Family Medicine in the era of health reform - 2

This is the second of three parts presenting the content of the 21^st G. Gayle Stephens lecture that I gave at the Primary Care Access Conference. It more specifically addresses the current status of family medicine, and in particular, family medicine training.

What about Family Medicine? There has been something of an uptick of interest in FM among medical students in recent years, which has been reflected in “better” matches: a larger number of US medical graduates (USMGs) entering family medicine residency training and fewer residency slots filled by IMGs; but these are small changes, nowhere near sufficient to meet the nation’s needs for primary care doctors.  In addition, we are not sure of the reason for this yet. We hope that it is a real increase in interest, but it may also be (and continue to be) a result of increases in medical class size and number of medical schools without a concomitant increase in residency positions, leaving more students who cannot match in their more desired specialties and thus “settle” for family medicine.

Common sense, and some recent data (especially regarding loan burdens), suggests that reimbursement is an major issue, and this is something I have addressed on several previous occasions (recently The challenge of expanded Medicaid and the dearth of primary care physicians, Feb 19, 2011). Although money (income and debt) was not found to be a major determinant of specialty choice in the “Arizona studies” several years ago;[1];, debt loads have increased since then, frequently exceeding $250,000 by the time of medical school graduation. More concerning, we are increasingly hearing reports of negative attitudes among medical students toward the real or perceived lifestyle of primary care, as well as persistence of the idea that primary care -- family medicine – is not as interesting or as challenging as practice in other specialties.

A recent article that appeared in the New York Times on Saturday, April 2, More Physicians Say No to Endless Workdays, illustrates many of these issues as it describes the decision of a young female student, Kate Dewar, to enter Emergency Medicine rather than the primary care practice of her father and grandfather. She is the mother of twins and although she says

“Look, I’m as committed to being a doctor as anyone. I went back to work six weeks after my boys were born. I love my job,” she adds “But I was in tears walking out of the house that first day. I’m the mother of twins, and I want to be there to feed them, play games with them or open presents with them on Christmas morning. Or at least I want the option to do those things without fearing I’ll be called back to the hospital.”

Yes, it is possible that her commitment is simply professed, not real; maybe in an objective sense she is not as committed to medicine as her father and grandfather. And if not, if she is more committed to her family, is that a bad thing? Her grandfather, Dr. William Dewar II, is quoted as saying “My son and I had deeper feelings for our patients than I think Kate will ever have… “ and her father, Dr. William Dewar III, adds “I’ve had three generations of [the owner of the café in which they are being interviewed]’s family under my care. Kate will never have that.”

Yes, but she will fewer work hours. The article notes that “…emergency room and critical-care doctors work fewer hours than any other specialty, according to a 2008 report from the federal Department of Health and Human Services.” And she will not get paid less for working those fewer hours; actually she will be paid quite a bit more. Personally, I have seen little indicating that, overall, students are willing to get paid less in exchange for having more time with their families.

What about the other part? The ostensible lack of intellectual, or at least, adrenaline-infused, challenge? The “Marcus Welby” vs “ER” dynamic? Kate Dewar told the Times “…that treating chronic conditions like diabetes and high cholesterol — a huge part of her father’s daily life — was not that interesting. She likened primary care to the movie ‘Groundhog Day,’ in which the same boring problems recur endlessly. Needing constant stimulus — she e-mails while watching TV — she realized she could not practice the medicine of her forebears.”

Constant stimulus aside – everyone emails while watching TV (is there any other way?) --  is she correct in that primary care does not have enough intellectual stimulation? If we look at medical and surgical subspecialties, it is hard to make that argument. They all see a much narrower range of diagnoses than primary care physicians do. For most of them, their top 5 diagnoses account for 80% or more of their visits; for family medicine our top 20 diagnoses account for perhaps 30%. Indeed, this is in part why we enter FM. 

Is the Emergency Department really that different? There are certainly the big, exciting cases, but also a lot of routine. ED docs often complain that they have to do so much primary care – and they do it without gaining the satisfaction that doctors like the older Dewars get from seeing people get better over time. In addition to the primary care, there are the overdoses, and accidents, and the “frequent flyers” that characterize much of ED work. Yes, ED physicians can resuscitate people from the overdose – but they don’t treat the depression or the domestic violence that frequently was the cause. Yes, they stabilize fractures and abdominal trauma so that patients can be admitted to the surgeons (unlike on television’s “ER” where they seem to do major surgery in the ED, not to mention pushing babies back into the uterus of eclamptic women for whom there is “no room” on the labor floor – this would never happen!) – but they can do nothing to prevent the next one walking in. Yes, they admit the person from the nursing home with decompensated congestive heart failure and get them into the ICU – but if the patient lives until they can be discharged, they will be back again soon. Yes, they complain about the lack of primary care services available that make people come in with relatively minor illnesses, or even worse, with advanced stage illnesses that could  have been ameliorated by primary care – but they don’t want to be the ones to do it.

Kate Dewar says “I like it when people get better, but I’d rather it happen right in front of my eyes and not years later… [I] like to fix stuff and then move on.” At its face value this can be seen as an immature statement; while such attitudes can and do persist for an entire career for some people, they become less pervasive as doctors learn both the satisfaction that her father and grandfather demonstrate that comes from following patients over years, as well as the frustration that comes from “fixing” the same stuff over and over again. Of course, if she is an adrenalin junkie, maybe the ED will be a good place for her.

But the adrenalin rush can wear off, or be eroded. I worked for many years at Cook County Hospital, where there is a Department of Trauma. It recruits many skilled young adrenalin-junkies who want to be like Hawkeye Pierce on “M*A*S*H”, seeing people get better right in front of their eyes. Except not always. Often they don’t get better, they die. And then you have to tell their family. Another auto accident, another gang shooting, another alcohol-enhanced beating.  And then you have to tell their family. And then again, and again. And then, after a while, you get tired of it, which is why so many trauma surgeons spend so much of their time out in the community, talking to people, trying to prevent themselves from having more business. They want to decrease, not increase, their business. 

Or maybe Kate Dewar just doesn’t have the interest in working with people over time and developing the relationships with patients that her father and grandfather did, and that all the stories they tell about their great longitudinal relationships with patients are, for her, dissolved in a memory of beepers going off as her dad sat down to dinner, or on Saturday and Sunday morning. Or maybe she is just selfish. I don’t know about her, but I think that all of these possibilities can apply to many different students.

What remains true, however, is that we  -- this nation – needs to change our health care business model, to keep people from getting so sick that they need emergency rooms and high-tech procedures. In Denmark, for example, the number of hospitals dropped from 190 in 1980 to 52 in 2004[2];, not because some have driven their competitors out of business but because they are no longer needed.

Wouldn’t that be a victory?

                                                                                      

---

[1] Senf J, Campos-Outcalt D, Kutob R, “Factors Related to the Choice of Family Medicine: A Reassessment and Literature Review”, J American Bd of Family Practice, 2003, 16:502-12.

[2]Kristensen T, et al., “Economies of scale and optimal size of hospitals: Empirical results for Danish public hospitals”, Health Economics papers 2008:11, University of Southern Denmark

Family Medicine in the era of health reform

At the recent Primary Care Access Conference in San Francisco, I was given the opportunity to present the 21^st G. Gayle Stephens lecture. It was a real honor, because it is named for one of the giants of family medicine, and one of the great thinkers on health and medicine of the last half century, in any field. Dr. Stephens was the first director of one of the nation’s first family medicine residencies, at Wesley Hospital in Wichita, KS, and later Chair of the Family Medicine department at the University of Alabama. He was an early and long-time member of the American Board of Family Practice (later Family Medicine) and the author of several of the most seminal articles and books in the field, including “The Intellectual Basis of Family Practice” and “Family Medicine as Counterculture”.  Both of these pieces, along with many others, are discussed in the outstanding “festschrift^;[1; put together by another giant of the discipline, John Geyman, in the January 2011 issue of Family Medicine.

Dr. Geyman says of Dr. Stephens that “He has been, and remains, by far the most original, thoughtful, and elo­quent voice in our field and among the few who best represents the mor­al conscience of the entire medical profession.” I have been privileged to have met, corresponded with, and even to a limited extent collaborated with both Dr. Stephens and Dr. Geyman. I can only hope that my talk was worthy of being associated with Dr. Stephens’ name. In this piece, I  would like to discuss a few of the points I made in that talk related to health care reform, or the Affordable Care Act (ACA); in a later blog I will discuss this in terms of the impact on primary care and family medicine.

Unquestionably the health care reform act, or ACA, is the biggest change in health coverage since Medicare and Medicaid in 1965. It remains deeply flawed, but is nonetheless the touchstone of the opposition to the current administration, as President Obama’s opponents apparently see in it everything that we don’t! The fact is that, rather than bringing us a health system in which everyone is covered, like Canada, or the UK, or Germany, or Switzerland, or Taiwan, it is in large part a big bailout of health insurance companies. And the price that for this – the requirement that everyone have to buy health insurance, the “individual mandate”, is what we hear being attacked, not the insurance companies that demanded it as the price for supporting ACA.

There are some of the parts of ACA that are rather non-controversial (except to the extent that they might not be funded as part of the “don’t fund anything” movement), and are good for family medicine, in the sense that they are good for the health of the American people. These include the increased funding for Federally-Qualified Health Centers (FQHCs), the creation of a panel to review the evidence of effectiveness, if it is left in, and the Primary Care/Health Extension services (which thus far have received no appropriation), among others.

One important component of ACA is the creation of “Accountable Care Organizations”, or ACOs, initially for Medicare patients. They are an effort to promote health by having health providers financially responsible for the health of their patients, that is, to have ambulatory care facilities and doctors, hospitals, nursing homes, and community care facilities coordinate their efforts to prevent illness, treat effectively, and have people cared for in the most appropriate setting, rather than perverse “gaming of the system”, where a failure of ambulatory health care can be a “win” for a hospital when a patient is admitted (as long as they don’t stay too long, or get re-admitted too soon). This kind of structure works well in HMOs, such as Kaiser, or other integrated health systems, but there are likely to be flaws in its implementation; for example, Center for Medicare and Medicaid Services (CMS) administrator Dr. Donald Berwick recently published guidelines for Medicare ACOs in the New England Journal of Medicine, “Launching Accountable Care Organizations — The Proposed Rule for the Medicare Shared Savings Program”.  He says that the ACOs will be “Held to rigorous quality standards (see table). Proposed Measures for ACO Quality-Performance Standards.), ACOs will be expected to be proactive in their orientation and to regularly reach out to patients to help them meet their needs for preventive and chronic health care.”

However, Berwick immediately adds that “Patients who seek care at their ACO will know that their physicians are part of that ACO, but as beneficiaries of fee-for-service Medicare, they will continue to be free to seek care from any Medicare provider they wish. They will not be locked into seeing only particular health care providers.” This sounds relatively benign, and certainly politically wise, but could completely undercut the effectiveness of the program. The reason that Kaiser and other HMOs are effective in managing care that delivers high quality at low cost is because their patients are restricted to where they can seek services; if a Medicare patient who is part of an ACO does not like that they have been “denied” any form of care by their doctor or hospital, no matter how appropriately, can now go “outside the system” to another doctor, hospital, emergency room or pharmacy-based urgent care clinic, all efforts at cost control are at risk. This is, of course, the conundrum: control of costs requires some degree of restriction of unlimited options. It is quite parallel, in fact, to the “individual mandate” that the insurance companies demand, and in this sense they are correct. It will not work to require insurance companies to insure everyone if everyone is not required to have insurance, because then only those who need care will demand coverage, risk goes way up, and so would premiums.

Some politicians and pundits have compared ACOs to the managed care era of the 1990s, and supporters worry it will receive the same backlash from the public that occurred then. I believe that in that period it was not managed care that was at fault but two major characteristics that happened in conjunction with it. The most important was that the entire operation was taken over by for-profit companies, largely insurance companies, that saw benefit to their bottom line by restricting care. The efficiencies of consumer cooperative HMOs had benefited their members; these new entities denied care to benefit their stockholders. It was the corporate for-profit control, not the management of care, that led to consumer dissatisfaction with restrictions on access to care.

The second big problem is related to one that I have discussed before (Red, Blue, and Purple: The Math of Health Care Spending, October 20, 2009), the fact that most people are not sick. In an effort to control costs, everyone was made to jump through hoops, such as gatekeepers and prior authorization, which made them angry but did not do much for the cost, since most people do not use much medical care. Indeed, for at least half the population, you could let them do whatever they want, and they wouldn’t use any significant number of health care dollars. To illustrate this, I am reproducing the graphs from the previous blog.

While there are some things we can do to reduce the risk of unexpected crises –cancer, multiple trauma from car accidents, infants in NICUs – and control the costs of caring for those who have them, the most obvious benefit will be achieved by pre-emptively working with people whose chronic diseases have gotten so bad that they are frequently admitted, often to Intensive Care Units. These are the people who should be targeted for intensive intervention, not only medical but in terms of the social determinants of health, such as in the programs highlighted by Atul Gawande in his February 2011 New Yorker piece, “The Hot Spotters”. Needless to say, such interventions are being funded on a shoestring, while the high-tech interventions get all the money.

 It doesn’t have to be this way. We could have a rational, cost-effective health care system if we start with coverage for all through a single-payer mechanism. We might be able to back into quality despite not having one, but it will be much harder.

                                                               

<!--[endif]-->

<!--[if !supportFootnotes]-->[1]<!--[endif]--> Festschrift: “A volume of learned articles or essays by colleagues and admirers, serving as a tribute or memorial especially to a scholar”

Perception and reality of economic inequality

.

We see a lot written about how political views in the US are very polarized. As an example, the April 17, 2011 “Doonesbury”, portrays Donald Trump bragging that he is polling 41% against President Obama and is not even running yet; the interviewer, Mark, replies “It’s a divided country. Virtually anyone who’s not Obama gets 40%. My mailman could get 40%.” The idea is that we cannot reach accommodation because we have such different basic understandings, “belief systems”, “worldviews”.

Certainly this has been the case in Congress, although recently, in passing a budget for the remainder of FY 2011, there were actually some Democrats and Republicans voting on the same side. It is important, however, to note that the Republicans who voted against the budget condemned those who did precisely because they did not hold rigidly and intransigently to their positions, even if, as in the case of Congressman Paul Ryan’s budget proposal, those positions are based in mythological faith rather than in data. Paul Krugman, (“Who’s Serious Now?”  April 16, 2011, writes that Ryan’s proposal was “In fact, it was a sick joke. The only real things in it were savage cuts in aid to the needy and the uninsured, huge tax cuts for corporations and the rich, and Medicare privatization. All the alleged cost savings were pure fantasy.” The threat to Medicare is critical, given both the role that health reform, ACA, “Obamacare”, has played as a touchstone of evil in the fantasy world of Ryan and his party, and the real loss of healthcare, along with their jobs, faced by so many Americans.

A lot of people wonder how it is that such a large portion of the US population, can support Republican proposals that are so obviously about increasing the financial benefit to the richest Americans while hurting most everyone else, including, obviously, most of those supporting the Republicans. Are they selfless advocates of big money, such that they are willing to sacrifice their own interests to aid the least needy? Do they truly believe that each of them, despite the mathematical odds, has a good chance of becoming part of that select group? Are they stupid? It may be that either or both of the last two are true, but the first, unsurprisingly, is not. This is demonstrated in a very interesting study by Michael I. Norton, of the Harvard Business School, and Dan Ariely, a psychologist from Duke, recently published in Perspectives on Psychological Science.

In “Building a better America: one wealth quintile at a time”[1], Norton and Ariely present a large (5522) random sample of Americans three pie charts showing possible distributions of wealth among income quintiles as possible ideal models. One is equal: 20% in each. One is less equal and is in fact the distribution of income (not wealth) in Sweden The third is the distribution in the US. (That the second one is not in fact the wealth distribution in Sweden is not really important here; it could be called “Mars”; it is just an intermediate distribution).  About equal percents chose the “equal” and “Swedish” distributions, 77% preferred “equal” to the US, and 92% preferred the Swedish to the US. Given that people were told to assume that they had a random chance of themselves being in any quintile in any of the distributions, the preference for a more equal distribution may be unsurprising; indeed it suggests that more than half of those in the top quintile are less selfish and would support a more equal distribution of wealth. This, by the way, is consistent with a report by CBS news report from April 17, 2011 “The US Tax code: a ‘huge convoluted mess’”, in which several multi-millionaires argue against the idea that “…the rich can't afford higher taxes.“ One says “Every time I get a tax cut, I get richer…‘I don't buy one thing that I don't already have. I don't put money back into the economy. I just get richer.”

An even more interesting part of Norton and Ariely’s study involved asking their subjects what they though an ideal distribution of wealth among Americans should be and what they thought it actually was.  While their ideal was not “equal” – it assigned over 30% to the highest quintile and just over 10% to the lowest –it was much more equal than their perception of the actual distribution, which had the top quintile having nearly 60% of the wealth, and the lowest quintile only about 2%.

But, as the figure shows, their estimates were way off; in actuality the top quintile has 84% of the wealth, the third (middle) quintile well less than 5% (not much more than their estimates gave to the lowest quintile), and the two lowest quintiles are not even visible on the graph, with a total of 0.3% of the wealth. More important, there was little difference between various groups such as men and women, income levels (<$50K, $50-100K, >$100K), or whether they had voted for Bush or Kerry in 2004 (the data was collected in 2005). All groups felt that the ideal wealth distribution should be significantly more equal than they believed it to be, and all groups believed it to be far more equal than it actually is.  

Norton and Ariely express the hope that this study will inform public policy creation; that by showing that the American people are much closer together in their vision of a just distribution of wealth in society than are the politicians and pundits we hear so much from, there is a chance of reaching some greater consensus in terms of economic policy. This hope is endorsed, from several different perspectives, by the 4 commentaries that accompany it in the same issue of the journal, by Dunn et al (“Consensus at the heart of division”), Tyler (“Procedural justice shapes evaluations of income inequality”), Kagan (“Unclear implications”), and Schwartz (“A new veil of ignorance?”).

So why do we have such divisions? Schwartz notes that “T. Frank (2004) argued, somewhat insultingly, that average Americans are being duped to vote against their real economic interests. But the Norton and Ariely data suggest that people vote against their preferences. How can people be duped to vote against their preferences?” That he can ask this question means perhaps Frank was correct. Kagan beings to get to the answer when she writes “To start with the obvious, precisely because such a huge portion of American wealth is held by such a tiny percentage of individuals, these individuals have an extraordinary interest in maintaining the currently inegalitarian distribution. And unlike the vast majority of Americans, who have so little and thus have so much to gain, this tiny minority has the immense resources to see to it that their interests are carefully attended to by lawmakers.”

Moreover, people do not vote on one issue, even if the issue is their economic self-interest. Indeed, this is what Thomas Frank writes about in “What’s the Matter with Kansas?” Frank says people may vote for candidates because of their stands on social issues (e.g., abortion, gay marriage) rather because of their positions on economic issues. On the other hand, in the recent (2010) elections, we observed a justified anger at the economic situation that led to a massive shift to those who were not in power (the Republicans), who have responded not with plans to increase jobs or equalize wealth but to dismantle all the progressive reforms of the last 100 years; not to get government out of people’s lives, but even more into their bedrooms.

And the economic arguments, as Krugman notes, have tremendous implications for health and health care, given the size of health spending as a portion of our economy. Rep. Ryan’s “solution” for the deficit relies in great part on the restructuring of Medicare to reduce its support for the health needs of American seniors, when indeed what is needed is the expansion of Medicare, as a single-payer, more-controllable, health financing model, to all Americans. Ryan’s attack on Medicare is part of his attack on any semblance of a social contract or social justice, and is part of the continued redistribution of wealth from the less-well-off to the rich.

In the CBS report discussed above, David Cay Johnston, who teaches tax regulation at Syracuse University Law School, notes that  "All the data are overwhelmingly showing that for the last 30 years, we've been redistributing wealth upwards….It's not trickle-down economics; it's Niagara-up!" The Norton and Ariely data suggest that the American people do not support such a flow, and this is consistent with the fact that every poll for the last 20 years notes that we would support a universal health insurance plan. Maybe Paul Ryan’s attack on Medicare will finally be the impetus for us to go beyond the limitations of ACA and get real health-care-for-all.

[1] Norton MI and Ariely D, “Building a better America: one wealth quintile at a time”, Perspectives on Psychological Science, 3Feb2011;6(2):9-12 doi: 10.1177/1745691610393524

"Cabaret" and "Inherit the Wind": Will we again reap what is being sowed?

.

Last year at this time, March 31, 2010, I wrote a piece about Obama and the Seder: Freedom and Multiculturalism, trying to capture the importance of the concept of freedom, and the historical relationship between African-Americans and Jews in this story of emancipation. In addition to enslavement, ancient for one and much more recent for the other, the two groups share both oppression, and, to a large extent, empathy for the oppression of others, and Passover is a good time to remember this. This weekend it is also Easter (after all, the Last Supper was a seder), during which Christians celebrate the resurrection of a prophet who preached against oppression and for peace.

Recently, I saw a very good performance of “Cabaret” at the Kansas City Repertory Theater. Of course, I had seen it before, or rather, had seen the Bob Fosse film version of this Kander and Ebb musical starring Liza Minelli. It has a long pedigree: the musical is an adaptation of the 1951 play “I am a Camera”, by John Van Druten, which was also made into a film in 1955 (both starring Julie Harris). It, in turn, was based on the story “Sally Bowles”, written by Christopher Isherwood and published in 1941. In 1972, when the movie “Cabaret” came out, it was a period piece, portraying the libertine “degeneracy” of Weimar Berlin set against the rise of the Nazis. The horror of this was not lost on me, or on the rest of the audience; for my generation, born soon after WW II, with fathers who had fought in the war, it was not that far away. For those of us who are Jewish, whose grandparents were immigrants, whose grandparents entire families were wiped out in the Holocaust, the story was more bitter than sweet. After all, 1972 was much closer to WWII than it is to the present; it was only 27 years after the end of the war, but it was 39 years ago.

Despite the pain, however, the events that were portrayed, we knew, were in the past, bad memories. 1972 was really still part of the “‘60s”. We believed that this was all behind us and we were in a new world, a new era. “Cabaret” was there to remind us of how bad things had been; most of us did not see it as a warning that it could happen again, to us. I’m not sure that this is still true. I am not sure we will not be seeing it again. I mean Nazism. Not as an accusation made as often by the right against those to their left as vice versa, but for real.

Let’s see. We have very serious, financially well-backed efforts to reverse not only the social changes implemented beginning about the time of “Cabaret” by the New Deal, but of even earlier changes, from the “Progressive Era” at the turn of the 20^th century. We have attacks on government and taxation, funded by billionaires but apparently bought into by regular people. (Question: How will they – the regular people, not the billionaires -- hire their own police and build their own roads?)  We have attacks on collective bargaining and the very existence of unions. We have increasingly restrictive laws about who we can be in relationships or have sex with (“gay marriage”), whether we can control our own bodies, whether we can use contraception or have abortions. State, and sometimes the federal, governments, led by those who say are against any kind of government regulation, are dictating how people should carry out the most personal of acts. I guess they are only against regulation of what they want to do; they’re into regulating things they don’t like. We have a tax breaks for billionaires and policies (pro-finance, anti-regulation) that have essentially transferred everyone’s wealth to those billionaires. Since they and their corporations don’t pay taxes, and those who are left no longer have enough money to pay enough taxes, we are getting cuts in essential services. And we are fighting several unfunded wars, we have demagogues demonizing “the other” (currently Muslims), and we are pretty far down the road to a religiously-driven, corporate funded, hypocritically moralistic military state.

OK, fascism. That’s where we’re headed. A state that is geared toward the interests of corporate power, that regulates people’s lives, that is militaristic and intolerant. But surely not Nazism? After all, they are not calling for the extermination of the Jews.

Yet.

“Cabaret” is not the only musical that may be more literally relevant now than when it first appeared. A few years ago I saw a wonderful production of “Inherit the Wind” on Broadway with Christopher Plummer and Brian Dennehy. When the play was written in 1955, and later (1960) made into a movie starring Spencer Tracy and Frederic March (with several versions since then), it was conceived of by its authors, Jerome Lawrence and Robert Edwin Lee, as a metaphor for the McCarthy era. The actual topic, the Scopes “monkey trial” in which a high school teacher is found guilty of teaching evolution, was not really the topic; after all, that had been nearly 40 years earlier. By the late 1950s no one doubted evolution. It was settled. But it made a great allegory for the close-mindedness and repression of that period.

They thought. But a few years ago, the state school board in Kansas, where I live, branded evolution a “theory” and mandated teaching “alternative theories” – such as creationism. The supporters of that policy were defeated in a later election, but turnout is light in school board elections and they could be back. No one doubts it could happen again. Powerful interests are questioning science; leading politicians attack those who question “American exceptionalism” – that we are different from everyone else, and programs that work in other countries are not for us. Is this different from the righteous xenophobia of the Master Race?

I do not mean to imply that the only or greatest racist threat is to Jews. Clearly, in this country the oppression of African-Americans is built into our very fabric. The great post-911 hostility is to Muslims. Jews are “our friends” (well, Israel is). Jews are powerful in Washington, as the American Israel Political Action Committee. Some Jews are even right-wing leaders. To the extent that they worry about oppression of Jews, they try to isolate anti-Semitism and oppose it, separating it from anti-Muslim hate (as the Israeli government is so good at), from racism.

They are a minority of Jews and they are outside the tradition of a people that has always recognized its own oppression in the oppression of others. Who were the majority of the international volunteers who fought in Spain against Franco and fascism. Who, way out of proportion to their numbers in the population, were active in the civil rights movement in the US and in the anti-apartheid struggle in South Africa. Who are disproportionately represented among scientists and human rights attorneys and advocates for social justice. They are also disproportionately represented among the leaders of the rapacious finance industry that led us to the Great Recession.

What a combination! A small number of people, tiny in comparison to white Christians, Muslims, Hindus, Blacks, Asians. Who have the poor judgment to both be out-front critics of racism and oppression, members and leaders of every progressive movement from unionism to socialism, and to have among them the leaders of the financial class that has wreaked havoc on the world’s economy. What a great target! No wonder Hitler could demonize them!

But it couldn’t happen here. At least we don’t think so now. Like Herr Schultz, the fruit merchant in “Cabaret”, who says “I am Jewish, but I am also German!” as he minimizes the significance of the broken windows in his store, who stays in denial for a long time. A lot of good it did him.

We have to fight all forms of intolerance, of racism, of know-nothingness. All forms of oppression and repression. All forms of “we are better than them” which can lead to “let’s kill them” pretty quickly. The memory of the Holocaust is “never to forgive, never to forget”. And to not forget that Jews can still be victims, and that they will never be safe as long as anyone is a victim. It is never too early to oppose bigotry, hate, and the loss of human rights.

Or we will surely inherit the wind.

--­­­­­­­­­­­­­­===========-

Do resident work hours limits create better physicians?

On a few previous occasions (e.g., Student Debt, Resident Hours, and Primary Care Redux, Jan 2, 2009) I have written about the issue of medical residents’ work hours and the implications that it had, good or bad, for patient care. A recent article in the British Medical Journal (BMJ) by Moonesinghe et al, “Impact of reduction in working hours for doctors in training on postgraduate medical education and patient outcomes: systematic review”, provides the most thorough review to date of studies evaluating the impact of work hours reductions for medical residents in the US and the United Kingdom, where they are even more stringent. They looked at studies examining both “training” (how are the residents learning?) and patient quality and safety.

This was not an easy task; true “meta-analysis” (grouping all the studies together as if they were one and re-analyzing the data) was not possible because they were so different in methodology, issues studied, and quality. In fact, the quality of most of the studies was not terribly high, and they often looked at several different outcomes making it hard to understand whether the changes all went one way, or there were some things that were better and some worse and whether the net result could be stronger (or weaker) if we could focus on only one at a time.

The good news for those who have implemented, supported, and argued for the work hours restrictions is that they seem to have improved the private life of residents, and to have not significantly harmed either the quality of training or patient care, at least insofar as these somewhat contradictory studies seem to indicate. Most of the studies were done in the US, and most were of surgical (28 of 41) or “hospital-based” (e.g., anesthesiology, critical care) trainees, rather than primary care.

Here are some of the results:

Training outcomes:

·    2 papers (both of “low methodological quality”, one of medical residents in the UK and one of surgical residents in the US, which “did not report statistical analyses of the results”) reported an improvement in training outcomes.

·   12 studies found a detrimental association; half from the US (all surgical) and half from the UK.

·    27 studies found no change (20 US and 7 UK)

·    There were also mixed results regarding the quality of “training opportunities” (exam scores, caseload)

Patient outcomes:

·    31 of 34 papers were US

·    4 studies showed improved patient outcomes, including the only randomized controlled trial in the group (note: this was in critical care and coronary care units, where shift work may arguably be more effective)

·    2 studies (in trauma and orthopedics) found increased complications

·    28 studies showed no significant difference

Surgeon and NY Times writer Pauline Chen commented on this article in “Is a well-rested doctor a better doctor?”, April 7, 2011. She describes talking with a surgical resident she knows who is very pleased at how much better her life is than she had feared. “’Training has changed a lot…My life is different than yours was — I have a lot of time outside the hospital.’ She described how she loved her work but was able to sleep at home most nights, go out regularly with friends, stay involved with her church and take an improv class.”  Cool. It is good to know that surgical residents are not acting as slaves, and can have some kind of life outside the hospital.

However, her resident friend was less sure about learning and patient care: “’To be honest, I don’t really know if this is better or worse,’ she said, recounting how she felt she was signing over responsibility for her patients more often than she ever imagined she would, missing key events in their hospital course and even getting dismissed during the middle of a patient’s operation in order to stay within the limits on work hours. ‘Sometimes it seems so counterintuitive to just sign out as if we were shift workers, but this is all any of us know right now…We have nothing to compare it to.’”

So, probably, as Dr. Chen observes, the discussion will go on. Those who believe that working longer hours results in tired physicians and therefore bad patient outcomes will continue to push those ideas; those who (largely, it seems, surgeons) believe that artificial limits on work hours compromise resident learning, thus not only having a negative impact on their current care of patients but, more importantly, their care of patients in the future care because they haven’t had sufficient experience in their residencies. One “side” says “Do you want to be operated on by a surgeon who has been up all night?”, while the other says “Do you want to be operated by a surgeon who is not as skilled because they were coddled in their training and didn’t get sufficient experience?”

“The most important test of success of postgraduate training,” say Moonesinghe and colleagues, “is the professional performance of those who reach the end of it.” They go on to make several suggestions, including, most importantly I believe, that “a consensus should be reached by the medical profession on appropriate measures to assess the quality of postgraduate medical training.” They agree with the assertion (from Temple, et al, “Time for training. A review of the impact of the European Working Time Directive on training 2010”) that “training is patient safety for the next 30 years”. Wise regulation must understand the balance, the risk-benefit of any change, and try to reach the greatest benefit with the least risk.

I would like to comment a bit upon the issues as they relate, in particular, to primary care training. Most of the studies that have been done have been on surgical specialties, which can measure surgical complications, deaths or morbidity, or in anesthesiology or critical care, because these are hospital based and more amenable to shift work. While a very few of the studies were in pediatrics, they also examined hospital work; none were looking at the training of primary care or family doctors. One of the other reasons that the surgical specialties have been so studied is that they have long been those with the longest work hours; thus, they are both the greatest target of reformers and the greatest resistance by current surgeons and teachers who fear that work hours restrictions will jeopardize the skill of their future colleagues.

The irony is that, as in so many areas, when laws or rules are being violated by one group, they are tightened on everyone, and those who were not violators of the old rules find their greater restrictions to comply with while, often, those who were violating it before continue to. In the 1970s when I was in training at Cook County Hospital, we had a resident union (yes!) and were limited to every-4^th-day overnight call. But the surgeons were on more often. If family medicine or internal medicine or pediatrics violated the rule, they were penalized, but the surgery residents were afraid to complain. And so, today, the violations of hours rules in some specialties increases the restrictions for all.

The problem with applying these rigid rules to primary care is that it is not shift-based. While residents spend time on inpatient services, the core of family medicine training is the continuity clinic where those doctors-in-training follow their own patients. It is important to be able to do this, to show up for your office hours to see your patients who are expecting to see you, even if you were up much of the night delivering the baby of one of your patients. If that happened every day, it would be a big problem, but it doesn’t. Yet there is a “zero tolerance” for work hour violations by the Accreditation Council for Graduate Medical Education (ACGME), so the program would be cited. Rigid cut-offs, indiscriminately applied, are a bad idea.

Residents should have work hour restrictions; they shouldn’t be on call every third night and up all night. They should get days off, should get time to spend with friends and family or sleeping. But the restrictions need to regulate hours in a more global fashion: hours in a week, days off in a week, average or typical number of hours off between shifts. They should not be counting minutes (and they currently do!), not create automatic violations for each instance in which, say, a resident returns to clinic after only 9 ½  instead of 10 hours off. They also should be specialty-specific, examining the character of the specialty’s practice, not to allow exploitation but to make them appropriate to how the specialty is practiced.

Some fields, like ER and critical care, work well with shifts. Some, like most hospital work that characterizes internal medicine and pediatrics training, generally work pretty well with “night floats” and days off, as long as there is careful attention paid to information transfer at the shift changes (“hand-offs”). Surgery may require longer shifts with more days off. And family medicine needs to allow residents to occasionally deliver their babies at night without canceling all the patients on their schedule the next day, as long as it is not the everyday norm.

We can do this rationally. We can have training that both provides time for the non-work lives of residents and good training for their careers; that ensures quality care of their patients now and in the future.

Disincentives to rural practice: from "Training Family Doctors" blog

.
Excellent post about the market disincentives to providing rural health care by Allen Perkins on his blog "Training Family Doctors". http://usafamilymedicine.wordpress.com/2011/04/14/health-care-and-the-market/
Dr. Perkins goes on to quote from President Obama, who quotes Abraham Lincoln, about the need to care for others; this is a core principle of social justice, and one that I have addressed explicitly in the past both from a principled point of view (Does the nation need a clear policy on a right to basic health care?, April 10, 2009) and from one of enlightened self interest (Red, Blue, and Purple: The Math of Health Care Spending, Oct 20, 2009).

The market, well-regulated, can serve many purposes and be of value, but it cannot, by its nature, be relied upon to serve social justice needs.

Conflict of interest 2: Clinical practice guidelines and Deans

.

My last blog post was about conflict of interest (COI) in medicine; there has been some recent literature on the subject, so I am providing a second posting on the topic.

In “Conflicts of interest in cardiovascular clinical practice guidelines”^[1], in the March 28, 2011 issue of Archives of Internal Medicine, Mendelson and colleagues reviewed the 17 most recent guidelines regarding the diagnosis and management of heart disease promulgated by the American College of Cardiology (ACC) and the American Heart Association (AHA), the most important issuers of such guidelines. These clinical practice guidelines (CPGs) are important, as not only do physicians use them as authoritative sources to inform their patient care, but increasingly payers – and courts -- are looking at whether they were followed to determine payment and bonuses, or culpability in malpractice cases. While thorough review of the published (and unpublished) evidence is required (indeed is a sine qua non) in the issuance of guidelines, these panels of experts are convened to allow their collective experience and knowledge fill the gaps where there is no evidence. The authors point to the 2009 Institute of Medicine (IOM, a group of distinguished physicians and medical scientists convened by the National Academies, which are private citizens gathered with federal support to advise on science and technology) report from its Committee on conflict of interest in medical research, education and practice, which states that there is insufficient study of COIs in guideline reporting, as the fact that both ACC and AHA have “recently placed restrictions on official participation in educational events and guidelines production”.

Using the concept of an “episode” to mean that 1 person participated 1 time in production of 1 guideline, there were a total of 651 episodes by 498 people in the production of the 17 guidelines. Overall, 56% of individuals (277) had some COI, and (coincidentally) a COI was present in 56% (365) of the total episodes, with a range among the 17 guidelines of 13% (2 of 15) to 87% (13 of 15). Interestingly, actual members of the guideline committees, as opposed to those who just reviewed the guidelines (“peer reviewers”) were more likely (63%, a level reaching statistical significance for those who care, p=.006) to have COIs, as were the chairs of the committees (or first authors) compared to committee members, 81% (p=.03). Only 6 of the 17 guideline committees reported whether the COIs were “modest” or “significant”; the authors found that of those 54% were modest and 29% significant. Perhaps more important, according to the authors, was that it was only a few companies, presumably those with the greatest economic stake in the outcomes, who were involved in most of the COIs. They also note that this is “a particular cause for concern given the fact that many of the newest ACC/AHA guideline recommendations are based more on expert opinion than on clinical trial data”.

Dr. Steven Nissen, commenting on the article in the same issue (“Can we trust cardiovascular practice guidelines?”^[2]), calls the “depth and breadth of industry relationships reported in this article…extraordinary,” in that they go beyond scientific collaboration to include significant stock ownership and serving as promotional speakers, and states that “no conceivable logic can defend [this] practice.” He continues “Such relationships are so antithetical to the academic mission that many medical schools have now forbid such relationships for their faculty. To allow such individuals to write CPGs defies logic.” I imagine his use of the word “extraordinary” is in the sense of “amazing”; since this is the first such study, we do not know if such COIs are indeed “extraordinary” in the sense of “well out of the ordinary”, or if they are, indeed, quite typical. Indeed, Mendelson et al cite a 2002 study by Choudry et al[3] in which the found that of the 52% of the authors of 100 CPGs for a variety of adult diseases who responded to their survey, 87% had “some type of relationship with the pharmaceutical industry” (and we would not imagine that the 48% who didn’t respond had fewer!) Dr. Nissen, who is from the Cleveland Clinic, reveals his own potential COIs, including research support from a number of companies and honoraria for speaking which he has turned directly over to charity. As covered in the New York Times (Duff Wilson, “Study finds conflict among panels’ doctors”, March 28, 2011), Dr. Nissen calls for “banning most of these conflicts rather than just disclosing them”.

But sometimes COIs are not even disclosed. The same issues of Archives of Internal Medicine contains a “research letter” titled “Failure by deans of academic medical centers to disclose outside income”^[4]. The authors, Freshwater and Freshwater, looked at holdings of deans of allopathic and osteopathic medical schools on the Morningstar directory of US corporate directors and executives, and EDGAR, the Securities and Exchange Commission database. They found that while there were only a few deans who served as directors of public companies involved in health care (9 of 161, with one serving as a director of 2 companies and one of 4), this information was not always disclosed on the schools’ websites, nor was the compensation received. This compensation for each directorship ranged from $11,250 to $386,439 with a mean of $217,454, with one dean who served on multiple companies receiving $640,038. “One dean’s official Web page disclosed the 2 directorships, but it did not disclose the compensation. Two medical schools’ Web sites disclosed 3 directorships, with one dean holding 1 and the other 2 directorships; however the Web sites underreported the deans’ compensation by 39%, 56%, and 80% compared with the compensation calculated from the companies’ EDGAR forms.” These deans are the same people who are expected to enforce the rules against COIs that Nissen refers to above. In a commentary[5], Lo (who was the chair of the 2009 IOM committee) et al, say that disclosure is not enough, and that “Some relationships need to be managed or even prohibited”. They do not go so far as to suggest that all should be banned, although I would note that 152 of 161 deans seem to do OK without serving as corporate directors.

So should all such conflicts, whether deans serving on boards of directors, guideline authors having financial relationships such as major stock holdings or speakers’ fees, or receiving grants from corporations, be disclosed or prohibited? I think that there is clear consensus that disclosure is the de minimis requirement. As I have noted before, without disclosure there is no way for the consumer of information in a research study to decide if their might be bias; this is at least as important for are those writing CPGs or presiding over our academic medical centers. But, as Nissen states explicitly and Lo hints at, disclosure is not sufficient. To extend the metaphor of the judge referred to by Howard Brody in his article Professional Medical Organizations and Commercial Conflicts of Interest: Ethical Issues and cited by me in The AAFP, Coca-Cola, and Ethics: Serving the public interest? August 20, 2010, knowing that a judge in a case you are party to owns large amounts of stock in the company you are suing is not sufficient to make you feel alright about her presiding in the case.

Mendelson et al note that “It has also been argued that relationships with industry may also bring a breadth of perspective and experience, especially if individuals have relationships with multiple different companies. Theoretically, these individuals may be less conflicted than those with fewer industry affiliations…”. Right. Taking graft from many sources makes you less beholden to any one of them. Unfortunately, if you buy this argument, then their study should disappoint you, as only a much smaller percentage of the CPG authors had more than one COI.

Come on. Prominent scholars take money from industry for the same reason that others do. They like the money. Perhaps they are eminent enough that their heads are so swelled that they can believe both that they are being paid solely for their wisdom, and not for any bias they might bring to the deliberations of academic groups like those writing CPGs or in the administration of medical schools, and that, in any case, they are so distinguished that there is no way they would demonstrate such bias. If so, they are deluded. No one else believes it, most especially the companies giving them money. These COIs need to be completely banned if we are to be able to trust their academic integrity and intellectual honesty.

---

[1] Mendelson TB, et al, “Conflicts of interest in cardiovascular clinical practice guidelines”, Arch Int Med 28Mar2011;171(6):577-85. (only abstract available on line without subscription).

[2] Nissen SE, “Can we trust cardiovascular practice guidelines?” Arch Int Med 28Mar2011;171(6):584-5.

[3] Choudhry NK et al, “Relationships between authors of clinical practice guidelines and the pharmaceutical industry”, JAMA 2002;287(5):612-17.

[4] Freshwater DM and Freshwater MF, “Failure by deans of academic medical centers to disclose outside income”, Arch Int Med 28Mar2011;1717(6):586-7.

[5] Lo B, Kelch RP, Grady D, “Illuminating physicians’ financial relationship with industry”, Arch Int Med 28Mar2011;1717(6): 587-8.

Conflict of interest reporting

.

looks like using Google Chrome instead of IE8 solves the problem. Hmm.

This is the first of a two-part series on conflict of interest, medical ethics, and whether we can trust recommendations.

In several posts last year (Harvard Medical School limits outside income: a good start January 10, 2010, Statins and scientific integrity July 6,2010 and especially The AAFP, Coca-Cola, and Ethics: Serving the public interest? August 20, 2010), I discussed the question of conflict of interest, citing the work of ethicists such as Howard Brody, along with common sense, to demonstrate that a “conflict of interest” is simply that; a conflict between one set of a person or organization’s interests and another. In the case of the American Academy of Family Physicians (AAFP) and its relationship with the Coca-Cola Company or that between the American Dietetic Association (ADA) and Hershey’s Chocolate, the conflict is between what is in the best interests of the health of the patients that the AAFP’s member physicians or ADA’s member dieticians serve and what is in the best interests of Coke or Hershey (making money). The latter is only important to the professional organization because those companies share some of the money they make with them. In defending themselves against what appears to many people, both within and outside the organizations, to be corruption, the leaders who made these deals (such as then AAFP-President Lori Heim, MD) make the argument that only by looking at whether the information presented on the AAFP’s http://www.familydoctor.org/ website (for which Coke provided support) is biased (presumably toward Coke) can the presence of a conflict be determined.

This is patently absurd; the conflict is there, and along with it the suspicion that information may be skewed. This is particularly true when dealing with a site such as http://www.familydoctor.org/, on which the information is intended for the general public, not for professionals. Its value depends entirely upon the trust of the members of the public who use it, and such conflicts of interest undermine that trust. “How can I trust information provided on a medical site with ads from a company that my doctor says makes stuff that is bad for me – heck, that everyone knows is bad for them?” is a reasonable question, a reasonable suspicion, and a legitimate reason for concern by the public. “Hey, take our word for it; taking Coke’s money (or Hershey’s, in the case of the ADA) didn’t influence the content of the information on our website,” is a pretty weak defense, not one that is likely to engender trust of the organization or, of greater concern, of its member professionals.

The issue of conflict of interest has been a significant focus in the medical literature. Most major journals now require the authors of original research studies, particularly those that evaluate the effectiveness of drugs, to indicate if they have conflicts of interest; that is to say, financial connections with the manufacturer of the drug (or any other drug manufacturer or potential conflict of interest). This is in addition to identifying the source of funding for the study – mainly whether it was funded by a drug (or device) manufacturer as opposed to funded by the federal government (through NIH or another agency) or, much less common for such studies, a not-for-profit foundation. Again, the reason is obvious: if the author has a conflict of interest (gets money for speaking for a drug company, say, that manufactures the drug being examined, we all have reason to be more guarded in our interpretation of the results, or at least the confidence that we have that the study was done completely without bias. One problem is that bias can creep in unconsciously, even if there is not intentional fraud. Another problem is selective publication: we may only see the papers that report on studies where the drug had a positive benefit, because negative studies are suppressed; this is further complicated by the general preference of journals for positive results, regardless of who is funding the research. If the authors do not disclose their conflicts of interest, we have no way of knowing about them, and may not be sufficiently skeptical in interpreting the findings.

Am I saying we need to be skeptical? Is it not possible to be paid for speaking by a drug company and still do unbiased scientific research on their drugs? Is it not possible even when the drug company is funding the research? Of course it is possible, but unfortunately the data show that it is less likely. In the Introduction to their recent article in JAMA, Reporting of Conflicts of Interest in Meta-analyses of Trials of Pharmacological Treatments[1], Michelle Roseman and colleagues note that “Results from positive trials and from favorable analyses are more likely to be published than results unfavorable to sponsors. Compared with nonindustry-funded trials, pharmaceutical industry–funded studies more often yield results or conclusions in support of the sponsor's drug, and authors' relationships with drug manufacturers have been linked to favorable assessments of drug efficacy and safety,” with numerous references for each of these assertions. The actual focus of their study is to look at meta-analyses to see whether they report conflicts of interest (COIs) in the original studies that they are analyzing. Meta-analyses can be the most potent source of information about a question, as they analyze the results of many studies (ideally, all randomized controlled trials) on a particular topic, and if well done can help to resolve the question of conflicting results from different studies. Of course, if the studies that are included are in themselves biased (either intentionally or not) it will of course impact the results of the meta-analysis. Roseman and her colleagues found that, while the authors of the meta-analyses reveal their own conflicts of interest (if any), consistent with the policies of the journals they publish in, they rarely indicate whether the many studies that they are re-analyzing had such conflicts.

This can be important. For example, if the different studies examined by the meta-analysis tend to show differences in the benefit of a drug treatment, it would be good to know if the ones that showed greater benefit were sponsored by a drug company, or if the authors were on that drug company’s speaker’s bureau. It just might make a difference. Wealth makes a difference because it can buy loyalty, buy favors. The old saw “It is as easy to love a rich man as a poor one” can be modified to “it is as easy to use a product made by someone who pays you as by someone who doesn’t”. Or even “it is as easy to believe an idea supported by the rich and the powerful as one supported by only the poor and disenfranchised”. The problem is that the connections are not random – the ideas of the rich and powerful are too frequently self-serving, and “just so happen” to favor them over the poor and disenfranchised. An excellent example, featuring Ayn Rand and her disciple Alan Greenspan, is provided to us by Matt Taibbi in chapter 2 of his book “Griftopia”[2].

Then it isn’t as easy. Then it is corrupt. Then it is immoral. Then it is selling your soul.

[1] Roseman M et al, Reporting of Conflicts of Interest in Meta-analyses of Trials of Pharmacological Treatments, JAMA. 2011;305(10):1008-1017

[2} Taibbi M. “Griftopia: Bubble machines, vampire squids and the long con that is breaking America“. Speigel and Grau. New York. 2010. Ch. 2, “The biggest asshole in the universe”

.

Common Sense Family Doctor: Coronary CT: nonindicated and costly screening test

.
Another excellent post by Common Sense Family Doctor Kenny Lin, MD, on the incredible fact that Texas, bankrupt largely due to Medicaid costs and limiting elective Caesarean sections to decrease Neonatal Intensive Care Unit (NICU) costs, will pay for the non-indicated (but very profitable) coronary artery CT screening test. Dr. Lin also calls to task Texas Senator Kay Bailey Hutchinson for her inaccurate article criticizing the US Preventive Services Task Force (USPSTF) for "interfering" with decisions that should be made by a patient and doctor.

Some years ago, after the sudden death of St. Louis Cardinals' pitcher Darryl Kile of a heart attack at age 33, I met someone who asked me if he should get a coronary CT. I said I didn't recommend it, and wondered why he wanted it. He said if it was negative he wouldn't have to worry. I pointed out that he was very overweight and smoked, and that what would help him to live to see his children graduate from High School was not a coronary CT, but eating less and stopping smoking and beginning to exercise.

He was hoping that a negative CT had would mean he wouldn't have to do the hard work of changing his lifestyle.

Sorry, Charlie. It's not a good screening test for coronary artery disease and it is certainly not protective against developing it.
.

US Medicine and Medical Education: The Good Part

.
I have often, and I think with good justification, been highly critical of the US health (non-) system, particularly in two areas: the fact that we do not have universal financial access to health care (a completely intolerable situation, which cannot be justified or defended morally, although it often is – always by those who have coverage!), and the fact that we have a great deficiency of primary care physicians. I thought it might be time to address two areas in which I think US medical education and practice is superior to that in Europe and much off the rest of the world.

The first is our medical education system. In specific, I am very happy that our medical schools are graduate schools, entered by students after achieving a bachelor’s degree. This is unlike the situation in most countries, such as Britain, where the medical degree is indeed a bachelor’s degree, MBBS, bachelor of medicine/bachelor of surgery. Medicine as a graduate school is the norm only in the US and in Canada; in virtually every other country, students enter medical school out of high school at 18, and graduate 6 years later. While this still can produce excellent physicians, it is in my opinion less desirable. First of all, they do not have the advantage of the broader education that comes with a bachelor’s degree. Secondly, they are very young. In the US, a student entering medical school right from undergraduate studies would usually be 22, but because many take off for a few years (or have another career first) the actual mean entry age in most US medical schools is about 24 (with the median a little lower). This means a more mature student body, with life experiences – at least the experiences of 4 years of college, if not in another profession, in business, in the Peace Corps, etc. This makes a difference. It also means that US medical students are more likely (and, throughout this piece, when I say “more likely”, that is what I mean – greater probability, not 100%) to really want to be doctors, rather than being there because, at 18, their doctor parents told them that they were going to medical school.

I believe that this greater maturity and life experience lead to greater independent community involvement, creation and management of free clinics, etc. As an example, at the University of Kansas Medical School, the Jaydoc student-run Free Clinic is not only completely student-run, it was student developed, maintained and expanded. There are physicians who supervise at each clinic session, but that is their entire role; the students make the schedules, recruit the volunteers, organize the operation, follow up the results, raise the money (including writing grants and doing benefits). When the clinic was created, a call went out from a student, and over 80 students attended the first meeting. They identified what had to be done: find a venue, decide on frequency, raise money, organize scheduling, on and on. Hands went up from volunteers: “I was an accountant!” “I was a community organizer!” “I was a grant writer!” “I was a teacher!” Even those who had not a previous job or career had their college experiences behind them: “I organized the fund raisers for my sorority!” “I volunteered in the free clinic in the community where my college was located!” I don’t think this happens – could happen – in a school whose students all entered at 18.

Moreover, US medical schools use a variety of criteria for choosing the students to admit. They look for such volunteer work, demographic diversity, achievements in a variety of arenas. While many students are “pre-med”, majoring in biology and chemistry, as we have seen in Medicine, science, and humanities: what is their role in medical education?, August 26, 2010, many are history, English, or art majors. (“What is the course for pre-med?”, a Brazilian medical student, in his 4th year at 21 and still confused about the 4 years US students do before medical school, asked me.) In most countries a cognitive examination is the sole criterion for entry into medical school, and social values are not even considered. Thus, say, in São Paulo (which I know a little) to say that the top 200 scores go to the most prestigious medical school, 201-400 to #2, 401-600 to #3, etc., would not be far off! I have been critical of US medical admissions because they are so skewed to upper-middle-class suburbanites (80% of our medical students come from the top 20% of income), but this skew is even more pronounced in other countries where the cognitive exam is the only criterion, and the greatest likelihood predictor of doing well on these exams is going to the “best” (and most expensive) private preparatory schools. The top 2 medical schools in São Paulo are both public and free – something the socialist government is proud of – but the catch is that it would be virtually impossible for a public school student to get a high enough score on the exam to get into one of them. To get into the free, public medical school requires attending the most elite private prep schools!

The second area in which I think American medical practice – here I am talking about the practice of family medicine – is better is that, to a large degree, our family doctors take care of their patients in the hospital. In Hospitalists, December 4, 2008, I bemoaned the fact that this was changing and that primary care doctors are more and more often choosing to (or being required by their employers to) delegate the care of their hospitalized patients to others. I will not reprise all the reasons why I think this is largely a negative trend, since they are detailed in that piece; what is relevant here is that in most other countries primary care physicians (who are, in most other countries, all family doctors or general practitioners), never cared for their own hospitalized patients, turning them over to internists or pediatricians. In this sense, the trend in the US to hospitalists is emulating practice in Europe and elsewhere; unfortunately, in my opinion, it is emulating one of the more less-desirable aspects of that practice.

Indeed, the trend over the last several decades to increase the proportion of medical students with a broad liberal education is being challenged by a counter-trend, which sees education not as important in itself, but as “job training”-- whether this is in trade school, technical college, professional school, or university. In Medical Student Selection, December 14, 2008, I present my concerns that we will narrow the cohort of medical students rather than broaden it.

Thus, as I take this opportunity to laud some of the aspects of US medical education and practice, I also caution us to continue the positive aspects of our system and guard against adopting the negative aspects of the health system in other countries, as we continue to stand rigidly against adopting their proven effective strategies of providing access to health care for all.
.

Men’s Health? Women’s Health? Valid screening opportunities or “Hallmark Holidays”?

.
This blog has previously discussed the use of PSA as a screening tool for prostate cancer (March 21, 2009: PSA Screening: What is the value?, and a guest column by Robert Ferrer, MD MPH in October 27, 2009: PSA Screening: “One of Medicine's Great Success Stories"? ), and indicated that it was not only a poor test, but a dangerous one, leading to unnecessary biopsies, diagnosis of disease that was unlikely to progress and treatment that would probably not change the outcome but would almost certainly lead to significant morbidity.

A new study by Vickers, et al., published in the Journal of the National Cancer Institute (An Empirical Evaluation of Guidelines on Prostate-specific Antigen Velocity in Prostate Cancer Detection, JNCI, doi: 10.1093/jnci/djr028, first published online: February 24, 2011), shows that the use of “PSA velocity” as a screening test for prostate cancer, is flawed and not a valid indicator. PSA velocity refers to the rate of change (presumably, increase) in the level of prostate-specific antigen (PSA) over time; the theory, which this study demonstrates to be invalid, is that the faster the rate of rise (velocity), the more likely someone is to not only have prostate cancer, but to have aggressive cancer needing intervention. In fact, the study shows that “Biopsying men with high PSA velocity but no other indication would lead to a large number of additional biopsies, with close to one in seven men being biopsied….We found no evidence to support the recommendation that men with high PSA velocity should be biopsied in the absence of other indications; this measure should not be included in practice guidelines.” And so another effort to find a way to use PSA to diagnose prostate cancer, like “highly sensitive PSA” before it, bites the dust.

Unfortunately, the issue of PSA screening will probably not die out, despite this study and the recent change in the recommendation of the US Preventive Services Task Force (USPSTF), downgrading PSA testing from an “I” recommendation (evidence is insufficient to recommend for or against testing), to a “D” – not recommended. The political pressure from physicians, hospitals, and others who are at best “true believers” (they know that eventually their faith will be proven correct) to, at worst, motivated by the fear of losing a major source of income, will continue. Indeed, the “PSA velocity” was never even seen as a way of confirming the veracity of a high single PSA value (which, for the true believers, was sufficient) but a way to identify men who had a normal PSA – but maybe slowly rising from one normal value to another – as a market who could be treated.

The USPSTF recommendation was in fact ready several months before it was released, as discussed by Kenny Lin, MD, on February 28, 2011 his blog Common Sense Family Doctor, PSA testing: will science finally trump politics?. Dr. Lin was, at the time, the staff member at the Agency for Health Research and Quality (AHRQ) that put together the evidence review upon which USPSTF based its recommendation, and then quit over political interference from the White House: “The USPSTF scheduled its "re-vote" on prostate cancer screening for its November 2010 meeting. As reported in the Wall Street Journal and on this blog, the Task Force was forced to cancel that meeting due to the unfortunate "scheduling conflict" with the critical midterm Congressional elections.” (Editorial note: postponing the recommendation didn’t help the President’s party in those elections!)

The attraction of PSA screening and prostate cancer goes beyond that single disease; it is the cornerstone of the ostensible discipline of “Men’s Health”. This is a conceit developed by astute marketers to compete, or more correctly, profit from the cachet associated with, the long-established “Women’s Health”. After all, if Women’s Health is a good and established (and profitable) area, why should men – and particularly, those who want to make money caring for men – be left out? Women’s Health (capitalized) has its own specialty, obstetrics and gynecology, but, because this is essentially a surgical discipline, has brought in also providers in family medicine, internal medicine and some of its subspecialties (especially endocrinology, because of the issue of bone loss and osteoporosis), nurse practitioners, and others. There are Women’s Health clinics, journals, and meetings all over the place; surely Men’s Health should be just as important?

The centerpiece from which Women’s Health derived is the classic “Well-Woman Exam”, an annual ritual for most adult women, so deeply enshrined in both the national culture and insurance reimbursement system that it is no danger of being overturned by a USPSTF recommendation, or probably anything else. The essential characteristic of the Well-Woman exam is the provision of preventive services because the woman is, well, Well. This is a critical concept – once someone has symptoms that are addressed by any examination (more history questions, physical exam, laboratory, imaging) or treatment, this is no longer “Well-woman”; these are problems, conceived of, addressed, and even billed separately. “Well-woman” means that the women has no symptoms and involves only screening. This screening has long been centered around the Pap smear for cervical cancer, and the internal examination (medical: bimanual = using two hands) that is so associated with the Pap that popular usage considers them together. In addition, breast health is addressed through some combination of provider exam of the breasts, teaching of self-breast exam, and referral for mammography. All of these have been re-evaluated by evidence-based studies and recommendations have changed, often for fewer tests.

Breast cancer screening has been a subject of intense controversy, with USPSTF recommending that not all women over 40 receive mammography screening, reversing a position that they took 8 years earlier, and which even at that time was not based on evidence (see October 30, 2010: Breast cancer screening: conflicting evidence? what are the important questions for health?). The political response from the “breast cancer” community – and it was a political and emotional, not evidence-based scientific response, was huge, and was likely a major reason for the White House pressure on USPSTF to not release its PSA recommendation. In addition, teaching self-breast exam was no longer recommended (this is not to argue against doing self breast exam, a major way women find lumps, but rather to acknowledge the evidence that routinely teaching it does not add benefit). Pap smears themselves, the single best cancer screening tests among a group that are mostly less effective than we would hope, are no longer recommended in women under 21 by the American College of Obstetricians and Gynecologists (ACOG), and do not need to be done annually if they have been normal. Bimanual exams never had any evidence to support their routine use in asymptomatic women, because they cannot screen for any disease. Osteoporosis treatment with bisphosphonate drugs can sometimes lead to serious fractures; recommendations are now to treat only frank osteoporosis, not the less severe osteopenia, and then only for a limited time. Even calcium supplementation has been found to have risks (August 2, 2010, Calcium, Heart Attack and Osteoporosis).

Does this mean that there is no valid place for Women’s Health as a concept or even a discipline? Not necessarily. Women do have risks for conditions that are different from those of men, including for a number of things that men are deeply involved in – contraception (not a risk if there are not men involved), sexual abuse, domestic violence. Asking about these issues is critical, with counseling about them necessary, even if this is not what “Well-Woman” exams usually pay for. And, to the extent that it increases the likelihood that these issues are addressed, Men’s Health may have a place. But in general, the examples above indicate the slippery slope of creating such a field, because there is a need to justify its existence. This means finding tests that can be done, expanding the use of these tests beyond those in whom they were originally found to be useful, and even implementing treatment for which there is no evidence, and which are often found to create net harm.

Prevention is a good thing, but if a test or intervention has not been shown to actually prevent something, doing it is useless and costly at best, and maybe dangerous at worst. Women and men should get the screening tests that are indicated, but not those that aren’t. These include Pap smears and mammography (in the appropriate women), colon cancer screening, blood pressure screening and treatment, counseling about tobacco and alcohol, contraception and investigation of risks of violence and abuse. There are others, particularly in certain sub-populations. But we need to be cautious about the creation of new disciplines and the motivation for their creation – is it increasing health or increasing revenue? Providers, doctors and hospitals, like to do things that make money and promote the fact that they do them; cancer prevention and care is particularly emphasized (January 16, 2010: Cancer Care and Hospital Advertising).

We have “Hallmark holidays” (and as a resident of Kansas City, home of Hallmark, I have to be cautious here), like Mother’s Day and Father’s Day, created and promoted to sell things, that have become very beloved by a large number of people. We don’t need “Hallmark medical care”, designed by marketers to fill a niche as an opportunity to make profit.
.