Monday 31 March 2014

Reform primary care first, and health care will follow

I mentioned in an earlier posting that fewer medical students each year are choosing to pursue careers in the primary care specialties (family medicine, general pediatrics, and general internal medicine). The reasons for the decline have been documented in other health-oriented blogs such as KevinMD, and are due to a number of factors, including an increasing income disparity between primary care and specialist incomes, the staggering array of conditions that primary care physicians encounter in a typical day at the office, insufficient funding for primary care residency training programs, and a basic research-centered medical education system that limits students' exposure to real-world community practices.

Most industrialized nations with efficient health care systems have roughly a 1:1 ratio of primary care to specialty physicians. In contrast, in the U.S., specialists outnumber generalists by more than 2 to 1, and with less than 15 percent of U.S. medical students choosing primary care careers in recent years, this imbalance continues to worsen.

As is probably obvious if you've been reading earlier posts in this blog, I very much support some form of health care reform that makes primary care available to all Americans. The current reform bills have all incorporated some variation of proposals advocated by groups such as the American Medical Student Association, including expanding the size of the National Health Service Corps (a program that rewards doctors who practice in rural and underserved areas of the U.S. by subsidizing their tuition or forgiving student loan debt), opening new independent, community-oriented medical schools, and preferentially recruiting college students with an interest in primary care during the medical school application process. All good ideas, but they won't be nearly enough to get us to the goal of 50% primary care physicians that will be needed in a transformed health care system.

Bigger, bolder steps are needed to attract medical students to primary care careers. Kevin Grumbach's post earlier this year in the Health Affairs blog summarizes what these steps - largely financial incentives - need to be. To this list, I add one more. For the past 5 years, I have taught medical students and primary care and preventive medicine residents at two universities where these disciplines are often underemphasized, and where my specialty - the essential cog in the wheel of any high-achieving health system - is openly degraded as not being prestigious enough for the best and brightest students. This perception can and must change before American health care can truly be considered to be "reformed."

Medicine and the not-so-free market

In the health care reform debate, some people argue that the solution to skyrocketing cost of health services is to encourage more "free market" competition to lower prices, rather than expanding public funding and controls. There is some value to this argument; generic drugs, which cost as little as $4 for a 30-day supply at national retailers such as Wal-Mart, Target, CVS, and Giant, have helped to take a bite out of many people's prescription costs.

Unfortunately, most of American medicine does not function like a free market or obey the laws of supply and demand. In an true free market, the supply of MRI machines would correspond to the number of scans that needed to be performed. In fact, MRI machines are huge money-makers for hospitals and radiology practices, which create their own artificial demand. Instead, the maxim uttered by Kevin Costner in "Field of Dreams" (If You Build It, They Will Come) applies. The more MRI scanners there are in a given city, the more MRI scans will be done, regardless of the actual need for this test. Every few days, I get a phone call from a private radiology unit in the DC area to "let you know that we have open appointments for today, just in case you need to refer a patient to us." While I'd like to think that I wouldn't order an MRI for something like back or neck pain unless it was really needed, same-day availability is awfully tempting to physicians and patients. (This also explains why there are so many more MRI machines in the U.S. than there are in Canada. It isn't that they have too few, it's that we have many more than we actually need.)

This practice isn't limited to Radiology, either - for examples of how the availability of procedures drives up costs related to heart procedures, see Atul Gawande's recent piece in the New Yorker. Build a cardiac catheterization laboratory, and more catheterizations will be performed. Build more hospital beds, and more patients will be admitted instead of sent home for treatment. For the past quarter century, a team of researchers at Dartmouth has been using data from Medicare to produce an atlas that documents wide variations in health resource utilization across the U.S. Not only have they found that where you live has everything to do with how much health care you receive, but there is no relationship between cost and quality of that care. So much for the free market!

Who are the uninsured?

If you're a fan of competitive cycling, like I am, you may have read Lance Armstrong's compelling memoir "It's Not About the Bike: My Journey Back to Life." A little-known fact is that soon after being diagnosed with a highly aggressive form of testicular cancer, Armstrong, having recently switched cycling teams, found out that his new sponsor's health insurance would not pay for cancer treatments because they considered his illness to be a pre-existing condition. Even though Armstrong was a wealthy world-class athlete, the cost of these treatments would have nonetheless rapidly depleted his considerable savings. Fortunately for him (and us), a personal appeal to his sponsor resulted in a quick reversal of the decision, permitting Lance to undergo arduous treatment, emerge a survivor, and win the Tour de France 7 straight times from 1999 to 2005 and finish 3rd in a comeback this year to raise awareness for his cancer foundation.

Most uninsured or underinsured Americans aren't so lucky. In contrast to public perceptions that the 47 million uninsured are either unemployed and destitute (and therefore actually eligible for Medicaid) or young, healthy people who choose to be uninsured to save money (see this recent Washington Times editorial), 3 independent national health surveys have found that 2/3rds of the uninsured are employed adults, more than half of whom earn less than 200% of the poverty level (less than $37,620 for a family of four in 2003). For example, although Wal-Mart recently came out in support of an employer mandate to provide health insurance, in 2006 they only provided insurance to 46% of their employees.

Physicians and storytelling, Part II

In 2003, while in my second year of family medicine residency, I wrote a personal statement for a leadership award that described the intertwining of my writing and doctoring ambitions into the occupation of a "physician-storyteller." I didn't win the award, but from my current vantage point, it still resonates. (This is the second of two posts.)
**

One story that I have found particularly compelling during residency is that of patients with HIV/AIDS. In July 2002, I did an elective rotation in Lancaster General Hospital’s Comprehensive Care Center, a Ryan White Care Act supported medical clinic. I was impressed at how the present-day management of HIV had become similar to that of other chronic diseases such as asthma and diabetes. Yet patients sometimes take their life-prolonging prescriptions sporadically or not at all. Curiosity about the reasons for these self-imposed “sustained treatment interruptions” (STIs) prompted me to join a fellow resident and attending in surveying our patients’ understanding of STIs and how it influenced their adherence to complex medication regimens. As part of this project, I personally reviewed the charts of nearly one hundred patients to collect information about past medical and social histories and am now involved in the analysis of this data. We plan to communicate our findings at the next Pennsylvania Academy of Family Physicians Research Day.

The service and research opportunities that I have enjoyed in residency would not have been possible without my program’s unwavering support and flexibility. That flexibility was severely tested during my internship year, when the program endured a crisis of change. The retirement of the only Program Director we had ever known, along with a decline in applications to family practice nationally and new resident work hour regulations, prompted the program’s most significant curricular revisions in a decade. As a member of my residency’s work hours committee, I became a tireless advocate for redesigning the intern schedule in a way that was more humane in terms of post-call duties but preserved the crucial educational value of those on-call nights. At the start of my second year, I and another resident formed an intern support group that meets monthly with a community preceptor to further bolster morale. These changes effectively reduced the burdens placed on current residents and made our program more appealing to prospective applicants. My positive experience in improving the working conditions of my fellow residents encouraged me to run for, and win election to, the position of Chief Resident. This year I’ve tackled several major administrative hurdles: scheduling for a block conference curriculum; developing an emergency plan for inclement weather days; and transitioning from a single continuity office practice to urban and rural tracks.

Of physicians, English professor Brian Ferguson-Avery wrote in JAMA: “Their years among the human animals have shown them futility, sadness, compassion, and the occasional hard-won triumph. As a result, they can better consider the big questions posed – and sometimes answered – in books.” I could not agree more. Although I have just begun my career as a family physician, my experiences in community service and resident leadership have melded with my writing talent to make me a better storyteller to my patients in every chapter of their lives.

Physicians and storytelling, Part I

In 2003, while in my second year of family medicine residency, I wrote a personal statement for a leadership award that described the intertwining of my writing and doctoring ambitions into the occupation of a "physician-storyteller." I didn't win the award, but from my current vantage point, it still resonates. (This is the first of two posts.)

**

I once believed that physicians belonged to just two types: the engineers and the storytellers. Let me explain. Physician-engineers scrutinize the human body and its components and recommend how to improve performance and extend shelf life. Physician-storytellers take a different approach. Instead of using hammers and slide rules, they ply patients with tales of struggles won and lost: for example, Johnnie Walker who couldn’t stay away from the neighborhood bar and died when his liver gave out. In place of diagrams, storytellers pester and cajole until pre-contemplation evolves into action, and they achieve the same – if not better – results.

Of course I now understand that the best kind of physician is both capable and humane. Yet I have always identified with the storyteller. In college, I combined a love of writing with a desire to make a difference in lives that I could not reach with a pen. I threw myself into volunteer work with children of all ages: as a Big Brother to Duy and Phuong, whose family had immigrated from Vietnam two years before; as a teacher at Martin Luther King, Jr. Elementary, where a fellow “ExperiMentor” and I conducted a series of lessons about the science of water; and as an SAT tutor in CHANCE, an after-school program for high school students who aspired to be the first in their families to attend college.

Although these interactions contained their share of inspiring stories, I was also driven to create my own. Along with contributing to an intercollegiate literary magazine, I wrote articles for and eventually served as Editor-in-Chief of the Harvard Science Review, a bi-annual popular science journal. In medical school, I helped to found a creative writing club and literary magazine Agora. During residency, I have taken evening classes in poetry and non-fiction at Elizabethtown College while writing medical articles for Central Penn Parent and American Family Physician.

Family practice called to me because I saw how the discipline’s emphasis on preventive health care allows physicians to shape patients’ life narratives. During medical school, I counseled teenage mothers on the importance of tamper-proof cribs and car safety seats. In addition, I spent Wednesday evenings at the Bellevue men’s shelter teaching residents about smoking and alcohol cessation. I’ve continued preaching the gospel of health maintenance in residency as a volunteer physician at the Water Street Rescue Mission Medical Clinic, where I add a dash of prevention to every spoonful of cough syrup. As a preceptor for a pre-medical program at Franklin and Marshall College, I advise future physicians that real-life medical drama isn’t always acute, and that success can be measured over decades as well as seconds. Last fall I became the program’s co-coordinator.

Sunday 30 March 2014

Why government-run health care can be good for you

Many politicians and television commentators are making "government-run health care" sound like a string of dirty words. I have a different view. To me, government-run health care makes me think about a patient I cared for during my family medicine residency - I'll call him Ed - whom I met while volunteering at a free clinic in Lancaster, PA. Ed was a well-educated man: he had a Masters in Divinity and formerly directed a nonprofit. But at that point he was just beginning to climb out from a disastrous time in his life, having fallen victim to alcohol and heroin addiction and losing his job, home, and family. A few months earlier he learned that he had diabetes, but having no health insurance or primary care doctor, Ed let his sugar level spiral out of control until he was hospitalized in a coma from diabetic ketoacidosis, an often fatal condition when the body's metabolism, unable to turn sugar into fuel, produces waste products that dangerously acidify the blood. Fortunately, doctors were able to reverse the process in time, and Ed pulled through.

Ed arrived at the clinic for his post-hospital follow-up visit the night I happened to be volunteering. I almost couldn't believe my eyes as I reviewed the laboratory results and hospital records he brought with him. He was lucky to be alive. Unfortunately, he had been prescribed several medications that, having virtually no income and living in a homeless shelter, he couldn't possibly afford. The clinic stocked some donated medications, but not nearly enough to supply Ed's needs for more than a few days - after which his diabetes would inevitably worsen until he would be back in the hospital again, or worse. Through a social worker at our hospital, I helped Ed apply for Pennsylvania Medicaid (health insurance administered by state governments with federal government subsidies), and was able to see him in my regular office.

I cared for Ed for nearly 2 years. During that time, we not only controlled his diabetes, but he was able to get back on his feet emotionally, spiritually, and financially, eventually moving into his own apartment and holding down a paying job as a counselor. That's what "government-run health care" can do. And if you're thinking that you'll never be stuck in a situation similar to Ed's, I'd ask you to consider what you would do if you suddenly lost your job, if you were disabled in an accident, or some other financial catastrophe happened to your immediate family or friends. The "safety net" isn't enough. Several national organizations representing primary care physicians recently came to the same conclusion; you can see their powerful message on the website Heal Health Care Now.

Lowering costs and improving quality of care

In my last post, I suggested that having fewer primary care doctors compared to specialists was a serious problem for U.S. health care. This may seem counterintuitive. Primary care physicians have a broad range of skills, but most specialists spend more years in training and know their particular area of expertise inside and out. You may wonder what would be wrong with going to see a specialist every time you had a health problem - for example, an orthopedic doctor for back pain or a cardiologist for chest pain? There are two very good reasons: cost and quality of care.



Simply put, there are powerful monetary incentives for specialists to do more to patients, and for primary care to do less. President Obama recently took some flak for suggesting that U.S. doctors' medical decisions are driven by economic incentives rather than what is best for the patient. In cases when the correct course of action is absolutely clear, I would agree with the many physicians who were outraged by Obama's comment. However, most of the time medical decisions aren't black and white - and it's in that wide "gray zone" where money comes into play. The more tests and procedures a specialist performs, the more money he or she earns. At a primary care office visit, on the other hand, payment maxes out quickly - so that there is essentially no difference between treating, say, 5 versus 10 medical problems, and writing more prescriptions or making more referrals doesn't have any effect on the practice's bottom line.


As a result, places with more procedural specialists have significantly higher health care costs (with the same or worse health outcomes) than places with fewer specialists, as Atul Gawande reported recently in the New Yorker. In fact, U.S. counties with more primary care physicians per capita have lower death rates, which some speculate has to do with specialists ordering additional procedures that are unnecessary (because they are not indicated for the patient's problem, or performed more often than guidelines recommend) and carry their own health risks. For example, Alex Krist and colleagues found that gastroenterologists in Washington, DC and Virginia recommended repeat colonoscopy (a screening test for colon and rectal cancer) at shorter intervals than necessary more than 60 percent of the time. They estimated that if this pattern of excessive procedures was similar throughout the country, it would cost an extra $3.4 billion and lead to more than 14,000 serious complications, including 142 deaths.


The bottom line? More primary care relative to specialists is not only good for the country's health, it's good for your health. So the next time you need to see a doctor, visit a family physician or general internist first. And tell your representative or Senator to make improving primary care access an essential part of health reform. As medical blogger KevinMD pointed out earlier this month in an address at the National Press Club, it does no good to give everyone health insurance if there aren't enough primary care doctors in the U.S. to care for them.

On the front lines of medicine

You've probably heard in the news lately that the role of primary care physicians (or primary care clinicians, which includes advanced nurse practitioners who can treat patients independently in many states) will be emphasized more in the health care system of the future. In the 1990s, the heyday of health maintenance organizations (HMOs), these physicians often functioned as "gatekeepers," among other things, determining if it was necessary for a patient to see a specialist for his or her medical problem. Some physicians had employment contracts that actually paid them more money to prevent patients from accessing specialty care - an uncomfortable (if not unethical) role that led to a popular backlash against, and eventual decline of HMOs as a means for controlling skyrocketing health care costs.


The Institute of Medicine has defined primary care as "the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community." That's quite a mouthful! But who counts as a primary care physician, and why are these particular doctors so important?


Family physicians provide comprehensive primary care to patients of all ages; about 1 in 3 family doctors routinely delivers babies. General internists provide primary care for non-pregnant adults, and pediatricians provide care to infants and children through late adolescence (variously defined as 18 or 21 years of age). To complicate matters, many generally healthy female patients rely on their obstetrician-gynecologist (OB-GYN) for primary care, and a few patients with complex medical conditions, such as insulin-dependent diabetes and acquired immune deficiency syndrome (AIDS) may obtain primary care from specialists, such as endocrinologists and infectious disease physicians.


Collectively, primary care physicians are the "docs in the trenches," laboring on the front lines of medicine to diagnose and treat most common acute and chronic health conditions. But for a number of reasons (which I'll get to in a later posting), fewer medical students are deciding to pursue careers in primary care each year, and that's a big problem - not only for the cost of health care, but the quality of health care too. Stay tuned for why this is.

Where do you get your health care information?

If you have a friend or relative who's a doctor or other healthcare professional, you probably ask that person. (I remember getting questions as early as my first semester of medical school, when I was completely unequipped to respond to the simplest of questions, such as what to take for a common cold - though even fully qualified physicians often prescribe unnecessary antibiotics in this situation, as ER physician Zachary Meisel explains.)

Perhaps the most consulted source of clinical information online is the venerable WebMD. But there are other sites that are nearly as good, including FamilyDoctor.org, sponsored by the American Academy of Family Physicians. These websites are becoming increasingly sophisticated, often featuring podcasts and other interactive features in addition to traditional, static educational handouts.

So who or what is your most trusted source of information when you or a friend or relative falls ill? Your family doctor? Your internist? The paramedic you sometimes shoot pool with on Friday nights? Or an "alternative" health provider such as a chiropractor or acupuncturist? I plan to discuss complementary and alternative medicine in depth in a future posting, but for now I'd like to hear from you.

Welcome to my blog

I've started this Blog as a medium for sharing my thoughts on health and health care. Obviously, health is a personal issue, but these days health care is a very public issue subject to heated debate, especially in my home town of Washington, DC. There's a lot of talk about how the plans currently being debated will "ration" health care, as if rationing is inherently a bad thing. But that view would be a reasonable one if you believed that health care isn't already rationed - which it is. Just lost your job and can't afford COBRA? No health care for you! Have a pre-existing condition? Then pay your own way. Can't afford the copay for that procedure? That's rationing too. And the inherent problem with our current "non-system" of care is that it's, well, irrational, as Peter Singer describes eloquently in a recent article in the New York Times Magazine.

Politicians like to talk about the health care "safety net," consisting of clinics who care for the uninsured or uninsurable (e.g. undocumented immigrants). The heroic efforts of clinicians and staff who run these clinics, often for low pay and exceptionally long hours, do indeed make a difference and save lives. But for every patient who manages to make it to a free or low-cost clinic, there are 3 more who end up in an emergency room, often with diseases that are preventable with routine, relatively low-cost visits to the doctor when well. For a quick primer on the value of prevention in health care, see Pauline Chen's NYT column from yesterday.

That's all for now. I plan to post to this blog at least once per week, so please check back (or sign up to follow new posts) if you'd like to hear more.