GME funding must be targeted to Primary Care

Much of the cost of training physicians is currently borne by Medicare (and, to a lesser extent, Medicaid). This is known as Graduate Medical Education, or GME, funding, and it pays some, all, or more than all (depending upon the hospital and based upon a complicated formula discussed on May 25, 2009, Funding Graduate Medical Education) of the cost of training residents in the various specialties that comprise medicine. For those unfamiliar with medical education, graduation from medical school, while it confers the MD (or DO, Doctor of Osteopathy) degree and the title “doctor”, no longer permits practice in any of the US states. A least one, and in some states two, years of residency (“GME”) is required for licensure, and most doctors complete an entire residency of 3 or more years to make them eligible for certification as a specialist in a field (eg, family medicine, general surgery, internal medicine, psychiatry, etc.). Fellowship training is requires addition years beyond the core residency to become a sub-specialist – for example, those who complete an internal medicine residency can then do additional years to become a cardiologist, gastroenterologist, endocrinologist, etc.

Medicare augments its payments to institutions (usually hospitals, although there are a few consortia and federally-qualified health centers) with two types of payments, Direct GME which is intended to pay residents’ salaries and cost of teaching, and Indirect ME which is for the additional costs that training hospitals bear for a variety of reasons. (In addition to the piece linked above, see also Training rural family doctors, Nov 5 2010; PPACA, The New Health Reform Law: How will it affect the public's health and primary care?, Apr 22,2010; Primary Care and Residency Expansion, Jan 7, 2010.) These payments have been the cornerstones for funding residency education. Because the amount is tied to the percent of Medicare patients in a hospital, rather than the total number of patients cared for in hospitals or outpatient settings, it could be (and has been) argued that funding GME should be done comprehensively and separately from Medicare. The most persuasive argument is that private insurers should also contribute to GME (they don’t, although Medicaid does in some, but not all, states). On the other side, many fear that uncoupling GME funds from Medicare would make it easier for a Congress looking at ways to cut the budget to cut GME than having it as part of Medicare.

Except this year, with exceptionally high pressure to cut the budget, Medicare is not even sacrosanct, although, as I have recently argued, (Medicare: A lifeline, not a Ponzi scheme, Dec 2, 2011) most of the proposals to cut it across the board by tactics such as raising the age of eligibility are poorly conceived. So there are now proposals to cut the funding from Medicare for GME. Unsurprisingly, this has created great anxiety in the community of academic health centers, and the Association of American Medical Colleges (AAMC), which has strongly supported expansion of GME residency slots, is quite alarmed (Preserve Medicare support for physician training, revised Oct 2, 2011). The Accreditation Council on Graduate Medical Education (ACGME), which accredits institutions that sponsor residency programs and, through its subsidiary Review Committees (RCs), each individual specialty and subspecialty, has done a study that shows that cuts in residency positions have already occurred and more major cuts are threatened if Medicare decreases its funding ("The Potential Impact of Reduction in Federal GME Funding in the United States: A Study of the Estimates of Designated Institutional Officials”). ACGME CEO Thomas Nasca, MD, is quoted by AAFP News Now as saying “We will actually reduce the number of physicians who are trained in the United States at a time when all workforce studies are demonstrating a mounting deficit of physicians….That will place us in a position where our physician-to-population ratio in 2020 and beyond is below (that of) most of the developed countries in the world." The study found that “With a 33 percent reduction in GME funding

• 68.3 percent of responders said they would reduce the number of core residency positions,
• 60.3 percent would reduce the number of subspecialty fellowship positions,
• 4.3 percent would close all core residency programs, and
• 7.8 percent would close all subspecialty programs.”

Because there are many more “core” residency positions than subspecialty fellowship positions, these would be disproportionately affected by across-the-board cuts. In addition, residency programs in primary care, which are not as profitable to the sponsoring institution, are even more likely to be cut despite the service that they provide to patients, especially those most in need. Perry Pugno, M.D., M.P.H., AAFP vice president for education, notes in that same article that "…any cuts to GME that go across the board are going to hurt primary care -- especially those of us who disproportionately take care of adults with chronic illnesses….In communities where primary care residency programs are present, those programs become the access point for the poor and disenfranchised of the area.” He says that it's not unusual for family medicine residency programs to see patients who live both in poverty and with numerous chronic illnesses. "The payment for taking care of those patients is so low that the local medical community often doesn't want to provide that care…But residency programs take all comers."

The key issue that Pugno is addressing is one that is very important issue and is not usually made explicit in national policy discussions: our current method of allocating Medicare GME funds to institutions (hospitals) rather than to individual residency programs tends to encourage funding the funding of positions in specialties that most profit those hospitals. The interests of the American people, in regard to the kinds of specialists they need, are not necessarily (and I would argue in fact are not) the same as the interests of the hospitals that sponsor residencies. Hospitals like to fund specialties whose trainees’ work enhances their revenue (e.g., cardiology fellows, who can increase the number of profitable procedures that are done) or at least decrease their loss (e.g., emergency medicine residents, who can fill gaps in seeing patients in emergency departments). Indeed, when hospitals can afford to, they often augment Medicare GME with their own funds to create more such positions. This is about their own financial interest, and does not take into account whether or not the US needs more cardiologists or ER docs, or more family physicians and general surgeons.

This contrast between the interests of the hospital (what kind of residency positions are most beneficial to its bottom line) and the needs of the population, is, of course, a subset of the larger tension. We train doctors in highly-specialized tertiary care academic health centers, while they will mostly practice in the community. There are a number of reasons that this is not brought up more often. For the general lay public, including most members of Congress and their staffs, it seems like a subtle difference. For experts, such as the AAMC, the issue is that they represent the interests of the medical schools, and want to have those interests seen as also representing the interests of the US population. Of course, they do not always, especially the interests of the most rural, poor, minority and other underserved portions of that population.

I think we need to use every opportunity to make this issue more clear and open. While it is probably true that it is a mistake to decrease federal funding for GME, it is absolutely necessary to increase the support for primary care and, in particular family medicine. And this will only happen if GME funding is explicitly tied to requiring it to be spent on primary care programs, and “prevents substitutions”.

Are primary care physicians fees a major contributor to the high costs of US healthcare? No.

A recent article in Health Affairs by Miriam J. Laugesen of Columbia University and Sherry A. Glied of the Department of Health and Human Services has generated a lot of attention. “Higher Fees Paid To US Physicians Drive Higher Spending For Physician Services Compared to Other Countries”[1] looked at the amount paid to 1) primary care physicians for office visits, and 2) orthopedic surgeons for hip replacements, in the US, and compared them to five other countries (Australia, Canada, France, Germany, and the United Kingdom). The study also looked at overall physician income in those countries, and at a variety of factors that contribute to both. These factors include the mix of public (primarily Medicare in the US) and private insurance and the ratio of what private insurance pays relative to the public payer, cost and extent of medical education, and overhead expenses. They noted the relative income of primary care physicians to orthopedists in the various countries. Their stated reason for this study is that “The differential in spending on physician services is greater than the overall difference in total health spending between the United States and other nations.”

The concept that a significant portion of the US’ extremely high health care costs is due to high physician reimbursement has long been widely accepted, but the assertion that a part of the blame lies with high primary care incomes is rather new, and is the part of this article that has engendered the most attention. Robert Pear’s NY Times piece on September 7, 2011, “Doctor Fees Major Factor in Health Costs, Study Says” and the response letter from the American Medical Association (AMA) addressed the first part (both/all specialities). The second issue, the article’s focus on the fees of primary care physicians generated pushback from the president of the American Academy of Family Physicians (AAFP), Roland Goertz, who issued strong criticism of the implication that it is primary care physicians who account for the high cost of US healthcare (AAFP President Refutes Claims That Primary Care Physician Incomes Contribute to High Health Care Costs.) More basic information on the economic issues and assumptions that inform this kind of work are described quite clearly by Uwe Reinhardt in a Times “Economix” column on September 18, 2011, “The role of prices in health care spending”.

So what does the Laugesen and Glied study really show? It does show that primary care physicians in the US makes more than primary care physicians in the five other countries, and in some cases a good bit more. It also shows that orthopedic surgeons in the US make a lot more than orthopedic surgeons in other countries. These differences are not due primarily to seeing more patients (patients in those other countries have more visits than do primary care physicians than those in the US, averaging 5.95 per capita per year to the US’ 3.8, and orthopedists do not do significantly more procedures) but rather to the higher fees paid by private insurance in the US.

The study also shows, very significantly, and as emphasized by Dr. Goertz, that the ratio between the income of orthopedists and primary care doctors is much higher in the US than in those other countries. This bolsters the argument that, to the extent doctors’ fees contribute to the high cost of health care in the US, it is much more because of specialist rather than primary care, reimbursement.  The authors of the study note that “Most other countries, however, have moved further away from fee-for-service

than the United States has”, and that “Where physicians may charge fees above the national schedule, the practice is consistently more common among orthopedic surgeons than among primary care

physicians, regardless of country.”

A key finding of the study that also supports Goertz’ argument is that [my bold] “Overall, fees paid by Medicare to US physicians for office visits are comparable to those paid by public insurers in several other countries, and fees paid by US private insurers are slightly higher than those paid by private insurers in other countries. In contrast, fees paid by public payers to orthopedic surgeons for hip replacements in the United States are considerably higher than comparable fees for hip replacements in other countries, and fees paid by private insurers in the United States for this service are double the fees paid in the private sector elsewhere .” This is exacerbated by the fact that “In general, Americans are very low users of office visits and relatively high users of hip replacement surgery.”

US orthopedic surgeons earned at least 50% more than those of other countries, and the ratio of primary care to orthopedist income was the lowest in the US, 42%, compared to 60% in other countries. The authors note that “The differences in incomes relative to fees provide more confidence in the overall comparability of the data. They suggest that higher US fees are a consequence not only of higher practice expenses, but also of higher rewards for the skill and time of physicians.” The authors also address the greater cost of medical education to the individual in the US, but conclude that the increased reimbursement more than compensates for this difference. Work by the Graham Center (see figure) shows that medical student specialty choice is highly tied to projected income.

One factor not addressed in most of the commentary on this article is that the authors of the study say “In the United States this definition [of primary care] includes family practice, general practice, internal medicine, obstetrics and gynecology, and pediatrics.” They do this despite the fact that “this” refers to the immediately preceding sentence, which presents the 2008 definition from the Organization for Economic Cooperation and Development (OECD) of a “primary care physician as one who does not limit practice to certain disease categories”. This definition certainly does not include obstetrics/gynecology (OB/GYN). Why, then, do they include OB/GYNs? Unsurprisingly, the answer is largely political; the argument in the US was that many women receive their “primary care” from their OB/GYN. This logic, however, is deeply flawed. To the extent that women do so, they are not receiving comprehensive primary care, because OB/GYNs care for conditions involving the reproductive system and women are more than their reproductive tracts. Lest this be seen primarily as a matter of my personal sensitivity as a family physician, there is a very important issue because including them can dramatically skew the income data. As OB/GYNs are largely surgeons, their fees and income are much higher than those of the other specialties that are actually primary care, and raise the measured income of “primary care” physicians when they are included.

Laugesen and Glied show that “US primary care physicians earn about one-third more than do their counterparts elsewhere” but that “…neither public insurance nor private insurance generalist physician fees for basic office visits are much higher in the United States than in many of the comparison countries. Instead, US primary care doctors do somewhat better overall mainly because a much larger share of their incomes is derived from private insurance. In other countries where private primary care practice is permitted, the market share of this form of practice is relatively small.” They go on to say, however, that “For orthopedic surgeons, the story is quite different. US orthopedic surgeons earn much higher incomes than do their counterparts abroad, and there are more such surgeons per capita here than almost anywhere else. In consequence, comparison countries spend only about one-quarter as much as the United States spends on orthopedic surgeons. Rates of hip replacement surgery are not higher in the United States than elsewhere, although rates of other procedures performed by orthopedic surgeons may be. Much of the difference in earnings appears to be due to differential fees. Public-sector fees for hip replacement surgery in other countries are about half as high, on average, as Medicare fees in the United States.”

Finally, the ratio of primary care physicians (essentially all general and family physicians) to specialty physicians in other countries is much higher than in the US, so this is also an area in which their costs are lower. That is, more care is provided by primary care doctors and less by more expensive (even in those countries) specialists. Thus, the problem with health costs in the US is not the high cost of primary care. It is the private for-profit marketplace and the excessive fees paid by private insurance for surgical procedures and other specialty care that drives physicians’ fees to be so much higher in the US.

Among the many other changes that we need in our health system, two important ones are increasing the percent of our physician workforce that is primary care, and creating greater equity in the reimbursement among physicians.

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[1] Health Affairs, 30, no.9 (2011):1647-1656

Legislating Public Health and Medical Care

It is pretty tempting, if you are a legislator and don’t like something, to try to pass a law against it. You can always find a constituency to support you, because there are people who will support almost anything. If you are lucky enough you can find a well-off and powerful constituency, or set of advocacy organizations, and then you are more likely to be successful (ref: see almost all laws passed by the Congress). Health and medical care are no exceptions; bills and laws that impact on public health and even how providers interact with their patients are increasingly common.

Some laws are very good for the public health: banning smoking in public places; requiring cars to have seat belts, airbags, and other safety features; requiring vaccination against infectious disease for entry into school. But the plethora of regulations governing the funding of health care providers from Medicare and Medicaid, the kind of documentation that needs to be submitted, and the rules that need to be followed (generally termed, collectively “compliance”) is bewildering. Complying with all the rules put forth put forth by federal agencies (including different division of Health and Human Services, as well as the Department of Justice and the Department of Treasury) requires large providers to have full-time “compliance officers” and small ones to operate at their peril. Then add in state and local regulations. These regulations are often contradictory, so complying with one violates another. The blame is usually placed on the bureaucrats that write these regulations, but in fact many of these bureaucrats are quite aware of these contradictions, but have no option, because the laws that they have to write regulations to implement are often very prescriptive. Beware the Law of Unintended Consequences!

This law, never to my knowledge passed by any legislative body, has a major impact on those that are passed, and this impact is just as true in laws regulating public health and medical practice. These effects are most serious when the law in question is passed to address a political agenda rather than to improve health. A famous example is the “gag rule” implemented in the early GW Bush years that prevented providers receiving federal funds from discussing the option of abortion with their patients. (Overturning this rule was a major, and under-recognized, accomplishment of the early Obama administration.)  A more recent example is the law passed in Florida (and now, thankfully, blocked from implementation by a federal judge) that would prohibit physicians and other medical providers from discussing gun safety with their patients. Let me be clear: the limitation was not on gun possession or use, but on doctors and nurses and public health officials talking to people about the risks that guns in the home posed to their children and themselves and how to keep the guns that they had more safe to limit accidental discharge, injury and death.  Guess what organization pushed this law? If you said “the NRA”, you’re right, but it was a “gimme”. And of course it was signed by the governor, former “health care” magnate Rick Scott, who as CEO of Columbia/HCA led the company in paying huge fines for Medicare fraud.

Those are the easy ones to find fault with. But, just as with the “compliance” issues described above, efforts to impose “good” medical practice can be flawed. Vaccine safety and benefit is a big topic I will probably post a separate piece on (short answer: get them), but there are many others. One example is the bill introduced by Sen. Jay Rockefeller (D-WV), along with Sen. Chuck Schumer (D-NY), that would require practitioners who prescribe opiates to have 16 hours of continuing medical education (CME) in their use every 3 years. This is motivated by a serious concern for the abuse of opiates, including re-sale by those receiving prescriptions, which leads to many deaths each year (and in which West Virginia leads the nation). There is no question that this is a huge problem.

We have seen two movements, often in conflict with each other, in recent times. One is the increase in the advocacy for patients with chronic pain to receive adequate treatment; the other is concerned with addiction and prescription drug abuse. Unfortunately, as in West Virginia, the same populations are often afflicted by both. Chronic pain often occurs in those who do physical labor, but people from these same populations are the ones often dying of overdose. The problem is that the same drugs that reduce pain also (initially) get people “high”, and in time create physical addiction where the “positive” effect of the “high” is replaced by pain and misery just from not having the drug. Ideally, there would be a pain reliever that was effective, did not cause any pleasurable symptoms (other than relief from pain), and was non-addictive. We don’t have one.

Will requiring this CME of physicians reduce the problem? I think that it will decrease the number of prescriptions written for opiates, and thus maybe the amount of potentially-abusable narcotics circulating in the community, but perhaps not through the intended mechanism. There is no question that there is a lot that many providers could learn about proper use of opiate pain relievers by taking such courses. One example is the use of long-acting pain relievers (methadone, sustained release patches, long-acting morphine) whose slow release controls pain while decreasing the “high” that results from a sudden infusion of narcotic. (An exception is the most widely-prescribed – and advertised, which might be related – long acting pain reliever, Oxy-Contin®, 30% of which is release immediately, making it more popular among drug abusers than other long-acting opiates.) Another is the use of the “pain contract” that limits a patient to receiving opiates from one physician, at determined intervals, refuses to ever refill if a person is found to be receiving prescriptions from multiple sources, and may require urine tests to be sure that s/he is not using other unprescribed substance.

However, for this plan to work it would require that physicians and other providers want to prescribe narcotics. Obviously some do. Many of these do so because they are concerned about the chronic pain so many patients are in; there are pain medicine specialists who come from a variety of medical backgrounds: anesthesiology, psychiatry, family medicine, internal medicine. There are certainly others (relatively few) who are “Dr. Feelgoods” who make their living prescribing narcotics and other controlled drugs in large amounts, knowing that they will be abused. But the reality is that most doctors find chronic pain patients, well, a chronic pain. They find it difficult to feel certain who is a “legitimate” pain patient and who is “abusing”, or selling, their pain medications. Or who is a “legitimate” chronic pain patient whose family members are using, or selling, that person’s pain medication, leading to both the spread of narcotics in the community and having the patient continue with unrelieved pain. These are the patients who, whether “legitimate” or “abusers”, call the office all the time for refills, call in the middle of the night, yell at the staff because they are in pain (or withdrawing from narcotics, or find their livelihood that comes from selling them is threatened). Most providers would be willing to not take the CME, and have a good excuse to not prescribe opiates, and be free from all these problems. This is, according to testimony at the recent convention of the American Academy of Family Physicians, already happening in some places. Of course, that will also mean reduced access for people who do have chronic pain.

I once lived in a moderately large condominium. I had kids, as did a couple of others, but the majority of residents were older, with no children in their homes. The association would sometimes pass rules that restricted what children could do, especially when the working parents couldn’t make the meetings. These rules affected my children and penalized me. My position was that the association’s rules should be limited to things that affected the safety of the building and maintained its property values, not just anything that 51% of the owners could agree upon. Legislatures, whether federal or state or local, can pass any law that they can get a majority to agree on (with the obvious exception of the US Senate, where apparently, at least with the current President, it requires 60% votes – 59% wouldn’t do it). It doesn’t matter how dumb the laws are, or how much they conflict with existing law, or how much trouble they cause the bureaucrats who have to write the regulations, or how confusing or sometimes impossible it becomes for folks to comply with them all. Unless the courts strike them down, they are law (thank goodness for separation of powers!).

But because you can pass a law or rule about something doesn’t always make it a good idea to do so, whether you are a legislature or a condominium association. Because the Law of Unintended Consequences is always present.

Conflict of interest reporting

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looks like using Google Chrome instead of IE8 solves the problem. Hmm.

This is the first of a two-part series on conflict of interest, medical ethics, and whether we can trust recommendations.

In several posts last year (Harvard Medical School limits outside income: a good start January 10, 2010, Statins and scientific integrity July 6,2010 and especially The AAFP, Coca-Cola, and Ethics: Serving the public interest? August 20, 2010), I discussed the question of conflict of interest, citing the work of ethicists such as Howard Brody, along with common sense, to demonstrate that a “conflict of interest” is simply that; a conflict between one set of a person or organization’s interests and another. In the case of the American Academy of Family Physicians (AAFP) and its relationship with the Coca-Cola Company or that between the American Dietetic Association (ADA) and Hershey’s Chocolate, the conflict is between what is in the best interests of the health of the patients that the AAFP’s member physicians or ADA’s member dieticians serve and what is in the best interests of Coke or Hershey (making money). The latter is only important to the professional organization because those companies share some of the money they make with them. In defending themselves against what appears to many people, both within and outside the organizations, to be corruption, the leaders who made these deals (such as then AAFP-President Lori Heim, MD) make the argument that only by looking at whether the information presented on the AAFP’s http://www.familydoctor.org/ website (for which Coke provided support) is biased (presumably toward Coke) can the presence of a conflict be determined.

This is patently absurd; the conflict is there, and along with it the suspicion that information may be skewed. This is particularly true when dealing with a site such as http://www.familydoctor.org/, on which the information is intended for the general public, not for professionals. Its value depends entirely upon the trust of the members of the public who use it, and such conflicts of interest undermine that trust. “How can I trust information provided on a medical site with ads from a company that my doctor says makes stuff that is bad for me – heck, that everyone knows is bad for them?” is a reasonable question, a reasonable suspicion, and a legitimate reason for concern by the public. “Hey, take our word for it; taking Coke’s money (or Hershey’s, in the case of the ADA) didn’t influence the content of the information on our website,” is a pretty weak defense, not one that is likely to engender trust of the organization or, of greater concern, of its member professionals.

The issue of conflict of interest has been a significant focus in the medical literature. Most major journals now require the authors of original research studies, particularly those that evaluate the effectiveness of drugs, to indicate if they have conflicts of interest; that is to say, financial connections with the manufacturer of the drug (or any other drug manufacturer or potential conflict of interest). This is in addition to identifying the source of funding for the study – mainly whether it was funded by a drug (or device) manufacturer as opposed to funded by the federal government (through NIH or another agency) or, much less common for such studies, a not-for-profit foundation. Again, the reason is obvious: if the author has a conflict of interest (gets money for speaking for a drug company, say, that manufactures the drug being examined, we all have reason to be more guarded in our interpretation of the results, or at least the confidence that we have that the study was done completely without bias. One problem is that bias can creep in unconsciously, even if there is not intentional fraud. Another problem is selective publication: we may only see the papers that report on studies where the drug had a positive benefit, because negative studies are suppressed; this is further complicated by the general preference of journals for positive results, regardless of who is funding the research. If the authors do not disclose their conflicts of interest, we have no way of knowing about them, and may not be sufficiently skeptical in interpreting the findings.

Am I saying we need to be skeptical? Is it not possible to be paid for speaking by a drug company and still do unbiased scientific research on their drugs? Is it not possible even when the drug company is funding the research? Of course it is possible, but unfortunately the data show that it is less likely. In the Introduction to their recent article in JAMA, Reporting of Conflicts of Interest in Meta-analyses of Trials of Pharmacological Treatments[1], Michelle Roseman and colleagues note that “Results from positive trials and from favorable analyses are more likely to be published than results unfavorable to sponsors. Compared with nonindustry-funded trials, pharmaceutical industry–funded studies more often yield results or conclusions in support of the sponsor's drug, and authors' relationships with drug manufacturers have been linked to favorable assessments of drug efficacy and safety,” with numerous references for each of these assertions. The actual focus of their study is to look at meta-analyses to see whether they report conflicts of interest (COIs) in the original studies that they are analyzing. Meta-analyses can be the most potent source of information about a question, as they analyze the results of many studies (ideally, all randomized controlled trials) on a particular topic, and if well done can help to resolve the question of conflicting results from different studies. Of course, if the studies that are included are in themselves biased (either intentionally or not) it will of course impact the results of the meta-analysis. Roseman and her colleagues found that, while the authors of the meta-analyses reveal their own conflicts of interest (if any), consistent with the policies of the journals they publish in, they rarely indicate whether the many studies that they are re-analyzing had such conflicts.

This can be important. For example, if the different studies examined by the meta-analysis tend to show differences in the benefit of a drug treatment, it would be good to know if the ones that showed greater benefit were sponsored by a drug company, or if the authors were on that drug company’s speaker’s bureau. It just might make a difference. Wealth makes a difference because it can buy loyalty, buy favors. The old saw “It is as easy to love a rich man as a poor one” can be modified to “it is as easy to use a product made by someone who pays you as by someone who doesn’t”. Or even “it is as easy to believe an idea supported by the rich and the powerful as one supported by only the poor and disenfranchised”. The problem is that the connections are not random – the ideas of the rich and powerful are too frequently self-serving, and “just so happen” to favor them over the poor and disenfranchised. An excellent example, featuring Ayn Rand and her disciple Alan Greenspan, is provided to us by Matt Taibbi in chapter 2 of his book “Griftopia”[2].

Then it isn’t as easy. Then it is corrupt. Then it is immoral. Then it is selling your soul.

[1] Roseman M et al, Reporting of Conflicts of Interest in Meta-analyses of Trials of Pharmacological Treatments, JAMA. 2011;305(10):1008-1017

[2} Taibbi M. “Griftopia: Bubble machines, vampire squids and the long con that is breaking America“. Speigel and Grau. New York. 2010. Ch. 2, “The biggest asshole in the universe”

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The Challenge of Global Health and Primary Care

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I recently attended the 7th American Academy of Family Physicians (AAFP) sponsored Family Medicine Global Health Workshop. Over a period of 3 days, we heard plenary speakers, attended small-group breakout sessions, reviewed a large number of posters, and had an opportunity to talk and share ideas with each other. As one of those in attendance with the least experience in international health (while I have spent some time in Brazil, including a rather short teaching Fulbright, I have never been part of so much as a “medical mission” trip, not to mention spent protracted or recurrent time in providing health care or developing health systems in other countries, either in disaster relief or ongoing care), I felt I had a great deal to learn and I tried hard to absorb as much as possible. The collective experience represented by the attendees was overwhelming. Senior participants had spent decades working in both direct patient care and the creation of clinics as well as in consulting with governments and Ministries of Health on developing health systems based in primary care and family medicine. Some of the participants had returned for years – or for decades – to the same regions, spending months there each year. Family physicians ran or were part of a number of not-for-profit organizations that provided disaster medicine or primary care in countries in need around the world. Others were still residents, or even medical students, who had spent some time in areas of need (most recently, of course, in Haiti) and were planning on making this a central part of their future careers.

There was a breadth of motivations for this work. While many of the participants, and many who work in international health, were inspired by their religious beliefs (and “medical missions” still, in most places including medical schools, is the de facto term for any trip taken by physicians and students even when not sponsored by a religious organization), there were others whose motivation was not, and in particular was social justice. A poster presented by Joanie Baumer, MD, from Fort Worth’s John Peter Smith Hospital Family Medicine Residency (the largest in the country), which has been involved in programs in many countries, surveyed participants on what their main motivations were – and what they perceived those of others to be. Social justice topped the both lists, with “mission” (religious) about 4th, although it was higher in motivations attributed to others.

Plenary sessions from former HHS Secretary and University of Miami President Donna Shalala and others addressed important issues. Fitzhugh Mullan, MD, of George Washington University raised the issue of “brain drain” (see also Primary Care, IMGs, and the Health of the People in this blog, August 14, 2010), in which physicians trained in developing countries, often at public expense, migrated to wealthy Western countries, where they were often welcomed (as in the US) to fill residency and underserved-area-practice positions. While there was some pushback from the (small number) of attendees who had come to the US from other countries, it is hard to argue with Dr. Mullan’s proposition that “the US ought to be able to train enough physicians to care for its population without having to import them from the developing world” (paraphrased). As in so much of policy, there is often a distinction between the individual stories, needs and aspirations of individuals and the overall effect. Cynthia Haq, MD, of the University of Wisconsin, told her own story; one of increasing involvement in international work, from naïve trips to longer stays, to work with WHO and helping other countries develop their health systems, seamlessly intertwined with the story of her own family (“Stepping Stones: Strategies to enrich your life with Global Family Medicine”, posted like many of the other presentations, to the Family Medicine Digital Resource Library, www.fmdrl.org). Steven Spann, MD, of Baylor, presented a superb discussion of ethical issues in doing international work. In a breakout session (and remember, I can only report on those I attended) Gary Morsch, MD, founder of Heart to Heart International, presented the work of that group, which provides opportunities for health professionals to work abroad for shorter periods, a week or two, in settings such as Haiti, in contrast to larger and more famous organizations such as Medecins sans Frontieres, which requires 6-9 month commitments. Dr. Morsch also described H2H’s affiliated group, “Docs Who Care”, which provides locums tenens opportunities in rural parts of the Midwest, both helping those communities with their health needs and the physicians with the opportunity to earn a living in a manner that allows them to spend much of their time doing international work.

Haiti, where the January 2010 earthquake created incredible needs in a nation already living on the edge, with over 300,000 killed outright and hundreds of thousands more severely injured physically, psychologically, and emotionally as well as having every aspect of their lives disrupted or destroyed, was obviously a major focus. Many of the presenters of posters and breakout sessions, and many more of the attendees, had spent some time working in Haiti, in the initial “disaster” phase or the (still disastrous) “primary care” phase. They discussed the good (the people and their resilience, the commitment of the volunteers, the resources pouring in) and the not so good (the historical background of oppression and de-resourcing of Haiti, the lack of coordination between relief agencies, the volunteers who were on occasion self-centered and more often ignorant of the needs and realities of the situation). One of the best sessions I attended was by André Vulcain and Michèle Dodard of the University of Miami Department of Family Medicine. In 1999, they helped to start a family medicine residency program in Haiti’s second city, Cap Haitien, which had graduated 35 family physicians by the time of the quake and is still functioning. Unlike many of the other collaborations described, which are often with private (usually religious) hospitals, this program is sponsored by the Ministry of Health of Haiti and is based in a government hospital. While Dr. Vulcain’s powerpoints are not yet available on FMDRL, Dr. Dodard’s description of the work of the University of Miami’s “Project MediShare”, Rebuilding Haiti’s Healthcare System, is. Rebuilding that system, working with the Haitian government and people, training Haitian health professionals so that they do not need to depend on “mission trips” has also become a key focus of the work of Partners in Health (PIH) (“Zanmi Lasante” in Haitian Kreyol) and many other groups.

One of PIH’s founders, Paul Farmer MD PhD, and his colleagues Vanessa Bradford Kerry MD and Sara Auld MD propose the creation of an “International Service Corps for Health” in an article in a the September 23, 2010 issue of the New England Journal of Medicine.[1] They talk about the work that has been done, particularly that done by academic medical centers, but also address the limitations, especially financial, of these efforts, and suggest that a government-sponsored program, working in collaboration with other US agencies, might be a very effective way of increasing the international reputation of the US as well as helping to meet the staggering needs that exist in the world, such as in Africa, which “…bears 24% of the global disease burden but hosts only 3% of the global health care workforce and is responsible for less than 1% of world health care expenditures.” They describe the enormous impact that the small country of Cuba has had internationally, “…between 1999 and 2004, Cuban foreign-service workers increased doctor visits in resource-poor communities by 36.7 million, provided health promotion outreach for millions of underserved people, and taught 900,000 medical education courses to local personnel.” If carried out reasonably and equitably, an International Health Service Corps (IHSC) might be a major step forward.

There are still great healthcare needs in the US, and very underserved communities (both rural and urban), as detailed in the recent US Census Bureau report “Income, Poverty and Health Insurance Coverage in the United States, 2009”, and it is sometimes distressing to medical educators to observe that many medical students have much greater enthusiasm for “international work” than they they do for helping to meet those domestic needs. However, as Kerry et. al., and the presenters at the AAFP Conference, among others, document, the international needs are staggering.

The interest and commitment of health professionals and students in working internationally, demonstrated not only in the AAFP Global Health Conference but daily in our schools and residency programs, is a wonderful thing. Developing meaningful, useful, and long-term opportunities to serve, such as the existing programs described above and at the conference, or a new “international health service corps”, are very important goals.

[1] Kerry VB, Auld S, Farmer P, “An international service corps for health – an unconventional prescription for diplomacy”, NEJM 2010Sep23;363(13):1199-1201
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The AAFP, Coca-Cola, and Ethics: Serving the public interest?

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Last fall, the American Academy of Family Physicians (AAFP) (full disclosure: the organization of family physicians, to which I belong) entered into a partnership agreement with the Coca-Cola Company for support of its patient information website, FamilyDoctor.org. The amount of the funding is uncertain, but it is reputed to be in the “mid-six-figures”. The arrangement came in for a great deal of criticism, both within and outside of the family medicine community, and several members of the organization resigned in protest. I addressed this as a small part of a larger blog, Harvard Medical School limits outside income: a good start, on January 21, 2010.

The debate has not gone away, and has been highlighted by two articles in the recent (July-August 2010) issue of Annals of Family Medicine, the research journal sponsored by all the family medicine organizations in the US and Canada. The first is by Howard Brody, the family physician and medical ethicist from the University of Texas Medical Branch at Galveston, “Professional Medical Organizations and Commercial Conflicts of Interest: Ethical Issues”, and the second is response by Lori Heim, President of the AAFP, “Identifying and Addressing Potential Conflict of Interest: A Professional Medical Organization’s Code of Ethics.” Brody’s essay is a clearly written review of the ethics of conflict of interest, addressing both whether the relationship between AAFP and Coke is a conflict of interest (COI) and whether it is ethically worrisome, and an analysis of the reasons and defenses put up by AAFP and Coke. In the first, he notes that a conflict of interest can, and often does, exist even when no “bad” outcome can be identified; it is simply a conflict between the primary set of responsibilities (in this case, of physicians and their organizations’ social responsibility for looking out for the best interests of their patients’ health; in other settings it might be awarding of government contracts or foundation grants) and a second, usually financially motivated set of interest.

Brody distinguishes between two strategies for addressing COI, a Management Strategy in which COIs are divulged so that others (presumably in this case, patients and the public) can take them into account, and the Divestment Strategy, in which organizations rid themselves of COI relationships. He dispenses with the conflation of COI with intellectual conflicts (that an investigator might want to show that his/her “pet hypothesis” is correct and put it in the best light) because readers will always be aware of the latter, but will not know of commercial relationships unless they are divulged. He notes that the Divestment Strategy is favored in most recent ethical literature (and in increasing numbers of medical schools, as per my January 21 blog), although not by the AAFP.

He then addresses the counterarguments and justifications that the AAFP has put forward in this case. These include:

· “Premature Accusation”, in which the AAFP says “you can’t know that we have a conflict until you see the content. He notes the conflict exists regardless, and offers this “crude” analogy: “imagine that a judge who is sitting on a case involving a contract dispute between two companies is discovered to own $100,000 worth of stock in one of the companies. The judge cannot divert criticism of this conflict of interest by saying, ‘But you haven’t waited until I delivered my verdict—how do you know that I won’t rule against the company in which I own stock?’ In the AAFP case, if the final educational material includes a strong statement against sugary soft drinks, we will never know whether, absent the Coca-Cola funding, the statement would have been even stronger. That such questions will inevitably be raised shows the conflict of interest is both present and serious, quite apart from the eventual contents of the educational materials."

· “Other Party not Evil”, in this case Coca-Cola. The issue, of course, is not whether they are evil, but whether their interests may lie in opposition to the interests of the health of doctors’ patients; “The physician has a duty to prescribe medications or make dietary recommendations based on scientific evidence. The companies have an interest in selling more beverages, or more drugs, regardless of the evidence.”

· “Wrong not to Engage” with organizations such as Coca-Cola. “Schafer[1] noted the propensity for engagement with industry, in such discussions, magically to convert itself into accepting large sums of money from industry.…No one is suggesting that the AAFP not engage Coca-Cola if the engagement avoids conflicts of interest and the result of the engagement would be improved public health.” [my bold]

Brody also addresses the similarities and difference between this and the 1997 relationship in which the American Medical Association (AMA) actually endorsed products made by Sunbeam. He notes that the relationship is called a “Consumer Alliance”, when it is more properly a corporate alliance. (I had missed this Newspeak usage in my January 21 blog, where I mistakenly called it a “corporate partnership”!)

Heim’s response states that Brody misses the point, and goes on to make the same arguments that AAFP has made before, that Brody has addressed and debunked, offering nothing new to the discussion. It refers to the AAFP Code of Ethics, and creates the disturbing sense that “we want the money, we don’t think we are doing anything unethical with the money, and so stop criticizing us.” In other words, it purposely and deliberately misses the point.

Does the AAFP’s relationship with Coke go beyond a conflict of interest (which it clearly is) to actually providing unhealthful material? Some authors believe so; public health attorney Michelle Simon, in her blog Appetite for Profit, addresses the issue on July 22, 2010. She notes that FamilyDoctor.org contains the disclaimer “This content was developed with general underwriting support from The Coca-Cola Company,” and comments “That makes it sound as if the Coca-Cola is just paying someone else to do the writing. But it appears the company is directing the substance of the content as well, since the verbiage is pretty similar to that found on Coca-Cola's own website on these very topics. (See for example, the company's page on sweetener ‘facts and myths’.)”

Simon quotes Dr. Heim’s article, “To gauge an individual or organization’s ethics, one must view its behavior over time, define the goal of that behavior and compare the outcome with the mission and values. Within this context, one can determine whether the assumption or appearance of conflict of interest or ethical lapse was, in fact, correct.” And comments: “What? She lost me somewhere between outcome and values. Taking money from Coca-Cola is not a science experiment that you watch over time, gather data, and then publish the analyzed results. But if one were to approach the issue that way, there's no shortage of evidence of Coca-Cola's 'ethical lapses.' Whether your concern is marketing to children, labor abuses, or contaminating water supplies in developing nations, Coca-Cola would be the one company you'd not choose as a partner. Journalist Michael Blanding has written an entire book called The Coke Machine: The Dirty Truth Behind the World's Favorite Soft Drink, due out in September, which chronicles these misdeeds and more.”

Certainly, the AAFP is not the only organization that has potentially undermined its public trust. For another big one, the American Dietetic Association (ADA) has a partnership (I don’t know if they’ve dared to call it a “consumer alliance”) with – Hershey! (see ADA’s press release at its own website; also see the Fooducate blog).

Maybe the ADA’s partnership is more outrageous, but as a family doctor and educator, I take the AAFP’s relationship with Coke more personally because it undermines me. At the time of this deal, several of the other family medicine organizations, including the Association of Departments of Family Medicine (ADFM, academic department chairs, to which I also belong) expressed serious concerns about this relationship to the AAFP leadership. These concerns related particularly to the fact that, to the public, family medicine is family medicine, and when the largest family medicine organization, AAFP, does something the entire discipline is affected; for example, medical students, or faculty in other departments, who may be distressed by the relationship express that concern to the faculty of family medicine. AAFP, the big dog on the block, listened. It didn’t change its policy, though. Money talks, of course, but if AAFP’s 55,000 active members (not including students, residents, and retirees) each sent in $10, it would be about the same amount as they received from Coke. Are we that cheap? As far as the content on FamilyDoctor.org is concerned, check it out for yourself. You can start by clicking on the benign (but somehow familiar) logo at the top of its web page.

Brody concludes his essay with: “Family physicians are widely trusted by their patients and communities. Merely by having chosen our specialty, family physicians have demonstrated a commendable commitment to putting the health needs of their patients ahead of personal financial gain. They deserve to be represented nationally by an organization that fully reflects those high ethical commitments and standards.” I couldn’t agree more.

[1] Schafer A. Biomedical conflicts of interest: a defence of the sequestration thesis—learning from the cases of Nancy Olivieri and David Healy. J Med Ethics. 2004; 30(1):8–24

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