sometimes if we asked for a medic, guards would show up quickly and our ill cage-mate would be taken to a medic. Sometimes guards would show up quickly but do nothing. Sometimes guards would not show up at all. This is the same arbitrariness that terrorized the peaceful protests at Queens Park and elsewhere, where riot cops made ‘dash and grab’ arrests—rushing quickly at a single protester (or passerby) with no warning, beating her, and taking her into custody. It is one of the most disturbing features of all the police violence that occurred over the weekend, because it defies logic and accountability.I’m acutely aware of how lucky I was relative to so many of the other innocent people who were arrested over the weekend. For one, I wasn’t physically abused prior to being taken into custody. But more than that, I’m an educated, well-off, straight white male. I’m sure it’s not a coincidence that the person in my cage held the longest was an indigenous man. And we now know that queer people were segregated into separate cages; women were threatened with rape and subjected to invasive strip searches (http://bit.ly/9Qlxfb).I’m now back in New York City, where I live, so I haven’t been able to participate directly in the growing collective efforts to seek justice for all the injustice that occurred in Toronto over the weekend. I wish I could. Being on the business end of police brutality hasn’t changed my politics at all; it’s confirmed them, and made me angrier. At the same time, while I am optimistic that forthcoming investigations and inquiries will condemn a certain amount of the police tactics, I don’t think that would be a ‘loss’ for the cops. It’s probably best to see their strategy as one of kicking the ball forward as far as they can in terms of the tactics they can get away with. Public outrage and judicial action may subsequently kick the ball back a certain distance, but as long as it ends up further than it was before last weekend, that is a police victory of sorts. So in general I am pessimistic about how much good can come directly out of all this. Indirectly, though, I think there is reason to hope that this outrage is bringing more people together, and building awareness of the fundamental injustice which underpins our society, which cannot be confronted until it is exposed, and which is now harder to ignore when over 1000 peaceful protesters and bystanders have been arbitrarily beaten, jailed, or both.
.
Arrested at the G20This weekend I was in Toronto demonstrating against the meeting of the G20 that was taking place there. At 2:45 AM on Saturday night I was arrested for a ‘breach of the peace’. The nineteen hours that followed were probably the most infuriating, frustrating, frightening ones of my life. Unfortunately, from what I now know, my experience was very similar to that of many of the over 1000 people who were arrested over the weekend. So what I'm about to describe, despite being intensely personal, probably speaks for many of us, at least in part.In preparation for the huge number of arrests they presumably planned on carrying out, the police had set up an ad hoc detention centre at an old film studio in the east end of Toronto. On Saturday night, I went with one of my best friends—who was a legal observer at the demonstrations—to the detention centre to join a midnight jail solidarity action in support of those who had been picked up earlier in a violent and arbitrary series of beatings and arrests, including of many people not demonstrating at all but simply in the wrong place at the wrong time. After a few hours of peaceful and spirited demonstration (featuring an excellent marching band), the police ordered us to disperse shortly before 2:00 AM. Like everything else this weekend, that was accomplished by surrounding us on all sides in enormous numbers of cops in full riot gear. (I filmed some video of the demonstration and the arrival of the police, which I have uploaded at http://bit.ly/aEiNaV.) The 150 of us were outnumbered at least two to one. There was some discussion of staying despite the order to disperse, but that only lasted a minute or so, and shortly everyone was filing between the ranks of riot police in the direction we had been ordered to go. A few minutes after we started leaving, and with no warning whatsoever, riot cops cut through the column of protesters and sealed off the two dozen of us at the back. We asked to be allowed to leave as they had just told us we were instructed to do, but we were instead told that we had had our chance to leave and had failed to take it (an odd idea, since we were walking away when they sealed us in). We were all arrested.The arrest itself took about 40 minutes and was uneventful. The only notable thing was how uncomfortable and difficult it is to hold your hands on your head for that amount of time. Since I was nearly the last person to get handcuffed, I had a lot of time for this to sink in. It is much more uncomfortable having your hands handcuffed behind your back, which is what happened next, but I expected that. The cop who dealt with me took me to the edge of where all the arrests were being made, asked me various questions, searched me, and so on. After a minute or two, I realized there was quite a lot of light on me, and it turned out that I was being processed right in front of a television camera, with a reporter making a report. So I asked to be moved to somewhere a little less obtrusive, but the reporter apparently got the footage she was looking for, since various people (including my mother) subsequently told me that they saw me on the news. This had at least the positive effect of letting my loved ones know what happened to me, since I was not allowed a phone call in the 19 hours during which I was detained. My arrest papers say I was arrested at 2:49 AM.We were slowly loaded into paddy wagons to be taken to the detention centre. After various delays, we were stuffed into little miniature jails inside the vans (in my van there were four cells, each of which held two of us) and off we went. We spent the next 30 minutes or so sitting in these tiny little van-jails. Sitting, because the drive was only a minute or so to the detention centre (we had been protesting outside of it). The rest of the time we were parked in what sounded (we couldn't see anything out the tiny little grated windows) like a big room with a lot of prisoners in it. The highlight of this time was the spontaneous round of mass meowing that came from the prisoners outside; the cages we were in really did feel like animal pens. The lowlight was my increasingly aching left arm from being held awkwardly behind my back in the handcuffs (the plastic cable-tie kind, incidentally, not the real metal deal).We were unloaded from the paddy wagons into a set of gender-segregated cages. In the end I spent time in three separate ones, although they were all the same. They were twenty feet by ten feet, with a four-by-four-foot washroom inside. The washrooms had no door, and no toilet paper (some previous inhabitant had stashed a little in our first cage, but it was quickly used up). There were generally 25 or 26 people in my cage, which comes out to just over seven square feet of space each. For the entire time we were imprisoned, we had to rotate between standing, sitting and lying down, since there wasn’t nearly enough room for all of us to do either of the latter two at the same time. Lying down wasn’t a means to actually sleep; at least in my case the combination of the cold temperatures and bright lights (plus the steady ruckus) ruled that out.I don’t know how to describe the way we were treated in those cages except as blatant and probably illegal harassment and violation of our basic rights and freedoms. The list is fairly long. None of us was ever given the opportunity to make a phone call or speak with a lawyer, despite having told that we had the right to do so upon being arrested. Some people (not including myself) were never even read their rights in the first place or informed of their charges. We were kept in handcuffs throughout the day. In the entire time I was incarcerated we were given two tiny little ‘sandwiches’—a single slice of soy cheese and a bit of margarine on a dinner roll. I believe we were given four small styrofoam cups of water, although it may have been five. One of us was a minor, who was never allowed to contact his parents. Two people had serious medical problems that received pathetically insufficient attention. It took us something like 40 minutes to get a medic when one of them was bleeding from under his fingernails and on the verge of collapsing. The guards alternatively taunted us, threatened us, lied to us, or ignored us. Once, when we had been calling for food for some time, a guard deliberately sat down in front of our cell and ate his lunch.And it was not as if we were a bunch of hardened criminals. Of course, even if we had been, the guards’ behaviour would have been completely inexcusable, but in fact not a single one of us had been arrested for anything that resembled just cause. A little under half of the people in my cages had been at the same demonstration as me. About the same number had been arrested en masse outside the Novatel hotel; they were surrounded on all sides by police while engaged in a peaceful demonstration, and then beaten and taken into custody. The rest of the people I met were random passersby. The most egregious was a TTC employee in full uniform, who was jumped by riot cops as he was arriving at his shift. I later found out that he spent 36 hours in custody with no phone call, lawyer, or charges, which I understand to be unequivocally illegal (http://bit.ly/aIXnUG). A few people were arrested for the hitherto unknown crime of dressing in black and going to punk rock shows. One of these was in from out of town, and didn’t even know what the G20 was. Two women we talked to cage-to-cage were trampled by cops on horseback (one, who looked like she was in her 60s, got a broken arm), and were being charged with obstruction of police.It would take far too long to describe all the various forms of harassment we were subjected to, but the major theme was fear and uncertainty. The guards took people from one cage and put them in another, keeping them disoriented and preventing them from getting to know their cage-mates, and keeping the rest of us uncertain about whether they had been released or just shuffled. The police told us on a number of occasions that we were about to be released, only to immediately ignore us for hours and hours. We were repeatedly asked to identify ourselves—twice guards took an inventory of everyone’s name and ID number, and tried to do so a third time—but we were also repeatedly asked if so-and-so was in our cage. He almost never was.While I was in the detention centre, I was inclined to chalk these things up to incompetence and confusion on behalf of the police. Almost 900 people were arrested, and the centre was clearly swamped. But after getting out, talking to others who were imprisoned, and thinking more about it, I now find it hard to escape the conclusion that this confusion and uncertainty was deliberate. We were told too many times to count that the guards were working as fast as they could to process us, but that the paperwork was taking a long time. But when they actually released us, the paperwork they had told us we would need to participate in never happened. They just walked us 50 feet to the exit and handed us our possessions. After talking with a number of people who were arrested, it seems clear that many or most people in my situation were held for 18 to 23 hours—just under the legal maximum—and that therefore the endless promises of impending release were deliberate lies.The result of all this was that we were constantly on edge. We were alternately furious, frightened, depressed, manic, and inert. At some points we were all banging on the cage and screaming at the top of our lungs. At other points we brooded silently. One of us went into shock. By the time we were released, the random passersby were sounding just as radical as the protesters. We had been arrested for different reasons, but the appalling treatment we received was the same, and united us in our outrage.Why did this happen? At the largest scale, it seems clear that the police made extended preparations for mass arrests and an intimidation campaign against people exercising their democratic rights to protest. This is a key component of the ‘Miami Model’ of protest disruption and repression that Toronto police followed so strictly (http://bit.ly/al8eaR). Earlier in the day, the police had strategically abandoned the streets to a group of 'black bloc' protesters, and left a few empty police cars in the middle of the road. This point should be emphasized: there were thousands of police on the streets throughout the entire weekend, but, somehow, when a small group of protesters decided to break off from the main rally and ‘go rogue’, the police simply melted away. The Sun has now reported that this was an explicit order from police central command: http://bit.ly/cnAqIv. The resulting hour or two of smashed windows and burned cars happened with more or less no police presence whatsoever, despite the fact that it happened on the busiest streets in the downtown. The cops didn’t lose track of the protesters; police helicopters were filming the black bloc from above (and passing on the footage to the media). It would have been the easiest thing in the world to simply surround the one or two hundred black bloc protesters with five or six hundred cops and arrest them, if that had been what the police had wanted to do. Instead, the cops left them completely undisturbed until they had smashed their way from King and Bay all the way up Yonge St. to College and then back to Queen’s Park (passing by police headquarters, even!), where they changed out of their black clothing.I can’t figure out an explanation for this other than that the police deliberately encouraged property destruction as a pretext for subsequent repression. The black bloc obliged, and after the cruisers were set on fire and a bunch of storefront windows were smashed, the cops announced that their tactics would have to change in response to this property destruction, and began a violent and arbitrary series of beatings and arrests, including of many people not demonstrating at all but simply in the wrong place at the wrong time.This was the context for all the arrests that filled the cages of the detention centre, and the harassment and intimidation that police inflicted inside the cages is an exact counterpart to the violence that they inflicted outside. At a smaller scale, many of the individual guards chose to taunt, harass, and abuse us, when they could have chosen not to. I’m sure many thought that we deserved it, and others who didn’t found it easier to just let it happen. The abuse was worse because it was completely arbitrary. Sometimes if we asked for a medic, guards would show up quickly and our ill cage-mate would be taken to a medic. Sometimes guards would show up quickly but do nothing. Sometimes guards would not show up at all. This is the same arbitrariness that terrorized the peaceful protests at Queens Park and elsewhere, where riot cops made ‘dash and grab’ arrests—rushing quickly at a single protester (or passerby) with no warning, beating her, and taking her into custody. It is one of the most disturbing features of all the police violence that occurred over the weekend, because it defies logic and accountability.I’m acutely aware of how lucky I was relative to so many of the other innocent people who were arrested over the weekend. For one, I wasn’t physically abused prior to being taken into custody. But more than that, I’m an educated, well-off, straight white male. I’m sure it’s not a coincidence that the person in my cage held the longest was an indigenous man. And we now know that queer people were segregated into separate cages; women were threatened with rape and subjected to invasive strip searches (http://bit.ly/9Qlxfb).I’m now back in New York City, where I live, so I haven’t been able to participate directly in the growing collective efforts to seek justice for all the injustice that occurred in Toronto over the weekend. I wish I could. Being on the business end of police brutality hasn’t changed my politics at all; it’s confirmed them, and made me angrier. At the same time, while I am optimistic that forthcoming investigations and inquiries will condemn a certain amount of the police tactics, I don’t think that would be a ‘loss’ for the cops. It’s probably best to see their strategy as one of kicking the ball forward as far as they can in terms of the tactics they can get away with. Public outrage and judicial action may subsequently kick the ball back a certain distance, but as long as it ends up further than it was before last weekend, that is a police victory of sorts. So in general I am pessimistic about how much good can come directly out of all this. Indirectly, though, I think there is reason to hope that this outrage is bringing more people together, and building awareness of the fundamental injustice which underpins our society, which cannot be confronted until it is exposed, and which is now harder to ignore when over 1000 peaceful protesters and bystanders have been arbitrarily beaten, jailed, or both.
.
Saturday, June 26, 2010
Mirror on the Wall: Commonwealth Fund report continues to show US has poor outcomes at high cost
.
On December 5, 2008, I commented on the data from the 2008 Commonwealth Fund report comparing health status in a number of countries (Not Getting What We Pay For). The US fared very poorly on that study. The Commonwealth Fund has just released its 2010 study “Mirror, Mirror on the Wall” (Commonwealth Fund executive summary, Commonwealth Fund full report) and the news is no better. In comparing 7 industrialized countries (Australia, Canada, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States), the US is #1 in health expenditures per capita at $7,290, 87% higher than second-place Canada, over twice that of the average of the other 6 ($3354) and nearly 2.5 times as much as the UK. [“Expenditures shown in $US PPP (purchasing power parity)”.].
Distressingly, but unsurprisingly to those who pay any attention to the area, including having read this blog or having seen the 2006 or 2008 Commonwealth Fund reports, this expenditure does not lead to good performance on the study’s measures of Quality Care (comprised of Effective Care, Safe Care, Coordinated Care, and Patient-Centered Care), Access (comprised of Cost-related Problems and Timeliness of Care), Efficiency, and Equity, nor on the all-important health outcome “Long, Healthy, Productive Lives”. In fact, the US ranks last -- # 7 – on that outcome indicator. And while there is not one country that leads in all the categories – Australia, for example, ranks #3 overall, but is #1 in “Long, Healthy, Productive Lives”, and is tied with the US for last in “Access”; the UK, while #6 on “Long, Healthy, Productive Lives”, is #2 overall (behind the Netherlands) despite spending the 2nd lowest amount (to New Zealand’s lowest) per capita, and ranks #1 or #2 on 6 of 10 criteria, and #7 on only Patient-centered care.
The US ranks very poorly, as it did in 2008, on Efficiency, which is interesting. We can more easily understand low rankings in Access and Equity, given our completely inequitable system of funding and access, but poor Efficiency scores reflect our poor communication, with tests often being repeated because information is not carried forward, patients being readmitted, and a variety of other characteristics. There are 8 subcategories comprising Efficiency, and the US ranks #6 on 4 and #7 on 4 (and for the whole category).
Of course, this kind of report doesn’t seem to affect policy makers too much. We already knew this, and the health reform process was in part an attempt to address it, but the current bill, PPACA, certainly doesn’t do enough. Some of the additional funding that is targeted to public health will make a difference, but it is clear from the debate in Congress that there are many who simply do not support improving the health of the American people if doing so will require cuts to the profits of the big healthcare industries who contribute large sums to them.
Some critics of the Commonwealth Fund report, such as Dr. Richard Cooper of the University of Pennsylvania, have stated that the problem in the US is not that that we have a health system which is overbuilt on the high-tech, high-cost specialty end rather than on primary care, but rather that we have more poor people; he provides evidence that, on a large regional basis, areas of the country with more poor people (e.g., the Southeast) have worse health status than those with fewer poor people (e.g., the upper Midwest). There can be no doubt that poor health status is tied to low socioeconomic status, and that the large number of poor in the US is in significant part responsible for the poor health system performance identified by the Commonwealth report and others. However, as I and many others have pointed out in the past (Public Health and Changing People's Minds, May 15,2010; Poverty, Primary Care and the Cost of Medical Care, Feb 18, 2010; Health is more than Medical Care, Jan 27, 2010), health is not simply a result of the health care, or medical care, system. The other countries measured in the Commonwealth Fund report do not have a lower percentage of poor people by chance or luck; they are, to greater or lesser extents, social democracies with policies that ensure that their people have housing, food, and education. There are poor people in those countries, but their most basic needs are ensured and this goes a very long way to decreasing their health risk. Public health, medical professionals and others in those countries are well aware – expert in – the social and socioeconomic needs of the poor in their societies, but the situation of those people, is significantly improved, to a much greater degree than in the US by a much more extensive safety net.
Poverty is bad for your health, and programs that help ameliorate the impact of poverty improve the health of populations. In addition, the presence of adequate health care services, especially primary care services, further enhances outcomes. It is not an either/or choice. Shi and colleagues demonstrated that the increased infant mortality and low birthweight rates in poor communities are virtually eliminated by a higher primary care presence.[1]
The data provided by the Commonwealth Fund should be embarrassing to every policy maker, every person of influence, and every citizen of the US. It is incontrovertible data that demonstrates yet once again that the issue is not that we aren’t spending enough money, but is the way that the money is spent: We spend it in ways that make our health status poor and our health corporations wealthy. There should be no tension between increasing primary care, increasing public health and prevention, and providing the core needs of people for food, housing, education, and work. They are all components of a society that is not only basically decent, but which is concerned about its future, the health of its people, and its workforce. What we clearly do not need, however, is to continue to spend money in the way that we are on high-tech subspecialty care that benefits few patients and often not for very long. Indeed we need to spend much less, and use the money where it will have a positive impact.
Maybe by 2012 the Commonwealth Fund will show the US making some progress. I hope so, but it is going to take some serious structural changes.
[1] Shi L, Macinko J, Starfield B, Xu J, Regan J, Politzer R and Wulu J, “Primary care, infant mortality, and low birthweight in the states of the USA”,J Epidemiol Community Health 2004;58;374-380.
On December 5, 2008, I commented on the data from the 2008 Commonwealth Fund report comparing health status in a number of countries (Not Getting What We Pay For). The US fared very poorly on that study. The Commonwealth Fund has just released its 2010 study “Mirror, Mirror on the Wall” (Commonwealth Fund executive summary, Commonwealth Fund full report) and the news is no better. In comparing 7 industrialized countries (Australia, Canada, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States), the US is #1 in health expenditures per capita at $7,290, 87% higher than second-place Canada, over twice that of the average of the other 6 ($3354) and nearly 2.5 times as much as the UK. [“Expenditures shown in $US PPP (purchasing power parity)”.].
Distressingly, but unsurprisingly to those who pay any attention to the area, including having read this blog or having seen the 2006 or 2008 Commonwealth Fund reports, this expenditure does not lead to good performance on the study’s measures of Quality Care (comprised of Effective Care, Safe Care, Coordinated Care, and Patient-Centered Care), Access (comprised of Cost-related Problems and Timeliness of Care), Efficiency, and Equity, nor on the all-important health outcome “Long, Healthy, Productive Lives”. In fact, the US ranks last -- # 7 – on that outcome indicator. And while there is not one country that leads in all the categories – Australia, for example, ranks #3 overall, but is #1 in “Long, Healthy, Productive Lives”, and is tied with the US for last in “Access”; the UK, while #6 on “Long, Healthy, Productive Lives”, is #2 overall (behind the Netherlands) despite spending the 2nd lowest amount (to New Zealand’s lowest) per capita, and ranks #1 or #2 on 6 of 10 criteria, and #7 on only Patient-centered care.
The US ranks very poorly, as it did in 2008, on Efficiency, which is interesting. We can more easily understand low rankings in Access and Equity, given our completely inequitable system of funding and access, but poor Efficiency scores reflect our poor communication, with tests often being repeated because information is not carried forward, patients being readmitted, and a variety of other characteristics. There are 8 subcategories comprising Efficiency, and the US ranks #6 on 4 and #7 on 4 (and for the whole category).
Of course, this kind of report doesn’t seem to affect policy makers too much. We already knew this, and the health reform process was in part an attempt to address it, but the current bill, PPACA, certainly doesn’t do enough. Some of the additional funding that is targeted to public health will make a difference, but it is clear from the debate in Congress that there are many who simply do not support improving the health of the American people if doing so will require cuts to the profits of the big healthcare industries who contribute large sums to them.
Some critics of the Commonwealth Fund report, such as Dr. Richard Cooper of the University of Pennsylvania, have stated that the problem in the US is not that that we have a health system which is overbuilt on the high-tech, high-cost specialty end rather than on primary care, but rather that we have more poor people; he provides evidence that, on a large regional basis, areas of the country with more poor people (e.g., the Southeast) have worse health status than those with fewer poor people (e.g., the upper Midwest). There can be no doubt that poor health status is tied to low socioeconomic status, and that the large number of poor in the US is in significant part responsible for the poor health system performance identified by the Commonwealth report and others. However, as I and many others have pointed out in the past (Public Health and Changing People's Minds, May 15,2010; Poverty, Primary Care and the Cost of Medical Care, Feb 18, 2010; Health is more than Medical Care, Jan 27, 2010), health is not simply a result of the health care, or medical care, system. The other countries measured in the Commonwealth Fund report do not have a lower percentage of poor people by chance or luck; they are, to greater or lesser extents, social democracies with policies that ensure that their people have housing, food, and education. There are poor people in those countries, but their most basic needs are ensured and this goes a very long way to decreasing their health risk. Public health, medical professionals and others in those countries are well aware – expert in – the social and socioeconomic needs of the poor in their societies, but the situation of those people, is significantly improved, to a much greater degree than in the US by a much more extensive safety net.
Poverty is bad for your health, and programs that help ameliorate the impact of poverty improve the health of populations. In addition, the presence of adequate health care services, especially primary care services, further enhances outcomes. It is not an either/or choice. Shi and colleagues demonstrated that the increased infant mortality and low birthweight rates in poor communities are virtually eliminated by a higher primary care presence.[1]
The data provided by the Commonwealth Fund should be embarrassing to every policy maker, every person of influence, and every citizen of the US. It is incontrovertible data that demonstrates yet once again that the issue is not that we aren’t spending enough money, but is the way that the money is spent: We spend it in ways that make our health status poor and our health corporations wealthy. There should be no tension between increasing primary care, increasing public health and prevention, and providing the core needs of people for food, housing, education, and work. They are all components of a society that is not only basically decent, but which is concerned about its future, the health of its people, and its workforce. What we clearly do not need, however, is to continue to spend money in the way that we are on high-tech subspecialty care that benefits few patients and often not for very long. Indeed we need to spend much less, and use the money where it will have a positive impact.
Maybe by 2012 the Commonwealth Fund will show the US making some progress. I hope so, but it is going to take some serious structural changes.
[1] Shi L, Macinko J, Starfield B, Xu J, Regan J, Politzer R and Wulu J, “Primary care, infant mortality, and low birthweight in the states of the USA”,J Epidemiol Community Health 2004;58;374-380.
Sunday, June 20, 2010
A New Way of Ranking Medical Schools: Social Mission
.
In the June issue of the Annals of Internal Medicine, Fitzhugh Mullan, Candice Chen, Stephen Petterson, Gretchen Kolsky, and Michael Spagnola, mostly from the Department of Health Policy at the George Washington University (and one from the Robert Graham Center) report on “The social mission of medical education: ranking the schools”. This study, sponsored by the Josiah Macy, Jr. Foundation as part of the Medical Education Futures Study (MEFS) is the first report to look at this area, and should be eye-opening to those who assume that “good” medical schools are “good” at everything. Most ranking systems, most notably those of US News and World Report, are based on NIH research funding, grades and test scores of entering students, “competitiveness” (how low a percent of applicants they accept) and reputation. Obviously, the grades and test scores are related to competitiveness and reputation is a tautology, because it reinforces itself. It should depend upon what you are looking at, of course. I addressed this in “Rankings of Medical Schools: Do they tell us anything?” (September 25, 2009), and observed that what they tell us is who does well in what is measured, and that this should only be important to us if those are the outcomes we value.
Mullan and colleagues evaluate different outcomes, the degree to which medical schools meet their “social mission”, or to put it another way, the degree to which they produce the physicians that will take care of the American people. More to the point, since it can be argued that most medical school graduates take care of some American people, physicians who will take care of those people who need it the most because they don’t already have doctors. This means largely those in poor communities, rural communities, and minority communities (and especially those communities that are two or three of these). They look at 3 characteristics of graduates: 1) what percent of their graduates are practicing primary care, 2) what percent of their graduates are practicing in designated Health Professions Shortage Areas (HPSAs), and 3) what percent of their graduates are members of underrepresented minority groups? This is pretty straightforward, and they take two other steps to try and ensure that this is an accurate reflection.
The first is that they examined students, in the graduating classes of 1999-2001, 8 years after graduation. As I have pointed out several times (Primary Care and Residency Expansion, January 7, 2010; Funding Graduate Medical Education, May 25, 2009), the “credit” medical schools claim for students entering “primary care” residencies includes all those entering internal medicine programs, the vast majority of whom will enter subspecialty training. By looking at students 8 years after graduation, after they have completed residency and subspecialty fellowship training, they are able to get a much more accurate picture of who is actually doing primary care. Similarly, it also means that those who are practicing in HPSAs have been doing it for several years. Overall, public schools did much better than private schools, and Southern, Midwestern, and Western schools better than Northeastern schools.
In terms of underrepresented minority students, the percent of graduates, for public medical schools, is compared to the percent of the underrepresented minority population for the state, while for private schools, which are presumed to draw from a more national base, it is the national percentage (26.5%). Thus, for example, the University of Iowa has a positive ratio with 8.1% minority students in a state that is only 6% minority, while the Universidad de Puerto Rico en Ponce has a negative ratio because, even though their students are 82.5% underrepresented minorities, their “state” is 98.8%. The underrepresented minority scores for the 3 historically black medical schools, Morehouse, Meharry and Howard are so high, compared to the national average (as they are all private) that they are easily the top 3 in the overall social mission score. This tends to wash out the significant differences between them on the other two areas. For example Meharry does well in producing primary care physicians (49.3%, or 2 standard deviations [SD] above the national mean) compared to Howard, which at 36.5% is only 0.19 SD above the mean; Howard, however, does better at placing students in HPSAs (33.7%, +0.78 SD) than Meharry (28.1%, +0.12 SD). Ponce, despite its negative underrepresented minority score and also a negative primary care physician score (-0.31 SD*), ranks #9 nationally in total social mission score. This is based on its high rate of physicians practicing in HPSAs (43.8%, +1.94 SD), because so much of its service area are HPSAs.
The data can be analyzed in a number of ways. Osteopathic schools have a much higher rate of producing primary care doctors, but none were in the top 20 because their percent of underrepresented minorities are low. Adding only the two dimensions of primary care and HPSA practice shows only 7 schools with a standardized score above 3, all of them public allopathic schools and 4 of them “community based” medical schools with a specific commitment to primary care (as is Wright State, the #4 ranked school in overall social mission). A few top NIH research schools (4, to be exact) “defied the trend” and were in, at least, the top quartile of social mission scores, again all public schools. Other than the historically black schools, private schools were nowhere to be seen.
The schools that traditionally do well on rankings such as that of US News tended to be at the bottom of this scale. They are overwhelmingly private (14 of the bottom 20) and generally highly NIH-funded. Comments from the leaders of those schools, unsurprisingly, tended to disparage the study and its methods, and to assert, essentially, that “our school does well on all of its missions.” If those missions include the social missions of meeting the health needs of the American people by producing minority and primary care physicians, and those that practice in underserved areas, they clearly do not. And, while some are better than others, no medical schools are doing very well at enrolling underrepresented minorities (except the historically black schools and the Puerto Rican schools) or at producing physicians for rural areas at anything approaching the percent of Americans who live in those areas (Primary Care and Rural Areas, April 28, 2010).
This is not to say that other missions of medical schools, such as biomedical research, cutting-edge medical care, and training of the future generations of academics, including the MD/PhDs who will be laboratory-based researchers, are unimportant. Lawrence G. Smith and Veronica M. Catanese emphasize this point in their accompanying editorial, “The Many Missions of Medical Schools”, as well as noting various possible ways in which the production of physicians who fulfill a social mission might have been underestimated by Mullan, et. al. They also note, as I have above, that different schools do better or worse on the different social mission measures, but also that success in the social mission needs to be pursued, as success in all other missions: “The lack of concordance among the 3 elements of Mullan and colleagues' social mission score suggests that medical schools that accept this mission—as they must—cannot define social mission narrowly. They must have multipronged initiatives and not simply 'wait' for programs aimed at recruiting and retaining underrepresented minority students, or at specifically incentivizing primary care, to bear fruit.”
The key point is that the data produced by Mullan and colleagues that shows that schools which are historically highly ranked do relatively poorly in social mission is not due to a flawed methodology. “The level of NIH support that medical schools received was inversely associated with their output of primary care physicians and physicians practicing in underserved areas.” It is because these schools do not emphasize the characteristics that they are measuring, combined into the concept of social mission, nearly as highly as they do their other missions and do not put as much energy, time, or especially money into them. Mullan et. al. conclude that “Some schools may choose other priorities, but in this time of national reconsideration, it seems appropriate that all schools examine their educational commitment regarding the service needs of their states and the nation. A diverse, equitably distributed physician workforce with a strong primary care base is essential to achieve quality health care that is accessible and affordable, regardless of the nature of any future health care reform.”
The authors note that “Medical schools, however, are the only institutions in our society that can produce physicians”. It is up to the people of the US, particularly the communities in need and the policy makers who represent them, to decide how high a priority producing physicians who will meet our social need by practicing in specialties, in areas, and with populations who do not have doctors, and how to use the public coffers to achieve this. The time is long past, however, for these characteristics not to be measured. We can no longer, in self-indulgence or ignorance, assume that those schools that are the “best” on US News rankings because of NIH research funding, selectivity, and “reputation” are the best in every area. In producing the doctors most needed by this nation’s most needy, they are, with few exceptions, mostly the worst.
*Like the other Puerto Rican Schools, Ponce has a low production of family physicians, ranking 117 out of 128 medical schools for producing FPs in the 10 years from 1999-2008, as reported by the American Academy of Family Physicians (AAFP) annual analysis.
.
In the June issue of the Annals of Internal Medicine, Fitzhugh Mullan, Candice Chen, Stephen Petterson, Gretchen Kolsky, and Michael Spagnola, mostly from the Department of Health Policy at the George Washington University (and one from the Robert Graham Center) report on “The social mission of medical education: ranking the schools”. This study, sponsored by the Josiah Macy, Jr. Foundation as part of the Medical Education Futures Study (MEFS) is the first report to look at this area, and should be eye-opening to those who assume that “good” medical schools are “good” at everything. Most ranking systems, most notably those of US News and World Report, are based on NIH research funding, grades and test scores of entering students, “competitiveness” (how low a percent of applicants they accept) and reputation. Obviously, the grades and test scores are related to competitiveness and reputation is a tautology, because it reinforces itself. It should depend upon what you are looking at, of course. I addressed this in “Rankings of Medical Schools: Do they tell us anything?” (September 25, 2009), and observed that what they tell us is who does well in what is measured, and that this should only be important to us if those are the outcomes we value.
Mullan and colleagues evaluate different outcomes, the degree to which medical schools meet their “social mission”, or to put it another way, the degree to which they produce the physicians that will take care of the American people. More to the point, since it can be argued that most medical school graduates take care of some American people, physicians who will take care of those people who need it the most because they don’t already have doctors. This means largely those in poor communities, rural communities, and minority communities (and especially those communities that are two or three of these). They look at 3 characteristics of graduates: 1) what percent of their graduates are practicing primary care, 2) what percent of their graduates are practicing in designated Health Professions Shortage Areas (HPSAs), and 3) what percent of their graduates are members of underrepresented minority groups? This is pretty straightforward, and they take two other steps to try and ensure that this is an accurate reflection.
The first is that they examined students, in the graduating classes of 1999-2001, 8 years after graduation. As I have pointed out several times (Primary Care and Residency Expansion, January 7, 2010; Funding Graduate Medical Education, May 25, 2009), the “credit” medical schools claim for students entering “primary care” residencies includes all those entering internal medicine programs, the vast majority of whom will enter subspecialty training. By looking at students 8 years after graduation, after they have completed residency and subspecialty fellowship training, they are able to get a much more accurate picture of who is actually doing primary care. Similarly, it also means that those who are practicing in HPSAs have been doing it for several years. Overall, public schools did much better than private schools, and Southern, Midwestern, and Western schools better than Northeastern schools.
In terms of underrepresented minority students, the percent of graduates, for public medical schools, is compared to the percent of the underrepresented minority population for the state, while for private schools, which are presumed to draw from a more national base, it is the national percentage (26.5%). Thus, for example, the University of Iowa has a positive ratio with 8.1% minority students in a state that is only 6% minority, while the Universidad de Puerto Rico en Ponce has a negative ratio because, even though their students are 82.5% underrepresented minorities, their “state” is 98.8%. The underrepresented minority scores for the 3 historically black medical schools, Morehouse, Meharry and Howard are so high, compared to the national average (as they are all private) that they are easily the top 3 in the overall social mission score. This tends to wash out the significant differences between them on the other two areas. For example Meharry does well in producing primary care physicians (49.3%, or 2 standard deviations [SD] above the national mean) compared to Howard, which at 36.5% is only 0.19 SD above the mean; Howard, however, does better at placing students in HPSAs (33.7%, +0.78 SD) than Meharry (28.1%, +0.12 SD). Ponce, despite its negative underrepresented minority score and also a negative primary care physician score (-0.31 SD*), ranks #9 nationally in total social mission score. This is based on its high rate of physicians practicing in HPSAs (43.8%, +1.94 SD), because so much of its service area are HPSAs.
The data can be analyzed in a number of ways. Osteopathic schools have a much higher rate of producing primary care doctors, but none were in the top 20 because their percent of underrepresented minorities are low. Adding only the two dimensions of primary care and HPSA practice shows only 7 schools with a standardized score above 3, all of them public allopathic schools and 4 of them “community based” medical schools with a specific commitment to primary care (as is Wright State, the #4 ranked school in overall social mission). A few top NIH research schools (4, to be exact) “defied the trend” and were in, at least, the top quartile of social mission scores, again all public schools. Other than the historically black schools, private schools were nowhere to be seen.
The schools that traditionally do well on rankings such as that of US News tended to be at the bottom of this scale. They are overwhelmingly private (14 of the bottom 20) and generally highly NIH-funded. Comments from the leaders of those schools, unsurprisingly, tended to disparage the study and its methods, and to assert, essentially, that “our school does well on all of its missions.” If those missions include the social missions of meeting the health needs of the American people by producing minority and primary care physicians, and those that practice in underserved areas, they clearly do not. And, while some are better than others, no medical schools are doing very well at enrolling underrepresented minorities (except the historically black schools and the Puerto Rican schools) or at producing physicians for rural areas at anything approaching the percent of Americans who live in those areas (Primary Care and Rural Areas, April 28, 2010).
This is not to say that other missions of medical schools, such as biomedical research, cutting-edge medical care, and training of the future generations of academics, including the MD/PhDs who will be laboratory-based researchers, are unimportant. Lawrence G. Smith and Veronica M. Catanese emphasize this point in their accompanying editorial, “The Many Missions of Medical Schools”, as well as noting various possible ways in which the production of physicians who fulfill a social mission might have been underestimated by Mullan, et. al. They also note, as I have above, that different schools do better or worse on the different social mission measures, but also that success in the social mission needs to be pursued, as success in all other missions: “The lack of concordance among the 3 elements of Mullan and colleagues' social mission score suggests that medical schools that accept this mission—as they must—cannot define social mission narrowly. They must have multipronged initiatives and not simply 'wait' for programs aimed at recruiting and retaining underrepresented minority students, or at specifically incentivizing primary care, to bear fruit.”
The key point is that the data produced by Mullan and colleagues that shows that schools which are historically highly ranked do relatively poorly in social mission is not due to a flawed methodology. “The level of NIH support that medical schools received was inversely associated with their output of primary care physicians and physicians practicing in underserved areas.” It is because these schools do not emphasize the characteristics that they are measuring, combined into the concept of social mission, nearly as highly as they do their other missions and do not put as much energy, time, or especially money into them. Mullan et. al. conclude that “Some schools may choose other priorities, but in this time of national reconsideration, it seems appropriate that all schools examine their educational commitment regarding the service needs of their states and the nation. A diverse, equitably distributed physician workforce with a strong primary care base is essential to achieve quality health care that is accessible and affordable, regardless of the nature of any future health care reform.”
The authors note that “Medical schools, however, are the only institutions in our society that can produce physicians”. It is up to the people of the US, particularly the communities in need and the policy makers who represent them, to decide how high a priority producing physicians who will meet our social need by practicing in specialties, in areas, and with populations who do not have doctors, and how to use the public coffers to achieve this. The time is long past, however, for these characteristics not to be measured. We can no longer, in self-indulgence or ignorance, assume that those schools that are the “best” on US News rankings because of NIH research funding, selectivity, and “reputation” are the best in every area. In producing the doctors most needed by this nation’s most needy, they are, with few exceptions, mostly the worst.
*Like the other Puerto Rican Schools, Ponce has a low production of family physicians, ranking 117 out of 128 medical schools for producing FPs in the 10 years from 1999-2008, as reported by the American Academy of Family Physicians (AAFP) annual analysis.
.
Monday, June 14, 2010
Oil Slicks and Abortion: Who do we regulate?
.
As the nation grapples with the “Deep Horizon” blowout, which will be uncontrovertibly a complete disaster for the Gulf of Mexico and life within it as well as for the people who live along the Gulf Coast and their way of life, a number of things have become apparent. Some of them are detailed in “Don’t Get Mad, Mr. President. Get Even”, the Sunday, June 6, 2010 New York Times column by Frank Rich. Rich, whose primary theme is the response of the President, details the incredible panoply of disasters and near-disasters caused by British Petroleum, and its apparently complete disregard for the few regulations it has been subject to. He is clearly amazed and disappointed that the President continues to place faith in experts, even those at BP, who had an
“…atrocious record prior to this catastrophe. In the last three years, according to the Center for Public Integrity, BP accounted for ‘97 percent of all flagrant violations found in the refining industry by government safety inspectors’ — including 760 citations for ‘egregious, willful’ violations (compared with only eight at the two oil companies that tied for second place). Hayward’s [BP CEO Tony Hayward] predecessor at BP, ousted in a sex-and-blackmail scandal in 2007, had placed cost-cutting (and ever more obscene profits) over safety, culminating in the BP Texas City refinery explosion that killed 15 and injured 170 in 2005. Last October The Times uncovered documents revealing that BP had still failed to address hundreds of safety hazards at that refinery in the four years after the explosion, prompting the largest fine in the history of the Occupational Safety and Health Administration. (The fine, $87 million, was no doubt regarded as petty cash by a company whose profit reached nearly $17 billion last year.)”
Just to restate: BP had 97% of all flagrant violations. Of “egregious, willful” violations – that is, “we ignored the rules on purpose, not by accident” – they had 760, while oil company offender #2 had 8. Clearly then, in an industry known for arrogance, and for preferring to wield political influence (see: George Bush, Dick Cheney) to actually being careful with our world and our environment, BP stands out. It, corporately (and, probably, individually in its leadership ranks) is the true slick scum, from which the oil slick scum washing up on Louisiana owes its paternity.
So let’s talk about Louisiana. It has a long, well-deserved, reputation as one of our more politically corrupt states. It is the home, most famously until this blowout, of the city of New Orleans that, you may remember, was the victim of Hurricane Katrina in 2005, a disaster that the city has nowhere near recovered from despite its absence from the front pages. The incompetence involved in not maintaining the levees that protected the city, especially its poorest parts, and not planning for what was obviously an event that was going to happen, was only eclipsed by the incompetence of the governmental response. The federal government’s terrible response (see: George Bush, Dick Cheney, FEMA director Michael “Brownie” Brown) has gotten most of the criticism, deservedly so, but the response of the state of Louisiana, under Governor Kathleen Blanco, was at least as incompetent – and it was their home state. Of course, in many ways, government in Louisiana has had some of the characteristics of that in nearby places such as Haiti – close collaboration with the wealthy minority that exploit its resources for their personal gain, and, of course, that of the politicians that they pay. It has frequently led to enough anger that populist, if scarcely reformist, politicians have been elected by regular people angry at this exploitation. They too, we well know, have been bought (see: Long, any first name).
The lack of regulation by the state government, in fact its coziness with, the oil industry has been a characteristic of Louisiana. The benefits are jobs for its citizens who work in the oil and gas industry that is so important to the state’s economy (and of course to the politicians who receive “contributions” if not outright graft). The risks are to those same workers, who, like their brethren in the coal industry, are periodically subjected to accidents leading to maiming and death, or, if they are lucky enough not to be sudden death victims, to long term health consequences from their occupational exposures. These industries need to be tightly regulated and controlled, and they can be. As in the case of Haiti (in the 19th century), and much of Africa, and other places rich in natural resources, the large corporations need them. The natural resources – oil and gas, or coal, or diamonds and goal, or tungsten and bauxite and copper – exist where they exist and the corporations need them, and despite their bluster will make the investment in safety, for the people and the environment, if they are absolutely forced to, not just by law but by enforcement.
And then there are oil rig blowouts polluting the waters of the Gulf and the marshes, as the strip mining in Appalachia scars the land there. And then there is Deepwater Horizon, an ecological disaster that may – likely will -- exceed the Exxon Valdez spill in Alaska, a result of the greed of a few and the lack of regulation by the state and federal government. Or, at least, enforcement of regulations.
Make no mistake, Louisiana is capable of passing laws with strict regulations and enforcing them. Take, for example, abortion. Striving to compete with the many other states that have wanted to take the lead in controlling women’s reproduction (see In Ultrasound, Abortion Fight Has New Front by Kevin Sack, NY Times May 27, 2010), Louisiana has passed some of the most restrictive abortion laws in the country. Many of these laws are clearly directed at harassing abortion providers so that they go out of business, and mainly have the effect of harassing the women who are seeking abortions. Recent laws include the requirement that a woman who wants an abortion see an ultrasound of the fetus within 2 hours of the procedure, having the images on the screen described to her, and be given a copy of the ultrasound in an envelope with sonogram results written on the front. There is no exception for fetal demise, rape, incest or anything.
Louisiana’s governor (Bobby Jindahl) and its anti-choice legislature may take pleasure in their “F” rating by the National Abortion Rights Action League (NARAL); the negative impact is suffered by the actual women who are already struggling with having decided that an abortion is the right thing for them, in their lives, at that time, and don’t need this additional harassment from their government. It would be wonderful if the Louisiana governor and legislator could take the same pride in the rigorous regulation of the oil industry in their state, protecting their people and their livelihoods and the environment from destruction with anything approaching the same vigor.
But they can’t take such pride. Because they don’t do it. If they did, we’d be living in a much better world.
.
As the nation grapples with the “Deep Horizon” blowout, which will be uncontrovertibly a complete disaster for the Gulf of Mexico and life within it as well as for the people who live along the Gulf Coast and their way of life, a number of things have become apparent. Some of them are detailed in “Don’t Get Mad, Mr. President. Get Even”, the Sunday, June 6, 2010 New York Times column by Frank Rich. Rich, whose primary theme is the response of the President, details the incredible panoply of disasters and near-disasters caused by British Petroleum, and its apparently complete disregard for the few regulations it has been subject to. He is clearly amazed and disappointed that the President continues to place faith in experts, even those at BP, who had an
“…atrocious record prior to this catastrophe. In the last three years, according to the Center for Public Integrity, BP accounted for ‘97 percent of all flagrant violations found in the refining industry by government safety inspectors’ — including 760 citations for ‘egregious, willful’ violations (compared with only eight at the two oil companies that tied for second place). Hayward’s [BP CEO Tony Hayward] predecessor at BP, ousted in a sex-and-blackmail scandal in 2007, had placed cost-cutting (and ever more obscene profits) over safety, culminating in the BP Texas City refinery explosion that killed 15 and injured 170 in 2005. Last October The Times uncovered documents revealing that BP had still failed to address hundreds of safety hazards at that refinery in the four years after the explosion, prompting the largest fine in the history of the Occupational Safety and Health Administration. (The fine, $87 million, was no doubt regarded as petty cash by a company whose profit reached nearly $17 billion last year.)”
Just to restate: BP had 97% of all flagrant violations. Of “egregious, willful” violations – that is, “we ignored the rules on purpose, not by accident” – they had 760, while oil company offender #2 had 8. Clearly then, in an industry known for arrogance, and for preferring to wield political influence (see: George Bush, Dick Cheney) to actually being careful with our world and our environment, BP stands out. It, corporately (and, probably, individually in its leadership ranks) is the true slick scum, from which the oil slick scum washing up on Louisiana owes its paternity.
So let’s talk about Louisiana. It has a long, well-deserved, reputation as one of our more politically corrupt states. It is the home, most famously until this blowout, of the city of New Orleans that, you may remember, was the victim of Hurricane Katrina in 2005, a disaster that the city has nowhere near recovered from despite its absence from the front pages. The incompetence involved in not maintaining the levees that protected the city, especially its poorest parts, and not planning for what was obviously an event that was going to happen, was only eclipsed by the incompetence of the governmental response. The federal government’s terrible response (see: George Bush, Dick Cheney, FEMA director Michael “Brownie” Brown) has gotten most of the criticism, deservedly so, but the response of the state of Louisiana, under Governor Kathleen Blanco, was at least as incompetent – and it was their home state. Of course, in many ways, government in Louisiana has had some of the characteristics of that in nearby places such as Haiti – close collaboration with the wealthy minority that exploit its resources for their personal gain, and, of course, that of the politicians that they pay. It has frequently led to enough anger that populist, if scarcely reformist, politicians have been elected by regular people angry at this exploitation. They too, we well know, have been bought (see: Long, any first name).
The lack of regulation by the state government, in fact its coziness with, the oil industry has been a characteristic of Louisiana. The benefits are jobs for its citizens who work in the oil and gas industry that is so important to the state’s economy (and of course to the politicians who receive “contributions” if not outright graft). The risks are to those same workers, who, like their brethren in the coal industry, are periodically subjected to accidents leading to maiming and death, or, if they are lucky enough not to be sudden death victims, to long term health consequences from their occupational exposures. These industries need to be tightly regulated and controlled, and they can be. As in the case of Haiti (in the 19th century), and much of Africa, and other places rich in natural resources, the large corporations need them. The natural resources – oil and gas, or coal, or diamonds and goal, or tungsten and bauxite and copper – exist where they exist and the corporations need them, and despite their bluster will make the investment in safety, for the people and the environment, if they are absolutely forced to, not just by law but by enforcement.
And then there are oil rig blowouts polluting the waters of the Gulf and the marshes, as the strip mining in Appalachia scars the land there. And then there is Deepwater Horizon, an ecological disaster that may – likely will -- exceed the Exxon Valdez spill in Alaska, a result of the greed of a few and the lack of regulation by the state and federal government. Or, at least, enforcement of regulations.
Make no mistake, Louisiana is capable of passing laws with strict regulations and enforcing them. Take, for example, abortion. Striving to compete with the many other states that have wanted to take the lead in controlling women’s reproduction (see In Ultrasound, Abortion Fight Has New Front by Kevin Sack, NY Times May 27, 2010), Louisiana has passed some of the most restrictive abortion laws in the country. Many of these laws are clearly directed at harassing abortion providers so that they go out of business, and mainly have the effect of harassing the women who are seeking abortions. Recent laws include the requirement that a woman who wants an abortion see an ultrasound of the fetus within 2 hours of the procedure, having the images on the screen described to her, and be given a copy of the ultrasound in an envelope with sonogram results written on the front. There is no exception for fetal demise, rape, incest or anything.
Louisiana’s governor (Bobby Jindahl) and its anti-choice legislature may take pleasure in their “F” rating by the National Abortion Rights Action League (NARAL); the negative impact is suffered by the actual women who are already struggling with having decided that an abortion is the right thing for them, in their lives, at that time, and don’t need this additional harassment from their government. It would be wonderful if the Louisiana governor and legislator could take the same pride in the rigorous regulation of the oil industry in their state, protecting their people and their livelihoods and the environment from destruction with anything approaching the same vigor.
But they can’t take such pride. Because they don’t do it. If they did, we’d be living in a much better world.
.
Tuesday, June 8, 2010
Reinventing Primary Care: Themes and Challenges
.
My May 27 entry, Universal Coverage and Primary Care: The US needs both, focused on one article from the May 2010 issue of the journal Health Affairs. That article, by Barbara Starfield, (“Reinventing Primary Care: Lessons from Canada for the United States”) was just one of 65 articles in this issue that addressed the topic of “reinventing primary care”. The articles cover the gamut of the history of primary care, the problem of undersupply of primary care providers, proposals for increasing the number of primary care providers, analyses (such as Dr. Starfield’s) of the health systems of other nations’ that are based on primary care, proposals for how the organization and structure of primary care practices need to be changed, and case studies of models of practices and demonstration projects that have implicated innovative approaches to primary care delivery. Many of these practice changes are contained under the rubric of the Primary Care Medical Home (PCMH), which is also the abbreviation for the related Patient Centered Medical Home. Indeed, the Patient Centered Primary Care Collaborative (PCPCC), a coalition of major employers, insurers, providers, pharmaceutical and device makers, and consumers, uses both “PC”s in its name (one hesitates to say that it is thus very PC!)
One of the articles is in fact “The multistakeholder movement for primary care renewal and reform”, by Paul Grundy, et. al., specifically addresses and discusses this collaborative, as well as its proposals for change in the entire structure of the primary care delivery system. Grundy, who is vice-president for global health reform of IBM, is president of the collaborative. It has brought together these various stakeholders in recognition not only of the overwhelming data that shows systems that are built upon primary care are more efficient, more cost-effective, and lead to better health outcomes, but on the actual experience of IBM and other multinational companies. These companies find that their health costs, and the health (and thus lack of time off for illness) of their workers is dramatically lower in countries in which the health system is built upon a primary care base. It is actively involved in educating, advocating, and demonstrating the importance of developing such a base in the US.
Many of the other articles in the journal address changes that need to happen to allow the small (and, as I have pointed out, likely to stay too small even if there is a significant increase in production from our current paltry 16%) number of primary care providers to care for larger panels of patients, while maintaining or increasing quality of care, patient satisfaction, and efficiency. Two of these are co-written by Thomas Bodenheimer, MD, ‘Primary Care: Current Problems And Proposed Solutions”, by Bodenheimer and H.H. Pham, and “Transforming Primary Care: From Past Practice To The Practice Of The Future”, by D. Margolius and Bodenheimer. Another perspective, more from that of the individual physician than the overall health system, is Lawrence P. Casalino’s contribution, “A Martian’s Prescription For Primary Care: Overhaul The Physician’s Workday”
What is striking about these articles in the similarity of their recommendations. The recurrent themes include the need for multi-disciplinary teams of health professionals who all play roles in caring for patients, and panels of patients. This goes beyond the simple “nurses doing callbacks” to patients before, or instead of, the physician. It means that nurses provide the care that they can, that pharmacists and psychologists and social workers all are part of the team, communicating with each other but often operating independently. Group visits are another theme; often people with the same (or, in fact, different) conditions can benefit from being seen in a group. This can be for a more formal didactic session of patient education about their condition by a nurse, or pharmacist, or health educator, or physical therapist, or physician, or medications, or other treatments, often combined with a great deal of person-to-person interaction. There is more to this than efficiency; people actually benefit from the fact of being in a group, of sharing experiences, and ideas, and successes and failures.
Another important and recurrent theme is that of physician-patient interactions that do not involve face-to-face contact, but rather phone calls or emails. Again, this is not just a matter of efficiency for the physician; patients often have concerns that can be successfully addressed by one of these other methods that do not involve them having to take off work, drive a long distance, look for parking, and wait in the waiting room. A physician can be far more effective, and interact with a much larger number of people, if an afternoon consists of seeing a few in person, a much larger number by telephone, and an even larger number by email; a number of products exist that provide not only secure email communication, but provide a structure for the patient to supply information that will help the doctor (or NP, or nurse, or whoever on the team is most appropriate) provide the greatest help.
In his article, Casalino lists five reasons why a physician should see someone in person:
“(1) for a first visit; (2) when it may be necessary to engage in some physical maneuver for diagnostic purposes—such as palpating the abdomen, listening to the heart, or performing a skin biopsy; (3) for specific therapeutic purposes, such as injecting a joint; (4) when the patient has problems for which lengthy discussion would be helpful; (5) when for psychological or emotional reasons it seems better to see the patient face-to-face; and (6) when face-to-face visits are necessary to build trust.”
These are very good, but I would simplify it even more: the physician should see the patient face-to-face when either the patient or the physician think it is important.
The effectiveness and satisfaction from increased phone calls substituting for visits was clear in the late 1990s when capitation, rather than fee-for-service, was a dominant mode of payment (of course, at that time the internet was not yet developed enough for most people to be using email). To reprise, and to improve upon that process will, obviously, require a reimbursement system that does not pay only for face-to-face physician visits. This is another common theme to many of the articles in this issue. It is also not happening in most places. It is, however, a sine qua non for such practice reorganization. And increasing the primary care supply.
Which of these themes is the most important: increasing the supply of primary care physicians, reorganizing practices to become true Patient Centered Medical homes, utilizing all of the strategies above and more, or restructuring the way health care is paid for? They are all important, all related, and all dependent upon each other for success. What is not addressed in most of the articles in this issue of Health Affairs, however, is arguably the most important: ensuring health coverage for everyone. The work of the Patient Centered Primary Care Collaborative may go a long way to having a more rational delivery system for those with access, but as long as the same old hands, in particular the insurance companies but also the drug and device makers, are part of the decision-making process, they are unlikely to come up with a plan that truly covers everyone, single-payer, “Medicare for All”, or any other rational system. And without that, all the primary care reform is not going to really work. It is not only a moral issue (although that should be enough!); it is that the cost, in terms of work hours lost, unnecessary suffering, direct dollars spent on diseases that have advanced too far because people have delayed care, and ultimately worse outcomes, is unsupportable and unsustainable.
We’ve passed PPACA. Now it’s time for real health reform.
.
My May 27 entry, Universal Coverage and Primary Care: The US needs both, focused on one article from the May 2010 issue of the journal Health Affairs. That article, by Barbara Starfield, (“Reinventing Primary Care: Lessons from Canada for the United States”) was just one of 65 articles in this issue that addressed the topic of “reinventing primary care”. The articles cover the gamut of the history of primary care, the problem of undersupply of primary care providers, proposals for increasing the number of primary care providers, analyses (such as Dr. Starfield’s) of the health systems of other nations’ that are based on primary care, proposals for how the organization and structure of primary care practices need to be changed, and case studies of models of practices and demonstration projects that have implicated innovative approaches to primary care delivery. Many of these practice changes are contained under the rubric of the Primary Care Medical Home (PCMH), which is also the abbreviation for the related Patient Centered Medical Home. Indeed, the Patient Centered Primary Care Collaborative (PCPCC), a coalition of major employers, insurers, providers, pharmaceutical and device makers, and consumers, uses both “PC”s in its name (one hesitates to say that it is thus very PC!)
One of the articles is in fact “The multistakeholder movement for primary care renewal and reform”, by Paul Grundy, et. al., specifically addresses and discusses this collaborative, as well as its proposals for change in the entire structure of the primary care delivery system. Grundy, who is vice-president for global health reform of IBM, is president of the collaborative. It has brought together these various stakeholders in recognition not only of the overwhelming data that shows systems that are built upon primary care are more efficient, more cost-effective, and lead to better health outcomes, but on the actual experience of IBM and other multinational companies. These companies find that their health costs, and the health (and thus lack of time off for illness) of their workers is dramatically lower in countries in which the health system is built upon a primary care base. It is actively involved in educating, advocating, and demonstrating the importance of developing such a base in the US.
Many of the other articles in the journal address changes that need to happen to allow the small (and, as I have pointed out, likely to stay too small even if there is a significant increase in production from our current paltry 16%) number of primary care providers to care for larger panels of patients, while maintaining or increasing quality of care, patient satisfaction, and efficiency. Two of these are co-written by Thomas Bodenheimer, MD, ‘Primary Care: Current Problems And Proposed Solutions”, by Bodenheimer and H.H. Pham, and “Transforming Primary Care: From Past Practice To The Practice Of The Future”, by D. Margolius and Bodenheimer. Another perspective, more from that of the individual physician than the overall health system, is Lawrence P. Casalino’s contribution, “A Martian’s Prescription For Primary Care: Overhaul The Physician’s Workday”
What is striking about these articles in the similarity of their recommendations. The recurrent themes include the need for multi-disciplinary teams of health professionals who all play roles in caring for patients, and panels of patients. This goes beyond the simple “nurses doing callbacks” to patients before, or instead of, the physician. It means that nurses provide the care that they can, that pharmacists and psychologists and social workers all are part of the team, communicating with each other but often operating independently. Group visits are another theme; often people with the same (or, in fact, different) conditions can benefit from being seen in a group. This can be for a more formal didactic session of patient education about their condition by a nurse, or pharmacist, or health educator, or physical therapist, or physician, or medications, or other treatments, often combined with a great deal of person-to-person interaction. There is more to this than efficiency; people actually benefit from the fact of being in a group, of sharing experiences, and ideas, and successes and failures.
Another important and recurrent theme is that of physician-patient interactions that do not involve face-to-face contact, but rather phone calls or emails. Again, this is not just a matter of efficiency for the physician; patients often have concerns that can be successfully addressed by one of these other methods that do not involve them having to take off work, drive a long distance, look for parking, and wait in the waiting room. A physician can be far more effective, and interact with a much larger number of people, if an afternoon consists of seeing a few in person, a much larger number by telephone, and an even larger number by email; a number of products exist that provide not only secure email communication, but provide a structure for the patient to supply information that will help the doctor (or NP, or nurse, or whoever on the team is most appropriate) provide the greatest help.
In his article, Casalino lists five reasons why a physician should see someone in person:
“(1) for a first visit; (2) when it may be necessary to engage in some physical maneuver for diagnostic purposes—such as palpating the abdomen, listening to the heart, or performing a skin biopsy; (3) for specific therapeutic purposes, such as injecting a joint; (4) when the patient has problems for which lengthy discussion would be helpful; (5) when for psychological or emotional reasons it seems better to see the patient face-to-face; and (6) when face-to-face visits are necessary to build trust.”
These are very good, but I would simplify it even more: the physician should see the patient face-to-face when either the patient or the physician think it is important.
The effectiveness and satisfaction from increased phone calls substituting for visits was clear in the late 1990s when capitation, rather than fee-for-service, was a dominant mode of payment (of course, at that time the internet was not yet developed enough for most people to be using email). To reprise, and to improve upon that process will, obviously, require a reimbursement system that does not pay only for face-to-face physician visits. This is another common theme to many of the articles in this issue. It is also not happening in most places. It is, however, a sine qua non for such practice reorganization. And increasing the primary care supply.
Which of these themes is the most important: increasing the supply of primary care physicians, reorganizing practices to become true Patient Centered Medical homes, utilizing all of the strategies above and more, or restructuring the way health care is paid for? They are all important, all related, and all dependent upon each other for success. What is not addressed in most of the articles in this issue of Health Affairs, however, is arguably the most important: ensuring health coverage for everyone. The work of the Patient Centered Primary Care Collaborative may go a long way to having a more rational delivery system for those with access, but as long as the same old hands, in particular the insurance companies but also the drug and device makers, are part of the decision-making process, they are unlikely to come up with a plan that truly covers everyone, single-payer, “Medicare for All”, or any other rational system. And without that, all the primary care reform is not going to really work. It is not only a moral issue (although that should be enough!); it is that the cost, in terms of work hours lost, unnecessary suffering, direct dollars spent on diseases that have advanced too far because people have delayed care, and ultimately worse outcomes, is unsupportable and unsustainable.
We’ve passed PPACA. Now it’s time for real health reform.
.
Wednesday, June 2, 2010
Who will care for the underserved? The role of off-shore medical schools
.
I have written in several previous posts (most recently Universal Coverage and Primary Care: The US needs both, May 27, 2010) about the challenges facing American medicine, particularly regarding specialty choice (=not primary care, not rural, not underserved) of US allopathic graduates, and the problems this has already created in providing health care to the American people, which is only likely to worsen as this trend continues. I have noted that, in the production of physicians as in any other process, the outcome results from variables in inputs (who is admitted in this case), the process itself (in education, the curriculum, both formal and informal), and output variables (in the case of physicians, what the practice environment is: reimbursement, work load, quality of life, respect and regard within the profession and community). I have argued that, while output variables may be the most important in terms of specialty choice and practice location, it is the one over which medical educators have the least control. While the curriculum, the process through which we educate medical students, is critical (see Are we training physicians to be empathic? Apparently not., Sept 12, 2009), it is likely that the characteristics of the students selected is most important in determining practice location, particularly for rural areas, but also for urban underserved settings (Medical Student Selection, Dec 14, 2008). Selecting students who grew up in the suburbs of major cities (what Robert Bowman, MD, who has done much research in this area, calls “major medical centers”) in homes with high socioeconomic status and excellent high school and college educations (which is what is mainly done) will result in students with excellent test performance and is likely to produce skilled physicians, but not ones likely to practice in rural or underserved areas.
Students from rural areas, from underserved communities, from low socioeconomic status backgrounds, and from underrepresented minority groups are much more likely to serve these populations, as are students who are older at the time of matriculation. But their lower grades and MCATs, may make them less likely to be accepted, and to have difficulty with the pre-clinical medical curriculum. Students, even from privileged backgrounds, whose prior life history includes significant service are also more likely to work in urban underserved settings; less so (although more than their colleagues without these characteristics) in rural areas. But what about schools of other types or medical schools not in the US?
In a conversation with US Senator Sam Brownback on a visit to his office last year, members of the Kansas Academy of Family Physicians (KAFP) noted the challenges in getting KUMC graduates to work in rural areas. In an off-the-cuff response (I don’t mean to suggest that this was thought-out or his real position; I use the statement as a basis for comment) he suggested that we then just start a medical school at Kansas State University that would train rural primary care doctors. This type of response to a system that is not having the impact that policy makers wish for is common – create a new school, or focus on another different type of school (e.g., osteopathic), or another profession (nurse practitioners, physician’s assistants). But, of course, if they take the same sorts of students and offer them the same range of career opportunities, why would one expect different outcomes? Osteopathic graduates, while still entering family medicine and primary care at higher rates than allopathic, are increasingly becoming specialists. NPs, and especially PAs, are increasingly joining specialty physician practices and remaining in urban areas with high income potential rather than high need. Why would they not? Would you, or your children?
Because there are far more residency training positions than there are US graduates, many of these positions are filled with international medical graduates. A special group of these are “US IMGs”, Americans who, unable to be admitted to US medical schools, attend those outside the country. In the Caribbean, there are many schools, for-profit, set up for precisely this purpose. I recently had the opportunity to give the “White Coat Ceremony” talk to the class entering the largest of these: Ross University School of Medicine (http://www.rossu.edu) on the island of Dominica. Ross, in existence for over 30 years and now owned by DeVry, the largest for-profit educational company in the US, has a “business model” that enrolls 3 classes per year paying tuition much the same as a private US private school or an out-of-state student at a US public medical school. After the first two years, students do clinical clerkships in 70 hospitals in the US that are affiliated with the school – and paid by them. The student body is ethnically very diverse, with over half the members of the class I spoke to born outside the US (although 95% are US citizens or permanent residents; the rest mostly Canadian), but not including a large percentage of students from traditional underrepresented minority groups, and certainly not many from poor families. Ross graduate disproportionately enter primary care specialties, but this is almost certainly because primary care is less competitive than many subspecialties, and the fact that they didn’t train at US schools puts them at a competitive disadvantage in the selection process. Nonetheless, there are several positive things to be said about the Ross experience. First, Ross has a single mission – medical education. The considerable funds it generates are not required to support a large research or clinical enterprise, but can be directed to that mission. Second, it takes students who, because of their grades, wouldn’t – didn’t – get into US medical schools, and gives them a chance to succeed. If there is a high failure rate as a result, there are also unquestionably outstanding doctors produced who would not have otherwise existed. They are able, because of their business model, to take a “chance” on these students – and if they work hard, they can be successful.
While there a very many Caribbean medical schools, of different ages, quality, and size, operated more-or-less on the Ross model, a quite different model exists on another island – Cuba. Whatever its failures, one of the great successes in Cuba since the revolution of 1959 has been the expansion of medical care to the entire citizenry of the nation, and exportation of trained physicians, both Cuban nationals (they are even on Ross’ home island of Dominica) and those from other countries educated in Cuba. The Latin American Medical School (Escuela Latino-Americana de Medicina – ELAM), which educates students from other Latin American countries, began to take students from the US a number of years ago. Unlike those attending Ross and other costly schools, US students at ELAM are virtually all from low socioeconomic backgrounds and mainly from underrepresented minority groups. Tuition is free and living expenses are paid, but there are prices for the students to pay. Admission requires a bachelor’s degree, but students are still required to spend the entire 6 years of medical school that is the usual for countries outside the US and Canada, or 7 if they need to learn Spanish first. They live in minimal dormitories, have very limited access to the internet (1-2 hours per week), and work very hard. They receive a medical education that particularly emphasizes public health, community medicine, and prevention. They promise to complete their training and enter practice in service to the communities from which they come, but it is a promise – obviously the Cubans have no way to enforce this. They receive no training in the US prior to graduation unless they are able to arrange summer observerships on their own, and are not particularly prepared for the “National Board” exams, the USMLE, that are required for US licensure and admission to US residencies. MEDICC (Medical Education in Cooperation with Cuba) , a US group that exists to support US students at ELAM and its graduates, tries to find them mentors who will help orient them to the health system in their own country, the US, teach them about applying to US residencies, and offer guidance in the study for USMLE. The first US graduates of ELAM have entered a few US residencies this year; I have met one, who is phenomenal. Other US medical educators are working with ELAM graduates and offering both advice and opportunities for volunteer training.
The US students at ELAM are the “right students”. They come from underserved backgrounds, are committed to their communities, and are willing to work very hard (perhaps ten years between bachelor’s degree and entering a residency). The question, of course, is not “how can they go to that Communist country?” but rather why are we allowing Cuba to pick up the role that our own medical education system fails to fulfill. Indeed, it would be particularly for those who oppose Cuba and socialism to develop such programs in our own country.
Senator Brownback, if we are going to start a new school in Kansas, let’s model much of it on ELAM. Let’s make it free, and recruit students from underserved communities and underrepresented minority groups, and low socioeconomic backgrounds, and teach them public health and prevention and primary care, and send them out to serve their communities of origin. In the meantime, let us at least have a “sliding scale” loan repayment program where the percent of your loan your repay is tied to your post-residency income, as well as your practice location and specialty choice.
.
I have written in several previous posts (most recently Universal Coverage and Primary Care: The US needs both, May 27, 2010) about the challenges facing American medicine, particularly regarding specialty choice (=not primary care, not rural, not underserved) of US allopathic graduates, and the problems this has already created in providing health care to the American people, which is only likely to worsen as this trend continues. I have noted that, in the production of physicians as in any other process, the outcome results from variables in inputs (who is admitted in this case), the process itself (in education, the curriculum, both formal and informal), and output variables (in the case of physicians, what the practice environment is: reimbursement, work load, quality of life, respect and regard within the profession and community). I have argued that, while output variables may be the most important in terms of specialty choice and practice location, it is the one over which medical educators have the least control. While the curriculum, the process through which we educate medical students, is critical (see Are we training physicians to be empathic? Apparently not., Sept 12, 2009), it is likely that the characteristics of the students selected is most important in determining practice location, particularly for rural areas, but also for urban underserved settings (Medical Student Selection, Dec 14, 2008). Selecting students who grew up in the suburbs of major cities (what Robert Bowman, MD, who has done much research in this area, calls “major medical centers”) in homes with high socioeconomic status and excellent high school and college educations (which is what is mainly done) will result in students with excellent test performance and is likely to produce skilled physicians, but not ones likely to practice in rural or underserved areas.
Students from rural areas, from underserved communities, from low socioeconomic status backgrounds, and from underrepresented minority groups are much more likely to serve these populations, as are students who are older at the time of matriculation. But their lower grades and MCATs, may make them less likely to be accepted, and to have difficulty with the pre-clinical medical curriculum. Students, even from privileged backgrounds, whose prior life history includes significant service are also more likely to work in urban underserved settings; less so (although more than their colleagues without these characteristics) in rural areas. But what about schools of other types or medical schools not in the US?
In a conversation with US Senator Sam Brownback on a visit to his office last year, members of the Kansas Academy of Family Physicians (KAFP) noted the challenges in getting KUMC graduates to work in rural areas. In an off-the-cuff response (I don’t mean to suggest that this was thought-out or his real position; I use the statement as a basis for comment) he suggested that we then just start a medical school at Kansas State University that would train rural primary care doctors. This type of response to a system that is not having the impact that policy makers wish for is common – create a new school, or focus on another different type of school (e.g., osteopathic), or another profession (nurse practitioners, physician’s assistants). But, of course, if they take the same sorts of students and offer them the same range of career opportunities, why would one expect different outcomes? Osteopathic graduates, while still entering family medicine and primary care at higher rates than allopathic, are increasingly becoming specialists. NPs, and especially PAs, are increasingly joining specialty physician practices and remaining in urban areas with high income potential rather than high need. Why would they not? Would you, or your children?
Because there are far more residency training positions than there are US graduates, many of these positions are filled with international medical graduates. A special group of these are “US IMGs”, Americans who, unable to be admitted to US medical schools, attend those outside the country. In the Caribbean, there are many schools, for-profit, set up for precisely this purpose. I recently had the opportunity to give the “White Coat Ceremony” talk to the class entering the largest of these: Ross University School of Medicine (http://www.rossu.edu) on the island of Dominica. Ross, in existence for over 30 years and now owned by DeVry, the largest for-profit educational company in the US, has a “business model” that enrolls 3 classes per year paying tuition much the same as a private US private school or an out-of-state student at a US public medical school. After the first two years, students do clinical clerkships in 70 hospitals in the US that are affiliated with the school – and paid by them. The student body is ethnically very diverse, with over half the members of the class I spoke to born outside the US (although 95% are US citizens or permanent residents; the rest mostly Canadian), but not including a large percentage of students from traditional underrepresented minority groups, and certainly not many from poor families. Ross graduate disproportionately enter primary care specialties, but this is almost certainly because primary care is less competitive than many subspecialties, and the fact that they didn’t train at US schools puts them at a competitive disadvantage in the selection process. Nonetheless, there are several positive things to be said about the Ross experience. First, Ross has a single mission – medical education. The considerable funds it generates are not required to support a large research or clinical enterprise, but can be directed to that mission. Second, it takes students who, because of their grades, wouldn’t – didn’t – get into US medical schools, and gives them a chance to succeed. If there is a high failure rate as a result, there are also unquestionably outstanding doctors produced who would not have otherwise existed. They are able, because of their business model, to take a “chance” on these students – and if they work hard, they can be successful.
While there a very many Caribbean medical schools, of different ages, quality, and size, operated more-or-less on the Ross model, a quite different model exists on another island – Cuba. Whatever its failures, one of the great successes in Cuba since the revolution of 1959 has been the expansion of medical care to the entire citizenry of the nation, and exportation of trained physicians, both Cuban nationals (they are even on Ross’ home island of Dominica) and those from other countries educated in Cuba. The Latin American Medical School (Escuela Latino-Americana de Medicina – ELAM), which educates students from other Latin American countries, began to take students from the US a number of years ago. Unlike those attending Ross and other costly schools, US students at ELAM are virtually all from low socioeconomic backgrounds and mainly from underrepresented minority groups. Tuition is free and living expenses are paid, but there are prices for the students to pay. Admission requires a bachelor’s degree, but students are still required to spend the entire 6 years of medical school that is the usual for countries outside the US and Canada, or 7 if they need to learn Spanish first. They live in minimal dormitories, have very limited access to the internet (1-2 hours per week), and work very hard. They receive a medical education that particularly emphasizes public health, community medicine, and prevention. They promise to complete their training and enter practice in service to the communities from which they come, but it is a promise – obviously the Cubans have no way to enforce this. They receive no training in the US prior to graduation unless they are able to arrange summer observerships on their own, and are not particularly prepared for the “National Board” exams, the USMLE, that are required for US licensure and admission to US residencies. MEDICC (Medical Education in Cooperation with Cuba) , a US group that exists to support US students at ELAM and its graduates, tries to find them mentors who will help orient them to the health system in their own country, the US, teach them about applying to US residencies, and offer guidance in the study for USMLE. The first US graduates of ELAM have entered a few US residencies this year; I have met one, who is phenomenal. Other US medical educators are working with ELAM graduates and offering both advice and opportunities for volunteer training.
The US students at ELAM are the “right students”. They come from underserved backgrounds, are committed to their communities, and are willing to work very hard (perhaps ten years between bachelor’s degree and entering a residency). The question, of course, is not “how can they go to that Communist country?” but rather why are we allowing Cuba to pick up the role that our own medical education system fails to fulfill. Indeed, it would be particularly for those who oppose Cuba and socialism to develop such programs in our own country.
Senator Brownback, if we are going to start a new school in Kansas, let’s model much of it on ELAM. Let’s make it free, and recruit students from underserved communities and underrepresented minority groups, and low socioeconomic backgrounds, and teach them public health and prevention and primary care, and send them out to serve their communities of origin. In the meantime, let us at least have a “sliding scale” loan repayment program where the percent of your loan your repay is tied to your post-residency income, as well as your practice location and specialty choice.
.
Thursday, May 27, 2010
Universal Coverage and Primary Care: The US needs both
.
In “Reinventing Primary Care: Lessons from Canada for the United States” (Health Affairs, May2010;29(5):1030-5), the eminent scholar Barbara Starfield provides just that – lessons from Canada for the United States. For decades, advocates of comprehensive health reform have pointed to our northern neighbor and suggested that a “single payer” system such as that in Canada would be a more-than-reasonable solution. In Canada, provincial governments provide the funding for health care services, under the guidance of the five principles set out in the Canada Health Act of 1972: public administration, comprehensiveness, universality, portability, and accessibility. The principle of universality means that every Canadian is covered, with the same health insurance benefit package, as every other Canadian. (In fact, because the various programs that are together called “Medicare” in Canada are provincial, it would be more accurate to say that every resident of a province has the same benefit package as every other; however, all provinces provide coverage for all essential services; more can be found on the website http://www.canadianhealthcare.org/.)
Dr. Starfield’s article goes systematically through a variety of indicators of health status and costs, comparing the two countries, citing both similarities and differences between them. Overall, the US looks much worse in health status and much greater in cost. While not the best performer among the Organization for Economic Cooperation and Development (OECD) countries (representing the most developed, “first world”, countries) in almost any area, Canada is ahead of the US in most, often significantly. A few examples from her “Exhibit 1” include Life Expectancy at birth (Canada ranks 9, the US 25), Potential Years of Life Lost at age 70 (Canada is 13, the US is 21), and Infant Mortality (Canada is 24, the US 26). Canadians have a lower death rate for conditions “amenable to medical care”, meaning that if you got care you’d be less likely to die, and the differences are not (as is sometimes asserted) due to racial differences between the two countries:
“Studies of deaths from treatable conditions also show better performance of the Canadian health system compared with that of the United States, and the differences are not a result of existing racial disparities. That is, the worse health of the U.S. population compared with that of Canadians is found even when comparisons are restricted to the white population. Longterm comparisons show that the life expectancy of Americans has been worse than that of Canadians since the beginning of the twentieth century, but that most of this difference was a result of lower life expectancy among African Americans. However, this situation changed in the 1970s, when Canadian life expectancy rose even above that of white Americans.
“Differences in death rates have increased over time, with Canada improving in rank and the United States declining in rank. Differences by cause of death for conditions amenable to medical care are on the order of 25–60 percent lower in Canada than among U.S. whites and have increased over time since the 1980s.”
Starfield attributes the difference primarily to two features of the Canadian health system, a “universal, publicly accountable health insurance system”, and the presence of a strong primary care base. The first should be a “gimme”; of course such a system would make a difference, of course it is likely to improve the health of the population and reduce the burden of disease, physical, psychosocial, and financial, on both the individual and their family and the society. It is absolutely obvious that a rational, mature, and responsible society would provide financial access to health care for its people.
Unfortunately, that is not the case for the US, the only OECD country which does not have such a system, relies on “employer-based health insurance for the nonelderly population”, and it is not going to change under the new health reform law, the Patient Protection and Affordable Care Act (PPACA). PPACA, even when fully implemented, will not cover everyone, will not control costs, will allow insurance companies to charge up to 3 times the premium for older (and note that this would be pre-Medicare; “older” could be over 40!), and will not have either the universality or public accountability to ensure quality care. We will continue to hear the pain of patients such as the woman featured in the “2009 Road Trip Video” by Mad As Hell Doctors (http://www.madashelldoctors.com/) who pulls off her turban to review her hair lost to chemotherapy, and tells us that “when I found out I had breast cancer I was worried that I might die, but I was terrified about how I would pay for it.”[1] Come on. This is simply not acceptable in a wealthy developed country. Those who do not support such a system are either incredibly greedy, selfish, and corrupt, as are the insurance companies and their minions in Congress, or incomprehensible.
The other difference between the US and Canada that Dr. Starfield emphasizes is the presence of a strong primary care base. She notes that “Several international studies have confirmed the importance of three health-system characteristics of countries that achieve better health at lower cost: government attempts to distribute resources, such as personnel and facilities, equitably; universal financial coverage either through a single payer or regulated by the government; and low or no cost sharing for primary care services…U.S. policy achieves none of the three structural characteristics of good health systems. Canada achieves all three. “
I have repeatedly written about the lack of sufficient primary care capacity, and primary care production, in the US, and clearly I am not alone. It has become almost a deafening chorus, with report after report identifying the deficiency in primary care, and the need to increase the number and percent of medical students entering primary care; much of this is presented in “Who will provide primary care and how will they be trained?”, the proceedings of a conference in April 2010 sponsored by the Josiah Macy, Jr. Foundation. PPACA does commit significant resources to supporting primary care, but we are far from having a sufficient number of primary care providers or a reasonable geographic distribution of those we have. Canada and the other OECD countries have at least 50% of their physician workforce in primary care. When Canada saw that percent decreasing, they took strong action to reverse it, and now have a majority of their medical students entering primary care.[2] The US, on the other hand, has only about 16% of its physician workforce entering primary care. [3],[4]
So how we will change this? Not by anything we are doing now. We have less than 30% primary care doctors, and we need to get to at least 50%, but are producing 16%. This is, obviously, going in the wrong direction. Doubling the production of medical students entering primary care will still have us going in the wrong direction, and we are nowhere near getting to double. Even if we produce 50% a year, on average, from all medical schools, it will take 30 years, a generation, to get to that goal. And we are very, very far from that goal. The BEST medical schools in terms of placing students in family medicine and other primary care specialties, such as the one I work at, the University of Kansas, are not close. Most other medical schools are much worse. Many, particularly the private, Eastern, “elite” medical schools highly ranked by US News do not even accept any responsibility for producing physicians who are in the specialties that are needed to meet the health care needs of the American people.
The University of Kansas School of Medicine will be establishing a rural track in Salina, KS, where 8 students per year, committed to rural health, will spend their entire 4 years. The goal is that 75% will enter rural practice and 50% primary care, and preferably both. Great idea. Except this is 8 students in one medical school! The entire KU medical school, and those of all states – “from Colorado, Kansas, and the Carolinas too, from Virginia to Alaska, from the old to the new, from Texas and Ohio and the California shore”[5], as well as those “elite” schools who feel no responsibility, all need to produce as high a percent of their graduates entering primary care as possible, to average over 50% nationally.
This will not be easy. It will probably mean taking different people into medical school, not those with the most elite educations and well-to-do backgrounds, not the children of the faculty, but those who are from rural areas and minority communities and want to go back to them; not those who want to become tertiary and quarternary care super-specialists but those who want to work in the community; not those likely to enter laboratory research (a noble career, but why take up seats in medical school?), but those who want to care for people. It will require rethinking and reprioritizing. But it must happen.
Dr. Starfield notes that “Universal health insurance alone is not sufficient to raise a country’s health levels to match those of countries with the best levels. Within the United States, there is a greater relationship between the presence of a good supply of primary care physicians and life expectancy than there is between either broad insurance coverage or affordability of voverage and life expectancy. Universal coverage alone, particularly if not organized through a single payer with uniformity of benefits, could expand access to inappropriate services.”
Well, we need both, the single payer system and the commitment to primary care. And we need action, not more words. And we need it now.
[1] Note that this comment may not appear on the abridged version of the wonderful video that appears on this website.
[2] McKee ND, McKague MA, Ramsden VR, Poole RE. Cultivating interest in family medicine: family medicine interest group reaches undergraduate medical students. Can Fam Physician. 2007;53(4):661–5.
[3] Roehrig C. Presentation to the Council on Graduate Medical Education, 2009 Nov 18. Data from the American Association of Medical Colleges Graduation Questionnaire.
[4] Sandy LG, Bodenheimer T, PawlsonLG, Starfield B. The political economy of U.S. primary care. Health Aff Millwood). 2009;28 (4):1136–45.
[5] From the late great Phil Ochs, “Power and Glory”, copyright Phil Ochs.
.
In “Reinventing Primary Care: Lessons from Canada for the United States” (Health Affairs, May2010;29(5):1030-5), the eminent scholar Barbara Starfield provides just that – lessons from Canada for the United States. For decades, advocates of comprehensive health reform have pointed to our northern neighbor and suggested that a “single payer” system such as that in Canada would be a more-than-reasonable solution. In Canada, provincial governments provide the funding for health care services, under the guidance of the five principles set out in the Canada Health Act of 1972: public administration, comprehensiveness, universality, portability, and accessibility. The principle of universality means that every Canadian is covered, with the same health insurance benefit package, as every other Canadian. (In fact, because the various programs that are together called “Medicare” in Canada are provincial, it would be more accurate to say that every resident of a province has the same benefit package as every other; however, all provinces provide coverage for all essential services; more can be found on the website http://www.canadianhealthcare.org/.)
Dr. Starfield’s article goes systematically through a variety of indicators of health status and costs, comparing the two countries, citing both similarities and differences between them. Overall, the US looks much worse in health status and much greater in cost. While not the best performer among the Organization for Economic Cooperation and Development (OECD) countries (representing the most developed, “first world”, countries) in almost any area, Canada is ahead of the US in most, often significantly. A few examples from her “Exhibit 1” include Life Expectancy at birth (Canada ranks 9, the US 25), Potential Years of Life Lost at age 70 (Canada is 13, the US is 21), and Infant Mortality (Canada is 24, the US 26). Canadians have a lower death rate for conditions “amenable to medical care”, meaning that if you got care you’d be less likely to die, and the differences are not (as is sometimes asserted) due to racial differences between the two countries:
“Studies of deaths from treatable conditions also show better performance of the Canadian health system compared with that of the United States, and the differences are not a result of existing racial disparities. That is, the worse health of the U.S. population compared with that of Canadians is found even when comparisons are restricted to the white population. Longterm comparisons show that the life expectancy of Americans has been worse than that of Canadians since the beginning of the twentieth century, but that most of this difference was a result of lower life expectancy among African Americans. However, this situation changed in the 1970s, when Canadian life expectancy rose even above that of white Americans.
“Differences in death rates have increased over time, with Canada improving in rank and the United States declining in rank. Differences by cause of death for conditions amenable to medical care are on the order of 25–60 percent lower in Canada than among U.S. whites and have increased over time since the 1980s.”
Starfield attributes the difference primarily to two features of the Canadian health system, a “universal, publicly accountable health insurance system”, and the presence of a strong primary care base. The first should be a “gimme”; of course such a system would make a difference, of course it is likely to improve the health of the population and reduce the burden of disease, physical, psychosocial, and financial, on both the individual and their family and the society. It is absolutely obvious that a rational, mature, and responsible society would provide financial access to health care for its people.
Unfortunately, that is not the case for the US, the only OECD country which does not have such a system, relies on “employer-based health insurance for the nonelderly population”, and it is not going to change under the new health reform law, the Patient Protection and Affordable Care Act (PPACA). PPACA, even when fully implemented, will not cover everyone, will not control costs, will allow insurance companies to charge up to 3 times the premium for older (and note that this would be pre-Medicare; “older” could be over 40!), and will not have either the universality or public accountability to ensure quality care. We will continue to hear the pain of patients such as the woman featured in the “2009 Road Trip Video” by Mad As Hell Doctors (http://www.madashelldoctors.com/) who pulls off her turban to review her hair lost to chemotherapy, and tells us that “when I found out I had breast cancer I was worried that I might die, but I was terrified about how I would pay for it.”[1] Come on. This is simply not acceptable in a wealthy developed country. Those who do not support such a system are either incredibly greedy, selfish, and corrupt, as are the insurance companies and their minions in Congress, or incomprehensible.
The other difference between the US and Canada that Dr. Starfield emphasizes is the presence of a strong primary care base. She notes that “Several international studies have confirmed the importance of three health-system characteristics of countries that achieve better health at lower cost: government attempts to distribute resources, such as personnel and facilities, equitably; universal financial coverage either through a single payer or regulated by the government; and low or no cost sharing for primary care services…U.S. policy achieves none of the three structural characteristics of good health systems. Canada achieves all three. “
I have repeatedly written about the lack of sufficient primary care capacity, and primary care production, in the US, and clearly I am not alone. It has become almost a deafening chorus, with report after report identifying the deficiency in primary care, and the need to increase the number and percent of medical students entering primary care; much of this is presented in “Who will provide primary care and how will they be trained?”, the proceedings of a conference in April 2010 sponsored by the Josiah Macy, Jr. Foundation. PPACA does commit significant resources to supporting primary care, but we are far from having a sufficient number of primary care providers or a reasonable geographic distribution of those we have. Canada and the other OECD countries have at least 50% of their physician workforce in primary care. When Canada saw that percent decreasing, they took strong action to reverse it, and now have a majority of their medical students entering primary care.[2] The US, on the other hand, has only about 16% of its physician workforce entering primary care. [3],[4]
So how we will change this? Not by anything we are doing now. We have less than 30% primary care doctors, and we need to get to at least 50%, but are producing 16%. This is, obviously, going in the wrong direction. Doubling the production of medical students entering primary care will still have us going in the wrong direction, and we are nowhere near getting to double. Even if we produce 50% a year, on average, from all medical schools, it will take 30 years, a generation, to get to that goal. And we are very, very far from that goal. The BEST medical schools in terms of placing students in family medicine and other primary care specialties, such as the one I work at, the University of Kansas, are not close. Most other medical schools are much worse. Many, particularly the private, Eastern, “elite” medical schools highly ranked by US News do not even accept any responsibility for producing physicians who are in the specialties that are needed to meet the health care needs of the American people.
The University of Kansas School of Medicine will be establishing a rural track in Salina, KS, where 8 students per year, committed to rural health, will spend their entire 4 years. The goal is that 75% will enter rural practice and 50% primary care, and preferably both. Great idea. Except this is 8 students in one medical school! The entire KU medical school, and those of all states – “from Colorado, Kansas, and the Carolinas too, from Virginia to Alaska, from the old to the new, from Texas and Ohio and the California shore”[5], as well as those “elite” schools who feel no responsibility, all need to produce as high a percent of their graduates entering primary care as possible, to average over 50% nationally.
This will not be easy. It will probably mean taking different people into medical school, not those with the most elite educations and well-to-do backgrounds, not the children of the faculty, but those who are from rural areas and minority communities and want to go back to them; not those who want to become tertiary and quarternary care super-specialists but those who want to work in the community; not those likely to enter laboratory research (a noble career, but why take up seats in medical school?), but those who want to care for people. It will require rethinking and reprioritizing. But it must happen.
Dr. Starfield notes that “Universal health insurance alone is not sufficient to raise a country’s health levels to match those of countries with the best levels. Within the United States, there is a greater relationship between the presence of a good supply of primary care physicians and life expectancy than there is between either broad insurance coverage or affordability of voverage and life expectancy. Universal coverage alone, particularly if not organized through a single payer with uniformity of benefits, could expand access to inappropriate services.”
Well, we need both, the single payer system and the commitment to primary care. And we need action, not more words. And we need it now.
[1] Note that this comment may not appear on the abridged version of the wonderful video that appears on this website.
[2] McKee ND, McKague MA, Ramsden VR, Poole RE. Cultivating interest in family medicine: family medicine interest group reaches undergraduate medical students. Can Fam Physician. 2007;53(4):661–5.
[3] Roehrig C. Presentation to the Council on Graduate Medical Education, 2009 Nov 18. Data from the American Association of Medical Colleges Graduation Questionnaire.
[4] Sandy LG, Bodenheimer T, PawlsonLG, Starfield B. The political economy of U.S. primary care. Health Aff Millwood). 2009;28 (4):1136–45.
[5] From the late great Phil Ochs, “Power and Glory”, copyright Phil Ochs.
.
Friday, May 21, 2010
Primary Care: What takes so much time? And how are we paying for it?
.
In a piece that has gotten a lot of attention, “What’s Keeping Us So Busy in Primary Care? A Snapshot from One Practice”(New England Journal of Medicine, Apr29,2010;362(17):1632-6), Philadelphia general internist Richard J. Baron writes about the many tasks – many of them unreimbursed – that occupy the time of the physicians in his practice. While the physicians in the practice saw an average of 18.1 patient visits per day (the one activity they were paid for), they also returned an average of 23.7 telephone calls, and 16.8 email messages. They refilled 12.1 prescriptions, reviewed 19.5 laboratory reports, 11.1 imaging reports and 13.9 consultation reports per day. They also filled out large amounts of paperwork that they do not report on because they are not captured by their electronic medical record, such as “…administrative forms (e.g., for physical examinations for work, camp, and school and Family Medical Leave Act forms), correspondence received from health plan (e.g., disease-management letters), and reports on home care and physical therapy.” That’s a lot of work that is not being paid for. This is a huge issue in providing primary care, and one that is not often appreciated by the subspecialists, medical and surgical, who are very highly reimbursed for the procedures that they do, so that the paperwork, phone calls, etc., such as they are, are well subsidized.
Dr. Baron’s report reinforces both frequent observations and studies that have been done earlier. In 2003, Yarnall, et. al., published an article that looked at the amount of time it would take a primary care physician with a typical practice of 2,500 patient to provide all of the preventive care recommended by the US Preventive Services Task Force (USPSTF) at the “A” or “B” level. In “Primary Care: Is There Enough Time for Prevention?” (Am J Public Health. 2003;93:635–641), they found that:
“In all, an annual total of 1773 hours, or 7.4 hours of every working day, is required for the provision of all recommended preventive services to a practice of 2500 patients with age and sex distributions based on the US population.”
That is a staggering statistic; in itself this is a full-time occupation, and yet it does not include any time for managing the chronic diseases that people have, or the acute conditions that are bothering them! In a later piece in 2009, “Family Physicians as Team Leaders: ‘Time’ to Share the Care” (Prev Chronic Disease Apr2009;6(2):A59), Yarnall and colleagues further assess all three types of care (preventive, chronic, and acute) and determine that together they would take 21.7 hours a day! This is reassuringly less than 24, as even doctors need to sleep and eat!
The recommendations from Yarnall, et. al., and from other recent pieces assessing the changes that will need to take place in the structure of primary care, coincide with the decisions made by Dr. Baron’s group to increase the size of their team. While the internists in Philadelphia mainly added a triage nurse, a true team requires a more comprehensive approach. Proposals planning for the Patient-Centered Medical Home (PCMH) understand that “it takes a team,” not just a physician. Among the best recent review and analyses is “Transforming Primary Care: From Past Practice To The Practice Of The Future” by David Margolius and Thomas Bodenheimer (Health Affairs May 2010, 29(5): 779–784 ). Virtually all these proposals advocate developing a team of providers, including doctors, nurses, medical assistants, pharmacists, secretaries/clerks, social workers, mental health specialists, even public health professionals, to collaboratively provide the appropriate and necessary care.
This is a great idea, but hard to implement in the current fee-for-service system, a system unlikely to change given the degree to which the new health reform law is built around insurance companies. Dr. Baron’s practice was participating in a demonstration project to provide coordination in the interest of the PCMH that was funded by the state of Pennsylvania; most practices are not. As I have said before, if proceduralist could do the procedures and subspecialists manage their particular rare or advanced disease, and allow primary care doctors to manage complexity and counsel and do prevention (and mental health professionals, and social workers, and pharmacists, and therapists to all do the things they were best able to do) rather than trying to do more procedures because they would make more money, this would make – sense.
Comprehensive care for people is a big undertaking. It is much more than consulting on one problem, or doing a single procedure and follow up. It is caring for many problems, and providing the preventive care that people need, and addressing their acute complaints, and doing counseling for both psychosocial issues and decision-making issues (e.g., “should I have this surgery?” “what is the risk of this diagnostic procedure recommended by the consultant?”) It is being available to refill lost or expired prescriptions, reviewing lab and imaging results and consultant reports, and answer questions by phone or email, and review and coordinate the care being provided by consultants. It is doing all those things that people expect that their “family doctors” (in whatever specialty they are actually certified) will do. It is a very different practice than that of a subspecialist; while for the latter “the buck stops here” for treatment decisions for a particular condition, for the former “the buck stops here”, period. There is nothing in the medical realm with which they cannot, reasonably, be expected to be involved.
Consider a patient who tells a subspecialist, say their cardiologist, about their knee pain. The cardiologist says “I don’t do knees,” and sends them back to their primary care doctor, or refers them to an orthopedist. On their next visit the patient says “I saw the orthopedist you sent me to,” and the cardiologist, reasonably, says “I don’t do knees. Do whatever s/he told you.”
Now consider the patient presenting with the same knee pain to their primary care doctor. Maybe that doctor has a good idea of what the problem is and how to treat it, but to be sure refers the patient to the orthopedist. On the return visit, the patient now wants to talk with “their” doctor about what the orthopedist said, what s/he recommended, what the primary care doctor thinks about that, and needs help making a decision. So, while for the subspecialist (cardiologist, in this example) a referral disposes of potential work, for the primary care physician, it will usually, while reassuring the doctor that the right care is being done, actually increase the amount of work.
Most primary care practices discover, as did Dr. Baron’s, that it is inefficient to have physicians doing virtually any of the work that could be done by a lower-paid staff member; this could be a nurse (which his practice did not employ initially) or a medical assistant. Subspecialists have always known this, employing nurses, physician’s assistants, and others (including medical “fellows”) to augment their productivity; for example, a surgeon can be in the operating room while a physician’s assistant sees patients in the office. But it takes money to pay such staff.
As long as the only reimbursement is for actual patient visits, and that reimbursement is spectacularly lower for primary care doctors than for subspecialists, and particularly proceduralists, the financial viability of such practices will be low, and the attractiveness to highly indebted medical students comparably low. This calls for a restructuring of the entire payment system, into one that encourages collaboration and the most appropriate management. A capitated payment system is very desirable because then patients can be “seen” in the most appropriate way based on the perception of patient and physician – phone, email, office, hospital, home – but only if that reimbursement is high enough to make the development and implementation of patient centered systems worthwhile.
.
In a piece that has gotten a lot of attention, “What’s Keeping Us So Busy in Primary Care? A Snapshot from One Practice”(New England Journal of Medicine, Apr29,2010;362(17):1632-6), Philadelphia general internist Richard J. Baron writes about the many tasks – many of them unreimbursed – that occupy the time of the physicians in his practice. While the physicians in the practice saw an average of 18.1 patient visits per day (the one activity they were paid for), they also returned an average of 23.7 telephone calls, and 16.8 email messages. They refilled 12.1 prescriptions, reviewed 19.5 laboratory reports, 11.1 imaging reports and 13.9 consultation reports per day. They also filled out large amounts of paperwork that they do not report on because they are not captured by their electronic medical record, such as “…administrative forms (e.g., for physical examinations for work, camp, and school and Family Medical Leave Act forms), correspondence received from health plan (e.g., disease-management letters), and reports on home care and physical therapy.” That’s a lot of work that is not being paid for. This is a huge issue in providing primary care, and one that is not often appreciated by the subspecialists, medical and surgical, who are very highly reimbursed for the procedures that they do, so that the paperwork, phone calls, etc., such as they are, are well subsidized.
Dr. Baron’s report reinforces both frequent observations and studies that have been done earlier. In 2003, Yarnall, et. al., published an article that looked at the amount of time it would take a primary care physician with a typical practice of 2,500 patient to provide all of the preventive care recommended by the US Preventive Services Task Force (USPSTF) at the “A” or “B” level. In “Primary Care: Is There Enough Time for Prevention?” (Am J Public Health. 2003;93:635–641), they found that:
“In all, an annual total of 1773 hours, or 7.4 hours of every working day, is required for the provision of all recommended preventive services to a practice of 2500 patients with age and sex distributions based on the US population.”
That is a staggering statistic; in itself this is a full-time occupation, and yet it does not include any time for managing the chronic diseases that people have, or the acute conditions that are bothering them! In a later piece in 2009, “Family Physicians as Team Leaders: ‘Time’ to Share the Care” (Prev Chronic Disease Apr2009;6(2):A59), Yarnall and colleagues further assess all three types of care (preventive, chronic, and acute) and determine that together they would take 21.7 hours a day! This is reassuringly less than 24, as even doctors need to sleep and eat!
The recommendations from Yarnall, et. al., and from other recent pieces assessing the changes that will need to take place in the structure of primary care, coincide with the decisions made by Dr. Baron’s group to increase the size of their team. While the internists in Philadelphia mainly added a triage nurse, a true team requires a more comprehensive approach. Proposals planning for the Patient-Centered Medical Home (PCMH) understand that “it takes a team,” not just a physician. Among the best recent review and analyses is “Transforming Primary Care: From Past Practice To The Practice Of The Future” by David Margolius and Thomas Bodenheimer (Health Affairs May 2010, 29(5): 779–784 ). Virtually all these proposals advocate developing a team of providers, including doctors, nurses, medical assistants, pharmacists, secretaries/clerks, social workers, mental health specialists, even public health professionals, to collaboratively provide the appropriate and necessary care.
This is a great idea, but hard to implement in the current fee-for-service system, a system unlikely to change given the degree to which the new health reform law is built around insurance companies. Dr. Baron’s practice was participating in a demonstration project to provide coordination in the interest of the PCMH that was funded by the state of Pennsylvania; most practices are not. As I have said before, if proceduralist could do the procedures and subspecialists manage their particular rare or advanced disease, and allow primary care doctors to manage complexity and counsel and do prevention (and mental health professionals, and social workers, and pharmacists, and therapists to all do the things they were best able to do) rather than trying to do more procedures because they would make more money, this would make – sense.
Comprehensive care for people is a big undertaking. It is much more than consulting on one problem, or doing a single procedure and follow up. It is caring for many problems, and providing the preventive care that people need, and addressing their acute complaints, and doing counseling for both psychosocial issues and decision-making issues (e.g., “should I have this surgery?” “what is the risk of this diagnostic procedure recommended by the consultant?”) It is being available to refill lost or expired prescriptions, reviewing lab and imaging results and consultant reports, and answer questions by phone or email, and review and coordinate the care being provided by consultants. It is doing all those things that people expect that their “family doctors” (in whatever specialty they are actually certified) will do. It is a very different practice than that of a subspecialist; while for the latter “the buck stops here” for treatment decisions for a particular condition, for the former “the buck stops here”, period. There is nothing in the medical realm with which they cannot, reasonably, be expected to be involved.
Consider a patient who tells a subspecialist, say their cardiologist, about their knee pain. The cardiologist says “I don’t do knees,” and sends them back to their primary care doctor, or refers them to an orthopedist. On their next visit the patient says “I saw the orthopedist you sent me to,” and the cardiologist, reasonably, says “I don’t do knees. Do whatever s/he told you.”
Now consider the patient presenting with the same knee pain to their primary care doctor. Maybe that doctor has a good idea of what the problem is and how to treat it, but to be sure refers the patient to the orthopedist. On the return visit, the patient now wants to talk with “their” doctor about what the orthopedist said, what s/he recommended, what the primary care doctor thinks about that, and needs help making a decision. So, while for the subspecialist (cardiologist, in this example) a referral disposes of potential work, for the primary care physician, it will usually, while reassuring the doctor that the right care is being done, actually increase the amount of work.
Most primary care practices discover, as did Dr. Baron’s, that it is inefficient to have physicians doing virtually any of the work that could be done by a lower-paid staff member; this could be a nurse (which his practice did not employ initially) or a medical assistant. Subspecialists have always known this, employing nurses, physician’s assistants, and others (including medical “fellows”) to augment their productivity; for example, a surgeon can be in the operating room while a physician’s assistant sees patients in the office. But it takes money to pay such staff.
As long as the only reimbursement is for actual patient visits, and that reimbursement is spectacularly lower for primary care doctors than for subspecialists, and particularly proceduralists, the financial viability of such practices will be low, and the attractiveness to highly indebted medical students comparably low. This calls for a restructuring of the entire payment system, into one that encourages collaboration and the most appropriate management. A capitated payment system is very desirable because then patients can be “seen” in the most appropriate way based on the perception of patient and physician – phone, email, office, hospital, home – but only if that reimbursement is high enough to make the development and implementation of patient centered systems worthwhile.
.
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