Several years ago, when my wife directed the third-year Family Medicine clinical clerkship at a highly ranked medical school, she developed a popular workshop on the cost of health care that presented students with scenarios of patients who were either uninsured or underinsured and challenged them to provide cost-conscious health care by selecting medications and tests that were clinically appropriate and financially affordable. Many students remarked that it was the only time during their two years of clinical rotations when they were required to consider costs in decision-making.
Now that the U.S. health reform bill is law, and over 95 percent of Americans (as opposed to today's 84 percent) are expected to have health insurance by 2014, many physicians may be tempted to think that they can ignore the costs associated with prevention, diagnosis, and management of patients' health conditions and just focus on doing what's "right" for the patient, since somebody else is footing the bill. But contrary to popular opinion, that "somebody else" isn't an insurance company or the government; ultimately, it's the patient, in the form of higher insurance premiums (or taxes) to pay for an ever-expanding range of tests or treatments of questionable or zero benefit.
In response to Dr. Howard Brody's challenge to the medical profession to identify lists of unnecessary tests and treatments, physicians have suggested antibiotics for colds, coronary calcium scans, PSA and thyroid tests in well patients, drugs for high blood pressure that are more expensive and offer fewer benefits than older drugs, MRIs and spinal fusions for low back pain. If it's so easy to come up with a list, then why is it so hard to eliminate the waste? According to a recent Newsweek article, the problem is that many of the items on the list are physicians' financial "bread and butter." "We doctors are extremely good at rationalizing," says Brody in the article. "Somehow we manage to figure out how the very best care just happens to be the care that brings us the most money." Other concerns voiced by physicians are that patients have come to expect (if not demand) much of the aforementioned unnecessary care because it's been going on for so long.
But if health care reform is to have any hope of slowing the extraordinary growth in the cost of health care in the U.S., doctors can't keep looking to patients, hospitals, pharmaceutical and medical device companies, and insurers for solutions. In an editorial in the New England Journal of Medicine, Dr. Molly Cooke argues convincingly that cost-consciousness must be systematically incorporated into medical and continuing education:
First, we should be honest about the choices that we make every day and stop hiding behind the myth that every physician should and does apply every resource in unlimited degree to every patient for even minimal potential benefit. Second, we must prepare every physician to assess not only the benefit or effectiveness of diagnostic tests, treatments, and strategies but also their value. Value can be increased through cost-conscious diagnostic and management strategies and by the engineering of better and less wasteful processes of care.
"Value" isn't about saving money, but means getting the maximum health benefit for our enormous investments in health care. This wake-up call needs to be delivered and reinforced to students, residents, and health professionals at every level - starting today.
Tuesday, April 13, 2010
Thursday, April 8, 2010
Guest Blog: Writing Poems on Antidepressants
Nikki Moustaki is the author of The Complete Idiot's Guide to Writing Poetry and is a recipient of a National Endowment for the Arts grant. She has taught at New York University, Indiana University, and the New School. The following poem was first published in the Bellevue Literary Review.
**
WRITING POEMS ON ANTIDEPRESSANTS
Writing poems on antidepressants
is hard. You can appreciate the difficulty
by reading the previous two lines.
Metaphors are easy
to come by when you're aching
or pining or wounded in love,
which scientists have proven is a type of madness
and madness can be cured with a pill.
Not everyday
is Paris. Not everyday
does a bird come winging
out of a carpet to give you a free metaphor,
especially if there are oranges on the table
and you're on your meds.
Each day offers some little irony or a dream
or a blind albino woman
sitting next to you on the train
with eyelashes like white silk threads
attached like broom-straw to her one closed eye
as she taps her cane against the window
and you, the poet on antidepressants,
thinks: look at that, hmmm, interesting.
Did I buy dog food? Here's my stop.
- Nikki Moustaki
**
WRITING POEMS ON ANTIDEPRESSANTS
Writing poems on antidepressants
is hard. You can appreciate the difficulty
by reading the previous two lines.
Metaphors are easy
to come by when you're aching
or pining or wounded in love,
which scientists have proven is a type of madness
and madness can be cured with a pill.
Not everyday
is Paris. Not everyday
does a bird come winging
out of a carpet to give you a free metaphor,
especially if there are oranges on the table
and you're on your meds.
Each day offers some little irony or a dream
or a blind albino woman
sitting next to you on the train
with eyelashes like white silk threads
attached like broom-straw to her one closed eye
as she taps her cane against the window
and you, the poet on antidepressants,
thinks: look at that, hmmm, interesting.
Did I buy dog food? Here's my stop.
- Nikki Moustaki
Saturday, April 3, 2010
The Girl in the Well
While this blog takes every opportunity to champion the essential role of family physicians in reforming our broken health system, I readily admit that the ability of primary care to affect the most important health problems in the U.S. pales in comparison to the impact of public policies. Restricting tobacco advertisements, raising cigarette taxes, and banning smoking in public places has done more for the health of Americans than thousands of clinicians advising their patients to quit. Laws that encourage the construction of sidewalks, parks, and supermarkets in low-income neighborhoods are more effective at increasing physical activity and healthful eating than armies of dedicated health counselors. Reducing highway speed limits and enacting seat belt and bicycle helmet laws has saved far more lives than injury prevention counseling from thousands of well-meaning pediatricians.
Why is it, then, that so much of our national conversation on improving health has focused on health care rather than public health measures? Why are we captivated by the interaction between a single clinician and his or her patient (the inviolate "doctor-patient relationship") rather than overwhelming evidence about interventions that could better the health of communities? The answer is that statistics are, by themselves, underwhelming. Most people are moved to action by anecdotes, a fact that politicians know very well. This is why there are always a few "special guests" sitting with the First Lady at every State of the Union Address for the President to use as props, and why speaker after speaker at February's health reform summit began their long-winded addresses with stories about individual citizens whose lives would be (depending on their political perspective) improved or worsened by the proposed legislation.
Dr. Alfred Somner, former dean of the Johns Hopkins Bloomberg School of Public Health, calls this the "girl in the well" phenomenon:
The world will watch with bated breath through a four-day rescue ordeal, while at the same time hundreds of millions of people go to bed hungry each night ... We accept the problems of the masses as just so much background noise; but it is background noise that causes immense, entirely unnecessary misery the world over and contributes in our own country to spiraling health-care costs.
For primary care to be most effective at improving health, it must work hand-in-hand with public health departments and community organizations, which themselves must be adequately resourced and funded. A case in point: the Communities Putting Prevention to Work Initiative, launched by the U.S. Department of Health and Human Services last September to target physical inactivity, nutrition, obesity, and smoking, takes the critical step of looking beyond the girl in the well, and in doing so, promises to make the one-on-one work of family doctors just a little bit easier.
**
Disclosure: I am employed by the U.S. Department of Health and Human Services.
Why is it, then, that so much of our national conversation on improving health has focused on health care rather than public health measures? Why are we captivated by the interaction between a single clinician and his or her patient (the inviolate "doctor-patient relationship") rather than overwhelming evidence about interventions that could better the health of communities? The answer is that statistics are, by themselves, underwhelming. Most people are moved to action by anecdotes, a fact that politicians know very well. This is why there are always a few "special guests" sitting with the First Lady at every State of the Union Address for the President to use as props, and why speaker after speaker at February's health reform summit began their long-winded addresses with stories about individual citizens whose lives would be (depending on their political perspective) improved or worsened by the proposed legislation.
Dr. Alfred Somner, former dean of the Johns Hopkins Bloomberg School of Public Health, calls this the "girl in the well" phenomenon:
The world will watch with bated breath through a four-day rescue ordeal, while at the same time hundreds of millions of people go to bed hungry each night ... We accept the problems of the masses as just so much background noise; but it is background noise that causes immense, entirely unnecessary misery the world over and contributes in our own country to spiraling health-care costs.
For primary care to be most effective at improving health, it must work hand-in-hand with public health departments and community organizations, which themselves must be adequately resourced and funded. A case in point: the Communities Putting Prevention to Work Initiative, launched by the U.S. Department of Health and Human Services last September to target physical inactivity, nutrition, obesity, and smoking, takes the critical step of looking beyond the girl in the well, and in doing so, promises to make the one-on-one work of family doctors just a little bit easier.
**
Disclosure: I am employed by the U.S. Department of Health and Human Services.
Thursday, April 1, 2010
Shining Knights and heroic family doctors
Not long ago, I attended the Shining Knight Gala, a fundraising dinner that benefited the trauma surgery and injury prevention programs at Virginia Commonwealth University Medical Center. The highlight of the evening was the dramatic presentation of the story of a young man who had suffered severe, life-threatening injuries in a car accident and, through the skill and dedication of first responders and the VCU trauma and rehabilitation professionals, was stabilized and over several months gradually restored to health. In recognition of their extraordinary efforts, all of the clinicians involved in this young man's care were awarded the "Order of the Shining Knight." As fire fighters, emergency medical technicians, emergency room physicians and nurses, trauma surgeons, and rehabilitation specialists trooped on to the stage to shake Virginia Governor Bob McDonnell's hand and pose for photos with their award (while their patient looked on happily from a nearby table), it was impossible not to be deeply moved.
It struck me somewhat later that there is no primary care analogy for what I witnessed that evening. General internists will not have the satisfaction of being recognized for the patients who didn't have heart attacks or strokes because of the blood pressure medications or aspirin they prescribed; family physicians and pediatricians won't be given awards of merit for all the children they "saved" from measles, mumps, polio, and a host of other vaccine-preventable diseases. While primary care physicians certainly provide acute care services for a variety of ailments, the greatest impact of our work is ultimately unmeasurable: all of the poor health outcomes that might have happened, but didn't.
Does this mean that there are no heroic family doctors? Far from it, but recognizing our behind-the-scenes efforts - and reinforcing of the appeal of the primary care specialties to medical students - is certainly more challenging. But I'm cautiously optimistic that the 2010 Residency Match results, which saw a 9% increase in the number of U.S. graduates choosing family medicine residencies and modest increases in interest in general internal medicine and pediatrics, represents a turning of the corner. With the millions of people expected to gain health insurance over the next several years, this country will need every primary care clinician it can get.
It struck me somewhat later that there is no primary care analogy for what I witnessed that evening. General internists will not have the satisfaction of being recognized for the patients who didn't have heart attacks or strokes because of the blood pressure medications or aspirin they prescribed; family physicians and pediatricians won't be given awards of merit for all the children they "saved" from measles, mumps, polio, and a host of other vaccine-preventable diseases. While primary care physicians certainly provide acute care services for a variety of ailments, the greatest impact of our work is ultimately unmeasurable: all of the poor health outcomes that might have happened, but didn't.
Does this mean that there are no heroic family doctors? Far from it, but recognizing our behind-the-scenes efforts - and reinforcing of the appeal of the primary care specialties to medical students - is certainly more challenging. But I'm cautiously optimistic that the 2010 Residency Match results, which saw a 9% increase in the number of U.S. graduates choosing family medicine residencies and modest increases in interest in general internal medicine and pediatrics, represents a turning of the corner. With the millions of people expected to gain health insurance over the next several years, this country will need every primary care clinician it can get.
Monday, March 22, 2010
Health reform forecasts and the Great Society
Even the most die-hard NCAA basketball fans should concede that the major headline of the past weekend was not Northern Iowa upsetting Kansas or Cornell advancing to the Sweet 16, but the health reform reconciliation bill squeaking through the House of Representatives by a 7-vote margin. So should we be celebrating along with President Obama's crowd or throwing in our lot with the Tea Party? I'll dodge that question for now, but suggest that history provides a possible answer, or at least an analogy. In her acclaimed biography of President Lyndon Johnson, historian Doris Kearns (now Goodwin) wrote this about Johnson's relentless political pursuit of the mid-1960s social welfare agenda that would collectively come to be known as the "Great Society":
Even in the more familiar areas of public policy, the need for haste often resulted in a failure to define the precise nature and requirements of social objectives. Legislative solutions were often devised and rushed into law before the problems were understood. Since time was limited and agreement on ends could be assumed, since surely all reasonable men - especially those likely to be consulted by a liberal Democratic President - favored the elimination of poverty, the expansion of educational opportunity, and improvement in the delivery of medical care, most of the attention was focused on means. ... as if putting more money into a poorly conceived system will inevitably make it better. Pass the bill now, worry about its effects and implementation later - this was the White House strategy.
Sound familiar? A common critique that has been leveled at the health reform bill from both extremes of the political spectrum (those who want a Canadian-style single-payer health system and those who are basically fine with the status quo) is that it isn't real reform at all, but sinking billions of additional dollars we don't have into the current system. Of course, some will be quick to point out that one of Johnson's "hastily" enacted Great Society programs was Medicare, the health insurance program for senior citizens that is not by any means flawless, but has become so successful and widely accepted that opponents of "government-run health care" were forced into the paradoxical position of attacking the bill because it might threaten the generous benefits currently provided by Medicare.
Like picking who will emerge from this year's March Madness at the beginning of the season, it's much too early to correctly forecast whether this health reform bill - which may not survive the next round of Congressional elections - will turn out to be (like Medicare) a rousing success, an incremental improvement, or a catastrophic failure. Liberal commentators such as the Washington Post's Ezra Klein are already calling for additional reforms, while 11 states, fearing the possible effect of unfunded mandates on their battered budgets, plan to sue the federal government to prevent implementation of the bill. In the meantime, my thoughts on this topic are perhaps best summed up by the question I asked my wife (also a family physician) as we were listening to the final hours of floor debate while driving home on Sunday evening:
"So what are those 32 million newly covered people going to do when they get their health insurance cards and can't find a family doctor to see them?"
Even in the more familiar areas of public policy, the need for haste often resulted in a failure to define the precise nature and requirements of social objectives. Legislative solutions were often devised and rushed into law before the problems were understood. Since time was limited and agreement on ends could be assumed, since surely all reasonable men - especially those likely to be consulted by a liberal Democratic President - favored the elimination of poverty, the expansion of educational opportunity, and improvement in the delivery of medical care, most of the attention was focused on means. ... as if putting more money into a poorly conceived system will inevitably make it better. Pass the bill now, worry about its effects and implementation later - this was the White House strategy.
Sound familiar? A common critique that has been leveled at the health reform bill from both extremes of the political spectrum (those who want a Canadian-style single-payer health system and those who are basically fine with the status quo) is that it isn't real reform at all, but sinking billions of additional dollars we don't have into the current system. Of course, some will be quick to point out that one of Johnson's "hastily" enacted Great Society programs was Medicare, the health insurance program for senior citizens that is not by any means flawless, but has become so successful and widely accepted that opponents of "government-run health care" were forced into the paradoxical position of attacking the bill because it might threaten the generous benefits currently provided by Medicare.
Like picking who will emerge from this year's March Madness at the beginning of the season, it's much too early to correctly forecast whether this health reform bill - which may not survive the next round of Congressional elections - will turn out to be (like Medicare) a rousing success, an incremental improvement, or a catastrophic failure. Liberal commentators such as the Washington Post's Ezra Klein are already calling for additional reforms, while 11 states, fearing the possible effect of unfunded mandates on their battered budgets, plan to sue the federal government to prevent implementation of the bill. In the meantime, my thoughts on this topic are perhaps best summed up by the question I asked my wife (also a family physician) as we were listening to the final hours of floor debate while driving home on Sunday evening:
"So what are those 32 million newly covered people going to do when they get their health insurance cards and can't find a family doctor to see them?"
Saturday, March 20, 2010
How fragmented U.S. health care endangers expectant moms
As I noted previously, the steady rise in the percentage of babies delivered via Cesarean section (currently just under 1 in 3 deliveries in the U.S.) is due in large part to "too much care" - a high-technology mindset that permeates training programs in obstetrics and gynecology, combined with a low tolerance for uncertainty driven by concerns about malpractice lawsuits. While surgical deliveries are sometimes unavoidable, it's clear that less interventional maternity care providers such as midwives and family physicians can spare many more women from having C-sections, with comparable maternal and infant health outcomes.
However, for many expectant mothers, the problem is too little care - poor access to prenatal care to poverty, a lack of health insurance, non-citizen status, or other barriers. "Deadly Delivery," a report released earlier this month by Amnesty International, chronicles the failure of the high spending U.S. health system to provide adequate prenatal care for 1 in 4 women, leading to a maternal mortality rate that ranks 41st in the world and has more than doubled over the past two decades. The report observes that 13 million women between the ages of 15 and 44 are uninsured, and many who become pregnant have trouble obtaining Medicaid coverage due to bureaucratic obstacles. Even women who obtain coverage have a hard time accessing care due to a shortage of maternity providers in rural and urban areas.
Living and working in the Washington, DC area since 2004, I've seen firsthand how difficult it is for uninsured women to get good prenatal care, despite a physician to population ratio that is one of the highest in the nation. It isn't surprising, then, that pregnant women in the District of Columbia have a risk of death that is nearly 3 times the national average, and more than 7 times the Healthy People 2010 goal of 4.3 deaths per 100,000 live births. The only five states that have achieved that goal are Massachusetts, Vermont, Minnesota, Maine, and Indiana. Interestingly enough, Massachusetts, Vermont, and Minnesota are #1, 2, and 3 in state rankings of the lowest percentage of the population without insurance. Coincidence? I think not.
However, for many expectant mothers, the problem is too little care - poor access to prenatal care to poverty, a lack of health insurance, non-citizen status, or other barriers. "Deadly Delivery," a report released earlier this month by Amnesty International, chronicles the failure of the high spending U.S. health system to provide adequate prenatal care for 1 in 4 women, leading to a maternal mortality rate that ranks 41st in the world and has more than doubled over the past two decades. The report observes that 13 million women between the ages of 15 and 44 are uninsured, and many who become pregnant have trouble obtaining Medicaid coverage due to bureaucratic obstacles. Even women who obtain coverage have a hard time accessing care due to a shortage of maternity providers in rural and urban areas.
Living and working in the Washington, DC area since 2004, I've seen firsthand how difficult it is for uninsured women to get good prenatal care, despite a physician to population ratio that is one of the highest in the nation. It isn't surprising, then, that pregnant women in the District of Columbia have a risk of death that is nearly 3 times the national average, and more than 7 times the Healthy People 2010 goal of 4.3 deaths per 100,000 live births. The only five states that have achieved that goal are Massachusetts, Vermont, Minnesota, Maine, and Indiana. Interestingly enough, Massachusetts, Vermont, and Minnesota are #1, 2, and 3 in state rankings of the lowest percentage of the population without insurance. Coincidence? I think not.
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