"The Public Health and Social Justice Reader"

I'd like to call attention to the publication of the PUBLIC HEALTH AND SOCIAL JUSTICE READER, edited by Martin Donohoe, MD, and just published by Jossey-Bass.

Those who are not familiar with Dr. Donohoe's remarkable website, Public Health and Social Justice (www.publichealthsocialjustice.org or www.phsj.org) will be amazed at the depth and breadth of the contents, addressing most important aspects of the subject, from Human rights to war, from issues addressing special populations and women to environmental health and justice, from the impact of the "modern epidemics" of obesity, tobacco and suicide by firearms to the modern epidemic of corporate control of our lives and health.

Those who are familiar with www.phsj.org and the breadth of powerpoints on that site will not be surprised to find that Dr. Donohoe himself has written a large number of chapters himself, although there is a very impressive list of other chapter authors.

The PUBLIC HEALTH AND SOCIAL JUSTICE READER is an indispensable resource for students and teachers of health and medicine as well as for policy makers and activists, and is a wonderful accompaniment to the resources available on www.phsj.org.

The table of contents is below; more information is available at www.phsj.org

Public Health and Social Justice Reader

TABLE OF CONTENTS::

PART I Human Rights, Social Justice, Economics, Poverty, and Health Care; 1. Universal Declaration of Human Rights; 2. Public Health as Social Justice, Dan E. Beauchamp; 3. What We Mean by Social Determinants of Health, Vicente Navarro; 4. The Magic Mountain: Trickle-Down Economics in a Philippine Garbage Dump, Matthew Power; 5. Family Medicine Should Encourage the Development of Luxury Practices: Negative Position,Martin Donohoe

PART TWO Special Populations; 6. Homelessness in the United States: History, Epidemiology, Health Issues, Women, and Public Policy, Martin Donohoe; 7. Historical and Contemporary Factors Contributing to the Plight of Migrant Farmworkers in the United States, Safina Koreishi, Martin Donohoe; 8. The Persistence of American Indian Health Disparities, David S. Jones; 9. Prejudice and the Medical Profession: A Five-Year Update,Peter A. Clark; 10. Sexual and Gender Minority Health: What We Know and What Needs to Be Done, Kenneth H. Mayer, Judith B. Bradford, Harvey J. Makadon, Ron Stall, Hilary Goldhammer, Stewart Landers; 11. Mental Disorders, Health Inequalities, and Ethics: A Global Perspective, Emmanuel M. Ngui, Lincoln Khasakhala, David Nndetei, Laura Weiss Roberts; 12. Incarceration Nation: Health and Welfare in the Prison System in the United States, Martin Donohoe

PART THREE Women’s Health; 13. Individual and Societal Forms of Violence Against Women in the United States and the Developing World: An Overview, Martin Donohoe; 14. Obstacles to Abortion in the United States, Martin Donohoe; 15. The Way It Was, Eleanor Cooney

PART FOUR Obesity, Tobacco, and Suicide by Firearms: The Modern Epidemics; 16. Weighty Matters: Public Health Aspects of the Obesity Epidemic, Martin Donohoe; 17. Cigarettes: The Other Weapons of Mass Destruction, Martin Donohoe; 18. Guns and Suicide in the United States, Matthew Miller, David Hemenway;

PART FIVE Food: Safety, Security, and Disease; 19. Factory Farms as Primary Polluter, Martin Donohoe; 20. Genetically Modified Foods: Health and Environmental Risks and the Corporate Agribusiness Agenda, Martin Donohoe; 21. Opposition to the Use of Hormone Growth Promoters in Beef and Dairy Cattle Production (American Public Health Association Policy Statement, Adopted 2009), Elanor Starmer, David Wallinga, Rick North, Martin Donohoe;

PART SIX Environmental Health; 22. Roles and Responsibilities of Health Care Professionals in Combating Environmental Degradation and Social Injustice: Education and Activism, Martin Donohoe; 23. Global Warming: A Public Health Crisis Demanding Immediate Action, Martin Donohoe; 24. Flowers, Diamonds, and Gold: The Destructive Public Health, Human Rights, and Environmental Consequences of Symbols of Love, Martin Donohoe; 25. Is a Modest Health Care System Possible? Andrew Jameton

PART SEVEN War and Violence; 26. The Health Consequences of the Diversion of Resources to War and Preparation for War, Victor W. Sidel, Barry S. Levy; 27. A Brief Summary of the Medical Impacts of Hiroshima, Robert Vergun, Martin Donohoe, Catherine Thomasson, Pamela Vergun; 28. Medical Science Under Dictatorship, Leo Alexander; 29. War, Rape, and Genocide: Never Again? Martin Donohoe

PART EIGHT Corporations and Public Health; 30. Combating Corporate Control: Protecting Education, Media, Legislation, and Health Care, Martin Donohoe; 31. The Pharmaceutical Industry: Friend or Foe? Jennifer R. Niebyl; 32. Unnecessary Testing in Obstetrics, Gynecology, and General Medicine: Causes and Consequences of the Unwarranted Use of Costly and Unscientific (yet Profitable) Screening Modalities, Martin Donohoe; 33. Urine Trouble: Practical, Legal, and Ethical Issues Surrounding Mandated Drug Testing of Physicians, Martin Donohoe

PART NINE Achieving Social Justice in Health Care Through Education and Activism; 34. Promoting Public Understanding of Population Health, Stephen Bezruchka; 35. Some Ideas for a Common Agenda, Peter Montague, Carolyn Raffensperger; 36. Taking On Corporate Power—and Winning, Robert Weissman; 37. US Health Care: Single-Payer or Market Reform, David U. Himmelstein, Steffie Woolhandler; 38. US Health Professionals Oppose War, Walter J. Lear; 39. The Residency Program in Social Medicine of Montefiore Medical Center: 37 Years of Mission-Driven, Interdisciplinary Training in Primary Care, Population Health, and Social Medicine, A. H. Strelnick, Debbie Swiderski, Alice Fornari, Victoria Gorski, Eliana Korin, Philip Ozuah, Janet M. Townsend, Peter A. Selwyn; 40. Stories and Society: Using Literature to Teach Medical Students About Public Health and Social Justice, Martin Donohoe

Health is not a commodity: Let us get the language right

Sometimes the starkest realities are hidden by the language that we choose to speak about them. This week I attended two important conferences, the annual American Public Health Association (APHA) meeting of about 8000 or more public health workers from across the country, and, on the day preceding it, the annual Physicians for a National Health Program (PNHP) meeting, with about 400 doctors and medical students.

While the PNHP program was more targeted, examining the impact of lack of access to health care in the US on the health of our people, it also included international participants. One, Dr. Alex Benos of Greece, talked articulately about the impact of European Union and IMF imposed “austerity” measures on the health of the Greek people -- so bad that the child poverty rate there has risen to 16%. The impact of the penalties for “bad” (albeit sanctioned and even encouraged by governments) behavior by bankers is being borne by the people, and especially the poorest, in Greece, in Spain, in Portugal – and in the US, where the child poverty rate, 23% still significantly exceeds that of Greece. While they have been dramatically underplayed by the US media, there have been massive, massive, and regular demonstrations against these attacks on the people, and in Greece (as elsewhere) physicians such as Dr Benos are there on the lines with their patients, providing medical care and demanding the core basic social services that their patients need.

“Health and health care,” Dr. Benos says, “are not commodities that exist to drive the economy. They are among the social goals which we have an economy to achieve.”

Think about that. We have been so inundated with news articles, pundits, politicians, and others talking about The Market, about the need for austerity, that we have forgotten to ask the key question of “why is there an economy? What is the goal of production?” It is the national and international version of the phrase we hear so often in businesses, including hospitals: “No margin, no mission.” Perhaps, but much more important is to have a mission; otherwise it is “No mission, no mission”. When a hospital makes money on its profitable “product lines”, what is the mission? To help provide for the basic healthcare needs of the poor and uninsured? Or to invest in expanding those already-profitable product lines? If our national and international economies generate wealth, is the goal to provide the basic health needs of those whose labor created that wealth? It is clear what we have, de facto, chosen in the US: since 1992 the top 400 taxpayers have had a 500% increase in income, and the rest of the top 5% a 150% increase. 50% of the total increase in income over that period has gone to the top 400 people, and 93% to the top 5%!

”Solidarity,” Dr. Benos adds, “means no one should be left alone in this crisis.”

His work and that of other Greek physicians is to be sure that this definition of solidarity is the one they live by. For us, in the US, a stronger sense of social solidarity would be important; indeed, any sense of social solidarity would be an improvement. The evil myth propagated by many in the US is that when we support the core needs of the most vulnerable, we weaken the economy; in fact, the reverse is true. Providing a core set of social service, including health care, education, housing, food, and opportunity, increases our ability to be a strong society. It is the opposite, the concentration of all wealth in a few, that jeopardizes our future. Trickle down, it should be clear now, doesn’t happen.

“The ideology,” said Andrew Coates, another speaker and PNHP president-elect, “is that whatever is private is good and whatever is public is bad. It is not true, and it is certainly not cheaper.” Let us compare the US to our closest neighbor, Canada, where most health care services are privately delivered, but are paid for by a single payer, the government. The US spends $8230 per capita on health care, of which $5290 are public $ (counting not only direct expenditures for Medicare, Medicaid, VA, military, and federal , state and local employees and retirees, but also the foregone tax revenue resulting from employer contributions to health insurance being tax exempt). In Canada, total expenditures are $4440 per capita. Thus our public fund expenditures per capita exceed Canada’s total expenditure. Hospital billing administrative costs in the US are $570 per capita and total administrative costs are $2685; in Canada, the numbers are $182 and $809 respectively. The gap in life expectancy between the highest and lowest quintiles of income was 1.5 years in 1972. In 2011 it was nearly 6 years. Life expectancy is lower in the US, as are life years adjusted for disability, infant mortality, and virtually every other health indicator. Our money is not buying value; it is accruing wealth to a few.

That language is important was emphasized by presenters at several of the APHA sessions I attended (there are literally hundreds of them over the course of the conference). Sonja Bettez, from the University of New Mexico, observed that talking about health “disparities” tends to minimize the structural violence done to the populations of people who suffer those disparities, and that in Latin America this term is never used; rather the discussion is of inequities, or inequalities. Broad-based differences in health status between populations based on class, race, and other characteristics are not just disparities, they result from deeply seated societal and social problems. Using the language of disparities serves a political purpose, she notes, as it tends to pre-empt social change by emphasizing individual behavior change. She also notes the absence of the term “social justice” from any of the decennial iterations of Healthy People, not to mention the absence of “racism”. How we label things has a great deal to do with how we think about what is necessary to correct them.

In another vein, Donald Light spoke about pharmaceutical companies and marketing, noting the language of “the risk-benefit” ratio (which I have used in this blog) does not make sense because it doesn't identify risk of what? Accurately, it is a risk-risk ratio, the risk of harm vs the risk of benefit, or “harm-benefit” ratio. This is more stark, and more correct. Dr. Light also discussed what he calls the “inverse benefit law”: that the more widely marketed and used a drug is, the less benefit and more harm results. This makes sense; the lowest harm-benefit ratio accrues from the limited use of a drug for those specific conditions, and in those specific people, in whom it has been shown to have the most benefit; as the use of the drug expands to conditions for which it has been less clearly shown to be beneficial, the risk of harm does not decrease and the harm-benefit ratio increases.

It was a very instructive week, and one in which a lot of information was shared. Sadly, it was not all good, and the future, from the economic crisis in Greece to the health care system in the US, is pretty cloudy. But using language carefully and accurately to correctly label problems helps us to identify potential solutions. I think a good touchstone is for us to reject the idea that our health, and that of our families and friends and the entire society, should be a vehicle for profit. Dr. Benos has it right when he says the health is a social good for which we must strive, not a commodity.

Now our task is to make that a reality in the US.

Medicare, falls, families, and risk: "Qualifying" to be in a safe place

Older people are, like all people, a widely varied group. Some are healthy and independent and can live on their own until very old age, while others have diseases that make them infirm at chronologically much younger ages. Some live with family members or have family members living with them. Most of those are well cared for, but some are exploited or even abused. Some elders live in assisted living facilities or nursing homes. A lot more of them are women than men, a reflection of differences in life expectancy. And most of them will, sooner or later, have an adverse event occur that leads them to be hospitalized. Sometimes it is almost routine, getting admitted for a complication of an existing condition such as chronic lung disease or heart disease; sometimes it a surprise, as when a 90-year old who has lived alone and been healthy falls and breaks her hip. The first time something happens, I find myself often repeating to these people and their families, is always the first time, whether at 20 or 90.

Whenever I am the attending physician on our inpatient service, we have a number of such people admitted, but in the last two weeks the number of people admitted who were what my residents call “little old ladies” seemed especially high. They ranged in age from their late 60s to 104; some lived in nursing homes, some with family, and some lived alone (including the 104 year old!). Some were admitted to the hospital for the first time, while others were “frequent fliers”; some had families hover around and others seemed to be left alone even when their family lived in town. A lot of them had falls, sometimes with broken bones (most commonly hip fractures, but others as well), sometimes, fortunately without. Some had moderate to very severe dementia, from Alzheimer’s or other causes, and may know only who they are (or not even that); others are “sharp as a tack” – at least when we can fix the dehydration or whatever else has brought them in.

One characteristic shared by many of these people is that they are unlikely to be safe returning to their homes. If they have fallen, they are likely to fall again. If they avoided a hip fracture this time, they may not next time. We do tests to see if there is an “explanation” for why they fell that might be treatable. Did they have a stroke? Should they be on blood thinners that make another stroke less likely but make the possibility of a bleed into their brain much higher if they do fall and hit their head? Heart rhythm problems? Maybe a pacemaker. Low blood sugar? Are they taking too much insulin? Maybe they “just” tripped: on the cat, on the rug, on the hem of their pants (which might be because those pants are hanging low from the 40 lbs they have lost since they were last seen a year ago -- really? I have been eating. I never noticed I was losing weight!) But, while anyone can trip, if it happens more than a couple of times, they are at risk of something bad. Sometimes it is possible for a health worker or family member to the home and help get rid of clutter, area rugs, and such, but sometimes that isn’t enough.

No one wants to go to a nursing home, especially compared to some idealized vision of being better and functional at home. Few families want to send their parents or grandparents to a nursing home, feeling that it is abandonment, or undignified, or irresponsible. Occasionally, there are complicating social issues, as nursing homes will take the Social Security check that family members are living on or Medicaid will require the sale of the house that family members are living in. And nursing homes are not a panacea; some are better than others, and folks get sick enough to require admission back to the hospital even from the best. But often they are a safer option, even when the family is committed to care. A person may be hospitalized by the family for a minor change that makes the Alzheimer’s victim even harder to care for; the primary care doctors may have already discussed admission to a nursing home, and, as one put it, “their voices said ‘no’, but their eyes and body language said ‘yes’.”

Medicare will pay for a period of time in a “skilled nursing facility” (SNF), where a person who was hospitalized but no longer needs to be in an acute-care hospital can get time to recover, get physical therapy, get to the point where they in fact, often with home health and a supportive family, go home. It works for someone who just had surgery, or someone who broke a bone and either had it surgically repaired or not. But to get this “benefit” the person needs to spend 3 midnights in the acute care hospital. Whether they need acute care or not. Indeed, if they don’t “meet Medicare criteria” for an inpatient hospitalization, they are not even officially “admitted” but are in a fantasy world of “observation status” where they are in the hospital, but are officially outpatients. And those nights don’t count toward “qualifying” for a SNF. So if you (or your father, or grandmother), “just” tripped and hurt themselves, and didn’t break a hip this time (sometimes they have already had both hips repaired), and is “just” bruised, and may have a “little” disorientation but no new stroke, and a little difficulty caring for themselves, and could really benefit from a month of skilled nursing, you better be able to pay for it, because Medicare won’t because they didn’t have 3 nights of “qualifying”.

This is crazy. I am a huge fan of “Medicare for All” rather than the nonsense patchwork of often-inadequate private insurance plans (and people who are uninsured) that we currently have. But that Medicare for all – and right now, for those who are on it – needs to have a rational payment and benefit structure. I understand the financial challenges facing Medicare (and the whole health insurance system – it is not a “Medicare” problem, it is a medical care problem) and believe that we need to save money by spending it rationally. This means, perhaps, not paying for every drug that the FDA approves even when it is not better than an existing, cheaper drug. This means not doing fantastically expensive interventions on people whose quality and duration of life will be marginally affected. It does mean placing people in the settings in which they can get the most appropriate, cost-effective care, whether at home with or without home health, in a skilled nursing facility, in a long-term care facility or in an acute care hospital. It does not mean requiring that someone who would benefit from a stay in an SNF first have to “qualify” by being in an acute care hospital overnight.

My local paper recently had a big front-page article about the fantastic new technology being employed at our hospital using GPS to map the location on the heart where an abnormal rhythm is being generated, so that it might be able to be fixed. Congratulations to the cardiologists and engineers who have developed this, and to the PR department that got it in the paper. It might be a big help for a few people, and will almost certainly be very costly (and profitable for the hospital). But as we develop all these expensive new technologies that might help a few people a lot and might help a few more a little, it is insane if we save money by not providing what we already know is the right thing in prevention and intervention for the conditions that affect the many. Right now, Medicare is trying to save money by identifying “fraud”; they do this (this is absolutely true!) by contracting with bounty-hunter companies called “RAC”s to discover when a patient has been “admitted” when their condition didn’t technically qualify and they should have been on “observation” status. They should be saving money by not paying for expensive high-tech procedures which offer little benefit.

A rational health care system, as we have discussed before, means that people are getting the right care in the right setting; this is the ostensible promise of health-care integrated systems. But, just as we will never have enough primary care doctors doing prevention and early treatment as long as we pay them a fraction of what we pay those doing heroic (and often ineffective) intervention for far-advanced disease, we will not have a rational health care system if we pay for huge high-ticket items but not for people to be in the right setting for them to receive the care that they need.

Medicare can, and should take the lead. For seniors, it is our national health program. Others will follow. 

Simple treatments: bad doctors or a bad health system?

The New York Times editorial on September 9, 2012, “Simple treatments ignored”, is a commentary on a report in the September 7 issue of the Centers for Disease Control and Prevention (CDC) publication Morbidity and Mortality Weekly Report (MMWR)  that many Americans with hypertension (high blood pressure) were not being adequately treated. The Times notes that the study “found that 67 million Americans had high blood pressure and that 31 million of them were being treated with medicines that reduced their blood pressure to a safe level. The remaining 36 million fell into three groups: people who were not aware of their hypertension, people who were aware but were not taking medication, and those who were aware and were treated with medication but still had hypertension.”

This is definitely not a good thing; hypertension is a serious disease that can have devastating results – most obviously in stroke, but also in increasing the risk of heart attack and kidney failure. Also, as the article states, treatment is relatively easy – that is to say, there are drugs that are available for effectively keeping hypertension under control. In fact, so many people are receiving effective treatment that the incidence of bad outcomes, such as stroke, has greatly decreased. The Times editorial, however, creates the impression that much or most of the fault of for lack of treatment is the result of ignorant, incompetent, uncareful (or uncaring) physicians; the reason, they write, is “…mostly because overburdened doctors did not give hypertension high priority.” This is a highly dubious assumption.

The editorial goes on to praise, specifically, the Kaiser Health System for doing a good job of controlling its patients’ blood pressure, and thus reducing the rate of strokes and heart attacks:  “The organization created a hypertension registry to track patients and the care they were getting; eased the burden on doctors by using pharmacists to initiate drug therapy and medical assistants to monitor patients’ progress; made it easy for patients to get free blood pressure checks; and showed doctors how their record on controlling blood pressure compared with others in the system.” This is great.

People should get treated effectively for treatable diseases, and hypertension is certainly one. There are, however, many reasons why they are not always treated, and this problem includes patient as well as provider issues. Hypertension is, on the whole, asymptomatic; it does not cause pain or weakness or even, usually, headaches; thus the sobriquet “silent killer”. The treatments, in addition to drugs, include things like “…weight loss, increased physical activity, lower sodium and alcohol consumption, and stress management,” which require significant effort and commitment on the part of the patient, and are not easy to do.

But, more important, the lessons of Kaiser are not easily translated into the rest of the health system. Kaiser is a very atypical in that it is a vertically-integrated, closed-panel health system. For starters, and it is a very important start, every patient in their panel is insured (though Kaiser) and every patient sees a Kaiser provider. Thus, they control both the coverage and direct care of this population, and they have a large enough scale to do outreach programs to encourage and support people in adopting and maintaining the behaviors listed above. This is, however, not the case for most of the community. Many people are not insured, and many others have insurance that does not cover drugs and other treatments. A variety of factors, some provider related (such as not being able to get an appointment) and others originating from patients’ own decisions (choosing to go to ERs and urgent care centers, and indeed “doctor shopping”), they see different providers. That the US has an uncoordinated health non-system is the key problem, not that "their doctors are asleep at the switch."

The article concludes: “The benefits of reducing high blood pressure — not to mention the cost savings — are obvious. The wonder is that the health care system has done such a bad job of delivering those benefits.” To me the wonder is that we have tolerated not actually having a health system for as long as we have, and that health policy continues to try to address issues of quality of care while ignoring the elephants in the room: that so many people have no coverage or poor coverage, and that reimbursement overwhelmingly rewards intervening once problems have arisen rather than preventing them. That a physician hired by a hospital to inject clot-busters into the brain’s arteries to try to reverse a stroke that has already occurred earns, literally, several times as much as (and works much less than) a primary care physician who treats hypertension (and many other diseases). The reimbursement system is completely inequitable and inappropriate, and the health system is a sick hodge-podge of half measures.

First, we need a health insurance system that covers everyone: Medicare for all. Then we need to reward systems-based and outcomes-based care. Then maybe all of us can see results like Kaiser's.

Physician advocacy: for patients and for social change

A recurring question for physicians and others in the health profession is what degree of health advocacy is expected or appropriate. For those of us in medical education, the question becomes how much of the training (and evaluation) of medical students and residents should be based on advocacy for their patients or populations. Sarah Dobson and colleagues provide a useful formulation of this question in a “Perspective” in the recent Academic Medicine, “Agency and activism: rethinking health advocacy in the medical profession”.[1] They note that “Health advocacy appears in various forms in professional charters and standards”; however, as Canadians they focus on the CanMEDS document. This is “…a competency-based framework developed by the Royal College of Physicians and Surgeons of Canada that describes the core knowledge, skills, and abilities of specialist physicians,” that has 7 core roles including “health advocate”.

In the United States, the clearest expression of the role of advocate is in the American Medical Association’s (AMA) Declaration of Professional Responsibility: Medicine’s Contract with Humanity, which contains, as item #8, “Advocate for social, economic, educational, and political changes that ameliorate suffering and contribute to human well-being.” Overall, the Declaration is quite an impressive document, the contents of which would surprise many in both the medical and lay communities who think of the AMA as professional advocacy group with no social conscience; sadly, there might be as many unpleasantly as pleasantly surprised by the discovery. Advocacy for patients is generally considered an appropriate role for physicians by physicians, but advocacy for social, economic, educational and political change is far less widely accepted.

Dobson and colleagues propose a parsing of the concept of advocacy into two components. They call these “agency”, working on behalf of the interests of a specific patient, and “activism”, which is more directed toward changing social conditions that impact health, and whose effect is seen on populations more than individuals. This is helpful in clarifying different perspectives on the term “advocacy”. While the CanMEDS framework, for example, calls for physicians to “…responsibly use their expertise and influence to advance the health and well-being of individual  patients, communities, and populations,” the authors observe that trainees “…have variously described it as charity or as going above and beyond regular duties.” They note that “...several studies have concluded that although physicians generally endorse the idea of advocacy, they rarely engage in it.” They summarize the difference between agency and activism by saying “…whereas agency is about working the system, engaging in activism is about changing the system.”

The article concludes that there is a distinction to be made between the role and responsibilities of the individual physician and that of the medical profession as a whole. “Physicians and other health professionals witness the effects of the socioeconomic determinants of health every day, made

visible to various degrees in every patient encounter, “ but they question “whether this authority translates into an obligation.”

There are, however, many physicians who do act as social activists, and we need more of them. The source will be medical students who then become residents. Luckily, there seem to be no shortage of entering medical students with this commitment. They demonstrate it by community volunteer work, creating and working in free clinics, volunteering their time to work in schools, and pursuing training in public health, public policy, and community involvement. Sadly, however, along with empathy, which has been shown to dramatically drop as medical students enter their clinical training (Hojat, et al.[2], and this blog, “Are we training physicians to be empathic? Apparently not.”, September 12, 2009), so does volunteerism and commitment to social change.

In the US, despite the AMA Declaration, there are no requirements for teaching advocacy included for teaching medical students by the Liaison Committee for Medical Education (LCME), which accredits medical schools, or in training residents by the Accreditation Council for Graduate Medical Education (ACGME), which accredits residency programs. In the absence of such requirements, it is less likely that advocacy programs will be developed for students and residents, and more likely that, when they are, it will be the students who are already interested in doing such activities who participate. That is great, and programs which allow students to be involved and helps “inoculate” them against from losing their interest and commitment will continue to exist (such as several that we have here at the University of Kansas School of Medicine, including our free clinic and longitudinal elective Community Leadership track). However, if these are not expectations of all students, of all physicians, then only a minority will be involved.

Indeed, when we look at the American political landscape, we see a fair number of physicians involved in politics. It could be argued that, in these roles, they are advocating for social, economic, educational, and political changes. What is disconcerting is that the majority of these physician politicians seem to ignore the second half of that sentence, “…that ameliorate suffering and contribute to human well-being”. They are often found among, and sometimes as leaders, in advocating policies that slash the social safety net, decrease funding for public education, and oppose universal health insurance. Too frequently, they act as agents of their own social class than as advocates for those most in need.

That doctors will most often adopt the “agency” role when it comes to issues that most directly affect the health of their patients, that can be arguably seen as “medical”, is very reassuring. I was once at a physician meeting in which a “conservative” state legislator was speaking against a statewide smoking ban. Reassuringly, the vibe in the room was very hostile to the content of her remarks. Sensing that, she turned to a physician from her district who was also very conservative and a political supporter of hers and said “You? Do you agree with this?” To which he shrugged his shoulders and replied, “I’m a doctor!”

The advocacy role is more complex. Not only are many physicians socially conservative and not, perhaps, in support of policies “…that ameliorate suffering and contribute to human well-being,” physicians are busy people who mostly see themselves in the role of providing direct patient care, not advocating for systemic societal change. Even physicians with public health roles may see their advocacy in a much more limited way (for immunizations, smoking cessation, cancer screening, seat belt use, etc.) rather than structural societal change.

I would like to think that all physicians manifest advocacy in the “agency” sense for their patients. It may be wishful thinking to hope that all physicians will manifest advocacy in the “activist” sense, that they will fulfill the AMA’s Declaration by actually advocating “…for social, economic, educational, and political changes that ameliorate suffering and contribute to human well-being.” But if we do not make this a core value for physicians that is ubiquitously taught in medical school and residency, if we do not select students because of their commitment to advocacy, we will have much less of it.

And we need it badly.

---

[1 Dobson S, Voyer S, Regehr G, “Agency and activism: rethinking health advocacy in the medical profession”. Acad Med. 2012;87:1161–1164.First published online July 25, 2012. doi:10.1097/ACM.0b013e3182621c25

[2] Hojat M, Vergare MJ, Maxwell K, et al, “The Devil is in the Third Year: A Longitudinal Study of Erosion of Empathy in Medical School”, Academic Medicine, Sept 2009;84(2):1182-91

Abortion and women's health: who truly has a conscience?

“Conscience clauses” have become increasingly common in laws about health care as state legislatures seek to limit people’s access to services that they don’t approve of but have not, as yet, been able to make illegal. Of course, it started with abortion care, with doctors being allowed to “opt out” of training requirements for abortion (not that anyone was ever required to “opt in”), and gained momentum with the development of mifepristone (formerly RU-486), the abortion pill, ensuring that pharmacists would not have to fill prescriptions for it if they opposed abortion.

Of course, mifepristone is only sold directly to providers, so pharmacists are not called upon to fill these prescriptions, so the laws moved on to whether pharmacists could refuse to fill prescriptions for emergency contraceptives (the “morning after pill”). A lot of jurisdictions passed laws under the guise of the “conscience clause”, some even permitting pharmacists to not even dispense regular contraceptive pills. Which, of course, can be used for emergency contraception. And which, of course, is not abortion. But so much for the facts.

It is not coincidental that these restrictions have focused on women’s reproductive health. It appears that legislators’ concern is not about “right to life” (which many make a joke of with their opposition to anything that might help people after they are born), and fall into the arena of “women’s reproduction and the things associated with it, like sex, make us uncomfortable and so we don’t want to be involved with it”. In addition, there is persistent undertone of “…after all, these are women, people who do not understand how to take care of themselves and make their own decisions, so we have to do it for them.” This is pretty clearly part of the agenda of the religious right – limiting the ability of women to make their own decisions about their bodies.

Indeed, a victory for women was achieved when emergency contraception was made available without a prescription – and then a step backward was taken when HHS Secretary Kathleen Sebelius overruled recommendations from the FDA and prevented its availability without a prescription to women under 17. Now that makes no sense at all if one is concerned about their health – women under 17 are the most likely to have sex without contraception, to be pressured into sex by men, to not be able to plan whether they are going to have sex and thus possibly become pregnant, to have the self-efficacy to walk into a pharmacy and ask for emergency contraception. So we are going to make it particularly difficult for them? Well, it does make sense for an agenda that says “limit rights where we can limit them” and we can move on from there. Yes, these girls are the most vulnerable. So let us victimize them.

What is particularly upsetting is the usurpation of the language of conscience by those who would restrict women’s reproductive options. We do not hear of conscience clauses about not dispensing Viagra, Cialis, and the like because the loss of ability to have an erection with age is natural. Or for that matter, against cosmetics, or drugs that will treat God-given genetic chronic diseases. A joke, but not so funny, supposes a Christian Scientist pharmacist who refuses to supply any medication. This usurpation of language is parallel to the current ownership of the language of “life” by the anti-abortion movement. The implication is that pro-choice people do not value life, but our argument is that we value the life of the born – the woman, children who are alive, and those who might be born.

Into this discussion comes the voice of Lisa H. Harris, in a New England Journal of Medicine “Perspective”, September 13, 2012, “Recognizing conscience in abortion provision”.[1] Dr. Harris argues that the provision of abortion is also driven by conscience, and that this right to conscience has not been protected. So firmly has “conscience” been associated in public discourse with the right to refuse to do abortion, the idea that conscience can be, and is, central to the decision of the abortion provider is almost jarring. And yet it is certainly true.

Harris refers to the work of the physicians who practiced abortion at great risk to themselves, their reputations and their ability to continue to practice medicine in the years before Roe v. Wade:

The conclusion that abortion provision is indeed “conscientious” by this standard is best supported by sociologist Carole Joffe [2], who showed in Doctors of Conscience that skilled “mainstream” doctors offered safe, compassionate abortion care before Roe. They did so with little to gain and much to lose, facing fines, imprisonment, and loss of medical license. They did so because the beliefs that mattered most to them compelled them to. They saw women die from self-induced abortions and abortions performed by unskilled providers. They understood safe abortion to be lifesaving. They believed their abortion provision honored ‘the dignity of humanity’ and was the right — even righteous — thing to do. They performed abortions ‘for reasons of conscience.’”

There are no doctors who showed more courage, more conscience, than these pre-Roe abortion providers. But the power of this commitment, of this conscience-driven provision of abortion, has not lessened in the post-Roe years. The ever-more restrictive laws passed by state legislatures, seasoned with the constant picketing and harassment of patients, leavened with bombings and fires, and finally consummated by the murder of abortion providers, should leave no doubt about the moral strength of these people. The testimonies on “Why I Provide Abortions”, on the website of Physicians for Reproductive Choice and Health (PRCH), or those its video “Voices of Choice” (including the voice of George Tiller, MD, murdered in 2009; see my post In Memoriam George Tiller, May 31, 2009) are clear and moving; they come from physicians who know that, if they do not provide safe abortions, women will obtain them unsafely at the risk of their lives:

"My experience goes back to my residency training at Boston City Hospital. I was appalled by the intermittent but steady stream of otherwise healthy young women dying in front of my eyes from septic shock due to unsterile, botched procedures.”

"When a woman acts in a responsible way, doing what she believes is in her best interests and the best interests of her family, she's being moral.”

“I believe women shouldn't have to explain to governments, religious groups, those of another opinion or the patriarchy at large that they've made a decision to deal with the condition of their own bodies.”

Dr. Harris indicates, correctly, that the same standards of conscience should be applied equally: “Certainly, if abortion providers’ conscience-based claims require scrutiny, so do conscience-based refusals, to ensure that refusals are indeed motivated by conscience and not by political beliefs, stigma, habit, erroneous understanding of medical evidence, or other factors.”

There are many people opposed to abortion who are sincere in their opposition and motivated by conscience. Beyond that, e.g., refusing to fill contraceptives, is getting to the point that maybe it is time to seek a new field of work. But to imply that concern for women and conscience only apply to abortion and contraception opponents and deny the conscience and morality of those who provide such care is unethical and dishonest. George Tiller’s motto was “Trust Women”, but many people don’t.

Another voice from “Why I Provide” says it simply and profoundly:

"I provide abortions because I value the life and health of my patients, and because when abortion is not legal, safe and accessible, women suffer and die.”

That is a conscience clause.

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[1] Harris, L. “Recognizing conscience in abortion provision”, NEJM 13Sept2012;367(11):891-3.

[2] Joffe CE. Doctors of conscience: the struggle to provide abortion before and after Roe v. Wade. Boston: Beacon Press, 1995.

Primary care, specialty care: what about health?

Three “Perspectives” in the September 6 issue of the New England Journal of Medicine address different, but clearly related, aspects of the transformation of health care. I have previously discussed one of them, “Becoming a physician: the developing vision of primary care" by Barnes, and Comfort in Social determinants key to the future of Primary Care (September 22, 2012). The two others are "What business are we in? The emergence of health as the business of health care"^[1], by Asch and Volpp from the Wharton School of the University of Pennsylvania, and "From Sick Care to health care -- re-engineering prevention into the US health system" by Marvasti and Stafford.^[2] Taken as a whole, the three provide some significant insight to the current US healthcare delivery system, the changes that need to be made in it, and the way we will get there.

Asch and Volpp discuss the need to shift from "what can we produce" (health care) to "what do people want" (health). They use the parallels of the failure of major industries (railroads in the last century; Eastman Kodak in this) to make this distinction. Each of those industries made the mistake of confusing what they produced with what people wanted when they bought their products. Thus, railroad companies provided railroads, when customers wanted transportation of goods and people; when alternatives (trucking, air) became available they were unable to adjust (although in Europe they did a pretty good job). Similarly, Kodak made film when what people wanted was to store images of their lives. Asch and Volpp do not mention that the ad agencies got this right (“we create memories”) but the corporation did not move into the digital age early enough and, last year, went into Chapter 11 bankruptcy.

The “health care” industry provides, at best, health care, but more often just medical care, and most especially disease care. People seek it out because it is what available; what they want is health, to not be sick, in pain, disabled. This is of course why “mainstream” medicine is not the only source of treatment people seek. It explains the allure, and extensive use, of products of the “alternative care” industry, which ranges from degreed practitioners like chiropractors and naturopaths to long-used herbal and other cultural treatments dispensed by various methods (botánicas and the Internet), to Eastern medicine such as acupuncture, to religious rituals including American Indian healing, Catholic exorcisms, and the rituals of Santeria, Candomblé, and Voodoo derived from Africa, to straightforward quackery. “Integrative medicine” is an effort by traditional western medicine to employ many of these techniques and traditions. While we probably would actually prefer the diagnostic and treatment magic of Star Trek’s doctors, we’d certainly like the magic pill, elixir, injection, herb, or prayer that would heal all our ills – preferably with no real or sustained effort on our parts, and without side effects. Interestingly, while “alternative” medicine is seen as more “holistic”, it is in fact often more biologically reductionistic, using interventions (e.g., enemas, diet changes, supplements) to cure social and psychological problems (see my 2005 piece “Towards a definition of holism” in the British Journal of General Practice).^[3]

Perhaps this is all “quackery”, or just some of it is and others are not. In mainstream American medicine, something doesn’t become a real disease until there is a test for it – or better yet a drug for it – thus the medicalization of many things that people have experienced as part of the mortal coil for thousands of years. Some things that were accepted as “part of life” (and death) are now diagnosable and treatable; others might be in the future. But those of us in the “health care” industry need to understand that folks will only buy what we are selling if it is, on the whole, the most effective way for them to get what they want: health.

Marvasti and Stafford discuss the need to change from a system designed to treat acute conditions and acute exacerbations of chronic diseases to one in which, in Fries' model, of "morbidity compression", "in which the disease-free life span is extended through the prevention of disease complications and the symptom burden is compressed into a limited period preceding death." This dovetails well with what I have discussed above; people want to be healthy. They recognize that they are going to die, but they want to do this quickly, painlessly, and at the end of a long and healthy life. As a loved one of mine who is closer to this than many puts it, “someday I just won’t wake up”. Morbidity compression. If he is lucky, if we are all lucky, that will be how it happens.

But right now, our health care system is in fact designed to treat acute conditions and acute exacerbations of chronic disease, not to maintain the care and the health of people who have not yet developed chronic disease or are stable. More to the point, our system does this because this is what is paid for; we are just scratching the surface of the ideas of “chronic disease management”. In fact, we pay so well for acute interventions that hospitals are hiring acute “interventionalists” at extraordinary salaries compared to their colleagues in the same specialties that actually manage people over time. For example, “stroke neurologists”, or sometimes interventional neuroradiologists, who can inject clot-busters into the arteries of people with acute strokes make perhaps 2-3 times what a neurologist who just manages chronic neurologic diseases does (not that much more than regular radiologists, who are overall much higher paid); this is because the hospitals that employ them are so highly reimbursed for these procedures.

The need to manage actual people, especially when they have chronic disease, not just an acute episode, is obvious to most of us. It may even be obvious to the insurance companies and other payers, to the hospitals who support the acute interventionalists, but so far they haven’t changed what it is that they pay for, what it is that is financially incented. I write a lot about primary care, but it is not only primary care. Commenting on my last piece, Social determinants key to the future of Primary Care, a neurologist colleague who cares for people with Amyotrophic Lateral Sclerosis (ALS), Lou Gehrig’s Disease, a terrible and always fatal degenerative condition that satisfies almost none of the criteria for “morbidity compression”, wrote:

But the group health care model is also the best for chronic rare diseases managed by subspecialists....this is what we do in ALS clinic on Monday mornings. You should come visit, Josh, at 8 when all the folks (speech therapy, physical therapy, occupational therapy, social workers, dieticians, equipment providers, respiratory therapy) meet with the neuromuscular neurologists to discuss each case. Then we see them and all weigh in and we give patient a printout with advice from each. But, alas, there is no way to pay for this without support from local and national foundations....Medicare doesn't cover it by far.

I wrote back:

Of course. In this sense, you are sharing the same issues as primary care doctors -- you are managing patients, not just a single episode of disease. Certainly ALS is a disease, but it is a chronic one that takes over people's -- and their family's -- lives, and requires not only complex and interdisciplinary, but long-term, management. Indeed, the concept of the medical home was developed in the 1960s by the specialty pediatricians managing kids with chronic diseases such as cystic fibrosis, juvenile diabetes, and sickle cell, which share with ALS the fact that there is one disease that dominates the lives of the patient and their family; to care for it requires managing not just the disease but working with the whole person and their family. It can also (but is not always in practice) be true of HIV clinics.

This is less true of many other adult diseases, which often co-exist --diabetes, hypertension, congestive heart failure, chronic lung disease, depression, arthritis -- so that one specialist is not interested in (or perhaps capable of) managing them all -- thus primary care for adults, geriatricians, etc.

It is virtually not at all true of those who do radiology, anesthesiology, single-time consults, or one-shot surgery, or one-shot-into-the-cerebral artery neuro-interventionalists. Or, to be short, any of the folks making a lot of money for single things, while the stuff that you do in ALS clinic is not paid for.

This is insane. We do not have a health system, and we do not even have a health care system. We have a medical care system, with the emphasis on the medical. It is fine to pay for an episode of care, but it is much more important to reward care.

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[1] Asch DA, Volpp KG, “What Business Are We In? The Emergence of Health as the Business of Health Care”, NEJM 367(10);887-89. DOI: 10.1056/NEJMp1206862

[2] Marvasti FF, Stafford RS, “From Sick Care to health care -- re-engineering prevention into the US health system", NEJM, 367(10);889-91. DOI: 10.1056/NEJMp1206230

[3] Freeman J, “Towards a definition of holism”, Br J Gen Pract. 2005 Feb;55(511):154-5. PMC1463203

Social determinants key to the future of Primary Care

A "Perspective" in the September 6 issue of the New England Journal of Medicine, "Becoming a physician: the developing vision of primary care"[1] by Kathleen A. Barnes, Jason C. Kroening-Roche, and Branden W. Comfort*, addresses the change in the practice of primary care enabled by changes in payment and structure and how this is more attractive to medical students. All three are medical students (although Kroening-Roche already has both his MD and MPH) from schools in different parts of the country (Harvard, Oregon, and Kansas); they met at the Harvard School of Public Health, and all of whom seem to be interested in being primary care physicians. They describe a model – or, more accurately, as they say, a vision – of primary care practice in which they see themselves in the future, and about which they are enthusiastic. By extension, one would hope that this is also true of many other medical students.

The practice that they describe is quite detailed in many ways:

 "…a day in a primary care office would begin with a team huddle….The team would discuss the day's patients and their concerns. They would review quality metrics, emphasize their quality-improvement cycle for the week, and celebrate the team's progress in caring for its community of patients…The RN would manage his or her own panel of patients with stable chronic disease, calling them with personal reminders and using physician-directed protocols…The social worker, nutritionist, and behavioral therapist would work with the physician to address the layers of complexity involved in keeping patients healthy. Clinic visits would ideally be nearly twice as long as they are now…"

It sounds great. As the authors note, there are practices that are working toward, and in some cases have begun to achieve this "new model" of care; these 3 did not originate these ideas. Practitioners and thinkers such as Tom Bodenheimer, Joe Scherger, Bob Phillips, and Kevin Grumbach have written about this, and many practices, particularly integrated groups such as Kaiser Permanente, Inter-Mountain Health Care, and Geisinger Clinic have implemented many of these characteristics. But will it be the future of all health care? Will, importantly, these changes – or ones like them – both provide the functionality that the health system needs from primary care and the physicians entering into this practice?

In many articles, including Transforming primary care: from past practice to the practice of the future [2], Bodenheimer has emphasized the need for teams from a practical standpoint – there are more people needing care and not enough primary care physicians to provide it. Phillips ("O Brother Where Art Thou: An Odyssey for Generalism", presented at the Society of Teachers of Family Medicine Annual Conference in May, 2011) shows data indicating that even including "mid-level providers" such as advanced practice nurses and physician's assistants there are way too few primary care providers, and the trajectory of production is in the wrong direction. Our own data[3] show the marked decrease in the number of medical students entering family medicine (and other primary care specialties) in the last dozen years. So it is profoundly to be hoped that the model of care described by these authors develops, that they are able to develop it, and that it will attract more future physicians.

While practice change is hard, and culture change is harder, there are issues that these authors talk about but do not seem to overly worry them. They note the importance of the Affordable Care Act, and how it "…emphasizes population health and primary care services, and establishes accountable care organizations that require strong primary care foundations," but do not, in my opinion, adequately address two key challenges to implementation that will present profound obstacles to the achievement of their vision.

The first is payment, reimbursement, allocation of health care dollars. They assume that, "…thanks to a restructured reimbursement system," medical assistants will "…have protected time to provide health coaching for behavior change and to ensure that the patients on their panel were current with their preventive care." Because reimbursement would be "…through global payments linking hospitals to primary care practices, the physician, too, would have a financial incentive to keep patients healthy…."  It is a great model, and one that I agree with, but it hasn't happened in most places. Because it is more costly and requires significant investment in prevention and primary care, and since there are unlikely to be additional dollars in the health system, it will mean lower reimbursement for hospitalizations, for procedures, and for the specialists who are the currently the most highly paid. This, I would argue, would not be a bad thing, but it will not happen easily. Those who are doing well under the current system are going to fight to hold on to it, and the reimbursement structure is not changing quickly enough to push such change outside of integrated health systems – and even within many of them.

The second is what can be summarized as the "social determinants of health". Good public health students, they observe that "…the health care system must strive to affect more than the 10% of premature mortality that is influenced by medical treatment," and note correctly that "Primary care cannot be primary without the recognition that it is communities that experience health and sickness. Providing better health care is imperative but insufficient." 

This is true, but there is more to it. Health care, in itself, even well-organized with adequate numbers of primary care practices working in teams, and collaborating with public health workers, and going out into the community, and employing culturally-competent health navigators/guides/case managers/promotoras, is not going to do it alone. The social determinants of health have to be addressed by the entire society.

Poverty, unstable housing, food insecurity, cold, and the social threats that often accompany the communities in which they are prevalent (violence, drug use, abuse, etc.) will continue to create situations in which people are not healthy and need medical care. Even in the larger society, in the part where people are not living at the edge, there are many anti-health forces; stress (including the stress of working harder and at more jobs to keep away from the edge), the ubiquity and ease of access of poor quality, high-calorie food, and the shredding of the social safety net that is almost gone for at the bottom and fraying at the sides (Social Security, Medicare), are not harbingers of a happier, healthier society.

I am thrilled about the enthusiasm of these young physicians and physicians-to-be, and their commitment to primary care and a new kind of practice. They begin by observing, echoing Bob Dylan from 50 years ago, and more important the movement that was growing then, that "times are changing", but I fear we are not yet clear what that change will be; there is tremendous energy – and even more money – behind a change that will be for the worse for everyone except the most privileged.

They end by saying that "We are here to engage in and advance the movement." They are talking about transforming primary care, but I hope that they and their colleagues recognize that it will not be enough unless they are willing to engage in and advance the movement to transform society.

*In full disclosure, one of the authors, Branden Comfort, is a student at the KU School of Medicine. Although he has spent his clinical years at our Wichita campus, I know him well because we worked together in the student run free clinic (and he was my advisee) in his first two years here in Kansas City.

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[1] Barnes KA, Kroening-Roche JC, Comfort BW, "The developing vision of primary care", NEJM Sept 6, 2012;367(10):891-4.

[2] Margolius D, Bodenheimer T, Transforming primary care: from past practice to the practice of the future, Health Aff (Millwood). 2010 May;29(5):779-84.

[3] Freeman J, Delzell J, ""Medical School Graduates Entering Family Medicine: Increasing The Overall Number", Family Medicine, October 2012, in press.

Research basic and applied: we need them both

 “Not every mystery has to be solved, and not every problem has to be addressed. That’s hard to get your brain around.”

This statement was the coda of a very good article, “Overtreatment is taking a harmful toll”, by Tara Parker-Pope, in the NY Times, August 28, 2012. The topic of the article, and the implication by the speaker, who was talking about her own family’s health care and unnecessary testing, is one that I have written about several times recently, in terms of both screening tests (“The "Annual Physical": Screening, equity, and evidence”, July 4, 2012) and investigation and treatment of disease (“Rationing, Waste, and Useless Interventions”, June 21, 2012). Thus, I certainly agree that there is too much testing and too much intervention, and that it has a high cost in both dollars and in potential risk to people (the English word for what the health system calls “patients”). So why do I feel a little uncomfortable with the quotation above?

I think it is because I very strongly believe that the decision on what tests to do and what interventions to take should be informed, as much as possible by the evidence. That evidence, I have also argued, should come from research, from well-designed studies, from science. This is also costly, but it is necessary. Your treatment should be based on evidence and probability gathered from studies of large populations. Without it, doctors and other health professionals are flying blind, with treatments based on their own experience, or worse yet “what makes sense”. Sometimes the doctor’s own experience is a good guide, if they see a lot of patients with the same problem, and have reason to know what works. It is even better when they can bring in knowledge of the local community (e.g., what antibiotics are common bugs resistant to here? What are the common belief systems of the people that I care for?) and better yet if they actually know you, and what you value, and what your medical history is, and what your belief system is, and what is most likely to engage your effort in the interest of your health.

But it is better if the set of options from which they choose are all based in evidence. That something makes sense, I have often pointed out to medical students and residents, makes it a research question, not an answer. If something makes sense, based on what we already know, it is likely to be a more valuable thing to study than something that does not make sense. However, until the study, or more likely several studies, are done we won’t know if it is, in fact, true. Human beings, both in terms of their biology and behavior, are too complex, and have too many different systems interacting with each other, to predict accurately how something that “makes sense” based on one of those dimensions is likely to turn out.

The thing is that not all research is immediately clinically relevant. Sometimes it is; the “Ottawa rules”, developed by research done in Canada, provide physicians with evidence based guidelines about when it is appropriate to do x-rays for injured ankles, knees, and feet – common problems. Other studies investigate whether particular drugs may provide real benefit to people with more uncommon problems. This is particularly satisfying when the drug is not some new, expensive blockbuster but something cheap and common like aspirin or folic acid. Or when an old drug, all but abandoned for its original purpose, turns out to be very effective for another condition entirely. (One of my colleagues just demonstrated this for an old heart drug that works for a rare neuromuscular condition – coming soon to your local JAMA!) But much research is at a very basic level. Before those drugs can be tested on particular conditions, they have to be developed. Before they can be developed, the biological and biochemical mechanisms upon which they have an effect have to be identified. Just as, before we can send rockets to the moon, we need to understand physics. Science, what in medicine we call “basic science”, has to continually move forward, and this requires not solely focusing on what might be of practical use tomorrow, but what is still a mystery that has to be solved.

I find it almost ironic that I am writing this defense of basic science research. Just recently, I was in NYC and went to brunch at the riverpark restaurant. On the block leading to it is a big vegetable gardens where they grow many of their own ingredients, much of it surrounded by a big wooden fence. And, since it is right there at Bellevue Hospital and NYU Medical Center and Rockefeller University, that fence is decorated with pictures and biographies of Nobel Prize winners in Medicine who had ties to NYC. My reaction was that all of these people (even if they had MD degrees) were doing laboratory, basic science research, not clinical research, even though the prize is for “Medicine”. Of course, having won Nobel Prizes, their research led to important practical breakthroughs, but for every Nobel Prize winner who discovers something that will make a major difference in health, there are thousands and thousands of others, working in laboratories everywhere, and this work is necessary.

Personally, I don’t think it is necessarily necessary that it  be done in medical schools, whether NYU or the University of Kansas, rather than in research institutes like Rockefeller or Kansas City’s Stowers Institute (or Karolinska in Sweden or the Pasteur Institute in France). I find, as a family doctor, that the fact that much basic research in human biology is done at medical schools leads to what I think are negative “side effects”. I believe that there is an over-emphasis on teaching medical students biological sciences in great detail (often at the level of minutia) and an under-emphasis on the social sciences. I think that these areas are just as important – maybe more important for the practicing physician -- but are usually not considered as “core” to medical student teaching.

In part this is because those working in the social sciences are most often “there”, at the main campus, not “here”, at the medical school. I am proud that the research conducted by faculty in my department is mostly community-based, looking at determinants of health and health disparities. But, whether biomedical research should be as important a part of medical schools as it usually is, or not, it is absolutely clear that it needs to occur, and that scientists need to solve mysteries.

Every mystery? Well, of course, that will never happen. And even for the ones they solve, the results are not always beneficial for folks. We can map the human genome! We can tell you if you and your family members are at increased risk for a terrible disease! Of course, often we cannot do anything about it, but it can make you depressed and pessimistic, and maybe you’ll lose your health insurance. So maybe we don’t need to tell your insurer, or even tell you, but getting to be able to do something about it first requires doing the science.

And of course there is a big difference between uncovering the mysteries of the universe, and even of finding evidence for what is appropriate diagnosis and treatment in populations, and in having to investigate everything in you. The father of another person quoted in the article developed delirium from overtreatment with drugs that was mistaken for dementia. “I don’t know if we have too many specialists and every one is trying to practice their specialty, but it should not have happened.” I agree; too many mistakes, too many errors (see Medical errors: to err may be human, but we need systems to decrease them, August 10, 2012) can come from there being too many specialists combined with too little communication.

The quote at the top of this piece notes that not everything has to be addressed and that this is hard to wrap your brain around, but it shouldn’t be.  All that research in the basic and clinical sciences should help us to understand when we need to investigate (do a CT scan for a black eye, in another example from the article, say) and when we don’t.

Often we should leave well enough alone.