Tag Archives: health care reform

Procedural Rural Medicine

“Primary care practice in the future may be more akin to an Amish barn-raising than care delivered by the fictional Marcus Welby.” – Valerie E. Stone, et al., “Physician Education and Training in Primary Care” (2010)[1]

Current proposals to remedy the crisis in primary care, especially among those Americans living in small, rural communities, are politically correct (or, in the case of J-1 waivers for foreign-trained physicians, ethically unacceptable) gestures.  Small adjustments in Medicare reimbursement schedules for physicians serving the underserved and unenforceable mandates by state legislatures that public medical schools “produce” more primary care physicians are all but meaningless.  Rural medicine programs at a handful of medical colleges basically serve the tiny number of rural-based students who arrive at medical school already committed to serving the underserved.  Such programs have had little if any impact on a crisis of systemic proportions.  If we want to pull significant numbers of typical medical students into primary care, we must empower them and reward them – big time.  So what exactly do we do?

  1. We phase out  “family medicine” for reasons I have adduced and replace it with a new specialty that will supplement internal medicine and pediatrics as core primary care specialties.  I term the new specialty procedural rural medicine (PRM) and physicians certified to practice it procedural care specialists.  Self-evidently, many procedural rural specialists will practice in urban settings.  The “rural” designation simply underscores the fact that physicians with this specialty training will be equipped to care for underserved populations (most of whom live in rural areas) who lack ready  access to specialist care.  Such care will be procedurally enlarged beyond the scope of contemporary family medicine.
  2. Procedural care specialists will serve the underserved, whether in private practice or under the umbrella of Federally Qualified Health Centers, Rural Health Centers, or the National Health Service Corps. They will  complete a four-year residency that equips all rural care specialists to perform a range of diagnostic and treatment procedures that primary care physicians now occasionally perform in certain parts of the country (e.g., colposcopy, sigmoidoscopy, nasopharyngoscopy), but more often do not.  It would equip them to do minor surgery, including office-based dermatology, basic podiatry, and wound management.   I leave it to clinical educators to determine exactly which baseline procedures can be mastered within a general four-year rural care residency, and I allow that it may be necessary to expand the residency to five years.  I further allow for procedural tracks within the final year of a procedural care program, so that certain board-certified procedural care specialists would be trained to perform operative obstetrics whereas others would be trained to perform colonoscopy.[2] The point is that all rural care proceduralists would be trained to perform a range of baseline procedures.  As such, they would be credentialed by hospitals as “specialists” trained to perform those procedures and would receive the same fee by Medicare and third-party insurers as the “root specialists” for particular procedures.
  3. Procedural care specialists will train in hospitals but will spend a considerable portion of their residencies learning and practicing procedurally oriented primary care in community health centers.  Such centers are the ideal venue for learning to perform “specialty procedures” under specialist supervision; they also inculcate the mindset associated with PRM, since researchers have found that residents who have their “continuity clinic” in community health centers are more likely to practice in underserved areas following training.[3]
  4. On completion of an approved four- or five-year residency in procedural rural medicine and the passing of PRM specialty boards, procedural care specialists will have all medical school and residency-related loans wiped off the books. Period.  This financial relief will be premised on a contractual commitment to work full-time providing procedural primary care to an underserved community for no less than, say, 10 years.
  5. Procedural care specialists who make this commitment deserve a bonus. They have become national resources in healthcare.  Aspiring big league baseball players who are drafted during the first four rounds of the MLB draft, many right out of high school, typically receive signing bonuses in the $100,000-$200,000 range.  In 2012, the top 100 MLB draftees each received a cool half million or more, and the top 50 received from one to six million.[4]  I propose that we give each newly trained procedural care specialist a $250,000 signing bonus in exchange for his or her 10-year commitment to serve the underserved.  Call me a wild-eyed radical, but I think physicians who have completed high school, four years of college, four years of medical school, and a four- or five-year residency program and committed themselves to bringing health care to underserved rural and urban Americans for 10 years deserve the same financial consideration as journeymen ball players given a crack at the big leagues.
  6. Taken together, the two foregoing proposals will make a start at decreasing the income gap between one group of primary care physicians (PCPs) and their colleagues in medical subspecialties and surgical specialties.  This gap decreases the odds of choosing primary care by nearly 50%; it is also associated with the career dissatisfaction of PCPs relative to other physicians, which may prompt them to retire earlier than their specialist colleagues.[5]
  7. I am not especially concerned about funding the debt waiver and signing bonuses for board-certified procedural care specialists.  These physicians will bring health care to over 60 million underserved Americans and, over time, they will be instrumental in saving the system, especially Medicare and Medicaid, billions of dollars.  Initial costs will be a  drop in the bucket in the context of American healthcare spending that consumed 17.9% of GDP in 2011.  Various funding mechanisms for primary care training – Title VII, Section 747 of the Public Health Service Act of 1963, the federal government’s Health Resources and Services Administration, Medicare – have long been in place, with the express purpose of expanding geographic distribution of primary care physicians in order to bring care to the underserved.  The Affordable Care Act of 2010 may be expected greatly to increase their funding.

————

These proposals offer an alternative vision for addressing the crisis in primary care that now draws only 3% of non-osteopathic physicians to federally designated Health Professional Shortage Areas and consigns over 20% of Americans to the care of 9% of its physicians.  The mainstream approach moves in a different direction, and the 2010 Macy Foundation-sponsored conference, “Who Will Provide Primary Care and How Will They Be Trained,” typifies it.  Academic physicians participating in the conference sought to address the crisis in primary care through what amounts to a technology-driven resuscitation of the “family practice” ideology of the late 1960s.  For them, PCPs of the future will be systems-savvy coordinators/integrators with a panoply of administrative and coordinating skills.  In this vision of things, the “patient-centered medical home” becomes the site of primary care, and effective practice within this setting obliges PCPs to acquire leadership skills that focus on “team building, system reengineering, and quality improvement.”

To be sure, docs will remain leaders of the healthcare team, but their leadership veers away from procedural medicine and into the domain of “quality improvement techniques and ‘system architecture’ competencies to continuously improve the function and design of practice systems.”  The “systems” in question are healthcare teams, redubbed “integrated delivery systems.”  It follows that tomorrow’s PCPs will be educated into a brave new world of “shared competencies” and interprofessional collaboration, both summoning “the integrative power of health information technology as the basis of preparation.”[6]

When this daunting skill set is enlarged still further by curricula addressing prevention and health promotion, wellness and “life balance” counseling, patient self-management for chronic disease, and strategies for engaging patients in all manner of decision-making, we end up with new-style primary care physicians who look like information-age reincarnations of the “holistic” mind-body family practitioners of the 1970s. What exactly will be dropped from existing medical school curricula and residency training programs to make room for acquisition of these new skill sets remains unaddressed.

I have nothing against prevention, health promotion, wellness, “life balance” counseling, and the like. Three cheers for all of them – and for patient-centered care and shared decision-making as well.  But I think health policy experts and medical academics have taken to theorizing about such matters – and the information-age skill sets they fall back on – in an existential vacuum, as if “new competencies in patient engagement and coaching”[7] can be taught didactically as opposed to being earned in the relational fulcrum of clinical encounter.  “Tracking and assisting patients as they move across care settings,” “coordinating services with other providers,” providing wellness counseling, teaching self-management strategies, and the like – all these things finally fall back on a trusting doctor-patient relationship.  In study after study, patient trust, a product of empathic doctoring,  has been linked to issues of compliance, subjective well-being, and treatment outcome.  Absent such trust, information-age “competencies” will have limited impact; they will briefly blossom but not take root in transformative ways.

I suggest we attend to first matters first.  We must fortify patient trust by training primary care doctors to do more, procedurally speaking, and then reward them for caring for underserved Americans who urgently need to have more done for them.  The rest – the tracking, assisting, coordinating, and counseling – will follow.  And the patient-centered medical home of the future will have patient educators, physician assistants, nurse practitioners, and social workers to absorb physicians’ counseling functions, just as it will have practice managers and care coordinators to guide physicians through the thicket of intertwining  information technologies.  We still have much to learn from Marcus Welby – and William Stepansky – on the community-sustaining art of barn-raising and especially the difference between barns well and poorly raised.


[1] Quoted from “Who Will Provide Primary Care And How Will They Be Trained?”  Proceedings of a conference chaired by L. Cronenwett & V. J. Dzau, transcript edited by B. J. Culliton & S. Russell (NY:  Josiah Macy, Jr., Foundation, 2010), p. 148.

[2] The prerogative to develop specialized knowledge and treatment skills within certain areas has always been part of general practice, and it was explicitly recommended in the Report of the AMA Ad Hoc Committee on Education for Family Practice (the Willard Committee) of 1966 that paved the way for establishment of the American Board of Family Practice in 1969.  See N.A., Family Practice: Creation of a Specialty (American Academy of Family Physicians, 1980), p.  41.

[3] C. G. Morris & F. M. Chen, “Training residents in community health centers:  facilitators and barriers,” Ann. Fam. Med., 7:488-94, 2009; C. G. Morris, et al., “Training family physicians in community health centers,” Fam. Med., 40:271-6, 2008; E. M. Mazur, et al., “Collaboration between an internal medicine residency program and a federally qualified health center: Norwalk hospital and the Norwalk community health center,” Acad. Med., 76: 1159-64, 2001.

[5] “Specialty and geographic distribution of the physician workforce:  What influences medical student & resident choices?”  A publication of the Robert Graham Center, funded by the Josiah Macy, Jr. Foundation (2009), pp. 5, 47; “Who Will Provide Primary Care And How Will They Be Trained” (n. 1), p. 140.

[6] “Who Will Provide Primary Care And How Will They Be Trained”(n. 1), pp. 147, 148.

[7] Ibid, p. 151.

Copyright © 2013 by Paul E. Stepansky.  All rights reserved.

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“Socialized Medicine,” anyone?

The primary season is upon us, which means it’s time for Republicans to remind us of the grave perils of “socialized medicine.”  One-time candidate Michele Bachmann accuses Mitt Romney  of “put[ting] into place socialized medicine” when governor of Massachusetts.  Newt Gingrich, rejecting Romney’s defense of the Massachusetts law as something other than socialist, declares that  “Individual and employer mandates are bad policy leading down the road to socialized medicine, whether the mandates are adopted at the federal level or the state level.”  Ron Paul, not to be outdone, derides our health care system as “overly corporate and not much better than a socialized health care system.”  Rick Santorum mournfully announces that socialized medicine is “exactly where we’re headed.”  And then of course there is that noncandidate and subtle political thinker Sarah Palin, who apparently tolerated Canadian single-payer health care well enough when it was available to her and her family members, but never fails to lambast the health care reform bill of 2010 (“Obamacare”) as the great evil, the capitulation to socialist medicine that will lead us straight into the bowels of socialist hell.

As a historian of ideas, I am confused.  What exactly do these Republicans mean by “socialized medicine” and, more generally, by “socialism”?  Are they referring to the utopian socialism of the early nineteenth century that arose in the wake of the French Revolution, the socialism of Charles Fourier, Henri Saint-Simon, and Joseph Le Maistre?  Are they referring to Marxist socialism and, if so, which variant?  The socialism of the early Marx, the Marx of the  economic and philosophical manuscripts of 1844 and The German Ideology or the socialism of the late Marx, the Marx of Das Kapital?  It is difficult to imagine the candidates rejecting the conservative socialism of Otto Bismarck, the German Iron Chancellor who, during the 1870s and 1880s, wed social reform to a conservative vision of society.  But then again they might:  Bismarck’s reforms, which included old-age pensions, accident insurance, medical care, and unemployment insurance, paved the way for the triumph, despite Bismarck’s own antisocialist laws, of Germany’s Social Democratic Party in the early twentieth century.

Perhaps the Republicans mean to impugn a broader swath of post-Marxist reformist socialism (also termed “democratic socialism”).  Does their antipathy take in the British liberal welfare reforms of David Lloyd George that from  around 1880 to 1910 constructed Britain’s social welfare state?  After all, Britain’s National Insurance Act of 1911 provided for health insurance, and many of Lloyd George’s  acts aimed at the health and well-being of British children.  Child labor laws, medical inspection of schools, and medical care for school children via free school clinics were among them.  Certainly all the candidates would repudiate FDR’s New Deal.  Depression or no, it was a medley of socialist programs that culminated in a social security program that workers could not opt out of.  But then again, perhaps the candidates do not understand socialism as the cumulative protections of democratic socialism.  Maybe the socialism they impugn is only hard-core late Marxism and its transmogrification after 1917 into Soviet Marxism-Leninism, both of which now slumber peacefully in the dustbin of history.  I don’t know.  Does anyone?  Maybe some of these candidates only see red when contemplating employment of physicians by the state.

When it comes to “socialized medicine,” just how far do the Republicans seek to turn back the clock?   Does more than a century of social welfare reform have to go?  Certainly they must repudiate Medicare and Medicaid, whose passage in 1965 was, with respect to the elderly and indigent, socialism pure and simple; for the AMA these programs sounded the death knell of democracy.  But why stop there?  If they really want to root out medical socialism, they can hardly condone Medicare’s precursor, the Kerr-Mill Act of 1960 that made federal matching funds available to states that underwrote the costs of health care for their indigent elderly.

And what of the FDA, that competition-draining, creativity-stifling offspring of Rooseveltian socialist thinking.  Who is the government to tell medical equipment manufacturers which devices they may sell to doctors and the public?  The 1976 Medical Devices Amendments to the Federal Food, Drug and Cosmetic Act of 1938 would have to go.  The more than 700 deaths and 10,000 injuries attributed to defective cardiac pacemakers and leaky artificial heart valves by the Cooper Commission in 1970, not to mention the 8,000 women injured (some left sterile) by their faulty contraceptive Dalkon Shields – this was a small price to pay for an open marketplace that encouraged and rewarded innovation.  The 1962 Kefauver–Harris Amendments to the Federal Food, Drug and Cosmetic Act of 1938, which arose in the wake of the thalidomide tragedy of 1961, would probably fare no better.  After all, these amendments dramatically expanded the FDA’s authority over prescription drugs by requiring drug companies to conduct preclinical trials of toxicity and then present the FDA with adequate and well controlled studies of drug effectiveness  before receiving regulatory approval.  I wonder if principled antisocialists can even abide the FDA-enforced distinction between prescription-only and nonprescription drugs, as codified in the 1951 Durham-Humphrey Amendment to the 1938 Act.  Before then, Americans did just fine self-medicating without government interference.  Sure they did.  Citizens of the late 30s could be relied on to decide when to take the toxic sulfonamides (which depressed white cell counts and led to anemias), just as citizens of the late 40s knew enough pharmacology and bacteriology to decide when and in what dosages to use the potent antibiotic “wonder drugs,” all of which could be obtained over-the-counter or directly from pharmacists until the 1951 Act.

But why stop there?  Perhaps Republican political philosophy obliges the candidates to repudiate the Federal Food, Drug and Cosmetic Act in toto.  After all, it authorized the FDA, a federal agency, to review the safety and composition of new drugs before authorizing their release.  Yes, the legislation arose in the wake of 106 deaths the preceding year – many children among them – from sales of the Tennessee drug firm S. E. Massengill’s Elixir Sulfanilamide.  The Elixir was a sweet-tasting liquid sulfa drug that – unbeknown to anyone outside the company — used toxic diethylene glycol (a component of brake fluid and antifreeze) as solvent.  But, hey, this was free-market capitalism in action.  Sure, hundreds more would have died if all 239 FDA inspectors hadn’t tracked down 234 of the 240 gallons of the stuff already on the market.  But is this really any worse than having 10,000 or so European and Japanese kids grow up with flippers instead of arms and hands because their pregnant mothers, let down by the regulatory bodies of their own countries, ingested Chemie Grünenthal’s sedative thalidomide to control first-trimester morning sickness?  A free medical marketplace has its costs, dead kids, deformed kids, and sterile women among them.  Perhaps, in the Republican vision of American health care, this marketplace had every right to bestow on Americans their own generation of thalidomide babies, not just the small number whose mothers received the drug as part of the American licensee’s advance distribution of samples to 1,267 physicians.

If we’re going to turn back the clock and recreate a Jacksonian medical universe free of intrusive, expensive, innovation-stifling, rights-abrogating big government, let’s go the full nine yards.  Let’s repudiate the Pure Food and Drugs Act of 1906, which compelled drug companies to list the ingredients of drugs on the drug labels.  Sure, prior to the act most remedies aimed at children were laced with alcohol, cocaine, opium, and/or heroin, but was this so bad?  At least these tonics, unlike Elixir Sulfanilamide, didn’t kill the kids, and the 1906 Act did put us on the path to government overregulation.  And, anyway, it’s up to parents, not the federal government, to figure out what their kids ingest.  Let them do their own chemical analyses (or better yet, contract unregulated for-profit labs to do the analyses for them) and slug it out with the drug companies.

And, while we’re at it, let’s roll back the establishment in 1902 of the brazenly socialistic Public Health and Marine Hospital Service, with its “big government” division of pathology and bacteriology.  Okay, it did a few things Republican candidates would likely applaud, like preventing incoming immigrants from coming ashore with infectious diseases like cholera, yellow fever, and bubonic plague.  But the Service couldn’t leave well enough alone. With its federal budget and laboratory of government employees, it went on to identify infectious diseases like typhoid fever, tularemia, and undulant fever.  Then, during World War I, after its name had been shortened to the Public Health Service, it isolated the organisms responsible for epidemic meningitis and developed tetanus antitoxin and antityphoid vaccine.  But, hey, private enterprise of the time would have addressed these issues better and more cost effectively, right?  And it wouldn’t have placed us on the road to socialist perdition.

Compulsory vaccination for smallpox and diphtheria?  State laws that beginning in 1893 required public schools to exclude from enrollment any student who could not present proof of vaccination?  Forget it.  States and municipalities had no right forcibly to intrude into the lives of children with their public health inspectors, followed by school physicians with their vials of toxin-antitoxin.  What was this if not socialist medicine, with the state abrogating the rights of parents and school principals alike – the former with the right to keep their children unvaccinated, that they might contract infection and pass it on to classmates and family members; the latter with the right to keep school enrollment as high as possible without government interference.

Here’s the point of this exercise in conjecture:  If we’re going to have a national debate about health care, then our candidates must cease and desist from using evocative words that incite fear and loathing but mean nothing because they mean anything and everything.  You can’t have a debate without people capable of debate, which is to say, people who grasp ideas as something other than sound bites that mobilize primitive emotions.  Debaters make arguments and cite evidence that support them; they don’t throw out words and wait for a primal scream.

It would be nice if we had presidential candidates willing and able to explain their take on specific ideas and then wrestle with the applicability of those ideas to the real-life problems of specific groups of Americans.  It would be nicer still if all this explaining and wrestling and applying were informed by the lessons of history.  I believe we will have such debates shortly after hell freezes over.  Therefore, I offer my own ideational stimulus package to inch us toward this goal.  I propose an Act of Congress that proscribes the use of certain words and phrases among all presidential candidates.  Each time a candidate uses a proscribed word or phrase in a campaign speech, a TV commercial,  or an internet posting, he or she, if nominated, forfeits one electoral vote earned in the general election.  In the realm of health care, “socialism,” “socialist medicine,’’ “big government,” “death panels,” “overregulation,”  “the people,” and “the American way” would top the list.  Such terms cannot be part of a national debate because they do not promote reasoned exchange.  They have emotional resonance but nothing else.  In fact, they preclude debate by allowing the word or phrase in question to carry an implicit meaning that reaches consciousness only as a gut-churning abstraction.  Gut-churning abstractions, be it noted, tend to be historically naïve and empirically empty.

So I end where I began:  What exactly do our Republican candidates mean by “socialized medicine” other than a global repudiation of the health care reform bill of 2010?  Do they mean that medicine was just socialist enough before the bill passed, but that specific components of the bill – like preventing insurers from denying coverage to people with preexisting conditions – take the country to a point of socialist excess serious enough to abrogate the new protections the bill affords uninsured and underinsured  Americans.  Or perhaps American health care, even before the legislation, was simply too socialist, so that it becomes incumbent on our elected leaders to turn back the clock, undo past legislative achievements, reverse specific governmental policies, and disembowel certain regulatory agencies.  But if the latter, exactly which laws and policies and agencies must be sacrificed on the altar of a free and open medical marketplace?   I don’t know what the Republican candidates have in mind, but I’m all ears – once they stop lobbing word grenades and actually make an argument.

Copyright © 2012 by Paul E. Stepansky.  All rights reserved.