Social Justice: Economic Stimulus and Bailout

As the Congress considers President Obama's economic stimulus package, it is distressing, if not surprising, to hear Republican leaders such as Mitch McConnell of Kentucky decry that there is too much going to spending and not enough to tax cuts. Has he, have they, learned nothing? Trickle down doesn't work. Tax cuts for the wealthy don't work to stimulate the economy (though I suppose they are good for the wealthy!) Tax cuts for lower income people, endorsed by the President, are not likely to be enough to get them out of the hole that they are in. The first $350B in "bailout" funds was not spent where it was needed -- to help working people pay or re-negotiate their mortgages, prevent bankruptcy from medical bills, and tide them through being laid off. Rather, it was given to banks and other financial institutions who hoarded it, gave it away to themselves, and paid dividends to shareholders, but didn't loan money to consumers. McConnell and friends are either stupid, crazy or evil. In any case, no matter what they say, it would be a terrible mistake for the President to let them in any way derail the plans to "bail out" the rest of us. The remainder of the financial bailout needs to go to help regular folks stay in their homes. The huge economic stimulus package needs to be passed, and to focus on how regular folks can get jobs, housing, health care, and other necessities. Spend in ways targeted to fix the problems, and tax rebates are not the way to do so.

The "no tax / balanced budget" fixation has led most states, unlike the federal government unable to print money, to be in a desperate situation. Not learning from Joseph in Egypt, who saved some of the crop from the seven years of plenty to tide people through the seven years of drought, they have in most states had two modes: tax cuts in times of plenty and budget cuts in times of shortfall. Now that most of them have the biggest shortfalls ever, the budget cuts will go way past the fat into the muscle and bone stripping the ability of many states to provide the most basic services.

President Obama rescinds Global Gag Rule

Sometimes there is really something to celebrate. As one of the first official acts of his administration, along with announcing the planned closure of the detention center at Guantanamo Bay, President Obama has rescinded the "global gag rule" (see posting of January 11, 2009). This evil and invidious rule, which limited crucial reproductive health funding to agencies and governments all over the world, is now history!

Congratulations and thank you, President Obama!

The "Neurontin Legacy"

The January 8, 2009 issue of the New England Journal of Medicine includes an article by Landefeld and Steinman called “The Neurontin legacy – marketing through misinformation and manipulation”[1] that should be required reading for every physician, medical student, and hospital or health facility administrator, not to mention students of, and those involved in implementing, health policy. Neurontin, the brand name for the drug gabapentin, was approved by the FDA only for adjunctive (meaning “in addition to first-line drugs”) treatment of epilepsy, but was heavily (and illegally) marketed by the manufacturer (Parke-Davis, a division of Warner-Lambert, purchased by Pfizer in 2000) for a variety of other indications including first-line treatment of epilepsy and, more importantly, pain relief, especially “neuropathic” pain – pain that arises from problems in the nerves themselves, commonly in people with diabetes.

The article notes that in May, 2004, “Warner-Lambert agreed to plead guilty and to pay more than $430 million to resolve criminal charges and civil liabilities. A class-action suit was filed the next day in federal court on behalf of private parties who had paid for illegally marketed Neurontin.” This is an extraordinary settlement, and quite appropriate given the fantastic series of marketing “tactics” that “…included education, publications, and research whose promotional intent was disguised, in addition to more transparent activities, such as advertising and sales visits.” It is illegal to market for non-FDA-approved indications, but Parke-Davis did it both incredibly aggressively and effectively, with Neurontin’s sales rising from $98 million in 1995 to nearly $3 billion in 2004. The company commissioned “research” to show the drug’s effectiveness, suppressed publication of studies that showed it had no effect on neuropathic pain, and in the words of epidemiologist Kay Dickersin, who performed a “recently unsealed 318-page analysis of research sponsored by Parke-Davis…concluded that available documents demonstrate ‘a remarkable assemblage of evidence of reporting biases that amount to outright deception of the biomedical community, and suppression of the scientific truth…’” It is worthy of note that the exposure of the Neurontin affair was the result of the efforts, almost worthy of being called heroism, of a young biologist who named David Franklin who worked for Parke-Davis.

What is the importance of this scandal? Is it that thousands of people were treated with a drug that was neither FDA approved for the indications for which it was being promoted, and may have been ineffective? Perhaps, although there are many physicians who would continue to argue that, at least in their anecdotal experience, gabapentin is effective for neuropathic pain. Or is it that pharmaceutical companies use aggressive and unethical, bordering upon and sometimes crossing the line into illegal, tactics to promote the use of their products and thus the enormous profits that accrue? Perhaps, but anyone who did not know this has long been deceiving themselves. The pharmaceutical industry has been for many years either the #1 or #1 most profitable industry in the US. The $430 million fine, while significant, is a small part of the profits that Parke-Davis/Warner-Lambert/Pfizer made through the off-label use of the drug. Is it that the court cases involving Neurontin involved the release of enormous numbers of papers (including the Dickersin report mentioned above, as well as internal company documents) that clearly demonstrate the invidious nature of pharmaceutical company promotion? If anyone needed more evidence, it is there. “Promotion,” write Landefeld and Steinman, “was neither discrete, compartmentalized, nor readily apparent; instead, it was intercalated in nearly every aspect of physicians’ professional lives, from the accoutrements of practice to lectures, professional meetings, and publications. Although some pharmaceutical marketing may be less opaque, deceptive and manipulative, evidence indicates that drug promotion can corrupt the science, teaching and practice of medicine.”

If David Franklin is the hero in this episode, the villains, in this particular case and overall in drug marketing, are the pharmaceutical companies who are willing to use any tactics to increase their enormous profits. The victims are clearly the patients who paid more for drugs that may have been ineffective, or no more effective than less expensive drugs (and, from their perspective in their class-action suit, the insurers who paid for these drugs). The facilitators, however, are the physicians who were too willing to take their information (as well as gifts, sometimes small, sometimes large) from pharmaceutical company representatives), rather than more reputable sources, and not pay attention to the principles of conservative prescribing (rule #1: use the drugs that we know are safe and work, be cautious of new “miracle drugs”). They are also certainly medical organizations, the paid physician flaks who gave the talks, and even the medical journals that uncritically published some of the company written studies. They are also, however, sometimes the patients themselves, living in a culture of NEW! BETTER! IMPROVED!, of Technology over All, who frequently beseech their physicians for something new, more effective, especially with regard to pain relief.

We have met the enemy, and it is them. But, in the words of the immortal Pogo (Walt Kelly) it is also us. If they did before (and a frightening number did!) no physician should now have any business trusting pharmaceutical companies to be completely honest, nor believe that they owe use of new drugs to the “nice men and women” who are the drug reps, nor that drug samples (always, only the newest, most expensive drugs, never the old “standbys” or certainly anything available generically) are “free”, nor most of all believe that they are not affected by advertising and gifts. All physicians and students should read not only this piece but the classic “A Social Science Perspective on Gifts to Physicians from Industry”[2] to understand the sublimal efficacy of these tactics. And patients (the medical word for “people”) need to recognize this too, and demand not “new”, but “best”, defined as well-established, effective, and safe.

[1] Landefeld CS and Steinman MA, “The Neurontin legacy – marketing through misinformation and manipulation, NEJM Jan 8, 2009; 360(2):103-05
[2] Dana J, Loewenstein G, “A social science perspective on gifts to physicians from industry”, JAMA July 9, 2003;290(2):252-5.

Martin Luther King, Jr. Day and the Inauguration

In celebration of Martin Luther King, Jr.’s birthday, more than 40 years after his assassination, let us struggle even harder for the values that we share with him. For peace: in Iraq, in Gaza, in Afghanistan, in the Sudan and all the lesser-known conflicts, for an end to hunger, in Zimbabwe and all over the work, an end to oppression, poverty, HIV/AIDs, lack of opportunity, lack of education. Let continue to donate our time and our dollars, but remember his statement that “Philanthropy is commendable, but it must not cause the philanthropist to overlook the circumstances of economic injustice which make philanthropy necessary,” and always continue to fight injustice in all of its forms.

And tomorrow, as Barack Obama, our first African-American President, takes the oath of office, let us hold that as a sign of hope for all of us for the future.

Ten Biggest Myths Regarding Primary Care in the Future

Introduction: This article is by Robert Bowman, MD, of the AT Still College of Osteopathic Medicine in Mesa, AZ. Dr. Bowman is a long time scholar of primary care and rural health workforce issues. He identifies and comments upon 2 important workforce concepts. The first is “primary care forms” of training, which include 3 physician forms (family medicine, general internal medicine, and general pediatrics), and primary care nurse practitioners and physician’s assistants. The second is the Standard Primary Care (SPC) year, which allows us to look at the success of the different “forms” in terms of how many SPC years they provide per graduate. This takes into account the percentage of graduates who enter primary care, the portion of their practice that is primary care, at what rate they leave primary care for another area, the number of years they practice, and the percent time (part time/full time) they practice. Thus if a form of training has 100% of graduates entering primary care who practice full-time for an average of 35 years with 100% primary care practice, that form would produce 35 SPC years per graduate. If another form had only 50% of its graduates entering primary care, who averaged 50% primary care practice, practiced for an average of 20 years with an average of 75% FTE, that form would produce an average of only 3.75 SPC years per graduate (do the arithmetic: 20 years x 75% FTE x 50% of grads in primary care x 50% of practice is primary care). This is important in comparing projections – one can’t just say, for example “nurse practitioners will take care of our primary care needs” without doing such a calculation.

• Myth Number 1: Primary Care has collapsed. Primary care internal medicine has collapsed with lowest production and lowest primary care retention levels. Those associated with internal medicine primary care perceive collapse. But primary care remains. Existing dedicated primary care practitioners continue to deliver primary care despite insufficient support. There are 5 training sources of primary care. Some are remaining steady and some are dropping. The ideal primary care provider would contribute 35 Standard Primary Care (SPC) years: a 35 years career, actively in practice 100% of those years, and 100% remaining in primary care and 100% or top volume of primary care. Among the 5 forms of primary care training, family medicine remains steady in primary care with over 25 Standard Primary Care (SPC) years per graduate. Pediatrics is also steady, but with only 16 SPC years per graduate. The other 3 forms have more graduates who are inactive or part-time, have fewer years in a career, retain a lower percent of graduates in primary care (retention), and have a lower volume of primary care. They thus make limited contributions with fewer SPC years per graduate. Internal medicine, nurse practitioner, and physician assistant forms have declined to less than 4 SPC years per program graduate. Collapse of primary care is found for forms that depart primary care during training, at graduation, and each year after graduation under the assault of poor primary care support. [1]
  
  
• Myth Number 2: Nurse practitioners will take over more primary care duties. Nurse practitioners will continue to supply less than 12% of the primary care supplied by the five primary care training forms using past measures as well as future estimates.[1, 2] Increasing departures to hospital and specialty careers, lowest activity (inactive, part time), lowest volume of primary care, and greatest delays in entering primary care limit nurse practitioner primary care contributions.
  

• Myth Number 3: Physician assistants will take over more primary care duties. Less than 30% of new physician assistants enter primary care and active physician assistants will dip below this level in the next 3 years.[3] Physician assistants will continue to supply less than 12% of the primary care supplied by the five training forms. Increasing departures to emergency medicine and subspecialty careers, lower activity (inactive, part time), and lower volume of primary care limit physician assistant primary care contributions.
  
  Only if physician assistants or nurse practitioners were required to stay in the family practice mode of care would they be able to increase share of primary care, rural primary care, and underserved primary care duties.
  

• Myth Number 4: Internal medicine graduates from international medical schools will make significant primary care contributions. Internal medicine residency program graduates from foreign origins and international medical schools will contribute the fewest years of primary care averaging 1.3 SPC years per graduate. The limitations are substantial with lowest primary care retention after graduation, loss of 8 years due to delayed entry into the United States workforce, and losses after graduation including 20% departing the United States for home nations, 8% chronic unemployment, and increasing fractions departing for other nations.[4, 5] Lowest primary care also means lowest rural primary care and underserved primary care. A family practice residency graduate contributes greater than 30 times the rural or underserved primary care per graduate. Changes in the J-1 Visa waiver program and increasing uses of international graduates by the military and teaching hospitals will further limit primary care, rural, and underserved contributions.
  

• Myth Number 5: The United States is unable to produce enough primary care. Through policy, medical education efforts, and statewide efforts, the US has been consistently successful. The US was able to quadruple primary care graduates in the 1970s. The US increased primary care production 50% during the span of a few years in the 1990s. Historically Black, osteopathic, and many allopathic public schools have been successful for over 100 years. Primary care contributions are maximized when schools and states focus together on health access in birth to admission preparation, admission preferences, training curricula/faculty/locations, and health policy.[6]
  
  To sum up: the only way that the United States can fail to produce primary care is to admit the most exclusive students (lowest probability primary care), train in locations with the least health access emphasis (lowest influence), fail to graduate enough family physicians (permanent form), and create a health policy that rewards the most exclusive careers and locations. This, of course, is exactly how US health care is structured.

• Myth Number 6: Generic expansions of medical school, nurse practitioner, or physician assistant graduates can increase primary care. During the current time period with the worst health access policy in decades, fewer students are choosing primary care and those that can move away from primary care are leaving. Osteopathic (DO) graduates will more than double from 2004 to 2017 but, with the current steady declines in family practice percentages, the end result will be only a gain of 100 more family physicians or a 20% increase despite a 100% increase in graduates. With primary care retention rates dropping steadily at 1 or 2 percentage points each year in the large and growing nurse practitioner and physician assistant pools (over 230,000 combined), new graduates entering the workforce in primary care are not able to keep up with losses of active primary care plus departures from active practice. Only specific expansions of family practitioners that remain in the family practice mode (physicians, nurse practitioners, and physician assistants) can address primary care and health access needs. Retention in the family practice mode is much less likely for NPs and PAs since they can and do depart the family practice mode at any time.
  

• Myth Number 7: Nurse practitioners make substantial rural primary care contributions. Rural primary care requires both rural location and primary care contributions. While 20-25% of nurse practitioners are rural, they do not have the primary care component. Nurse practitioners contribute 1 rural Standard Primary Care year per graduate (4 SPC years times 25% rural) in rural workforce whereas family physicians contribute 5 Standard Primary Care years per graduate (25 SPC years x 20%) in rural locations.
  

• Myth Number 8: Primary care is not marketable to the American consumer.[2, 7, 8] It is very hard to understand how respected authorities in leadership positions could make such statements. Only a severe lack of awareness explains their comments. Workforce experts, trainers and educators in major medical centers and medical schools, leaders in the Council of Graduate Medical Education and the Association of American Medical Colleges all live in areas with the highest concentrations of people, physicians, and medical schools. These experts have spent their entire lives in locations that employ the fewest primary care physicians and support primary care at the lowest levels. They have tolerated the training of medical students and residents in dysfunctional primary care settings.[9] It is not surprising that primary care does not appear marketable to those clustered in the 3,300 US zip codes which make up 4% of the land area with 75% of physicians and 95% of medical schools. This limited perspective ignores the 38,000 zip codes in which 65% of the American population and 70% of the elderly are cared for by the remaining 23% of total physicians. In these locations, 30 – 100% of the total physicians are primary care physicians.
  
  The total elimination of health care for millions is unconscionable and this is what is suggested by the statement that primary care is not marketable. The locations that depend upon primary care are also locations that offer better primary care salaries, better primary care support, better practice options to generate more revenue, lower costs of delivering health care, and lower costs of living. Those designing health care for an entire nation must place much more emphasis on care for the 65% of the population left out of the current health care design. All of medicine and medical education will pay dearly for the choices of a few leaders. Current leaders appear to have abandoned Butler’s call to a season of accountability and social responsibility for medical education.[10 ]
  

• Myth Number 9: The nation needs more pediatric graduates to meet primary care needs. More pediatric graduates will not meet primary care needs. According to pediatric leadership, pediatric primary care is saturated in the locations where pediatricians choose to locate, at the same time that the United States has fewer children. Even though 15% of white female medical students remain committed to pediatric residency choices, they and other pediatric graduates will compete with all other primary care graduates already delivering pediatric primary care. This is likely to result in more practicing in part time, specialty, hospital, urgent, and emergent pediatric care settings.[11]

• Myth Number 10: Care for Age 65 and Up Will Be Provided By Geriatric Specialists. Geriatricians are a small fraction of new physicians, they are less likely to be found in locations with concentrations of older Americans, they have limited support, they have lower volume of patients, and they have some of the most complex patients. Older patients move toward locations with lower costs of living and health care and they move away from concentrations of internal medicine physicians, geriatricians, geriatric training programs, stroke centers, and heart attack centers.[12] They move steadily toward locations served predominantly by family physicians.
  
  National studies confirm patterns of care for the elderly and for all seeking ambulatory care in the United States in 2004. About 62.5% of age 65 and older patients saw a family physician compared to internists for 29%, and somewhat less than 19% seeing a nurse practitioner.[2] This is not what numbers of graduates predict since both internal medicine graduates and nurse practitioner graduates are about twice the number of family practice graduates. In 2004 family physicians led in all but one ambulatory category. In addition to seniors, family physicians were seen by 43.4% of adults seeking care, and 39% seeking women’s health care. The family physician share of 20% was second to pediatricians although family physician percentages increased for children over age 4 and for the 65% of the population beyond concentrations of pediatricians.[2] This is why increased family physicians can address pediatric care needs while more pediatricians cannot.
  
  

Myths persist unless they are compared to reality. Primary care must be measured according to a standard and the standard is set by forms of primary care training that produce providers who remain for 35 years of a career, who continue to provide primary care, who remain in the wide range of most needed locations, who continue to serve the populations most in need of care, and who continue to do so whether the current “policy era” is supportive or unsupportive of primary care. For physicians, nurse practitioners, and physician assistants, the standard is set by those that remain in the mode of care known as family practice.

1. Bowman RC. Measuring Primary Care: The Standard Primary Care Year. Rural Remote Health. Jul-Sep 2008;8(3).
2. Ferrer RL. Pursuing equity: contact with primary care and specialist clinicians by demographics, insurance, and health status. Ann Fam Med. Nov-Dec 2007;5(6):492-502.
3. American Academy of Physician Assistants. Data and Statistics. http://www.aapa.org/research/index.html. Accessed October 26, 2006, 2006.
4. International Medical Graduate Section of the American Medical Association. Report on International Medical Graduates. Chicago 2007.
5. Quick Views. J-1 Waivers on the Decline. amednews.com. January 22, 2007.
6. Bruce TA, W.R. N. Improving Rural Health. Little Rock, Arkansas: Rose Publishing Company; 1984.
7. Philibert I. An interview with Carl Getto, MD. ACGME Bulletin. 2004;Spring:10-11.
8. Salsberg E. Physician Workforce Policy Guidelines for the U.S. for 2000–2020. Presented to the Council on Graduate Medical Education. Bethesda, MD. September 17–18, 2003.
9. Keirns CC, Bosk CL. Perspective: the unintended consequences of training residents in dysfunctional outpatient settings. Acad Med. May 2008;83(5):498-502.
10. Butler WT. Academic medicine's season of accountability and social responsibility. Acad Med. Feb 1992;67(2):68-73.
11. Committee on Pediatric Workforce. Pediatrician workforce statement. Pediatrics. Jul 2005;116(1):263-269.
12. Perrotta BL, Perrotta AL. Access to state-of-the-art healthcare: a missing dynamic in consumer selection of a retirement community. J Am Osteopath Assoc. Jun 2008;108(6):297-305.

Mr. Bush’s Legacy: The Global Gag Rule

The New York Times, Jan 3, 2009, has an editorial entitled “Mr. Bush’s Health Care Legacy.” Acknowledging that “This page has criticized the Bush administration’s weak performance on many important health care matters: its failure to address the problem of millions of uninsured Americans or stem the rising costs of health care, its refusal to expand eligibility for the State Children’s Health Insurance Program, its devious maneuvers to cut Medicaid spending, its support of unjustified subsidies for private health plans, to name a few,” the editorial goes on to laud his “achievements in health care”. The editorial names his work on proposing funds (increased by Congress to $50 billion over 5 years) to fight AIDS, tuberculosis and malaria worldwide and his pushing the Medicare drug-benefit program, Medicare Part “D”, despite their disagreement with “many features of the program – the refusal to allow the government to negotiate with manufacturers for lower prices, shortfalls in providing subsidies to low-income Americans, a failure to protect many patients from high out-of-pocket costs.”

I am willing to credit anyone, even George W. Bush, for anything that they do that is good, and I am willing to acknowledge that funding for fighting these terrible diseases and to help older Americans obtain prescription drugs are important. I will not add to the Times’ list of flaws in Medicare Part “D”, though they are very serious and could be expanded upon. I will point out that the current funding for fighting AIDS, TB, and malaria comes with strings attached, but it is also a very good thing. I do, however, want to focus on a particularly vile part of Bush administration policy that has had very destructive effects worldwide, the Global Gag Rule (“Mexico City Policy”) preventing any agency using any of its funds from any source to do – or counsel about – abortion from getting any family planning funds from the US Agency for International Development (USAID).

You may remember an effort by the Bush administration to impose such a "gag rule” domestically, that was thankfully unsuccessful. However, this policy has been in placed for international aid through all Republican presidencies since it was announced at the Mexico City Conference of the United Nations International Conference on Population by Alan Keyes of the Reagan administration in 1984. It was repealed by executive order by President Clinton in 1993, and reinstated by President Bush in 2001. Its effect has been devastating in the developing world, particularly in Africa and Asia, where local organizations have had to decide between losing significant portions of their funding (the International Planned Parenthood Foundation lost 20% of its funding) or not performing critically important family planning services to their clients. The impact of this rule are detailed at the website www.globalgagrule.org. “The Global Gag Rule Impact Project is a collaborative research effort led by Population Action International in partnership with Ipas and Planned Parenthood Federation of America and with assistance in gathering the evidence of impact in the field from EngenderHealth and Pathfinder International. The Project’s objective is to document the consequences of the Global Gag Rule. The Project was initiated soon after the policy was reinstated by President George W. Bush in January 2001. While the missions of the collaborating organizations are diverse, we are united in our belief that policies governing U.S. assistance should be evidence-based and reflect proven public health practices.” Since much of the concern about AIDS revolves around sex, this restriction impacts much of the vaunted AIDS funding also.

Since there are many who support this rule because they are opposed to abortion, it is critical that the data supplied by those at www.globalgagrule.org and others, such as that of physician Isaiah Ndong, on the blog RH Reality Check (http://www.rhrealitycheck.org/blog/2008/12/22/the-time-lift-global-gag-rule-is-now) are so important. These rules restrict information, about sex, safe sex, contraception, and, yes abortion. The result of the restriction of such information is that there is just as much (perhaps more) sex, more unsafe sex, less contraception – and no less, perhaps more, abortion. But the abortions are more unsafe, especially in countries in which, often influenced by the US, it is illegal. This is true not only in the Third World, but in the US and Europe – restricting access to abortion, and making it illegal does not make women have fewer abortions, it makes them have less safe abortions, and makes more of them die. This may not be what abortion opponents want to happen, but it is what does happen. And when funds are stripped for educational programs, again in the US as well as in the Third World, young people do not have less sex, but they have less-safe sex, and are more likely to contract and transmit STIs, including HIV. And they have more abortions.

The USAID funds available for HIV/AIDS, lauded by the Times, are also tied to “abstinence only” educational programs, similar to those supported domestically by the Bush administration. These programs, which hope to decrease STIs including HIV, and unwanted pregnancy (and thus, presumably, abortion) by teaching ONLY abstinence, are abysmal failures in every venue. Teaching abstinence as one, perhaps the best, method of not getting pregnant or sick, is a good idea; teaching only abstinence is cynical and disastrous. Other wishful-thinking-with-terrible-results ideas include “virginity pledges”; another study was just published describing its failure (from the abstract, bold mine): “Five years after the pledge, 82% of pledgers denied having ever pledged. Pledgers and matched nonpledgers did not differ in premarital sex, sexually transmitted diseases, and anal and oral sex variables. Pledgers had 0.1 fewer past-year partners but did not differ in lifetime sexual partners and age of first sex. Fewer pledgers than matched nonpledgers used birth control and condoms in the past year and birth control at last sex.” [i] A recent publication in the US demonstrates that People – including young people – will have sex, and will get pregnant, and will often seek abortions. There are only two things that have ever helped to decrease this are 1) comprehensive and accurate sex education, which at best empowers young people to only have sex when they want to and are ready, or at least provides them with the information to protect themselves, and 2) freely available safe abortion, so women do not die of septic abortion.

Finally, the ultimate irony. The factor most associated with economic and social development in a country is the educational level of its women. In many third-world countries women struggle against enormous barriers to achieve education. Unfortunately, it is often costly and often the only avenue open to earning money is prostitution. So our policies, rather than encouraging and supporting education of girls and women, make it likely that, should they get pregnant, they will either have to end their education, or risk their life having an unsafe abortion, or get HIV. Or all of them.

We can do better. We must do better.
[i] Rosenbaum JE, “Patient teenagers? A comparison of the sexual behavior of virginity pledgers and matched nonpledgers”, Pediatrics. 2009 Jan;123(1):e110-20.

Sanjay Gupta for Surgeon General?

I feel compelled to post this message from Physicians for a National Health Program.
Goodness gracious! A health reporter? With the recycling of so many questionable-to-bad Clintonites, why not take the best -- David Satcher?

"The report this week that President-elect Obama is considering Dr. Sanjay Gupta, CNN's chief medical correspondent, for the position of U.S. surgeon general is deeply troubling.
Among our concerns are these:
He has very little background in public health, preventive medicine or administration.
He has openly opposed progressive health reform, going so far as to cite false information to denigrate single payer (e.g. in his error-laden attack on Michael Moore's film "Sicko") and parroting the health insurance lobby's distortions of single payer.
As a media figure, he has been disturbingly cozy with Big Pharma. He co-hosts Turner Private Networks' monthly show "Accent Health," which airs in doctors' offices around the country and which serves as a major conduit for targeted ads from the drug companies. Another example: In 2003, despite mounting evidence to the contrary, he publicly downplayed concerns about the dangers of Vioxx. It was removed from the market a year later by its manufacturer, Merck.
In the 2008 election campaign, his reporting on John McCain's health proposals was misleading and implicitly positive, giving undeserved credence to McCain's claims that buying private health insurance on the open market is a financially viable option for most Americans.
We urge you to write to President-elect Obama and express your opposition to Gupta's possible nomination, and to urge Obama to nominate a more acceptable candidate for this critically important post. You can do so by clicking here: http://salsa.democracyinaction.org/dia/track.jsp?v=2&c=VQcr%2B9YPm7HVdjzAicv%2FgKcrNJ24hBg4."

Enthoven: Consumer Choice Health Plan -- Again

An Op-Ed in the New York Times of December 28, 2008 by Alain Enthoven, Professor of Management at Stanford, brought back memories of his “Consumer Choice Health Plan” published in the New England Journal of Medicine in 1978[1] and brought back in 1989.[2] In this current piece, Prof. Enthoven cites a plethora of problems with the health system that are not likely to be addressed by the current Obama health plan. These include having ”…a health care system that regularly rewards waste and punishes efficiency…”, that we are weak on and do not reimburse for preventive services, and a fragmented, unintegrated system of care. He also notes the cost to the federal budget of more than $1 trillion, citing not only the direct costs (Medicare, Medicaid, federal employee benefits, military, VA) but ”…the cost of excluding employer health contributions from workers’ taxable incomes”. Woolhandler and Himmelstein have demonstrated in a number of studies (extensive references) that this amount, plus the amount spent by states and local governments, is not only nearly 60% of US healthcare spending, but exceeds the amounts spent per capita by all other countries. (Thus, they note, we are paying for a national health system, but not getting it!)[3]

Unfortunately, Enthoven’s solution is to bring back out his same plan. There is nothing wrong with having the same ideas in 2008 as in 1978 and 1989 – single payer, for example, was a good idea at those times and remains so. The problem is that the Consumer Choice Health Plan was a bad idea then and remains so. It advocates efficiency, large group practices, physicians working for salary instead of fee-for-service, preventive care and cost-conscious behavior. However, it seeks to achieve it by a complex system based, essentially, on making patients pay for a larger percent of their health insurance premiums, which will incent them to insist on cost-effective, efficient practices. This concept is heavily based on the idea that it is the doctors’ fault that the system is bad. In talking about the “85 percent of doctors [who] work in small, fee-for-service practices, he is willing to admit that “Many of these doctors are very good and hard-working.” Not even “most”. But they are also “…unable and unwilling to be held accountable for the quality and cost of the care they deliver.” Unable perhaps; the system does not encourage this, and frequently does not make it possible, but “unwilling”? Based on what? Moreover, employees have been having their health benefits cut back dramatically over the last several years, bearing larger and larger percentages of the cost and this has not resulted in increased competition, increased efficiency, or increased quality. Mostly it has resulted in fewer people being able to afford, and thus having, insurance.

I agree that we need a health system in the US that encourages and rewards quality care, that increases communication and sharing of information, that fosters the development and implementation of system-based practices. But there is no reason to think that Prof. Enthoven’s plan will result in such a system, much less is a good way to get there. It does not address the issue of the uninsured, the fastest-growing part of our population. He makes it seem that most employees have generous health plans, while the fact is that they don’t, and even those who have – notably employees of large car manufacturers such as GM and of state governments (he cites Wisconsin and California) are having great cuts to their benefits.

As noted by Schiff, et. al. in 1994[4], lack of access is the greatest quality deficit, and Enthoven’s plan does not even begin to address this. We need a comprehensive health insurance plan, preferably a single-payer plan such as an expanded Medicare-for-all as called for in HR 676, so that everyone is covered and can get access to the health care that they need. Only then do plans to increase quality, efficiency, and cost-effectiveness make sense. Otherwise such consumer directed health plans are, in Woolhandler and Himmelstein’s words “except for the healthy and wealthy, unwise”.[5] My in my Christmas Day (Dec 25) post I discussed a funding situation that makes hospitals and other health care institutions pursue some (profitable) “product lines” and not others demonstrates this insanity. Why should the diseases some people have be “profitable” and some “unprofitable” resulting in inadequate or unavailable care? Why should care for some people be profitable or unprofitable?The only solution is to develop a system where everyone is covered, where access to care is based upon health needs, where the payment system doesn’t perversely encourage treatment rather than prevention, or intervention rather than waiting, or high-cost drugs rather than low-cost, or care for some conditions rather than others of equal or greater health risk/benefit.
[1] Enthoven AC, Consumer-Choice health plan. A national-health-insurance proposal based on regulated competition in the private sector (two parts), NEJM 1978 Mar 23;298(12):650-658 and 1978 Mar 30;298(13):709-720
[2] Enthoven A, Kronick R, A consumer-choice health plan for the 1990s. Universal health insurance in a system designed to promote quality and economy (two parts), NEJM 1989 Jan 5;320(1):29-37 and 1989 Jan12;320(2):94-101
[3] Woolhandler S, Himmelstein DU, “Paying for national health insurance – and not getting it.” Health Aff (Millwood) 2002 Jul-Aug;21(4):88-98.
[4] Schiff GD, Bindman AB, Brennan TA “A better-quality alternative. Single payer national health system reform. JAMA 1994 Sep 14;272(10)803-8.
[5] Woolhandler S, Himmelstein DU, “Consumer directed healthcare: except for the healthy and wealthy it’s unwise”, J Gen Int Med 2007 Jun;22(6):879-881.

Student Debt, Resident Hours, and Primary Care Redux

HAPPY NEW YEAR! May 2009 be a big improvement!

The December 18, 2008 issue of the New England Journal of Medicine includes Perspectives on 3 topics that have been previously addressed on this blog: Medical student debt (Dec 14), resident duty-hours (Dec 3, 9), and the future of primary care (Dec 11).

The piece on “Medical Student Debt – Is there a Limit?” by Robert Steinbrook presents data on the extraordinary rise in tuition, and debt, among medical students, most surprisingly in the public medical schools. “For the current academic year, tuition, fees, and health insurance at private medical schools range from $15,278 (for Texas residents) or $28,378 (for non-residents) at Baylor University to $51,969 at Tufts University in Massachusetts and $52,236 at Temple University (for nonresidents of Pennsylvania – state residents are charged at $43,232.” While tuition rates at private medical schools are generally higher than at public, the non-resident tuition at public schools is about the same as that of the privates, and the rate of rise (percent change) in the last 10 years at public schools has far exceeded that at private schools (100% vs 50% increase). Indebtedness ranged from an average (high is different) of $80,000 to $163,000 at public schools, and $70,000 to $182,000 at private schools. Some schools give significant tuition scholarships, but others are more challenged: Stanford’s endowment allows it to give a far larger number of scholarships relative to loans than does, say Drexel. More important, the article points out that the high debt burden may discourage lower-income students from applying to medical school, and to enter specialties with higher income potentials. “It is not surprising that a recent analysis showed a ‘strong direct correlation’ between higher mean salary in a specialty, such as orthopedic surgery or radiology, and the percentage of residency positions filled by US graduates.” The piece says that there is no easy solution, and probably there is not. But most countries have very low medical school tuitions, but require national service of their graduates.

“Revisiting Duty Hour Limits – IOM Recommendations for patient safety and resident education” by John Iglehart, discusses that topic in a balanced way. It points out the acknowledgment in the IOM report that “Although some might propose further reductions in total duty hours, the report notes, ‘evidence suggests it is an indirect and inefficient approach given the moderate correlation that exists between resident duty hours and sleep time.’” Igelhart also notes that “the 2003 limits on duty hours have resulted in an increase in handoffs of patient care between physicians – transitions associated with increased risks to patient safety.” I have discussed this at length, but I did note that this article includes a table with a recommendation I had missed – that internal and external moonlight be counted against the 80-hour per week limits. I have no difficulty with that conceptually, as it makes perfect sense – what is the point of limiting work hours in the residency if residents can moonlight for extra money in an unrestricted fashion? – but I wonder about the legal ability of program directors to restrict the moonlighting activities of their residents in their off hours.

“The Future of Primary Care – the Community Responds” involves a followup to a series of opinion pieces and a roundtable discussion with Drs. Thomas Bodenheimer, Barbara Starfield, Katharine Treadway, Allan Goroll, and Thomas H. Lee that appeared in the November 13, 2008 issue. The comments, and responses from the roundtable participants, are salient and generally useful. Several writers noted the role of physician assistants, and one (Paul Lombardo) states that “Patients, and the U.S. health care system as a whole, would be better served if the content of and level of primary care education were better matched to the needs of patients. The physician assistant (PA) model of medical education, with its emphasis on physician-physician assistant teams, needs to be expanded.”

These are all thorny, and not unrelated, issues. What is the relationship between resident work hours and physician’s assistants? Well, someone has to do the work. Since residents, even with the 80-hour restriction, work twice as many hours as do physician’s assistants, for about half the salary, and have a greater scope of practice, it would be incredibly expensive for hospitals to replace resident labor with that of physician’s assistants, not to mention physicians. As hospitals complain about the “cost” of resident education, this needs to be kept in mind; they are much better at accounting the cost than the benefit. Even if a hospital closes its residencies because it assesses the costs are greater than the benefit, this usually includes the fact that the residents care for many medically indigent patients, and you can be sure that the hospitals are planning to no longer care for them at all, not to pay someone else to do it. This, of course, again decreases access for the most needy.

I have repeatedly said that the nucleus of a solution is a comprehensive national health program, which includes a single-payer and a system that is tasked with ensuring the health and access to quality health care of all Americans. With such a system, addressing issues such as resident work hours, medical student debt, and the composition of the physician (and NP and physician assistant) workforce could be feasible; without it, they all remain insoluble because they all depend upon each other.

Community Health Centers

Boxing Day, December 26, 2008, the New York Times has a shortage of news, and its featured right-hand column page 1 story is “For Bush, a rise in health clinics shapes a legacy”. While scarcely “news”, the article addresses an important topic: the expansion of Community Health Centers during the Bush years, arguably the only contribution that the outgoing administration made to health and health care. The first paragraph notes that the legacy is in “bricks and mortar”, with creation or expansion of 1,297 clinics in medically underserved areas. As one reads on, the article documents the problems: there are still too few, the demand still exceeds the supply, and the funding for them (beyond the physical expansion of “bricks and mortar”) is inadequate. In addition, it notes an issue that has been addressed on this blog: there are not currently enough primary care physicians to staff them, and given the rate of entry of students in to primary care, the problem is likely to get worse.

Community Health Centers originated in the Great Society program of the Johnson years. Contrary to false claims that the War on Poverty didn’t work, it did; while poverty surely was not eliminated, its impact was reduced. Of course, the funding for the programs suffered with the expansion of the Vietnam war, and the Reagan administration decimated most of the programs. (Poverty rates in the US dropped from about 20% in the early 1960s to less than 10% in the early 1970s, to rise again through the 80s and 90s.)[1] Known as “330 clinics” because they were established under Title 330 of the Public Health Service Act,[2] and currently know as Federally Qualified Health Centers (FQHCs), these Community Health Centers (and their “cousins”, the Title 329 Migrant Health Centers) provide sliding scale fee-for-service care to the urban and rural underserved. T[3]hese terms are clearly and simply explained in a University of North Dakota publication. In exchange for meeting a variety of service and reporting requirements, including management by a Board that is at least 51% consumers (clinic clients), these clinics get enhanced reimbursement from Medicare and Medicaid at rates far higher than ordinary doctors or clinics. They also get “grant funds” intended to help them care for the uninsured who are not eligible for one of these federal (Medicare) or federal-state match (Medicaid) programs. (There is also a class of clinics called FQHC-“look alikes” that have to meet the same criteria and get the same Medicare and Medicaid reimbursement, but do not get the cash grant.) Of course, these are the funds that are grossly insufficient for most clinics; the needs of the number of working poor who do not have health insurance and do not qualify for Medicaid, which is the fastest growing portion of our population, far exceed the funding.

According to the Times article, “As governor of Texas, Mr. Bush came to admire the missionary zeal and cost-efficiency of the not-for-profit community health centers.” This is admirable, and I am certainly glad that this admiration has resulted in his expansion of the program. But there remain issues to be addressed, hopefully, by the incoming administration, related to this admiration. First, as we and the article have noted, is the need for additional funding so that these centers, as zealous and cost-efficient as they may be, can begin to meet the health care needs that exist. Second, there need to be programs – unquestionably tied to increased reimbursement – to encourage more young physicians to enter primary care so that there are physicians to staff these clinics. The Bush administration has been less concerned about this issue, continuing to oppose funding for Title VII of the Public Health Service act that funds training of primary care doctors, as well as other programs including physician’s assistant training.[4]

Another issue concerns our expectation that those caring for the poor should sacrifice, be volunteers, be less well paid, than those caring for the insured or more affluent, who we expect to earn as much as possible. The Times article notes that CHCs often start their primary care doctors at $120,000 a year. While there is some regional variation, and it is difficult to get sympathy from people who are losing their jobs for someone “only” making $120,000 a year, this is a salary that is far lower than even primary care doctors make in practices serving the insured, and an amount significantly lowered by the medical school debt accumulated by many of the same committed doctors who wish to work in such settings. And this is “good”, that is, these are at least living-wage jobs for physicians; in many settings that do not have CHCs or publically-funded (usually county or city) clinics, those caring for the poor are actually much closer to being “volunteers”. In my town, the Missouri side of the Kansas City area has a (inadequately) county-supported hospital and two large FQHCs. The Kansas side has neither public hospital or public clinic or its own FQHC. Wyandotte, the poor county, has a high rate of uninsured people and has two one-doctor branches of the Missouri FQHC, 3 volunteer-doctor clinics, and a clinic that works because all the staff including the physicians earn $12/hour. And depends on grants. Johnson County, one of the richest in the nation, has just over 1/3 the uninsurance rate of Wyandotte, but with over 3 times the population, has more uninsured, and poor, people in total. And it has 2 volunteer clinics, with a half-time medical director. So, for the nearly ¾ million people in these two counties there are about 3-4 jobs that pay anything close to a reasonable wage for physicians; in these circumstances it would not matter if a lot more graduating physicians wanted to serve the underserved; the jobs are not there. Johnson County, in particular, with a high income population and a smaller percentage of poor and uninsured, deserves censure for not having a publically funded clinic system, not to mention hospital.

A two-class health system is not desirable, but it is better than when the lower “class” can get no care at all. Those working in CHCs, public clinics, and public hospitals, chronically underfunded, rightly bemoan their inability to truly meet the health needs of their patients, but there are many places where even that level of care is simply not available. CHCs may be excellent models for health care delivery for all people, but while we laud and honor those who work in volunteer clinics and public hospitals, we cannot consider this the solution. Martin Luther King, Jr., said “Philanthropy is commendable, but it must not cause the philanthropist to overlook the circumstances of economic injustice which make philanthropy necessary.” (More pithy, Jonathan Kozol: “Charity is not a good substitute for justice.”) We must never stop struggling against this injustice.

If we ever achieve a national health system, where financial barriers are eliminated and hospitals and physicians are paid the same for the care of a homeless person as a millionaire, we will be much closer. Sure, some hospitals and doctors will still try to avoid caring for the homeless and poor but then, at least, without the financial disincentive, we can correctly identify them as what they are (? how about “scum”?) Until then, we depend on volunteerism and sacrifice to try – very incompletely – to meet the health needs of our most needy. Tudor Hart’s inverse care law again validated.

[1] US Census Bureau, Historic Poverty Tables, http://www.census.gov/hhes/www/poverty/histpov/hstpov2.html
[2] http://bphc.hrsa.gov/about/legislation/section330.htm
[3] Health Professional Shortage Areas (HPSAs) and Medically Underserved Areas (MUAs) http://ruralhealth.und.edu/pdf/hpsa.pdf
[4] Freeman J, Kruse J “Title VII: Our Loss, Their Pain” Annals of Family Medicine 4:465-466 (2006).

A Rational Health Care System

A rational health care system would require access, both financial and (within practical limits) geographical, for all our people. It will also require a rational system for allocating resources, choosing the resources to use, and distributing those resources based upon need. Systems for determining which drugs are worth developing and utilizing will require a different approach than that the FDA currently uses, requiring only that a new drug be shown to be more effective (and not necessarily safer than) a placebo, rather than that it be more effective, or at least as effective, or safer than, or at least as safe as, the currently used drugs. It will require purchase of a limited number of medical devices, replacing the one currently used only when a new one is shown to be more effective, safer, or cost-effective (at least in certain populations) than the one currently being utilized.

It will also require a more rational and systematic allocation of resources, based on NEED rather than the opportunity for every individual provider or hospital to maximize its income. Current incentives are perverse, because they do the latter but do not do the former, whatever advocates of a “market-based” approach would say. It doesn’t work, if by “work” one means, as I do, meet the health needs of our people in a high-quality, comprehensive, rational, systematic, and cost-effective manner.

Consider hospitals. A rational system would build upon a network of clinics that utilize a community hospital, with several community hospitals feeding into a district referral hospital, and several referral hospitals feeding into a large regional medical center in which the most difficult and complex care can be provided (such as that in use in most industrialized countries, and designed for the US in the old “Dellums bill” for a national healthcare system). Rather, each hospital functions on its own, usually to maximize revenue, although sometimes with other goals such as maximizing research opportunities (usually combined with maximizing revenue) but rarely primarily the health care needs of the population. University academic medical centers, whether state supported or “private” (although these always have large amounts of public money) choose what services they wish to provide; the smallest and local community hospitals are often left only with the opportunity to meet the needs of those left over – or not, if they cannot afford to. Many large academic health centers, such as Johns Hopkins in Baltimore and the University of Chicago, are located in communities of great need, but do little do meet the core needs of their surrounding communities. They frequently indicate that they see themselves as national leaders, coincidentally existing in their neighborhoods, but make these decisions on their own, rather than as part of a rational health system.

The University of Kansas Hospital illustrates some of the contradictions that arise from the perverse incentives in our current health system. The hospital justifiably prides itself on a tremendous “turn-around” in the ten years since the creation of an independent hospital authority (KUHA) made it a “quasi-public” institution no longer under the control of the University, Board of Regents, or State of Kansas. Skilled leadership, with particular financial skills, have led it from losing to earning hundred of millions of dollars, from a building with serious physical plant failings to one which has added new floors, a new heart hospital (“Center for Advanced Heart Care”), a new Cancer Center, and is planning a new Medical Office Building for the physicians’ practice. It has also moved from near the bottom to near the top of the national rankings for quality of care. All good. The skills of the leaders were helped by the freedom from state purchasing and hiring processes (unions, seen by some state universities as a bane in their insistent efforts to protect the living wages of their members, were already not much of a factor in Kansas), allowing it to move much more nimbly. In addition, the fact that the facility, which if not in great shape was at least owned outright, allowed the hospital to take on capital debt for its renovation and expansion. All this is described in a celebratory article in the Business section of the Kansas City Star on Oct. 7, 2008, “KU Hospital's independent path has led to success”, which also quotes hospital leaders as crediting the success in part to not trying to be great in everything, but concentrating on two areas, heart and cancer care.

So far, so good. The hospital has indeed been successful in the current market and reimbursement system. But the concentration on heart and cancer care was not a random decision, and illustrates the problem created by our having the “non-system” of health care described above (and analyzed brilliantly by Bob Ferrer in his classic piece “Within the System of No System” published in JAMA in 2001.)[1] Cancer and heart disease are major health problems in our country, but they are also the most lucrative “product lines”; there is no coincidence that every hospital that can wants to expand these services and increase their “market share” by making their facilities for caring for these conditions more attractive to physicians and patients (note: in this context please read “well-insured patients”) than those of their competitors. They (all hospitals, not just KUH!) are not developing services as arguably important, such as obstetrics, pediatrics (which is in some ways a special case; while general care of children is not a profit center, in most large cities – including Kansas City – it is concentrated in children’s hospitals that are huge recipients of philanthropy), psychiatry, or goodness knows, primary care for the poor. There just is no money in it. So hospitals build excess capacity for caring for the well-reimbursed problems of the well-insured, hoping to lure these patients from other institutions, and quite understandably de-emphasize programs to care for the problems that are poorly reimbursed, or care to the poorly insured. This can provide a challenge for the educational function of academic health centers, which need to train students and residents in all facets of medicine. More important, the problem is that these are, well, health problems. We do not have a system that provides all needed care to all people because the individual institutions are driven by their own individual bottom line.

A study some years ago in Oregon looked at the characteristics of those family medicine residency programs that were closing. They were not those that were inferior in quality or had a more difficult time attracting good students. It turns out that the greatest determinant was whether they were in “one hospital” or “two hospital” towns. In a one hospital town, the hospital knows that everyone will end up there eventually, even the poor; if a family medicine residency can keep their private doctors happy by taking care of the poor and uninsured, and maybe even keep them healthier so they don’t end up in the emergency room in extremis, that is a good investment. In a two-hospital town, there is only one financial goal – all the uninsured should go to the other hospital. Thus, any program, such as a family medicine residency, that might attract the poor, make them feel more welcome, in your hospital than in the other is a negative! How financially understandable, how morally and socially bankrupt!

The competitive market has no place in healthcare because it leads to perverse incentives that lead each institution to look out for its own interest, rather than being based in how the health needs of our people are best met, in terms of medical quality and cost effectiveness, from a system perspective. Even if we develop universal financial access, we will need a rational system of service, and we are long way from having that.
[1] Ferrer RL, “Within the System of No System”, JAMA.2001; 286: 2513-2514.

Happy Holidays to All!

The financial sector, for a change…

Just a brief digression from health care and medicine to just social justice. The New York Times of Sunday, Dec. 21, is full of information. The right-hand column on page 1 (the most important story of the day) is: “In need of cash, more companies cut 401(K) match”. Not good for folks contemplating retirement, huh. Especially when the story on page 6 of the Business section is entitled “Maybe this time, it’s buy, buy, buy and hold”. A challenge for regular people who mostly “buy” (and “hold”) with their retirement money, which is now being cut. Hmm. There is also a very long piece beginning on page 1 and continuing with a full double-page spread detailing how the Bush administration housing policies encouraged, perhaps led the collapse. Oh, well, they’re soon gone, but have we learned anything? Frank Rich, in his column “Who wants to kick a millionaire?” details the continued irresponsible arrogance of the financial “leaders” and their enablers in the administration such as Henry Paulson:

“Last week ABC News asked 16 of the banks that have received handouts from the Treasury Department’s $700 billion Troubled Assets Relief Program the same two direct questions: How have you used that money, and how much have you spent on bonuses this year? Most refused to answer.
“Congress can’t get the answers either. Its oversight panel declared in a first report this month that the Treasury is doling out billions ‘without seeking to monitor the use of funds provided to specific institutions.’ The Treasury prefers instead to look at ‘general metrics’, indicating the program’s overall effect on the economy. Well, we know what the ‘general metrics’ tell us already: the effect so far is nil. Perhaps if we were let in on the specifics, we’d start to understand why.”

Let’s get this clear. The American people, who are actually financing this bailout, just as they financed the wealth accumulated by these “titans of banking”, think that they should not get any bonuses. In fact, they don’t even think they should have jobs. We think that the ones who can be convicted of anything should be imprisoned, and the rest should have to give up all their money[*] and be living on unemployment (if their companies were keeping up with the premiums!) in second-hand FEMA trailers, before their companies receive dollar one from the bailout! Can we be clearer?

Obviously hasn’t happened with the Bush administration, and don’t get your hopes up for the incoming administration, not with Citigroup’s Robert Rubin (“I’d do the same all over again”) and his disciples being appointed to Obama’s key financial advisory positions. Sorry, the same people are going to win, and the rest of us are going to keep losing.

[*] For those of you who wonder if we can take all the money they already “earned”, I acknowledge that I am not a legal expert. For those of you who are, here is my question on what seems a parallel set of circumstances: I break into your house and steal the $1000 cash you keep in your sock drawer. For the next week I “put it on the street” in short term, high-interest loans and now have $2000. Then the cops arrest me for my original crime. My question: Do I get to keep the whole $2000, or just the $1000 I “earned”?

Notes on Diversity

On Dec 11, 2008 I posted information about how medical systems built around a strong primary care infrastructure enhance the health of everyone. In my Dec 14, 2008, I addressed the topic of medical student selection, arguing that if we as a society wish to decrease health disparities and increase the health of the entire population, we need to have doctors who practice among those populations who do not have access to doctors (“underserved communities”) in both rural and urban areas. Again, this will require many more physicians entering the specialties, mainly primary care, that are needed in those areas. However, our current practice of admissions tends to select for students who will not enter such practices; selecting students who overwhelmingly come from high income families (80% of medical students come from families in the top 20% of income) in the suburbs of major cities is not likely to produce physicians who will enter the lower-paid specialties of primary care and work in rural and underserved inner city areas.

Taking different types of students into medical school requires a different approach to and understanding of the concept of “qualified”. In the past there has been general consensus that “high scores on exams” was “qualified”, but, as I have noted, these scores only predict performance in the “pre-clinical” (= “courses just like college”) curriculum, not in the clinical; moreover, the students who are most likely to have the characteristics that would lead them to practice in areas of need also have characteristics (such as coming from rural or inner-city high schools, coming from families with lower socioeconomic status) that make their scores lower. The “qualified” student for medical school is one who is likely to make a difference in the health of the American people. These same standards should be applied to the curriculum and reimbursement of physicians – how do they impact on improving the health of the people.

It turns out, unsurprisingly, that medical schools are not the only schools concerned with these issues. The effort to create diverse student bodies in universities and professional schools is widespread. A conference on the “Future of Diversity and Opportunity in Higher Education” was held at Rutgers University Dec 3-5, 2008, co-sponsored by the Center for Institutional and Social Change based at Columbia University. (Website: http://www.groundshift.org/.) Speakers addressed the idea of redefining “merit” to understand context; business has long understood that people hired need to add to the overall value of the organization, often by bringing different backgrounds and complementary skill sets. Lee Bollinger, President of Columbia University and the respondent in the two earlier University of Michigan affirmative suits (Gratz v. Bollinger and Grutter v. Bollinger) notes that those decisions allow selection on characteristics such as socioeconomic deprivation, but also notes that pretending that using socioeconomic characteristics obviates the need for racial and ethnic diversity is wrong. Richard McCormick, President of Rutgers and formerly President of the University of Washington noted the impact of the anti-affirmative action “Initiative 200” in Washington state: in 1998 1/11 freshman was non-Caucasian, but in 1999 it was 1/18. However, by developing new standards, including a required essay on diversity/adversity, within 4 years the ratio was at pre-Initiative rates without explicit use of affirmative action. In a particularly important panel on “Redefining Merit”, Sheila O’Rourke of the University of California at Berkeley spoke to the need to look at the definition of “merit” as not just test scores, but achievement in the context of opportunity. Prof. Lani Guinier from Harvard referred to the work of Malcolm Gladwell, looking at the differences in approach in selecting applicants to modeling schools and to the US Marines. Modeling schools looks for beautiful people in order to enhance their brand; this is selectivity effect. The Marines take people with a basic level of aptitude and skill and make them into Marines. This is treatment effect. The concept of “Democratic Merit” measures people on how they contribute to the mission of the organization or institution, and characteristics should include not only race and gender but socioeconomic status and geography. Much of this work is discussed in the book Prof. Guinier and Prof. Susan Sturm, from Columbia and the Center for Institutional and Social Change, wrote in 2001 “Who’s Qualified?” (Beacon Press, Boston.)

This is a critical concept. It understands how people contribute to the overall mission of a school, workplace or society. It recognizes how such institutions benefit from the difference in background, perspective, and experience of different people – and even how they think. Such a comprehensive perspective has to be of more value than simply performance on a test measuring one slice of knowledge and aptitude. As a simplistic example presented, consider 3 applicants for 2 positions in a company. If the criterion is performance on a 10-question test, and applicants A, B, & C respectively score 7, 6 & 5, should we take A & B? What if A got all 6 of B’s correct answers plus one more, but C’s 5 correct included the 3 both A & B missed? Would not C bring another perspective of value?

Businesses are far ahead of academic institutions in such thinking, even among those attending such a conference. It was from the panel of business leaders responsible for diversity in their companies, that the boldest assertions were made, and I paraphrase: “If there are only 12 top African-American law school graduates, the issue is not whether I can recruit them to my firm, because they will get good jobs somewhere; the issue is growing the number and pool,” and “We want diversity because it is good for our company, and will help it survive in a competitive market, but ultimately even if our company doesn’t survive, it is necessary for the success of our society.” I didn’t hear anything like that from the academics.

We need outcome-based criteria. In medicine, this is not how high the scores of a cohort of students are on exams given after 2 years of “basic science” or even “medical boards” (the USMLE, US Medical Licensing Exam) as long as they are adequate. It is also not whether they “match” in high-status residency programs. It can only be how well they contribute to the improvement of the overall health of our people.

Medical Student Selection

The US has great health disparities, and reducing them is a major component of the federal government’s Healthy People 2010 goals. We have spoken earlier about the fact that many people lack of access to quality care, most often because of lack of health insurance, adequate health insurance, or availability of health providers in their area. Doctors do not locate in areas that are already underserved, rural and inner city, but rather overwhelmingly choose to locate in already well-served areas, particularly in suburbs and the wealthier portions of cities. Julian Tudor Hart, the British physician and epidemiologist, called this the “inverse care rule”: the availability of health care is inversely proportional to the need for it.[1] The previous entry (Dec 11, 2008) addressed the issue of the need for a primary care infrastructure as the bedrock of any quality health system, and also noted that medical students are not entering the primary care specialties. Beyond the overall need for primary care in the society as a whole, it is obvious that rural areas require almost exclusively primary care, and primarily family medicine, physicians.

Given the decrease in interest among medical students in entering primary care careers, the existing health disparities are only likely to increase. I noted that the 20% of the US population that lives in rural areas has only 9% of physicians, but fewer than 3% of medical students are planning practice in rural areas. Even among the decreasing number of students entering primary care training, most come from the urban and suburban areas surrounding what Dr. Robert Bowman calls “major medical centers”, and are used to the life and lifestyle available in those settings. Moreover, even an individual student from a rural area who is otherwise interested in rural primary care practice, may find that the background or work requirements of their spouse or partner precludes a rural location.

The market affects specialty choice by medical students in terms of income; specialties with higher incomes are more in demand by students, increasingly so as medical student debt climbs to $200,000 or more. It is estimated that an anesthesiologist, for example, can (at current reimbursement rates) expect to make $7 million more in his/her career than a family physician, so we’re talking real money. The market is not so good, however, at diffusing physicians. More than for many professions, in medicine, and especially medical subspecialties, supply leads demand. Thus, while the suburbs of a large city may have plenty of X-ologists based on any estimate of need, one more is likely to do just fine financially, generating a comfortable standard of living for his/her family, pride from his/her parents, and maybe even great personal satisfaction; s/he will not, however, have a significant impact on overall population health, or make a dent in the health disparities that exist.

In any process of creating a product (and, with apologies, in this sense medical students can be seen as a “product”) the determinants of outcome (in this case which specialties students enter) will be affected by three variables: input variables (who we take into medical school), process variables (what is the curriculum, and the overall experience in medical school), and output variables (what is the practice environment like, especially reimbursement). If the latter is the most important, it is also the one that medical schools have the least control over. Changes certainly need to be made in the process, the experience in medical school, so that students do not hear messages that the more sub-specialized you are the “better” you are – or the ironic dual messages “You’re too smart to be a family doctor,” and “You have to know too much about too many things to be a generalist!”. But medical schools also need to look carefully at who is admitted. We actually know what characteristics are more associated with students entering primary care and underserved practice. These fall into demographic characteristics and individual characteristics.

Demographic characteristics distinguish between populations. The evidence is clear that students who enter primary care and underserved practice are more likely to be from rural areas, under-represented minority groups, and families with lower incomes, as well as to be older. They are also, unsurprisingly, as a group likely to have lower grades, come from “lower status” colleges, and have lower scores on the Medical College Admission Test (MCAT). Thus, using MCAT scores and grades as the main criteria for the selection of medical students will select a cohort of students less likely to practice in the sorts of specialties and areas where there is the most need. I would argue that schools should identify a threshold level of MCAT score above which students rarely if ever fail out of medical school, accept students with scores above that, but not otherwise use it for ranking (i.e., if the cutoff is, say 28, then 32 is not “better” than 30, in terms of making admissions decisions).

There are, of course, individual characteristics as well. Some students from wealthy families, from majority groups, from the suburbs, with high grades, will become primary care physicians and care for the underserved. But, in entering medical school, this cannot be assessed by an essay, or even an interview. The most reliable indicator of future behavior is past behavior; the student who says s/he wants to care for the underserved needs to demonstrate a past history of action; if they have been in the Peace Corps, or VISTA, or Teach for America, or helped start a free clinic or a rape crisis center in college, they are much more likely to actually serve the underserved in the future.

Of course, there is resistance to changing admissions criteria. Many say that it is “lowering standards”. This is only true if one assumes that grades and scores on tests such as the MCAT are the best measure of who will become the best doctor. They are not. In addition to not predicting who will meet society’s needs, they do not even predict performance in the clinical curriculum. (They do better in predicting performance in the pre-clinical, or basic science curriculum, where students mainly sit in class and are assessed by short answer tests measuring recall of facts. Surprise.)

In fact, if we continue to use the same criteria to accept students that we always have, we are likely to continue to produce the same doctors that we always have: smart, competent, and not practicing in the areas of greatest need and thus not likely to reduce health disparities. Paul Bataldan has famously said “Every system is perfectly designed to get the results that it gets,” and we know what the results that we get from our current selection system are. Albert Einstein is credited with saying “The definition of insanity is doing the same thing over and over again and expecting different results.”

Let us not be insane, and do what is needed to be done to meet the health care needs of all of our people.


[1] Tudor Hart, Julian, “Three decades of the inverse care law”, Br Med J, 2000 Jan 1;320(7226):15-8.

A Quality Health System Needs More Primary Care Physicians

“Health care reform in Massachusetts has led to a dramatic increase in the number of people with health insurance. But there's an unintended consequence: A sudden demand for primary care doctors has outpaced the supply.”
--NPR’s “All Things Considered”, November 30, 2008 (http://www.npr.org/templates/story/story.php?storyId=97620520)

A national health system will need to cover everyone, as I have discussed, but it must go farther. The goal is not simply to “cover everyone”, but to provide universal access to high-quality, cost-effective health care. To do this, we need the right mix of health professionals, practicing in the right locations, and a payment system that reimburses them for providing the care we want and need. Our population is poorly served in many areas, particularly rural and inner-city areas; our physician workforce now has too few physicians practicing in these areas. Twenty percent of the US population lives in rural areas, while only 9% of physicians practice in those areas, and an even smaller percentage of medical students is planning to practice in these areas. The main specialty needed in rural areas is primary care, particularly family medicine but also general internal medicine.

Having more primary care physicians is important beyond the need to supply doctors to underserved rural and urban areas. A past article (December 5) cited the recent Commonwealth Fund health scorecard, which shows we are on the wrong track, with the US’ scores dropping from 67 to 65 out of 100 from 2006 to 2008; of note is that our worst score is for “efficiency” (53/100), the area where primary care has the greatest impact,[1] although we can also expect primary care to improve our poor performance on “access” and “equity.” The Fund’s scored indicators for “efficiency” include: Potential overuse or waste (duplicate medical tests, tests results or records not available at time of appointment, received imaging study for acute low back pain with no risk factors); ER use for condition that could have been treated by regular doctor (hospital admissions for ambulatory care–sensitive (ACS) conditions); Medicare costs of care and mortality for heart attacks, hip fractures, or colon cancer; Medicare costs of care for chronic diseases: diabetes, heart failure, COPD; Health insurance administration as percent of total national health expenditures.

Virtually all of these conditions are improved by having a greater primary care infrastructure. Extensive work has demonstrated that health systems built around primary care, both in this country and abroad, provide higher quality care at lower cost. When people have a provider who is “their doctor”, not the doctor for a piece of them, or one disease, a doctor who can coordinate, manage, and refer appropriately, who is available to them when they are needed, then people’s health is better and the system is more effective. This data is extensively documented by Baicker and Chandra from Dartmouth[2], Starfield, Shi and Macinko from Johns Hopkins,[3] [4] Ferrer, Hambridge and Maly[5] and others.

Baicker and Chandra looked at cost and quality in Medicare patients by state, and found that states with higher Medicare spending had lower-quality care. In addition, states with more primary care doctors had higher quality and lower cost, while those with more specialists had higher cost and lower quality. [Click on the graph to see it more clearly.]

Starfield, Shi and Macinko note that “Evidence of the health-promoting influence of primary care has been accumulating ever since researchers have been able to distinguish primary care from other aspects of the health services delivery system. This evidence shows that primary care helps prevent illness and death, regardless of whether the care is characterized by supply of primary care physicians, a relationship with a source of primary care, or the receipt of important features of primary care.”
They also note that “The evidence also shows that primary care (in contrast to specialty care) is associated with a more equitable distribution of health in populations, a finding that holds in both cross-national and within-national studies. The means by which primary care improves health have been identified, thus suggesting ways to improve overall health and reduce differences in health across major population subgroups.”

They posit six mechanisms why primary care has a beneficial impact on population health:
--Greater access to needed services,
--Better quality of care,
--Greater focus on prevention,
--Early management of health problems,
--The cumulative effect of the main primary care delivery characteristics, and
--The role of primary care in reducing unnecessary and potentially harmful specialist care.

In addition to these strong population health arguments for a primary care infrastructure, there are also the direct benefits to individual patients. People should have a provider who cares for them, the whole person, and understands their health in the context of biology, social situation, psychology and in the context of their family and community. The primary care provider (terrible word, but while it will most often be a doctor it could also be a nurse practitioner) knows the patient over time; the epistemology of the doctor-patient relationship in primary care is longitudinal, rather than acute or episodic. Ferrer and colleagues identify several primary care functions for individuals: “…although not unique to primary care, a strong emphasis on person-focused care projects beyond the patient–physician dyad to support important system goals such as quality of care and efficient use of services. Person-focused care also helps caregivers reach decisions that meet the needs of the patient rather than the health care system. This entails careful consideration of procedures that may be driven by availability rather than benefit; self-perpetuating cascades of diagnostic or therapeutic interventions; and interventions aimed at reducing clinician rather than patient uncertainty.”

The big problem, however, is that we have a shortage of primary care doctors and that problem is getting worse. The number of students entering family medicine residencies has been dropping precipitously. Between 5% and 10% of family medicine residency programs have closed in the last several years, and those that are left are able to fill less than half their positions with American allopathic (MD) graduates. Osteopathic (DO) graduates make up some of the rest, but the bulk are filled by graduates of international medical schools, including US citizens who go to medical school abroad. These students may have even less internal motivation to practice in rural areas than do US graduates, although there is a program that allows foreign nationals on J-1 (student) visas to stay in the US if they practice in an underserved area. General internal medicine, another primary care specialty, has seen even a greater decline. Residents completing a 3-year internal medicine residency may enter primary care (or become a hospitalist; see blog entry December 4, 2008) or may enter subspecialty training, such as cardiology, gastroenterology, or pulmonary medicine. Garibaldi, writing in Academic Medicine (the journal of the Association of American Medical Colleges) in 2005[6], found that while 54% of internal medicine 3rd-year residents were planning to enter primary care in 1999, in 2005 it was only 27%, and only 19% of 1st-year residents. In a July, 2008 study in JAMA that got a great deal of press coverage, Hauer and colleagues found that only 2% of graduating medical students from 11 US medical schools were planning careers in general medicine.[7] For the US to have the primary care workforce it needs, the factors encouraging medical students to not choose primary care careers will need to be addressed; this is the subject of a future entry.

[1] “Why not the best? Results from the national scorecare on US health system performance, 2008”, Commonwealth Fund, Jul 2008, http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=692682
[2] Baicker K, Chandra A, “Medicare spending, the physician workforce, and beneficiaries’ quality of care”, Health Affairs on line, W4-184, 7 Apr 2004.
[3] Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83:457–502
[4] Shi L, Starfield B, Kennedy B, et al. ”Income inequality, primary care, and health indicators.” J Fam Pract. 48(4): 275-284, 1999.
[5] Ferrer RL, Hambridge SJ, Maly RC, “The essential role of generalists in health care systems”, Annals of Internal Medicine 2005;142:691-699.
[6] Garibaldi, RA, Popkave C, Bylsma W, “Career plans for trainees in internal medicine residency programs”, Acad Med 2005 May;80(5):507-12
[7] Hauer KE, Durning SJ, Kernan WN et al., “Factors associated with medical students’ career choices regarding internal medicine”. JAMA 2008;300(10):1154-64

Resident Work Hours: Addendum

I know I said wouldn't post daily, but a short addendum to the Dec 3 post on Resident Work Hours, motivated by the Editorial in the NY Times today (http://www.nytimes.com/2008/12/09/opinion/09tue3.html?_r=1&ref=opinion)
The article notes that the Institute of Medicine (IOM) report expresses concern about the current 10-year old regulations may not be being enforced: "By most accounts, the current, weaker rules are widely ignored, so it will be imperative to make sure that any revisions are adhered to..." While this raises the obvious question of "how" this will be done, it also raises the issue of where this assertion, "By most accounts..." comes from. I have seen no citations, and know of no programs where these rules are violated in any regular way (of course, there may be a rare intermittent exception). The Accreditation Council for Graduate Medical Education (ACGME) monitors this very closely, and programs violating it have serious sanctions, so I am quite surprised and wonder whether this is really true.

Physician Conflict of Interest

The NY Times, Dec 3, 2008, has a story on the Cleveland Clinic’s new policy requiring disclosure by its physicians of potential conflicts of interest; it is on page 1 – of the Business section. Entitled “Doctors Disclose Their Hand” (cute!), it indicates that the Clinic will begin disclosing all ties its 1,800 doctors have with drug and device makers, and that “It appears to be the first such step by a major medical center to disclose the industry relationships of individual doctors.“ It is about time. As in the case of issues recently addressed on this page (such as universal health care and “not getting what we pay for”) this has been a concern that has been raised by those within, and outside, the profession for many years, but has been stonewalled and “pooh-pooh”ed not only by the doctors receiving the gifts, but also the institutions that employ them and are afraid of losing high-status and high-dollar researchers if they implement restrictions. The Cleveland Clinic is to be congratulated for implementing such standards, and every single medical school, medical center, and hospital should immediately emulate them or be ashamed. It should not have to take Congressional action: “Senator Charles E. Grassley, Republican of Iowa, has brought Congressional scrutiny to the issue and introduced legislation that would require drug and device makers to divulge the payments they make to doctors. In a statement, Senator Grassley praised the clinic’s move, citing it as evidence of change. ‘Patients deserve easy access to information about their doctors’ relationships with drug companies,’ he said, ‘and the Cleveland Clinic is making that possible.’”

There are reasonable arguments in favor of physicians in academic medical centers having relationships with manufacturers of drugs and devices. The most important is that most of the original research done to develop new drugs and devices is done in such centers by such scientists, usually sponsored in the initial phases by the National Institutes of Health, a federal taxpayer supported agency (contrary to the marketing claims of manufacturers that they support most research and development). When the new compound is promising enough to need industry support for further development and manufacture, it is good that the physicians and scientists involved in development, and the institutions that employ them, get credit and even financial payment. The argument in support of physicians as speakers for drug or device companies (“flaks”) is much less reasonable. There can be no reasonable argument for non-disclosure; indeed, to the extent that such relationships are ethical, there should be no hesitancy on the part of physicians and institutions to disclose. Can’t have it both ways, guys – can’t say it is OK to do, but you would be embarrassed to have your patients and the public and the media know about it.

The Times reports that Guy Chisolm, chair of the Cleveland Clinic’s conflict-of-interest committee, says “῾Disclosure is a minimum,’…The current disclosure simply lists the companies for whom the consulting takes place. He said the group was planning to improve the clinic’s ability to audit the information it received from doctors, because the clinic must now rely on doctors’ self-reporting to find potential conflicts.” and I absolutely agree. When you have scandals such as that of Emory University’s “…Dr. Charles B. Nemeroff, [who] drew criticism in October for failing to disclose at least $1 million in consulting fees from drug makers,” it is clear that self-disclosure is insufficient.

Then there is the question of whether the disclosures will make any difference to patients. “Some experts wonder how useful the industry disclosures actually are to patients when they are told of a doctor’s industry ties before agreeing to take part in a research trial. A patient, they argue, may not know what to make of such information.” Well, that is the doctor’s job. Ethically, it is part of informed consent. It is not only the doctor’s job to be able to not only explain clearly why s/he thinks that this is a good idea (which is obvious); s/he needs to make the counter-arguments him/herself, and direct the patient to places where they can find informed alternate, independent, and even opposed information. This is the responsibility of the academic medical center to enforce. Beyond the direct effect on patients, it is only through such disclosure that the colleagues of a particular physician or scientist will know of these potential conflicts, know that independent information will be needed by patients, and be in a position to exert peer influence and policing in excessive cases.

Finally, the Times quotes Dr. Delos M. Cosgrove, a cardiothoracic surgeon who is the Cleveland Clinic’s chief executive. He “…acknowledges that the environment has changed significantly in recent years as doctors’ industry relationships have come under scrutiny. In fact, he considers some of that scrutiny to be excessive. `You can’t get a coffee mug from a drug company,’ Dr. Cosgrove said.”

While quite a different issue from the big-dollar relationships that the Cleveland Clinic is addressing, and probably worthy of at least another blog entry, the question that comes to mind is: Why would Dr. Cosgrove, who presumably makes a good living and can afford his own coffee mugs, want one from a drug company? Why would any doctor? Why compromise yourself for coffee mugs, pens, sticky pads, calendars, and donuts? While not worth thousands in themselves, these “small” gifts have a big impact. The individual physician may not think much of using a pen with a drug company logo to write a on a note pad with a drug company logo while sitting under a poster or calendar or clock with a drug company logo, but patients notice these things, and understandably might think that the doctor is endorsing these products.

The American Medical Association position is that small gifts are ok, but large gifts are not. Fortunately, many academic medical centers are restricting even small gifts, for both the “appearance of propriety” and for the good reasons noted above. Essentially, gifts to physicians are a form of graft, in that they are given to one person (a physician, a politician) to encourage them to spend money on the company’s product – but not their own money – someone else’s (in the politician’s case, the public’s; in the physician’s case, the patient’s.) Arguing that small amounts of graft are OK is not a position I would care to defend.

Of course, most physicians would argue that their prescribing habits are not affected by gifts, large or small, or dinners. While that always could be true for a particular individual, it is clearly not true for the universe of doctors or the pharmaceutical companies wouldn’t spend so much money doing it! For those who are interested in how what is in one’s financial self-interest is seen, often subconsciously, as “coincidentally” the “fair” or “right” thing, I strongly recommend the article “A Social Science Perspective on Gifts to Physicians From Industry” by Dana and Loewenstein (JAMA.2003; 290: 252-255). While directed to the topic at hand, it is actually very useful in understanding a variety of self-justifying behaviors.