Can you be "too strong" for family medicine?

Last week medical students and residency training programs received their “match” results, the end product of a complex computerized process. Now (except for the 1100 students at US allopathic schools who did not match and programs that did not fill), students know where they will be training and residency programs know who will be joining them. The number of “un-matched” US students is greater than last year; so is the number of positions. This is the result of recent expansions in both the number of medical schools and the number of students in existing medical schools.


The Association of American Medical Colleges (AAMC) has been lobbying hard for the expansion of residency positions, arguing that expanding medical school class size is not going to translate into more doctors if there are not more residency positions. AAMC is not, however, calling for those increases to be tied to a certain percentage of primary care. Since primary care residents are not big money-makers for the hospitals that are the main sponsors of residency training, and not in great demand by medical students (see more below), it is quite likely that, absent specific stipulations, the opposite will occur – most of the expanded number of residency slots will be in non-primary care specialties. This will, of course, further exacerbate the already unbalanced subspecialty/primary care ratio that currently exists.

Unlike AAMC, many family medicine organizations are calling for expansion of residency slots to be tied to primary care, and I am in agreement with that. However, the concept of “forcing” students to choose primary care residency slots who may not want to makes many people uncomfortable. They would prefer to “make family medicine” more desirable to our students. I would argue that this is going to be an uphill battle given the priorities of many current medical students.

As a family medicine educator, I try to stay on top of the trends in medical education, student preference, and workforce. I also interact with a lot of medical students, so have, I think, some idea of what their priorities are. Sometimes, however, I am surprised by the lack of knowledge about family medicine among students who, I thought, should “know better”. For example, a student recently contacted me about a friend who had applied to family medicine residencies as a “backup” for their preferred, more “selective” specialty, and did not match; the perception was that this student was rejected because they were seen as “too strong” for family medicine. I was surprised. I wrote the following in response:

"I don't think it is possible to have someone be "too strong" for family medicine regardless of how you define strength (grades, board scores, compassion, ability to learn and apply learning, multi-tasking, or how much you can bench press). Family Medicine is truly the most complex and difficult specialty. The breadth is enormous, as I am reminded as I -- for the sixth time in my career -- study for my recertification boards, and study maternity care, sports medicine, caring for people with heart disease, well-child care, ICU care, lung disease, diabetes, fractures, arthritis, acutely-ill children, preventive care, epidemiology, nutrition, diabetes, gynecologic problems, management of psychiatric problems, adolescent issues, and on and on. There is nothing like it. It is also true that the skills, preferences, and experiences that make someone strong for one specialty may not make them "stronger" for another.

"As far as the practice is concerned, family physicians have to see undifferentiated patients and try to come to a conclusion about what they have and how to manage them. This is a lot more conceptually challenging than seeing someone with a ready diagnosis or a narrow scope of diagnoses and applying your in-depth knowledge to figuring out a best method of treatment for it, or doing a procedure on it. Family Physicians (and other primary care/generalist physicians) do not care for one disease or organ system of a person, they care for the person. They manage multiple co-existing chronic diseases -- our adult patients typically have a large number of them such as hypertension, diabetes, heart disease, arthritis, depression, and social stressors in their lives, for example -- and balance the treatments for each so that they do not make the others worse and are best designed for that individual person. And to, while doing so, learn and care for the person. This is harder than doing the same limited set of procedures or treating the same limited set of diagnoses day after day. While a typical subspecialist may have 5 diagnoses that account for 80% of her patient visits, for family medicine the top 20 diagnoses do not cover more than 30%!

"I do not mean in any way to insult or seem to be critical of other specialists; they do important things and we need them to refer to for the procedures that we don't do or the uncommon cases of diseases that are rarer or unresponsive to usual treatment (although I do think that the current balance between subspecialists and primary care doctors is way off). I also do not mean to seem ignorant of the fact that many other specialties, including orthopedics, are much more competitive than family medicine to match in. This is because demand (from students) exceeds supply (of positions) and allows those specialties to set higher (by whatever they mean by this, usually grades and scores) standards. But this should not be confused with the complexity of the specialty. Demand is driven by many things including (but I am sure not limited to), the particular interest of a student in the diseases cared for by a specialty, their interest in performing psychomotor skills (such as procedures), anticipated income, anticipated lifestyle issues, and many others. It is also true that many other specialties require strong medical students. But do not confuse supply/demand issues with the intelligence, hard work, difficulty, decision making ability needed, breadth, and conceptual complexity of a specialty. For these, nothing exceeds family medicine."

I also sent a link to this (I think) wonderful post called "Desperately Seeking Herb Weinman" by Steve Lewis in Pulse, an online journal of narratives about health and medical issues, that gets to other characteristics of primary care doctors that are important to people. The author has a very scary health episode that takes him to the emergency room, and acutely feels the depersonalization of not having a doctor who knew him (like his old, now retired, doctor, Herb Weinman, did): “I know that the overworked ER staff who treated me were good and competent healthcare providers. But I also know that there was not a soul in the ER that day who would have cried if I had died. As Herb Weinman would. And I want that. I want that.”

A colleague, who also has concerns about the motivations of some medical students, reposted a post from a student on “studentdoctor.net”, the largest discussion group for medical students about whether Allergy should replace Anesthesiology on “the ROAD” [Radiology, Ophthalmology, Anesthesiology, Dermatology, which are widely considered by medical students to be the specialties with the highest income-to-work ratio] because it seemed like “…such a cush job.” Then followed a listing of the incomes of different specialists, which I will not replicate, but will note that the low end of all was much higher than the high end of primary care incomes; however, primary care doctors earn a lot more than the average person!

My colleague commented: ”We need a different pool of applicants...We need a different yardstick...We need payment reform. There are plenty of smart people who want to serve. There are a lot of folks who would be thrilled to be the smartest, best paid person in their town.”

I agree. I want many more medical students to want to go into primary care. If it is about money, we are not going to be competitive. It is going to have to be about wanting to care. And that means, to me, using different criteria to accept people to medical school.

More people like Herb Weinman, I guess.

Squeezing the needy: a truly flawed financing system for healthcare

In his always-valuable “Quote of the Day” for February 26, 2013, Don McCanne, MD, cites an article by Robert Pear in the New York Times from February 25, “States Can Cut Back on Medicaid Payments, Administration Says”. He quotes from the article that “In a brief filed with the United States Court of Appeals for the Ninth Circuit, in San Francisco, federal officials defended a decision by California to cut Medicaid payments to many providers by 10 percent…. [it] urged judges to uphold those cuts, which are being challenged by patients, doctors, dentists, hospitals, pharmacists and other health care providers in California…[who] said California’s payment rates were inadequate even before the cuts. They pointed to a federal study that said,’ “California stands out because of its very low Medicaid payment levels.’”

 A similar article that he cites from the Los Angeles Times by Anna Gorman, February 25, 2013, “Healthcare overhaul may threaten California's safety net” states that “An estimated 3 million to 4 million Californians — about 10% of the state's population — could remain uninsured even after the healthcare overhaul law takes full effect,” while at the same time the public hospitals and clinics that would provide care to those additional millions are having their funding streams from the state cut.

And this is in a state with a long history of providing care for its medically indigent by having such hospitals and clinics (unlike, oh, say, Kansas) and with a reasonably progressive Democratic governor, Jerry Brown. But it also has a huge budget deficit. At the most narrow level, the state has no choice but to spend less on the programs over which it has control, and these programs are the ones that benefit those whose low-wage jobs (or no jobs at all) make them dependent on public programs to ensure the health of their families.

The key point here is that the huge transfer of funds from the public sector to private control, as a result of tax cuts on corporations and wealthy individuals, has led to the inability for even states such as California, which arguably want to, to provide the basic health and social safety net for its most needy citizens. This is precisely the result that advocates of these programs want, to “choke” government, and precisely the impact on the poor that would be predicted. Meanwhile, at the local, state and federal level, tax “relief”, in terms of both cuts and direct giveaways to major industries, continue to support the least needy.

At the same time (February 20, 2013), Time magazine has published an amazing exposé by Steven Brill of the ridiculous over-pricing and capricious billing done by US hospitals, “Bitter Pill: Why Medical Bills are Killing Us”. It is a long and through article, citing case after case and example after example, of how the current system of billing and reimbursement in health care, and particularly in hospitals costs a fortune, is sapping the economy overall. And, of course, the burden falls hardest on those who are either uninsured or poorly insured, and are billed “list” prices, which are much higher than those paid by either public (Medicare or Medicaid) or private (eg., Blue Cross, Aetna) insurers. MUCH higher. Often dozens of times higher. A few examples that he cites:

• A troponin (blood test for a heart attack) test billed to an uninsured patient at $199. Medicare pays $14; a CBC (blood count) billed $157 when Medicare pays $11.
• A nuclear heart scan for which Medicare pays $554 billed at $8,000.
• A Medtronic spinal stimulator that lists for $19,000 from the manufacturer (if the hospital paid full list) billed to the patient for $49,000.

The article is good investigative journalism, and goes beyond such simple examples to look at the entire structure of the health system’s payment mechanism, including the incentives to do more and more (even when unnecessary or possible even harmful) expensive – and high profit – tests and procedures. It looks at enormous hospital profit margins and salaries of “C-suite” executives: “…in our largest cities, the system offers lavish paychecks even to midlevel hospital managers, like the 14 administrators at New York City’s Memorial Sloan-Kettering Cancer Center who are paid over $500,000 a year, including six who make over $1 million.” (Of course, salaries in the measly low one-digit millions pale before the incomes of those in the pharmaceutical industry!) It helps us to understand both why costs are so high and why programs that limit payment, like Medicare and Medicaid, are so hated/fear/despised by hospital administrators.

The hospitals may well be taking a loss on Medicaid/Medicare reimbursement, because “Medicare takes seriously the notion that nonprofit hospitals should be paid for all their costs but actually be nonprofit after their calculation.”  But while “Hospital finance people argue vehemently that Medicare doesn’t pay enough and that they lose as much as 10% on an average Medicare patient...even if the Medicare price should be, say, 10% higher, it’s a long way from $11.02 plus 10% to $157.61.”  The thing is that they “need” to make more because, although “non-profit” they make big profits – they just don’t share them with stockholders. “…thousands of nonprofit institutions have morphed into high-profit, high-profile businesses that have the best of both worlds. They have become entities akin to low-risk, must-have public utilities that nonetheless pay their operators as if they were high-risk entrepreneurs.”

What was interesting to me is that most of the patients who received those outrageous bills above were neither unemployed nor uninsured (although the one who was uninsured had the misfortune of being 64 rather than 65, so paid the $199 for her troponin instead of Medicare paying the $14). Rather, they were employed in low wage jobs and had lousy insurance, with very low per-visit, per-year, or lifetime caps and were treated by the hospitals as if they were uninsured (“’We don’t take that kind of discount insurance’ said the woman at MD Anderson [Cancer Center]” when Stephanie Recchi called to make an appointment for Sean; they needed to come up with $48,900 cash up front – and that was just the down payment!). So all estimates about the burden on the uninsured need to be augmented by the impact on the under-insured.
Dr. McCanne’s incisive comment on the two articles notes that while “We have said over and over again that Medicaid, as a welfare program, will never have the political support to fund it adequately. The burden of the additional load of Medicaid patients will surely find the health care resources strained beyond the capacity of willing providers, especially when you consider that California already is not meeting the costs of providing care to this vulnerable population…

"Here's an amazing fact: Low income patients do not have the money to pay for health care. (What an intuitive stroke of genius!) What they need is an affordable system that removes financial barriers to care while ensuring adequate financing of our entire health care delivery system, thereby removing health system disincentives to providing essential care for this vulnerable population. Make that for all of us.”

All of the nonsensical billing and collecting issues that are so horrifyingly reported on by Brill do not need to occur. The simple answer is that there should be a single, posted, price for each item or service and everyone is billed at and pays (or their insurance pays) the same amount. This is the situation in Canada, where fees for physicians are negotiated annually with the provinces and hospitals operate within a global budget. Probably fewer millionaire hospital administrators, but of course creating them should not be the goal of the money we spend on health care.

No poorly-insured, well-insured, uninsured, Medicaid-insured or Medicare insured. Just everyone covered. Simple, clean, elegant, and effective.

Corruption and Scandal in the NHS: What happens when you introduce private incentives to public services

The United Kingdom has a National Health Service which covers everyone (although it allows those with private insurance to access care elsewhere). While not perfect – nothing is – and historically underfunded, it is one very reasonable model for how we could ensure access to health care for everyone. It goes back to the post-WW II period, when the British Labor Party made the decision to expand the existing National Health Insurance program to create the NHS through the political process, while in the US the emphasis among unions was to use collective bargaining to get health insurance as a member benefit.

But the NHS, while profoundly supported by the vast majority of British people, has been a target of attacks by Conservative governments since the Thatcher years. One of the big changes was the creation of several regional “trusts”, quasi-public entities that were invested with NHS funds and made responsible for the provision of care in their regions. This was consistent with the Tory assertion (held even more strongly in the US) that the private sector, or as close as they could get politically to the private sector, would be more efficient and effective than a public “bureaucracy”. Success at meeting "targets" (often high production with inadequate resources) could lead a trust to "foundation" status, where they would have even more control.

Many in Britain had their doubts, certainly among those to the left of the Conservatives. There was concern that the trusts might not be responsive to the health care needs of the people and might be more concerned with enhancing their own salaries, perks, and power. Conservatives (small 'c') tend to believe that government bureaucracies are more inefficient; those on the left see more evidence that privatization is much more likely to serve the self-interest of those in control than the interests of those who are supposed to be served.

I recently read the 1996 mystery novel “Quite Ugly One Morning” by the Scottish writer Christopher Brookmyre. One of the major plot lines involves corruption in the Edinburgh-based regional NHS trust. I don’t want to spoil the plot, and I do recommend the book, but the portrayal of self-serving, stealing, and lack of attention to the actual care of the patients of the NHS was scary. Of course, it was a novel; there were not actual patients being harmed by corruption in the actual regional NHS trusts in the actual United Kingdom. After all, I thought, the British don’t do such things. We do, but that is because so much of our system is private and for-profit. Surely the British value the NHS too much for such things to really happen.

Wrong. It appears, however, that this in fact has been happening. In “English hospital report cites ‘appalling’ suffering”, NY Times February 6, 2013, Sarah Lyall describes conditions cited in a government report on Stafford Hospital, operated by the Mid-Staffordshire Trust: “Shockingly bad care and inhumane treatment at a hospital in the Midlands led to hundreds of unnecessary deaths and stripped countless patients of their dignity and self-respect, according to a scathing report published on Wednesday…. The report, which examined conditions at Stafford Hospital in Staffordshire over a 50-month period between 2005 and 2009, cites example after example of horrific treatment: patients left unbathed and lying in their own urine and excrement; patients left so thirsty that they drank water from vases; patients denied medication, pain relief and food by callous and overworked staff members; patients who contracted infections due to filthy conditions; and patients sent home to die after being given the wrong diagnoses.”

HUNDREDS of people. Maybe as many as 1200 people died unnecessarily. And, in the followup of this scandal, there are investigations into at least 14 other trusts, reported across the British press such as this article in the Telegraph, “Head of NHS ignored warning that patients were in danger, alleges whistleblower”. One of these trusts is United Lincolnshire, whose former chief executive has turned whistleblower, accusing the head of the entire NHS, Sir David Nicholson, of ignoring warnings that substandard care was being provided there. The whistleblower, Gary Walker, was fired from his job and paid off to the tune of about a half-million pounds, to keep quiet.

This would be a great example of “life imitating art” if it weren’t for all the people who died or suffered serious morbidity as a result of “…its efforts to balance its books and save $16 million in 2006 and 2007 in order to achieve so-called foundation-trust status, which made it semi-independent of control by the central government, the hospital laid off too many people and focused relentlessly on external objectives rather than patient care,” (NY Times).  As further documented in the report, this was essentially “speed up”, a condition familiar to assembly-line workers.

“Speaking in the House of Commons,” the NY Times article goes on, “Prime Minister David Cameron apologized for the way the system had allowed ‘horrific abuse to go unchecked and unchallenged’ for so long. So deeply rooted was the trouble, he said, that ‘we cannot say with confidence that failings of care are limited to one hospital.’” Apparently not, given the accusations at Lincolnshire. However, despite these accusations, and perhaps more damningly, the fact that he was the Chief Executive of the Mid-Staffordshire trust during much of the time that the scandalous activities were occurring there, Nicholson is staying put, and so far the government is backing him. (more coverage in the Mail (Feb 13 and 17).

Well, he is staying put so far, but people in Britain far and wide are calling for his resignation, as well they might. Demonstrations in support of the NHS as a system designed to serve the people, not its administrators, have broken out across Britain; an example is this wonderful “Youtube” video of a “flash mob choir” (!) at King’s Cross railroad station in London singing in support of National Health (h/t Alex Scott-Samuel).

It would be possible to pin these atrocities on the National Health Service, as an example of the failing of socialized medicine, but that would be wrong. It would even be wrong to point out that the problem is chronic under-funding of the NHS. The problem, in fact, is a public good being run for private benefit, for the temptation of even great “autonomy” (read: potential for exploitation) by becoming a “foundation” led to deaths far in excess of the scale fictionally portrayed by Brookmyre in the mid-90s. The NHS does not suffer because it is tasked with providing health care to all of the British people; it suffers when a lack of adequate regulation and supervision allow such abuses to go unchecked.

The British people deserve much better. So, for that matter, do Americans. Let’s listen to the “flash mob choir” again!

Creating team based care: are non-physician providers more effectively used in primary or subspecialty care?

The shortage of primary care physicians in the US, which I have often discussed (most recently in “When is the doctor not needed? And who should take their place?”, January 5, 2013), has become a national theme. The Robert Graham Center of the American Academy of Family Physicians (AAFP) has done much of the work in documenting this shortage, such as in the article “Projecting US Primary Care Physician Workforce Need” by Petteson, et al., discussed in my post “Health reform, ACA, and Primary Care: Is there still a conundrum?”, December 24, 2012. Essentially the problem is we have too few primary care doctors for the current population, the demand for them will continue to grow, and the rate of production (medical students entering primary care specialties) is below that even needed to replace those who retire. The growth in demand is a result of (in order of impact): population growth, aging of the population, and a more-or-less-one-time blip from increasing coverage under ACA (although for the latter, the people with a need for care were already there; it is just that with having insurance they will be able to seek it more easily).

 In a recent issue of Health Affairs, Green and colleagues argue that “Primary Care Physician Shortages Could Be Eliminated Through Use Of Teams, Nonphysicians, And Electronic Communication “.^[1] This is not a new concept; it is a central component of what is known as the “Patient Centered Medical Home”. The article suggests that many functions now carried out by physicians can be done by others, ranging from nurse practitioners and physician’s assistants, to nurses, to others on the health care “team”. It also suggests that many problems that now require face-to-face communication (trips to the doctor’s office) could be done by phone or “virtually”, such as by structured email or web-based visits. Thomas Bodenheimer and his colleagues in San Francisco have done much of the work in this area, most recently published in Annals of Family Medicine “Estimating a Reasonable Patient Panel Size for Primary Care Physicians With Team-Based Task Delegation”.[2]

Green, et al., use computer simulation models to estimate the “panel size” (number of patients that can be cared for per doctor) by the employment of such techniques; they add calculations for “pooling” of physicians, that is, sharing of patients among a group of doctors. This allows greater efficiency by “smoothing out the bumps” that may occur when one physicians has more or fewer patients coming in for same-day care or not showing up for their appointments by allocating them among the group. Using these statistical models they estimate that the ability of patients to access care (get in to be seen) would be dramatically increased by the implementation of such policies.

The work done by both the Green and Bodenheimer groups is convincing, and provides a model for more efficient primary care practice that would help to address the problems our country faces from having too few primary care doctors. Indeed, these approaches utilize the “crisis” as a way to actually improve both access to and quality of patient care. There are, however, challenges to implementation of this model. One is payment; while health systems in many parts of the nation have demonstrated that it is possible to restructure their practices to achieve these advantages, this is most effective in settings in which the provider is also the insurer (notably Kaiser). In those parts of the country where this model of care is less prevalent, where most payment to medical providers is “fee for service” for face-to-face visits to doctors, there is not only no incentive to change, there is a large negative financial incentive since any non-face-to-face care is, essentially given out free.

A second challenge is that such models only work where there is a large enough concentration of patients and providers to achieve the benefits of scale; as with most such analyses, it leaves out the needs of rural populations. Some large systems, such as Geisinger in Pennsylvania, have been successful in creating such efficiencies in their clinics in rural areas, but Geisinger is atypical; there are not many like it. In addition, it is a financially integrated system (like Kaiser) – that is, it is also the payer -- and it works in a relatively-densely populated rural area of northeastern Pennsylvania, not like the vast empty frontier counties of the West.

It is interesting to me that so much of this emphasis on efficiencies, and particularly the use of professionals other than physicians to provide care, has been on primary care. This, I am sure, is due in part to the need for primary care in all settings, while much specialty care can be centralized in larger cities. It is also because there is not a shortage of many non-primary-care specialists for the needs of the population (although there are for some, such as general surgery, especially in non-urban areas). The reason usually given for this non-shortage is largely that these specialists make so much more money than primary care doctors, so medical students are attracted to them. To the extent that some specialties also have more regular work hours and a limited scope of work, it may also increase their attractiveness.

The limited scope of work (although not, necessarily, less difficult work, especially when considering surgical interventions) also makes them, in many ways, more appropriate fields to use non-physician professionals than primary care. This is the reverse of the usual assumptions that sub-specialists are seeing difficult problems, while primary care providers see mostly colds and blood pressure checks. In fact, primary care is complex, as it sees both undifferentiated patients and those with multiple chronic diseases. Most specialty care is more routine, seeing a much more limited set of diagnoses with a more limited set of interventions; for the typical subspecialist, less than a half dozen diagnoses may account for 80% of visits, while for a family doctor the top 20 are probably 30%. Thus, the breadth of knowledge and skills in making complex decisions and appropriately prioritizing problems, require a level of sophistication and training not taught or developed in most other health professionals (family nurse practitioners are one other provider group where there is at least an effort to have this breadth of training). It is, then unsurprising that most of the tasks suggested for nurses and others to increase the efficiency of primary care practices have limited scope: maintaining disease registries, calling for recommended preventive care, screening a small set of diagnoses.

This type of narrow, in-depth scope of work is much more characteristic of subspecialty care, and it is one of the reasons why expanded-scope nurses and physician’s assistants have found so much use in these practices. They follow people with congestive heart failure for cardiologists or diabetes for endocrinologists, they manage chemotherapy recipients for oncologists, they use algorithms to care for people in intensive care units, they do pre- and post-operative care for orthopedists and other surgeons. And they do not go outside of the set of diagnoses and treatment options with which they are familiar; following the model of the physicians with whom they work, when a patient’s problem is not in their narrow area, it is referred.

The targeted but limited expertise of such nurse specialists have explains why they function so well clinically in subspecialties. What explains why it works financially is that the doctors (or hospitals, or health systems) that employ them are reimbursed at subspecialist physician rates (already very high) for work that is done by others; thus they can afford to pay such “physician extenders” relatively well compared to folks working in primary care. Reimbursement for “teams” follows the model of reimbursement for physicians: care for a limited set of diagnoses in a detailed way, especially when it involves procedures, is paid much better than management of complex sets of interactive diagnoses.

Unfortunately, the problem with such practice is challenging because the same person often has multiple conditions, and interventions that help one may make another worse. While efforts to build teams, and have each professional work at the “top of their license”, is important, so is payment. As long as primary care is reimbursed at lower rates it will continue to face challenges in recruitment of physicians, nurses, and other team members. 

We need to develop and implement great strategies for team-based care. We also need to dramatically decrease the ratio of income for subspecialists and their subspecialist teams relative to those working in primary care.

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[1] Green LV, Savin S, Lu Y, “Primary Care Physician Shortages Could Be Eliminated Through Use Of Teams, Nonphysicians, And Electronic Communication”, Health Affairs, 32, no.1 (2013):11-19

doi: 10.1377/hlthaff.2012.1086

[2] Altschuler J, Margolius D, Bodenheimer T, Grumbach K, “Estimating a Reasonable Patient Panel Size for Primary Care Physicians With Team-Based Task Delegation” , September/October 2012 vol. 10 no. 5396-400 doi:10.1370/afm.1400

Creating more family doctors: should we shorten medical school? How?

At the recently-completed Society of Teachers of Family Medicine (STFM) Conference on Medical Student Education, held in San Antonio, one of the big areas of discussion was the shortening of the medical school experience to 3 years for students planning to enter family medicine. Steven Berk, Dean of the Texas Tech University School of Medicine, and Betsy Goebel Jones from the Department of Family Medicine, described the Lubbock medical school’s recently-instituted program in a plenary presentation, and a later seminar featured presenters from several other schools which have instituted or are planning such tracks, including the Savannah campus of Mercer University School of Medicine, Medical College of Wisconsin, as well as Texas Tech. The goal of such tracks is to increase the number of students choosing to enter family medicine by eliminating one year of school, and thus tuition; these schools believe that this financial incentive at least helps a little to offset the lower income that accrues to family physicians compared to other specialists. To the extent that these students then enter family medicine residencies at those same schools, it also decreases uncertainty for both the student and the program.

The most direct forebears of these programs were in the 1990s, at some of the same schools. They offered an “accelerated track” for family medicine, in which students began their first year of FM residency while completing their final year of medical school, getting the MD degree after that year. While initially approved by the American Board of Family Medicine as a pilot, these programs were closed when the decision was made by the body that accredits residencies that one could not get credit for residency training until after receiving the MD degree. This latest effort gets around this by granting the MD degree after 3 years, mainly by compressing the final year of medical school; in most schools the fourth year is already largely used for electives.

Not all accelerated MD programs are about increasing the number of primary care, or certainly family medicine, physicians. A program at the NYU School of Medicine, which remains one of the few US medical schools to not even have a Family Medicine department, was featured in the New York Times "N.Y.U. and Other Medical Schools Offer Shorter Course in Training, for Less Tuition" by Anemona Harticollis, December 24, 2012. While the Texas Tech and Mercer-Savannah programs are also mentioned, NYU’s program is clearly not about producing more of the primary care physicians that the US needs, as this is not something NYU seems to care about at all. As of now all of these programs are “tracks”, rather than for all students; they recruit “high-performing” students who can finish the traditional curriculum in a shorter time.

Interestingly, these current programs do not focus on shortening the amount of time or changing the content of the first two years of medical school, the “basic science” years. This struck me as odd, because when I went to medical school (Loyola-Stritch) in the mid-1970s, it was precisely this component that was shortened (to 12 months, with 2 full years of clinical training). Loyola was far from the only school to do so during that period; my current school, the University of Kansas and many others did so; according to an article by Walling and Merando in Academic Medicine[1] “…By 1973, 27% of U.S. schools offered compressed three year curricula.”  For most, this was not a “track” but was the curriculum for all students. The primary method of shortening the curriculum was abbreviating the time spent in basic science, although the amount varied (at KU it was 15 months). It is thus, to me, surprising that in the current efforts to decrease the length of training very little attention has been paid to shortening the basic sciences. Walling and Merando note that “Although educational outcomes were very similar for three-year and four-year curricula, most schools subsequently reinstated the fourth year to provide students with a broader clinical experience.” I don’t completely buy that; at least at Loyola, the clinical experience was not shortened during its 3-year curriculum. It surprised me in talking to people at the conference that so few even knew about these “experiments” from the 1970s.

My guess is that the current efforts focus on reducing the 4^th year rather than the first two years because of politics. No one “owns” the 4^th year, but the first two years are “owned” by the basic sciences in most medical schools, and by a strong advocacy constituency in the Association of American Medical Colleges (AAMC), the National Board of Medical Examiners (NBME) which offers the US Medical Licensing Examinations (USMLE) and other groups. They have strongly resisted efforts to decrease the time spent on basic science teaching in medical schools individually, as well as nationally. An effort by the NBME to combine the 3 “steps” of the USMLE into two was seen as “elimination of Step 1” and generated huge opposition from the basic science community; the change has been put on hold for several years.

While the need for students to pass “Step 1” is often used as the ultimate reason to not cut back biologic science curricular time, the fact is that students can pass this test with significantly pared-down content. Hopefully, however, there is a better reason to teach basic sciences. That would be that learning the concepts that are important for everyone training to be a doctor to know rather than forcing the memorization of details that are irrelevant, can be looked up, or are likely to change regularly. It means both subjecting the content of curriculum to the this test of relevance, and increasing the breadth of disciplines included as “basic” to include social sciences such as psychology, anthropology, sociology, epidemiology. The teaching -- and testing -- of all this material should focus on understanding concepts, solving problems, and knowing where to look up detailed facts, rather than memorization.

We do need more primary care doctors, and more family physicians to meet the health needs of the American people. We need to do everything possible to make this happen, and addressing financial incentives is a big part of it. Another plenary presentation at the meeting from STFM President Jerry Kruse addressed the successful efforts in Canada to increase the number of primary care doctors (in that country, all family physicians); the key element is decreasing the ratio between primary care and specialist income, and the effective ratio is between 80-85%. There are also good arguments for decreasing the cost of medical education, and perhaps shortening medical school is one method of doing so, especially if it can be done without sacrificing important training; it certainly needs to be relevant training.

But these efforts – to increase the primary care workforce and to consider the appropriate length of medical education – are different. They may complement each other, or may not. The strategies that we employ should be based on their effectiveness at achieving our goals, and for that to happen we need to be clear on what those goals are.  Piecemeal approaches may ultimately work, but they are not the most efficient ways of approaching the problem.

Of course, in terms of health insurance reform, piecemeal is the way we have chosen to go rather than a comprehensive national health program such as Medicare for All; why would we expect a more rational approach to improving medical education?

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[1] Walling A, Merando A, “The Fourth Year of Medical Education: A Literature Review”, Acad Med  November 2010  85(11): 1698-1704.

Kansas, Medicaid expansion, and human rights

In his well-covered “state of the state” speech, the Governor of Kansas, Sam Brownback (full text from the Lawrence Journal World, reported by the Kansas City Star or as you prefer either the Huffington Post’s reporting of it or the Kansas City Business Journal’s), addressed the thorny issue of Medicaid, the program that ostensibly provides medical coverage for the poor, but in reality only covers a portion of them. Most states do not cover childless adults, no matter how poor, unless they are demonstrably disabled, and what qualifies varies from state to state. The financial standard for eligibility is also very variable from state to state; in many places, including Kansas, it is well below the poverty line. Most Medicaid recipients are children in dire poverty and their mothers, and most Medicaid dollars are spent on nursing home care for the medically indigent (and, given the cost of nursing home care, it is really easy to become indigent if you are in one for very long). One of the mainstays of increased coverage for the uninsured in the Affordable Care Act (ACA) is the expansion of Medicaid to all people under about 140% of the federal poverty level.

Brownback said that “Many states have made the choice to either kick people off Medicaid or pay doctors less. Neither of those choices provides better outcomes. Kansas has a better solution,” but, while whether it is better or not may depend upon one’s interpretation of that word, it is not likely to cover more Kansans. He has indicated that no state money would be spent on expanding Medicaid. This does not, however, mean that there will be no Medicaid expansion in Kansas, as for the first several years the costs of such expansion under the ACA will be 100% borne by the federal government. If the state opts for taking the money (and the governor, unlike many other very conservative governors in the US, has been coy about this) it will be able to do so without state dollars. Brownback is committed to eliminating the state income tax, to compete with states like Texas (“Look out Texas, here comes Kansas!”) and is confident, along with his funders like “Americans for Prosperity”, that business growth resulting from his already-implemented tax cut, which has cut almost 1/3 of the state budget income, will more than make up for it (critics note that other states without income taxes have other big sources of revenue, such as oil in Texas and tourism in Florida, that Kansas does not have). This job growth is also part of his plan for getting people off Medicaid “With jobs providing an off ramp from Medicaid, we will be able help those in need of services and reduce our waiting list.” (Did I mention there was a waiting list?) But, of course, this assumes that those jobs will come with health insurance. Definitely not a certainty, as most will be low-wage jobs, the kind most likely to not have health insurance coverage, and a state requirement for such coverage is definitely not something supported by the Governor or his political allies.

Whether Brownback will actually refuse the federal funds is uncertain; not all conservative governors have stuck to this principled, if cruel, position. Governor Jan Brewer of Arizona, a darling of the right with her aggressive enforcement of Arizona’s anti-immigrant laws (in an interesting coincidence, largely written by Kansas Secretary of State Kris Kobach), has reluctantly agreed to accept this money (“Medicaid expansion is delicate maneuver for Arizona’s Republican governor”, New York Times, January 20, 2013), as have Republican governors Susana Martinez of New Mexico and Brian Sandoval of Nevada. Of course, all three have a large and growing Latino population which supports and will benefit from Medicaid expansion, and whose votes are becoming increasingly important. Latinos are also the fastest growing population in Kansas, accounting for 70% of the state’s population growth from 2000-2010; they are not only in the bigger cities such as Wichita and Kansas City – the state’s first majority-minority counties are in its southwest -- but they are still not a significant enough voting block for Brownback to have any concern that they might swing an election to a Democrat. Indeed, in the 2012 election, extremely conservative Republicans supported by the Governor and lots of money from Wichita’s Koch brothers unseated most of the states just very conservative Republicans in primaries, giving him control of the state senate as well as house. Indeed, one of those defeated was the Senate majority leader, a rancher from the far southwestern corner of the state where the Latino vote did not prevent him from being beaten by a Koch-funded political newcomer.

Of course, there are reasons to doubt the core economics of Governor Brownback’s policies, based on the state’s economy picking up as a result of his tax cuts; even if one believes that will happen, it will be a long time and those whose benefits have been cut (who, given that the vast majority of the state budget is spent on education, followed by Medicaid and other core social services for the aged and disabled, will be the most vulnerable and our future) will suffer. As for the benefit of no state income tax, I lived in Texas, and the result is that every other tax is burdensome, and those taxes are much more unfair than a graduated income tax: real estate taxes that hurt the elderly and sales taxes that hurt those for whom the costs of the necessities of life are most of their income.

Expanding Medicaid, as called for by ACA, will not solve the problems of uninsurance. There remain not only the undocumented, but those who are employed by businesses that do not provide health insurance, including many that are too small to be required to do so even under the new law (and these are the jobs that Brownback’s policies, if they are successful, are most likely to create). But it will certainly help many families. And that should be the role of government, to help its people survive, and become educated, and be able to maintain their health. Economic growth will likely follow, at least much more likely than by cutting the taxes on the most wealthy.

And of course, at the most basic level, economic growth is not the goal; it is at best a strategy for improving the lives of our people. An article in Kansas City Star on January 20, 2013 ( “As the number of minority students grows in area schools, a learning gap remains” addresses the growth of minority, African-American and Latino, students in suburban as well as inner-city school districts. The article notes that the way school taxes are tied to real estate, “The rich get richer.” But it also quotes an educational leader who notes that “The moral imperative is now an economic imperative….The purchasing power of the new generation will depend heavily on the achievement of students of color. Social Security will need their economic success.

‘Everyone needs to understand…Someone else’s child is directly linked to your economic security.’” That is all true, but, at bottom, the core reason to provide education and health care is not so people will be able buy more stuff.

Recently, I saw the movie Les Misérables. I may be one of the few who did not see the stage play, but I am familiar with the story and loved the Jean-Paul Belmondo version set in WW II. Yes, it was long and not every actor was a great singer, but it told the story, and the story is of the oppression of the poor by those with power, and the occasional brave resistance of people who speak truth to power. And, in the last scene, after Jean Valjean dies, he is transported to a heaven not of clouds and harps and angels with wings, but one in which he and all of those who fought with him are standing on a barricade, continuing the fight.

Yes, the rich and powerful will buy and will influence politicians, and they will often win. But as health workers, and as citizens, it is our job to keep on advocating for the core needs of people, especially education and health care, to be met, not as a byproduct of economic development but as a human right.

The flu is a virus!

It is winter and a lot of people are sick. Around here, and around the country, there are two big kinds of sick – one is mainly gastrointestinal disease with vomiting and diarrhea as the main symptoms, and the other upper respiratory infections with congestion, cough, and sometimes shortness of breath as the main symptoms. The first (GI) are mostly caused by norovirus in adults and adolescents and rotavirus in small children (and, recent reported, the elderly). The respiratory version is frequently influenza, or other viruses.  Viruses. Not bacteria, which can be treated with antibiotics. Viruses do not respond to antibiotics.

This is not to say that they cannot make you very sick. They can, and do. Especially in the old and very young and immunocompromised, influenza virus can lead to major bacterial complications and death; the swine flu outbreak of 1918 killed more people than WW I. When there are major influenza epidemics, there is a big excess of deaths. This is a really good reason to get the flu shot. Everyone who does not have a firm contraindication (e.g., allergy to eggs, a previous episode of Guillain-Barre syndrome) should receive the vaccine. People should expect that their health care providers have received the vaccine. It is not 100% effective, but it is very effective, and helps make the disease milder even if you contract it, and it decreases transmission.

It is not a reason to get antibiotics for a viral upper respiratory infection or bronchitis. Pneumonia, yes (even though a fairly large percent of pneumonias are viral, it is hard to tell); pneumonia as a complication of influenza, particularly in elderly or immunocompromised people with other chronic diseases (heart, lung, kidney, diabetes, cancer) is very serious. But these people, who have or are likely to have bacterial pneumonia and need antibiotics, represent a tiny fraction of the people treated with antibiotics for viral bronchitis (not to mention even less severe viral upper respiratory infections such as sinusitis, non-strep pharyngitis, and otitis). Bronchitis is no fun. It can make you feel miserable, create chest pain when you cough, and generally make you really sick. It can also last a really long time – 4-6 weeks of coughing is typical. But viruses don’t respond to antibiotics, even if you’ve been sick for a week or a month.

A recent study published on-line-before-print in JAMA-Internal Medicine by Gonzales and colleagues[1] looked at the use of decision support by either paper algorithms or computer systems in reducing the use of antibiotics for acute bronchitis in a very large multi-practice group in rural Pennsylvania (Geisinger Health System). They found basically two things: both the paper and computer assisted decision support tools reduced the rate of antibiotic prescribing about equally and both did so significantly more than in “control” practices that got neither. Unfortunately, the rate dropped from about 80% of to about 68%; that is, a large majority of those presenting with acute bronchitis received antibiotic prescriptions even after the intervention.

In a “Commentary” in the same issue, “Antibiotic Prescribing for Acute Respiratory Infections—Success That’s Way Off the Mark”[2] , Jeffrey Linder notes that the problem with the study is that the “success” was very limited; that is, it moved the inappropriate use of antibiotics down, but it was still many times too high. His comparison is to the use of aspirin after heart attack, and how improving the rate from 30% to 40% would have been inadequate; luckily we are now at 94-99%. Another metaphor, more graphic, would be if we were happy that, over 10 years, the number of people killed by the average mass murderer dropped from 15 to 12!  

“Since 2005," Linder notes,"a Healthcare Effectiveness Data and Information Set measure for patients aged 18 to 64 years states that the antibiotic prescribing rate for acute bronchitis should be zero. Despite the evidence, meta-analyses, and performance measures, antibiotic prescribing for acute bronchitis in the United States remains at more than 70%.” He is critical of the Gonzales study because, even after its “statistically significant” intervention, “The antibiotic prescribing rate—an event that should never happen for these patients—in ‘successful’ intervention practices was still more than 60%. For individual clinicians…we need to redefine success. Success is not reducing the antibiotic prescribing rate by 10%; success is reducing the antibiotic prescribing rate to 10%.”

Or less. Many people will say “I got antibiotics and I felt better in a couple of days”.  Almost all of these people would have gotten better anyway. There are some studies that show, in large populations, taking antibiotics can shorten symptoms by about a half-day. (This is probably because of some minor bacterial co-infection in some folks, especially those with chronic lung disease). But not by a week, or 2 or 3. Length of time of symptoms is not an indication for antibiotics for a viral illness. And that half day? Linder points out that “5% to 25% of patients who will have an adverse reaction. Worse, at least 1 in 1000 patients who take an antibiotic will wind up in the emergency department with a serious adverse drug event.”  This is, to put it mildly, not good.

Let’s review this: acute bronchitis, much less other “colds”, are viral and viral infections do not benefit in any way from treatment with antibiotics. They can, however, last a long time, and make you miserable. These symptoms are still not indications for antibiotics. The algorithm used by the Geisinger group, and posted on the walls of their examination rooms, is attached. There are some people, particularly the old, immunocompromised, and those with chronic bronchitis (mostly long-time smokers) who can develop pneumonia, which should be treated with antibiotics. They do not have acute bronchitis.

Doctors and other health professionals should know this, and most of them do. Sadly, however, they not only frequently prescribe antibiotics for viral illnesses because their patients “want them”, but also take them themselves for the same non-indications. Doctors, nurses, and others are among the greatest “abusers” of antibiotics (by which I mean taking them when they are not needed). Amazingly, many of these same health care providers are those who do not get the influenza vaccine, which they should be getting! The justification of “I need to stay healthy, and can’t miss work, because I need to care for my patients and don’t want to transmit illness to them” is wrong on 3 counts: 1) Taking antibiotics for a virus won’t make you less sick or shorten the course of your illness, 2) Taking antibiotics won’t prevent you from transmitting a viral illness, and 3) Taking antibiotics for a viral illness increases the risk of superinfections (e.g., yeast vaginitis), drug reactions, and the development bacteria that are resistant to common antibiotics, which you can spread to your patients. By the way, you also don’t need antibiotics for norovirus or other viral (or, indeed many forms of bacterial) gastroenteritis.

This Batman-and-Robin cartoon illustrates the frustration that many of us feel. Obviously, we cannot even think about literally or figuratively treating our patients that way, but I think one of the interesting parallels is that the person asking Batman for antibiotics is not a “regular person” but Robin, a kind of Batman-in-training, and thus Batman’s frustration mirrors that many of us feel when our own trainees (students and residents) inappropriately use antibiotics for themselves.

Linder says “We should address patients’ symptoms, but for antibiotics we need to tell our patients that ‘this medicine is more likely to hurt you than to help you.’” Those of us who are sick and not health care providers need to understand that; those of us who are health care providers have an even greater responsibility.

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[1] Gonzales R, et al., A Cluster Randomized Trial of Decision Support Strategies for Reducing Antibiotic Use in Acute Bronchitis, JAMA-Internal Medicine Published online January 14, 2013. doi:10.1001/jamainternmed.2013.1589

[2] Linder, J, “Antibiotic Prescribing for Acute Respiratory Infections—Success That’s Way Off the Mark” JAMA-Internal Medicine Published online January 14, 2013. doi:10.1001/jamainternmed.2013.1984

Weight and class: who is obese and why should we care?

One of the things that people are most fixated upon, in both the health arena and in society at large is weight. In popular culture, weight is a major issue. Celebrities are (mostly) thin; when they are not, and look like more of the regular people who are around us, they are seen as unusual. Diet books and “fad” diets abound as do classes to help us exercise. Issues of body image are major stressors for adolescents in particular, and health problems like anorexia are all too common. And, yet, an increasing number of Americans are obese, and health problems that are certainly associated with obesity – notably, but not only, Type II diabetes – are rapidly growing.

There is a major class association with weight; as income and class go down, prevalence of obesity goes up. Perhaps ironic compared to earlier centuries, when being heavy was associated with money – that is, the ability of the person to afford all that food – and poor people were starving. But if ironic, it is serious; the abundance of cheap, high-calorie foods in our society mean that poor people are not denied the opportunity to have lots of calories, but the stressors of poverty that affect all aspects of social life are still there, creating obesity as just one more problem to be confronted (or not).

In this context, a recent article in JAMA by Katherine M. Flegal and colleagues has garnered a lot of attention. “Association of All-cause mortality with overweight and obesity using standard Body Mass Index Categories: A systematic review and meta-analysis”[1], reviewed 97 studies with over 2.8 million people and encompassing 270,000 deaths, and performed a meta-analysis (a set of statistical techniques that allows accounting for studies that are somewhat different in design and have different numbers of people). The results were that people whose body mass index (BMI, a ratio of weight to height) was in the “overweight” range (25-30) had lower all-cause mortality than those in the “normal” range (18.5-25). In fact, the all-cause mortality rate was no higher for those in the range of “grade 1 obesity” (30-35) than for those in “normal” weight range. However, it was higher for those with grade 2 obesity (35-40), grade 3 obesity (>40) and for all obesity taken together (>30). In addition, unsurprisingly, the “hazard ratios” for mortality were greater for the same BMI when heights and weights were self-reported rather than measured (suggesting people under-estimate or under-report their weight, which would mean their BMIs are actually higher than reported).

This is not, of course, really new news, since all of the studies reviewed had been previously published. There was already a sense among many in the medical field that people at the “low end” of overweight (say 26-27) might be as least as healthy (have as low a mortality risk) as those at the low end of “normal” (18.5-25).  Heymsfield and Cefalu, in their editorial commenting on this study, “Does body mass index adequately convey a patient’s mortality risk?”,[2] say “Persons with a BMI between 18.5 and 22 have higher mortality than those with a BMI between 22 and 25. Placing these persons in a single group raises the mortality rate for the normal weight group. The average resulting from combining persons in the lowest mortality category (BMI of 22-25) with those who have greater mortality (BMI of 18.5-22) might explain why the NHLBI category of normal weight has an observed mortality similar to class 1 obesity (BMI of 25-30).”

If people with a BMI of 18.5-22 have a higher mortality rate than those with a BMI of 25-30, why, for goodness sakes, is 18.5-25 considered “normal”. For reference, a 5’4” person with a BMI of 18.5 would weigh about 108lbs, at a BMI of 22 it would be 128lbs, at 25, 145lbs, and at 30, 175lbs. For a person who is 5’10”, the weights at the same BMIs would be about 129, 152, 174, and 207. I think most people would not think that the lower range was normal except for models and marathon runners (hey, I’m overweight and would like to lose about 10-15 pounds of fat, but I think I’d be pretty sick before I lost the 60 lbs needed to get me to 22! My son was heavy when he developed Type I diabetes as a young adult, and went from a BMI of about 32.5 to about 21; let me tell you, he looked bad!), but the real question is “what are the healthiest ranges to be at”? This is what official recommendations should be based on, and it is clear from the work reported by Flegal and colleagues that this is not the case for the current numbers.

The relationship between adiposity (presence of significant amounts of excess fat) and risk for many diseases is well-established; the relationship between adiposity and BMI less well so. Variables include amount of muscle mass (not a risk factor but leading to greater weight-for-height), sickness (people who lose weight as a result of disease), and overall body structure. I tried to find out where these ranges come from, but have, so far, been unsuccessful. I found the references to the “Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults”, put out by an expert panel in 1998, but at least their “Executive Summary”^[3] does not reveal the source of how the “normals” were derived; they are just asserted. 

Obviously, this is going to be controversial. Paul Campos’ op-ed piece in the NY Times on January 3, 2013, “Our absurd fear of fat”, makes many of the same points I have, but letters generated in response range from those lauding it and saying people (especially children) should be taught to be proud of their bodies, to those arguing it minimizes the health dangers of obesity. What is clear, though, is that the fixation on “ever thinner” that exists in much popular culture has no place in health discussions. The JAMA article strongly suggests that our standards for “normal”, “overweight” and “obese” BMI are too low, although not irrelevant. It calls our attention to a tendency to other similar areas in which health professionals have adopted uni-dimensional disease markers and driven them even lower, to result in poor health outcomes for many. Recent examples include blood sugar (or its related value, hemoglobin A1c), blood pressure, and cholesterol. Studies that held everything else equal found benefit in lower values, so experts kept driving down the definitions of normal and desirable for these tests. Unfortunately, not everything else is equal. Pushing the desirable hemoglobin A1c level of people with diabetes to 5% instead of 6% led to a lot of morbidity from hypoglycemia; lowering cholesterol goals led to toxicities from drugs; lowering blood pressure goals to poorer functioning and greater mortality in some populations, especially the elderly. Most people don’t exercise regularly, but rather than lauding all efforts to exercise, “experts” keep raising the bar for how often, how long, and how intense exercise should be.

So let’s get back to class, and its associated characteristics. It is time for health professionals to recognize that they are also social service professionals and members of a society whose broad policies have a much more profound impact upon health than small numbers variation in BMI, blood pressure, cholesterol, and blood sugar. We need to treat, as well as support and encourage, people at the extremes whose health is at risk, but we shouldn’t fall prey to definitions that name more people as diseased and needing interventions and distract us from the real business at hand.

Which is creating a more just, fair, equitable and safe society.

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[1] Flegal KM, et al., “Association of All-cause mortality with overweight and obesity using standard BMI Categories: A systematic review and meta-analysis, JAMA Jan 2 2013;309(1):71-82

[2] Heymsfield SB, Cefalu WT, Does body mass index adequately convey a patient’s mortality risk?” JAMA Jan2 2013;309(1):87-88.

[3] Expert panel, “Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: executive summary”, Am J Clin Nutr, 1998;68:899-917.

Mental Illness and Guns: A public health perspective

I have been somewhat reluctant to write about the issues surrounding the mass shootings that have become epidemic in our country. Since the Newtown elementary school massacre it appears as if everyone else has done so, and I didn’t know what, if anything, I could add that would be of value. I still don’t, but I would like to try to emphasize the public health and medical issues here. Everyone talks about getting beyond rhetoric, but mostly we hear rhetoric and have yet to see results.

In his column in the New York Times on December 28, 2012, “Guns and Mental Illness”, Joe Nocera addresses those two aspects of the controversy, which I agree are the key ones. However, while I generally think his points are valid, I disagree with his characterization that gun control is a “liberal” issue while mental health has been the focus of conservatives. For good, or bad, and too often bad, both issues have been neglected by too many for too long. When it comes to death, dramatically in the case of mass killings such as Newtown or Aurora or Columbine, much more commonly in “simple” individual killings, and most commonly in the case of suicide, they are tied together. Nocera starts with mental health, so I’ll start with guns.

I have written about guns several times before (“Mexican Murders and US Guns”, March 24, 2009,

 “The Arizona shootings: When will we ever learn?“, January 9, 2011, “Why we don’t spend enough on public health”, September 22, 2011, and even discussed a New England Journal of Medicine article (Why we don’t spend enough on public health”)[1]  by Dr. David Hemenway of the Harvard School of Public Health and Director of their Injury Control Research Center and Youth Violence Prevention Center (“Public Health and Changing People's Minds, May 15, 2010). Guns are efficient and effective killing machines. This is, after all, the reason that hunters and warriors like them. They can be made more efficient, by being automatic or semi-automatic, and by having magazines that hold many bullets. These are generally considered positives on the war side (and by gangsters), but are often seen as “un-sporting”, so that most states have laws governing their use in hunting. The statistics on gun violence in the US are staggering, and seen from a public health perspective represent a severe and continuing epidemic. Likely the best book on this topic is “Private Guns, Public Health”[2], by Dr. Hemenway. He presents extensive statistics on injury and death resulting from guns, and emphasizes a addressing this problem through efforts to both increase the safety of guns themselves (as we have for cars) and limiting their availability (as we have for cigarettes). This is a harm-reduction approach.

Much of the data cited by Hemenway is sobering, and some is so downright shocking that one might think it difficult to ignore. There are over 30,000 suicides in the US per year, and a high proportion are from guns, because guns are much more effective, and are less likely to allow a second chance; the “success” rate for suicide by gun exceeds 95% while for intentional overdoses it is less than 5%. One of the populations most at risk for suicide is young men; Hemenway notes that the successful suicide rate in this group is several times higher in “low gun control” states (mostly Southern and Mountain) than in “high gun control” states (mostly Northeast and Hawaii). This is not because of less suicidal intent in, say, Massachusetts than Montana, but the easy availability of guns.[3]

But we know about the effectiveness of guns. You can kill someone with a baseball bat, or a knife, or a lead pipe or wrench or candlestick in the Library, but not as efficiently, reliably, effectively, and potentially randomly as you can with a gun. The recent episode of a knife-wielder in China is one example. Adam Lanza wouldn’t have been able to kill many with a candlestick. Innocent children are rarely victims in drive-by knifings. The NRA used to say “guns don’t kill people, people kill people”. Yes, but they do it much better with guns. Now they say that the solution to “bad guys with guns” is “good guys with guns”. This is so ridiculous (can you imagine a bunch of “good guys” blazing away at whoever they thought might be the shooter in the dark in the Aurora, CO, theater?) that NRA bumper stickers are now being amended by new ones saying “Not MY NRA!” in response.

What about mental health? Nocera does an excellent job of summarizing the problem confronting the chronically mentally ill; with a progressive philosophy of “de-institutionalization” mental hospitals were closed with the promise of comprehensive, community-based mental health services being available in the community. But, of course, funding was not forthcoming for those services, nor does it appear that it will ever be adequate. Nocera is correct in saying conservatives have pointed to mental illness (rather than guns) as the cause of such violence, but in addition to not supporting any gun regulation, these same “conservatives” have led the charge in de-funding and under-funding mental health services. The constituency supporting such services, especially for those who cannot afford private care, is not big or effective enough. Apparently these politicians are in favor of supporting (retroactively) mental health care for those who commit mass murder, but not prospectively for the millions in need. One word that is commonly used for such an approach is “hypocrisy”, but this does not shame politicians.

I have written about the “sensitivity” and “specificity” of tests, particularly with regard to screening.  However, the same concept can be used for assessing risk of any condition, such as mental illness and the probability of committing gun violence on a large scale. If “committing mass murder” (as opposed to individual homicide or suicide) is considered the disease, then assessing for mental illness would be pretty sensitive – that is most mass murderers are mentally ill and there are relatively few “false negatives” – people who are mass murderers but not mentally ill. But it is pathetically not specific, for the overwhelming number of mentally ill persons will never be mass murders. They would be “false positives”. But this in no way means that they should not receiving comprehensive and effective mental health services.

So, which is the greater problem? Which should be addressed first? The answer is both, and, more to the point, either would be an improvement. On guns, there need to be bans on assault and automatic weapons and on high-capacity clips and “cop-killer” bullets, and background checks on gun purchasers and closure of the “gun show loophole”. On mental health, there need to be ubiquitous and well-funded mental health treatment programs in all of our communities, with outreach workers and close collaboration with primary care medical providers. Both strategies are critical, both are quite (although, obviously, not completely) effective in other countries.

But I would be happy if we would do one of them. I mostly, however, hear a lot of talk and am fearful that we will, ultimately not do either.

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[1] Hemenway D, “Why we don’t spend enough on public health”, NEJM 6May2010;362(10);1657-8.

[2] Hemenway D. “Private Guns, Public Health”. University of Michigan Press. Ann Arbor. 2004.

[3] Full disclosure: Ten years ago, my 24-year old son committed suicide with a gun. As far as I know, he’d never used one before. He left his home in a “high gun control” state and went to a “low gun control state” where he knew no one, acquired the gun, and completed his suicide. A testimony to the impossibility of preventing suicide? A condemnation of the ease with which he obtained the gun? Make of this what you will.