Alfred O. Berg, MD, MPH
Professor and Associate Chair
University of Washington Department of Family Medicine
The Fourth G. Gayle Stephens Lecture
Alfred O. Berg, MD, MPH, presented the Fourth Stephens Lecture, entitled Access to What?
Fifth National Conference on Primary Health Care Access
Hyatt Regency Maui
Ka’anapali Beach, Lahaina, Maui, Hawaii
March 26, 1994
Mark Clasen, MD, PhD (Chair, Department of Family Medicine, Wright State University): If I could just make a few comments to jog your memory; Gayle Stephens for whom this lecture is named, has reminded us about patient care being a covenant, rather than a contract – an interesting notion in managed care days. He has reminded us not to abandon our low-tech medicine in our high touch medicine, preferentially in the converse. Many of us really enjoyed his analogy of the Big Red Bull, who eats and eats and never really gets full. All of those have to do with the fact that he’s a philosophic leader of our profession.
Presenting the fourth G. Gayle Stephens Lecture is Alfred O. Berg, M.D., M.P.H., who is well-known to many of us. He received his MD degree at Washington University in St. Louis, did his family practice residency training program in Missouri, and participated in the Clinical Scholars Program at the University of Washington and also did a residency in preventive medicine. He is currently on the faculty of the Department of Family Medicine at the University of Washington where he’s a professor and an associate chair. It’s a real pleasure to have Al give this lecture.
Dr Berg: Thank you, I am really not that good with jokes but felt some pressure this morning after Bill Norcross’ introduction from yesterday, and also in musing at breakfast this morning where anesthesiologists were taking quite a hit. Primary care anesthesiology is what we were talking about, so I thought I would tell a true story. At the University of Washington, of the 12 anesthesiologist graduates last year, all of whom wanted to stay in Seattle, none were able to find jobs. One of our family practice faculty is married to a faculty member in our anesthesiology department. The current pun circulating in his department is, “What does the anesthesiologist say to the family physician? Ma’am, will you be having fries with that order?” (Laughter)
It is quite an honor to be invited to give this lecture. I know the program committee had no idea of the personal significance to me of the invitation. This event marks to the month, 25 years since I first met Gayle Stephens. I was very sorry to hear he was not able to attend the meeting. I spent the summer between the first and second years of medical school watching one on one as Gayle served as doctor, teacher, and administrator of a new family practice residency program in Wichita, Kansas. That experience was the necessary foil to the overwhelmingly reductionist biomedical education that I went through at the Washington University in St. Louis. I became part of a fairly early group in family practice residency training and am one of an exceedingly small minority of Washington University graduates who went into family medicine.
Over the years Gayle and I have kept in touch. Whatever nervousness I might have had talking to this group has been diminished considerably by that fact that he’s not going to be here – because his is the only opinion that I was very much worried about. (Laughter). I have one warning. I have always appreciated Gayle’s ability to place things in larger perspective. His original lecture to this group on the Red Bull – that Mark already mentioned, that I was not able to attend but have read – was a classic model of the things he does best. I have often wished I had the mental capacity to do the same. This session actually seemed to me a good and I hope a safe place to try my hand at this kind of business.
My presentation is fairly brief – you’ll be pleased to know – and you should see it as being tentative, provisional and perhaps confidential. I am the only person here from my department and I may not want this to get back. (Laughter) I will welcome a vigorous discussion at the end.
Access to what? I will start with the confession (and I feel like this is somewhat coming out of the closet), that I have never been much interested in the access problem. I have been moved at times, or sad or angry, but interested enough to devote time to it? No, definitely not. And the reason I give myself for this socially unacceptable behavior is that I do not believe that access is a fundamental problem. I view access as a tragic, transitional issue that we have to put up with until health care reform gets moving.
What does have me interested, indeed terrified, is looking ahead to when access is not the issue and we are forced to face the fundamental problem of the ends of medicine and the completely appalling lack of evidence that most medical care provides net benefit. Now, although at first glance, this appears to be irrelevant to the access issue, in my view, it is the core problem and casts the access debate into an entirely different light.
In advocating access to medical care for patients, we should be perfectly clear on what parts of medical care provides net benefit. Too often I see access being emotionally advocated for services that have unknown benefits. Or worse, that are known to cause harm. Now for the next few minutes I am going to ask you to bear with me. I am going to give you a family physician scientist’s tour of medical practice. I will try to show that the medical care which we are so fervently trying to provide access to, is as full of unproved and potentially harmful treatments as ever. In the end it is the question of efficacy that is the most important.
We still need an answer to the question, is a random patient visiting a random physician for a random problem likely to benefit? My conclusion is that the ends of medicine are more important, more challenging and ultimately will require more from us in family care than the access problem ever could. I will also argue that, in the long run, attention to this issue – the efficacy of medical care – is more important for primary care faculty physicians than is developing a primary care basis for academic health centers. Indeed, I believe that pressure for academic family medicine faculty to develop academic care networks is another attempt by specialists to marginalize, tame and control primary care faculty in hopes that we will help bail out academic health centers with their large numbers of highly paid and superfluous specialist physicians. My advice is, do not be seduced.
I base these comments on my own recent experience in the business of developing policies for use in clinical practice. This work has forced me to confront, time and time again, the thin matrix of scientific evidence upon which common clinical practices are based. I am on the ten -member United States Preventive Services Task Force. This is one of the oldest and I think best respected of the groups producing scientific policies. I am co-chair of the Agency for Health Care Policy and Research Panel on Otitis Media with Effusion. This is a four year, million dollar project to decide how to treat Otitis Media with Effusion in young children.
I chaired the Centers for Disease Control expert panel that develops the STD treatment guidelines that you all probably saw released late last year and I serve on the joint CDC/AMA panel developing guidelines for prevention in adolescents, also released last year. Now, all of these groups are in the process of developing science-based recommendations for clinical practice. There are some similarities in my experience across these groups. I think I have as much experience as anyone in primary care with this new direction of clinical medicine.
Let me, first, place science-based clinical policies in perspective. Practice policies are pre-formed recommendations issued for the purpose of influencing decisions about health interventions. We have always had them. There are a number of examples: textbooks, professors, journal articles, editorials, consensus panels, guidelines – including insurance decisions based on “community standards”. So what is the problem, what is wrong with these? Well, there may not be anything wrong with them. The problem is that it is impossible to tell.
In all of these traditional practice policies, the methods used to reach each conclusion are not explicit. A reader of a textbook is not told whether literature was examined, how the individual articles were judged and how the final recommendations were arrived at. Really all of these practice policies are essentially black boxes that one must take on faith.
There are two terms that you will see a lot of in the coming years: “explicit and evidence-based” and “global subjective judgment”, both ways of constructing clinical practices policies. Global subjective judgment refers to the usual method where you ask an expert or a group of experts to decide – basically to hash it out. You lock them up in a room and ask them to figure out how to manage such and such. Exactly how it is done is really not important.
Explicit and evidence-based process is a new method which attempts to be explicit and publicly accountable by laying out at every part of the process how judgments were made so that readers may judge whether the choices made are reasonable or whether they were made on evidence or opinion. What I will do for the next few minutes is to take some examples from several of the clinical policy groups that I have worked on to illustrate my concerns. We’ll get back to access eventually.
I will briefly discuss the management of otitis media, screening for prostate cancer, and treating sexually transmitted diseases [STDs]. First, consider otitis media with effusion [OME]. I co-chair a panel funded by the Agency of Health Care Policy and Research to develop an evidence-based clinical policy on how to diagnose and treat OME in young children. The reason this topic was chosen is that OME is common. It is thought to contribute to learning problems in children. It costs a lot of money – about a billion dollars a year. On the access debate, OME figures prominently because advocates feel that vulnerable children are experiencing OME with all its consequences at higher rates than children who do have access.
So access to care for this condition is seen as a good thing, something to work towards. First of all, consider how we put the problem together. It is a causal pathway: you begin with a healthy child, who somehow develops OME. This leads to hearing impairment, and that leads to speech, learning and behavior problems. Such a causal pathway provides the framework for the panel to conduct its search. We started with 16,000 articles. We narrowed that down to about 4,000 and I will run you though, quickly, of what we found. And this, by the way, is in galley format now, and will be published, we hope, in May or June.
First of all, what causes OME? Lists of causes include allergy, infection, passive smoking, feeding practices and day care. Well, in spite of these causes being listed, we really do not know if any of these do cause OME. In infection, we know the fluid from otitis media is a good medium for bacteria growth, but we do not know which is cause and which is effect. In looking at allergy, we looked at association between allergy and otitis. But none of the studies defined things quite the same way. None were controlled. All were small. None provided enough information about the young children that we were most concerned about.
Passive smoking shows a fairly consistent relationship with acute otitis media. But, there is almost no evidence linking passive smoking with OME. The information on infant feeding practices is very limited and it is irrelevant once the child begins to have OME. He or she is months or years beyond the time when breast or bottle feeding is an issue. We have all heard about the clinical peril of not propping bottles. It boils down to two anecdotal comments – neither offering any evidence that bottle propping is a problem.
Finally, what about day care? There is a fairly consistent statistical relationship of a modest relative risk, somewhat less than two. The problem with day care is that there is no evidence that if you have a child with OME and you take them out of day care that the OME goes away. Further there is no evidence that most families could accommodate such a recommendation if it proved true.
In the causal pathway, the next linkage is between OME and hearing impairment. We found that not all OME is associated with hearing impairment. In fact, it looks like something less than 20% – probably about 10% of OME is associated with any hearing impairment. An even smaller portion of that is bilateral and significant. Besides that, we found that OME fluctuates and that the hearing impairment that goes along with it also fluctuates. Does intermittent and mild hearing impairment matter? What about OME if it is only in one ear? Does it make a difference? No one knows.
The next linkage that we examined was between hearing impairment and later speech, language and behavior problems. This was a real shocker for me. There is no question that severe and persistent hearing problems early in life can lead to problems, congenital deafness, anatomic abnormalities and so forth. But there is no evidence that the mild and fluctuating hearing losses that go along with OME cause any of these problems.
I am going to pause to let that sink in. There is no evidence that the mild and fluctuating hearing losses that go with OME cause any problems. Now, if there is no evidence that OME causes these problems, then why treat it at all? What’s the point of using antibiotics, steroids, decongestants, ventilating tubes, adenoidectomy, tonsillectomy, or any other treatment if the underlying condition does not have adverse effects?
Well, because there is no scientific evidence that OME has long term effects, the panel chose to look at a more plausible outcome: do the treatments that we use, at least get rid of the effusion, and improve hearing? Therefore, we looked at antibiotics, steroids, antihistamines, decongestants, ventilating tubes, adenoidectomy, and tonsillectomy.
Now the evidence for antibiotics is voluminous, controversial and contradictory. Four medical analyses have been published examining the same studies, reaching different conclusions. The best one can say is that if there is an effect, it is small – on the order of less than 10%. In other words, one would have to treat 10 children with antibiotics to improve the outcome in one of them.
The evidence for steroids is weaker still. The confidence for efficacy hovers right around zero. There is actually quite good evidence that antihistamines and decongestants do not work. The evidence for ventilating tubes is that it removes the effusion, but if you recall, that we do not know if removing the effusion is a good thing. And there is no evidence for other surgery or tonsillectomy.
So where does this leave us with OME? We are not sure what causes it. We do not know how to prevent it. We do not know whether it has adverse affects. And, we do not know whether any of the treatments are effective. Oh, and by the way, OME resolves spontaneously in 60% of children at three months, and 85% at six months, according to some large European studies. This is an extremely common childhood condition. Over a million visits to family physicians and pediatricians occur each year, for which we may be currently subjecting hundreds of thousands of children annually to possibly useless, potentially dangerous and certainly costly treatment, a billion dollars last year.
And this is also after some 15,000 articles published since 1966 on the subject and many hundreds of millions of dollars in NIH on research, much of it without scientific merit. Now, lest you dismiss these remarks as being nihilistic, let me point out that at present all I am saying is that there is little evidence that we know what we are doing. I am not arguing that as a result we not do anything, I will get to that later. I am just pointing out that whatever we end up doing for our next patient with OME is not based on scientific evidence. Now, I personally consider this to be a dangerous state of affairs.
Next, I am going to discuss prostate cancer screening using PSA tests. And these issues are undoubtedly more familiar to you. My comments here are based on the work with the U. S. Preventive Services Task Force. It is a group that has been in the forefront of evidence-based recommendations longer than any other group in this country. A recommendation is coming out, I believe in June  in JAMA and also in a second edition of our book coming out later this year. Here is the causal pathway for prostate cancer: a healthy male develops asymptomatic prostate cancer, then systemic prostate cancer, eventually complications, then death. These are the questions that arise out of that causal pathway. What causes prostate cancer? Can we detect asymptomatic prostate cancer? Does early treatment make a difference? And, does treatment at all make a difference?
First of all, what do we know about the causes of prostate cancer? Not much. There is a hotly disputed association between prostate cancer and vasectomy, but even if it is true it accounts for a small minority of the amount of patients with prostate cancer. The prevalence of prostate cancer approaches 100% in men over the age 85. Whatever the cause is, it must be pretty darn common. (Laughter) What would be more interesting, but for which we have no evidence, is why some men get prostate cancer that spreads and kills, and some get prostate cancer that never causes any trouble.
Second question is whether we can detect asymptomatic prostate cancer? The evidence is pretty good that you can if you use a very progressive approach combining – you name it – rectal exam, PSA, TRUS, biopsy. The problem is this next step. Does early treatment make a difference? And the answer is no. Worse, there actually is no high quality evidence that treating prostate cancer at any stage is efficacious.
Which leads to these questions: Is cure possible in those for whom it is necessary, and is cure necessary in those for whom it is possible? Preventive Services Task Force has concluded NO. Our recommendation will be out in a couple of months. The bottom line here is that there is no good evidence that prostate cancer can be effectively diagnosed or treated. Yet we subject countless men to testing, radiation and surgery that we know has very significant morbidity and mortality and also at very high personal and economic costs.
Finally, in this quick tour of medical practice, I am going to briefly discussed sexually transmitted diseases. My experience here was truly a remarkable process at CDC, chairing the CDC STD treatment panel in 1993. Myself excluded, the panel comprised the leading experts on research and treatment on STDs from around the country. There were some international individuals as well. The evidence-based process that we tried to employ – this was the first time the CDC tried to do this – forced us to confront the many areas of STD treatment for which no science is available. I cannot begin to cover all of these, so I just came up with a small list here.
First of all, what is the best treatment of syphilis? There never have been any properly conducted studies to determine how best to treat the later stages of syphilis. We also do not know what diagnostic tests are really needed – for example, the time honored LP. We do not have good alternatives in certain groups of patients, especially those who are allergic to first line treatments or to pregnant women.
Second, does treating chlamydia prevent infertility? This one surprised me. There is no evidence that early treatment of chlamydia infection reduces the evidence of infertility. We can show it reduces infection but we cannot show that women are better off in the long run.
What about the diagnosis and treatment of pelvic inflammatory disease [PID]? This is also a mess. The criteria are clinical and non-specific, there is too much guesswork, and worse, once the diagnosis is made or suspected, there is surprisingly little high quality evidence of how to treat it, whether as inpatient or outpatient. The new outpatient regime that is printed in the guidelines is an expert guess. There is no evidence to support it. We have the same problem as with chlamydia, wondering whether treatment of PID has a long term positive impact.
Does counseling to change sexual behavior make a difference? Counseling to change unsafe sex practices is the cornerstone of US Public Health Policy, yet there is very little evidence to show that it works. Is screening for STDs effective? The issue here is whether we are detecting a disease that needs treatment and whether early detection makes a difference. Of that, there is no evidence.
What about the treatment of STDs in pregnancy. STDs in pregnant women are common occurrences, but we have little information regarding the best treatments that are also safe for the fetus. What do we do about HPV treatment? The virus that causes warts is common and besides causing warts it can cause cervical cancer. Although we know quite a bit about how to identify HPV, there is no effective treatment. There is only guesswork to provide prevention.
Consider some really common ones – treating recurrent trichomoniasis or BV. There is little understanding as to why these conditions become recurrent, and there are so few therapeutic options that we have little idea as to what to do if the first line of treatment has failed. We really do not know how common that is, but it is estimated at probably 10 to 15 percent.
I could go on with this list but it gives the flavor. Going through the process with the STD panel, there are actually a few topics where the science was definitive. And even where the science appeared definitive, say, the antibiotic treatments for chlamydia, the treatment options studied were restricted by the drug companies that paid for the studies. It is no accident that the first new drug for chlamydia was Azithromycin. That got a lot of discussion. Half the people around the table had conducted studies on chlamydia paid for by Pfizer.
Okay, I am sounding like Ivan Illich. It is really not that bad, I chose some bad examples. There are lots of areas of medicine where we know we can do a lot of good. Undoubtedly that is true, but I am impressed that without exception – I emphasize, without exception – where this evidence-based explicit methodology has been applied, there have been many more gaps in knowledge than there have been answers.
We still have the question: is a random patient with a random condition seeing a random physician likely to benefit? As a brief digression, consider the top causes of death by disease category: heart disease, cancers, cerebrovascular disease and so forth. This is the traditional medical view of what needs to be prevented. It is roughly how money gets divided up among the National Institutes of Health. It is why more is spent on heart disease prevention than accident prevention.
It summarizes the kinds of things that the standard medical approach uses to argue for access to care. The argument goes: it is through attention to these diseases that health will be achieved; and conversely, that unless access to care for these diseases is available, these diseases will do us in. Contrast that list with one, published last year (1993) in JAMA by [Dr J. Michael] Mike McGinnis. This redistributes the diseases in the first list to demonstrate that tobacco, diet and activity patterns, alcohol, toxic agents, firearms, sexual behavior, motor vehicles, and illicit drugs are the real killers.
Now, as you will readily appreciate, the implications of the latter list for medical practices are profound. If we were to follow this list, we would redirect our research, educational and practice efforts radically. Instead of focusing as we do now on the end results – the diseases – we would focus on the basic causes. I would emphasize that using this list, access to medical care is not terribly relevant. It makes clear that the root causes for ill health are social and cultural. They are not medical. Achieving access to medical care will not solve these problems.
My view is that our interest in access is driven principally by our concerns of the effects of poverty on health. But we come at it assuming that medical care – what we do best and know the most about – is an appropriate intervention. I actually see little evidence that the remedies for what ails us lie in the domain of medical care per se. Offering more access to medical care as currently practiced is a blunt, crude, terribly expensive, inefficient and perhaps counterproductive way to address the real needs. It is also a typically American approach. The remedies are much more likely to come from elsewhere, public health intervention and other social programs. I believe that in pressing for access we significantly oversell the value of what we have to offer in solving these social problems.
There was a very provocative essay in the New England Journal of Medicine a few weeks ago [February 10, 1994 by Dr Nortin M. Hadler] entitled “The Last Well Person”. In responding, Dr. Clifton K. Meador made the point that our society is so thoroughly medicalized that no one is truly healthy nowadays. The author found at a dinner party of apparently well people that everyone had something – high cholesterol, borderline blood pressure, atypical PAP smear, or the worst, co-dependency. (Laughter) He laments the disappearance of health, speculating at this rate that the last entirely well person will be identified at a health fair in a shopping mall near Kansas sometime during 1998. (laughter).
I sympathize. It is not hard to see that the current case surrounding health care reform takes on special significance because in our culture so much of our view of life is wrapped up in our definition of health fed to us over the years by the medical perspective. In Leonard Poon’s study of 100 year olds in Georgia, the study subjects did not get to be the age of 100 by having access to medical care. Indeed, most shunned it even when browbeaten by friends and relatives to embrace it. Their health was not insured by screening tests and interventions.
Now, although I am a family physician, I am also an epidemiologist and a researcher. I spent much of my professional career directing the research section at the University of Washington. I have been on this issue – the need for better quality research on primary problems in family care for years. It should be no surprise that I end up saying that we – I mean us here – that we need to conduct more research in primary care clinical medicine. But I am also increasingly concerned about where will we be in ten years if the medical care we win access to does not produce much benefit or, worse, produces net harm.
I see this as a serious possibility that warrants more and more attention. Let me also restate the conclusion that I opened with, that the problem of the ends of medicine is more important, more challenging and will require more from us in primary care than the access problem does. In the long run attention to this issue, the efficacy of medical care, is more important for us, I believe, than in developing primary care networks for our academic health centers.
I think the pressure for the academic family practice faculty to develop primary care networks is diverting us now and promises to do more so in the future – diverting us from our core mission of education and research. I agree with Bruce Bronzan’s comments on Thursday. By the way, this is one of the bloody battles between the generalist and the specialist view of medical practice. I would like to be able to say that generalists and specialists can talk about clinical medicine on the same level. Unfortunately the level of the debate is getting nasty.
Here is a comment from Dr. William Catalona, who is one of the expert advocates for PSA screening. “This new crowd, what they say is, unless you can prove that this treatment is going to save lives and be cost-effective, you should not do it.” Here is one that I am choosing to leave anonymous, “Medicare has been willing to pay for PSA testing in asymptotmatic individuals based on long practice. It would be a tragedy to change it just because there are no data to support it.” (Laughter)
What can I say? Guilty as charged. The generalist’s use of the evidence-based approach calls into question many routine practices currently paid for mostly by specialist physicians. What has some physicians terrified is that these evidence-based clinical policies might be translated into review criteria or performance standards for payment under the new rules in health care reform. It does not take a very sophisticated economist to predict what might happen to the relevant specialist’s income if one of their high volume procedures suddenly falls outside routinely reimbursable practice.
So where do I end up? Well, I thought we would end with three questions to think about. Why are we interested in access? Are we interested in access because we are interested in health? Or is it because we are really interested in addressing poverty? Or righting an injustice? What evidence do we have that access is a good thing? What evidence do we have that access to medical care as currently practiced will actually solve the problems that we are really interested in with the first question? And third, what can we do about addressing the need for better research guiding clinical practice?
I think if Gayle Stephens were here he would say that family medicine has never been about power. Family medicine in his view is counterculture. And for me I find it ultimately ironic that at this point the cutting edge of counterculture for family medicine may be in research, not in clinical care. So that ends my foray in perception and philosophy. In retrospect, maybe it was good that Gayle wasn’t here. Let’s stop here for comments/questions, maybe 15 to 20 minutes.
Dr Clasen: We invite questions for Dr. Berg and then we are going to invite the other panelists up to join him.
David Pepper, MD (Faculty Member, Department of Family Practice, UCSF/Valley Medical Center, Fresno, CA): Part of the perception change involves changing patient perception because I think people perceive that somehow better tests, laser therapy for HPV is somehow better than GPA treatment or no treatment at all. How do you think we are going to best address that?
Dr Berg: It is a good question and it is what I said about how medicalized our society has become. Medicine with a big M has been very successful in selling a particular view of life for our society. That is one of the bloody battles ahead because the view of life that we have sold is not substantial and one of the challenges that we all have as practitioners is helping patients understand that the answers to all of their life problems is not in the doctor’s office.
William C. Fowkes, MD (Co-Chief, Stanford Primary Care Associate Program, Division of Family and Community Medicine, Palo Alto, CA ): You were in the same discussion group [at this National Conference] and you raised this issue about whether or not, assisting the medical school in developing a primary care base would not divert us from teaching and research, which is one of the major things we should be doing. Yet, you know that the counter opinion is that finally we have a role at the University that is going to give us a power base from which to develop programs. In ignoring that, are we helping ourselves or not? You know there were two major opinions voiced. Could you discuss that?
Dr Berg: I am not an expert here. I hope others can discuss that. My view is Gayle Stephens’ view that family medicine has not been about power. And one of the reasons that we have been successful is that we have not been powerful. We might want to consider very carefully where we might be in ten years. If our power base is clinical care, if the clinical care, as I pointed out, has problems in it, my view is that in ten years I would rather be a fairly small discipline that has been hammering away at the ends of medicine and doing high-quality clinical research in primary care settings. I would rather be in that position than have large departments with enormous numbers of clinical faculty taking care of hundreds of thousands of lives providing a kind of medical care that I am not sure provides net benefit. But there are more experts in the room, I am sure.
Marc E. Babitz, MD, (Regional Clinical Coordinator, Public Health Service, Region VIII, Denver): You kept talking about this discrepancy between medicine and society and culture. I think it does exist, but I think that is part of the problem. As soon as we take medicine and make it a separate thing into itself that is not incorporated into social culture, we have a problem. I think that even looking at native healing and other cultural approaches to health, you see where the interweaving perhaps has more efficacy in many ways. I wish you would have some comments about whether there is room for at least primary care, family medicine, to remain intertwined with the broader cultural-sided aspects of delivering health care.
Dr Berg: Oh, absolutely. And I think that is a fascinating frontier for research. I think family physicians should be examining the usefulness and the benefits of other kinds of healing, not medical care, but other kinds of healing interventions. This goes back to where family medicine started out. We all have this deep feeling that some of the benefits that family medicine provides are not things that you can quantify and write down. These are the things that have to do with relationships between the doctor and the patient and knowledge about the family and contacts and so forth. I think bringing those up to the level of high quality resource would be a real contribution for us.
William Norcross, MD (Director, Family Practice Residency Program, University of California, San Diego): A couple months ago in the New England Journal there was an article addressing these issues, the fact that much of what we see as health care problems really are social problems. The author came up with a proposal for developing something like an Institute of Social Health or an Institute of Social Medicine, much as we have in NIH. He pointed out that physicians are not trained, nor really good at handling social issues, even though we try to. The subsequent letters to the editor, as I recall, were enraged, as one would expect from a physician audience. What would your thoughts be on redistributing funds toward something like that?
Dr Berg: Well, personally, I think that the NIH is a national scandal. I have gone through so many of these evidence-based processes, and have seen what kind of research has been conducted on OME, for example, paid for by hundreds of millions of dollars of tax dollars, most of which has had no direct clinical benefit and has not answered any of these important questions about this condition. So what exactly happens to most of the NIH dollars? I am not sure what would happen to it.
I would certainly be enthusiastic about redirecting those dollars towards clinically important questions that physicians care about the next time they see patients. NIH has always been, of course, emphasizing basic science and one cannot deny the benefits of some of that basic science, but large amounts of it have not been productive in changing clinical practice and in improving the health of the people to whom it has been directed. So I am all for changing NIH. I think the idea of having this new office to look to alternative health interventions is a terrific one and we need to do more of that kind of thing.
Bruce Bronzan (Associate Dean, UCSF Medical Education Program, Fresno, CA): I thought your comments were really beautiful and visionary in terms of the role maintaining one of the most precious aspects that this discipline has achieved into the future. I would just like to add one thing if I might. Someone once said in the television industry, and was probably tarred and feathered for it, that one of the most important things that television could do now was to teach youngsters to turn off the television.
Rightly or wrongly, we non-physicians put physicians on an enormous pedestal. You still have, rightly or wrongly, a very strong influence on our lives. I met a cardiologist who when he received a patient suffering from heart disease directly related to smoking and was still smoking, he would tell the patient to stop smoking. If the patient said I will not quit smoking, but I want you to fix my heart, this particular cardiologist would say then you are not going to have me as a physician and would refuse the patient. When the patient was shook up by that, he would say, if you are not willing to stop smoking, what point is it to have me as a physician and spend all of the money to try to fix your heart?
The point I am making, is that I think one of the long term values that family practice physicians have is educating their patients about turning off the television set. I know that in my own personal life that of all of the physicians that I have run into in my personal care needs, I have learned more from my family practice physician about how not to use the system and how to become personally responsible. I think that is a fantastically powerful role and that long-term that could be one of the main missions of family practice, along with advising policy makers. It is a very important role indeed.
Charles North, MD, MS (Senior Medical Officer, PHS Indian Hospital, Albuquerque): Before we all go out to treat our acute depression with sunshine this afternoon, would you enumerate just a few of the things that we do that might actually work and be beneficial to society? (Laughter)
Dr Berg: Well, the U. S. Preventive Services Task Force is the only group that I have worked with that has attempted to look comprehensively at a whole area of medicine prevention. And the current group is revising the first edition of the book. The new book will cover about 180 or 190 topics. Of those, probably ten or eleven got the highest ?A? level of recommendation for which we found strong and persuasive and generalizable scientific evidence that it was a good thing.
Many of them were not surprising, things like immunizations, some things like doing mammograms in women over the age of fifty, and some educational interventions as well. But it is really rather a short list and I would not presume to make a percentage predication about the whole of medicine. But if it holds, that is rather a small portion of the190 interventions that physicians do as prevention. We found that, of the things physicians do all the time, between five and ten percent of them are based on good, quality scientific evidence.
Eugene C. Rich MD, (Chief, Division of General Internal Medicine, University of Kentucky, Lexington): Al, I agree very much with your argument, but disagree with your conclusion. You gave an eloquent presentation of all the problems with medical services that people currently have access to in the United States, and also demonstrated it is important that the general disciplines reconceptualize their role. Is it not an appropriate conclusion to say that American medicine in general and academic medical centers in particular, need much more of the perspective of the generalist in order to right the wrongs of American medicine?
Dr Berg: I must have been misunderstood. My point was certainly that we need more of us, but we do not need more of us spending 70 percent of our time seeing patients in family medical centers. I think we need more of us doing the research and education that are unique, and that are almost uniquely done in teaching centers. Actually, we have a tremendous shortage of generalists serving on these kind of panels. The AHCPR and other agencies are figuring out that the generalist’s point of view is absolutely indispensable to doing science-based clinical policy. The specialist cannot do it – in fact the experts stand in the way. There are not enough of us to represent it.
Personally, I can tell you that the pressure that I get from my chair to spend more time in clinical work seeing patients is diverting me from the time I should be spending doing this kind of stuff that I think is more important. So, I do not disagree that we need more of us doing this, but I do not think that we need more of us to develop primary care networks for academic health centers.
Dr Rich: Just a rebuttal though. If there were a significant number of us, then by having evidence- based generalists working in the academic medical centers, informing medical practice, would not that e another important way to alter the direction of these medical centers?
Dr Berg: I can’t argue with that. I just think that is just a little bit more visionary than I am prepared to be, to have enough people to do all those things.
Henry Foley (Waianae Health Center, Oahu, Hawaii): Could I respond, just for a second, to your access question? I think we have touched on it in our Kellogg Foundation sponsored community initiative [described at this National Conference]. I am 54 and am probably a revolutionary like the most of you in the room. We are not talking about access to medical care services in our project. Our theme is the access to caring communities. That is quite a bit different. It says, in fact, that if the community interaction with the faculty and students come to a different conclusion about what they need for their community, then the community choice prevails (which has happened in a couple of situations already).
On the Hawaiian coast they came to the conclusion that they needed anger management – that they did not need the clinicians in the center. They organized with the students and the faculty anger management for the homeless that were in housing projects. Then they stood up and said that is what we want and need in our community. That is the kind of access we want in our community.
When they went to see the movie What’s Love Got to Do With It?, the Tina Turner story, you can imagine who they were cheering for. The husbands who did not attend these sessions were not allowed to go. Dr Darryl Leong is in the back of the room. He was at a meeting where we met with the native Hawaiians, which was an earlier question this morning. I must tell you it is a shaking experience when the data is there and native Hawaiian leadership can turn to you and say, you must understand Doctor Gulbranson, Doctor Foley, Doctor Curtis Takemoto-Gentile – it is Western medicine that has destroyed Hawaiian culture. This was coming from a leader, a major leader in this state that is also Hawaiian.
When we go into the community, and we try to work with them, we are going to be surprised. I suspect that what we are going to see, frankly, in our state, over time, is a down-sizing in the number of medical services being provided, certainly through tertiary medical centers, but also in terms of some of the medical practices in the community itself. It is going to be changing. When I talked earlier about managed care, I think the wiser owls in the managed care movement will begin to come to the conclusion that it is precisely these other issues that you have to address. If you are maintaining in West Los Angeles a population of 10,000 whose median age is 75 and 10 percent of them are over 80, you start to provide a lot more services in the community that may not be of a medical nature and involve other kinds of teams.
I think the issue is on the table in terms of access, but it is not necessarily access to specific medical services. It may be only a range of what is needed. It is an income issue in this country. It is a poverty issue. Perhaps there are some of us who are better off for having too much access as you indicated in your report, but others are not having enough of simple access to not just medical services but a whole range of human services as they define it.
So when we talk about access here, we are very specific where access to caring communities in which we have to be extremely culture-sensitive, and if our students are not imbued in that and basically come through that process, frankly they will be like many of us who reached a dull age and had to relearn how to basically relate to certain populations just on a human basis. If the Hawaiian health status is to improve and their life status is to improve, it will because they see it and we listen and will be able to respond to that. Thank you.
Dr Berg: I would say that, unfortunately, that doesn’t quite dodge the bullet. We still do not know whether anger management programs work. We do not know whether advice to change sexual behavior works. We do not know how to stop teenage pregnancy. There are any number of things we are doing in programs like this which we are doing within the context of a culture that we need more information about.
Again, I think that is the place where primary care can contribute working with those communities. I can well understand their reluctance to participate in further NIH randomized trials, but doing research based in those communities which is culturally sensitive to find out what makes a difference is a very important role for primary care physicians and other professionals.
Mr Foley: Agreed, what I am suggesting is that it may not be the NIH randomized trials to do it. It is having your students and faculty and community collecting that information. I can tell you what it does mean. It means a great deal of difference in Waianae that the amount of use of the emergency room decreased for six months significantly for that community while this anger management class was going on. Now that is a short term result. If the students were following that longitudinally over time, at least for the Waianae community and perhaps for other parts of Oahu, that could have a lot of merit that you would start to look at.
I think that we start too high in the protocols and we need to begin at the local level in the community. That is what I am suggesting.
Lucy S. Crain, MD MPH (Clinic Director, Pediatric Primary Care Practice, UCSF Ambulatory Care Center, San Francisco): Before I ask my question, any of you on the panel, would you like ketchup with your fries? (Laughter) My concern about research is not on the research per se, but over the clinical response and sometimes the overreaction to the implications of that research. I think there is the responsibility of health care providers to respond, in body and in practice, in terms of research such as you presented on prostate cancer and chronic OME. This is supported by what we have observed in our pediatric practices at UCSF where in the several months since articles were published on treatment of neonatal hyperbilirubinemia by Doctors Tom Newman, Jeffery Maisels and others. We have had three newborns who were not treated for their hyperbilirubinemia and indeed, our discussion shows that there probably was a cavalier response to the babies? degree of jaundice and it was not followed up. Now, two of these three children appear to have kernicterus. I think responsibility goes both ways.
Thomas C. Brown, Ph.D. (Director, Medical Education, Pacific Hospital, Long Beach, CA): Since this is a Gayle Stephens lecture, I thought you might enjoy this, Al. I got a paper that he wrote at 4 a.m. in the morning. I think the primary things it said is something that characterized, certainly family practice, and I think it characterizes primary care internal medicine and primary care pediatrics, which is the caring aspect of the primary care physician. That the primary care physician is a person who cares! That he or she is a person who is there after the technology has failed! We will always be there.
As a patient, when I bring my child in with an earache, otitis media, I am bringing that child into the physician because I am afraid. I am terrified for the life of that child. By your seeing and reassuring me that child is going to be okay is an extremely important function of the physician, caring about my children, caring about me. I think that when we reduce everything, as we are doing here, on the clinical kinds of aspects of family practice, it is doing a disservice as to what the whole issue of primary care is about. I think that the clinical medicine and the clinical research part of medicine are only small portions of what family practice has to offer.
Dr Berg: I agree with you, but of course the question is, in the coming health care reform, if we cannot show that some of those added aspects provide net benefit, what is the likelihood that we can get it covered in the benefit package?. So I think there is a lot of research to be done on the objective value of these other kinds of care that probably the people in this room and our colleagues in academic centers are the only ones who can do. I certainly agree with you, but I do not think that lets us off the hook. I think that in health care reform, we are going to have to have better evidence for the efficacy of what we do and those interventions fall into the same category.
Marc E. Babitz, MD: One of the concerns that I have is that when you look at this research and you look at the point, the outcome seems to always be the absence of disease, quote, unquote, as defined by Western medicine, or the prolongation of life, as a value. What ever happened to being able to take care of your family? Going back to work? Or make love to your wife? What happened to those values, or being able to do those things? I think when we look at the end points of research around primary care research and actually the result of the caring, it is not the absence of the disease, it is whether you can do the things that are important to you or your community in your life.
Dr Berg: That is an excellent question. It comes up in every one of the panels that I have been on. What are the relevant outcomes for the condition that you are looking at? Most of the literature in the treatment of OME has looked at the outcome. Is the effusion gone after the treatment? But these outcomes are evaluated, without looking at the amount of time the parents had to take off to take the child to the doctor and have the surgery done, without paying attention to the travel costs, without paying attention to all the other outcomes that are clinically important for the patients that have never been really looked at.
So I completely agree with you. And again, it is one of the scandals of the last four years worth of research, that the outcomes that we have examined have often not been the outcomes that are important for patients.
Darryl Leong, MD (Vice-President, Primary Care Systems, Inc., Burtonsville, MD): I really appreciate what you are saying. I remember that when I was a student, a resident told me that every 25 or 30 years we say that the previous generation practices medicine of the fifties, or the forties, or the thirties. That means that everything that we are doing today must be wrong. Because in the future, our predecessors will say that we were all wet. I think there is some truth in that. And I really appreciate the gentleman that raised the NIH issues. I mean, again, rightly or wrongly, NIH is the most prestigious organization in the country. It is also big. Twelve billion dollars buys a lot of property and a lot of papers, and everything you read, even JAMA or a lot of the New England Journal is funded mainly through NIH research dollars.
It is also putting out a particular viewpoint. So the viewpoint that you talked about, these diseases and what is happening to them, they are not getting out to the mainstream of the public, because there are not enough people doing them, not enough of the right kind of people and there is not enough dissemination of the information. This reminds me of another study that shows unequivocally, that we as medicine people think that our interventions make a difference and so we never go out to prove it. When we do study it, I think we find that our interventions do not make a difference.
The best study that I have seen on that subject is a study of mortality through the 1970’s that showed mortality was decreasing before the advent of TB drugs. In fact, there was no change in the mortality decline with TB drugs. And most significant, the one that shocked me most of all, the mortality curve did not make one blip of a change in 1947 with the introduction of penicillin. We think it was a wonder drug. But, if you look at the real mortality of population, it was going down anyway. And that relates to the public health changes that were occurring – housing, nutrition – things that probably do make a difference, but are inadequately researched. So, I just wanted your comments on the dissemination side of these ideas, how you would see that going forward.
Dr Berg: Well, there is some optimism about using this evidence-based process for looking at clinical issues. Dr. Philip Lee [the Assistant Director for Health within the US Department of Health and Human Services] now is very well aware of it and is trying to put together a Public Health Service-wide approach to developing clinical policies which use this evidence-based method. Whereas, a number of specialists and experts were very suspicious of the process at first, I think that many – for example, the individuals on the STD panel – now recognize this as one of the most powerful tools to set the research agenda, which will generate the next twenty years worth of their funding.
There are some signs that some of the evidence-based policies developed by the preventive services task force and others, have led to very sharp scrutiny of where the gaps in evidence exist in research. This is having an impact on the kind of research proposals that are now coming in to NIH and other funding agencies. Unfortunately, family physicians, general internists and general pediatricians are not well represented among those proposals and there is a lot of this stuff being funded that is not very good, because better stuff is not coming from us.
So there is, I think, hope that this evidence-based methodology will help direct the research agenda and in the long run will speak to the ends of medicine that we are all concerned about. But again, I think primary care disciplines are underrepresented in that effort and we need to be doing more and not less of it.
Charles Gessert, MD (Associate Professor & Vice Chair, Dept. of Family and Community Medicine, Medical College of Wisconsin, Milwaukee): I want to thank you first of all for your stimulating, intelligible honesty presented to us. I felt, initially, a bit of relief in a sense that I always suspected that a lot of the things I am doing are not very effective. I feel I am kind of off the hook now. As a matter of fact, I may be looking for a new line of work.
But I also realize in listening to your remarks that much of what I do is directed at goals which are parallel to or congenial with specific clinical outcomes that you are talking about. In other words, I am working hard to influence the behavior of medical students, of residents, of faculty and others, to address goals which I did not myself define – to address goals which come from communities that are underserved or perceive themselves to have access problems.
My question to you is, can you envision or discuss for us a bit, some of the common ground between what I referred to earlier as intelligible honesty – that comes from thoughtful research on what is actually effective clinically – and the social goals to which many of us devote our careers? The connection between the two is not immediately obvious. I presume you have been challenged about these kinds of issues many times in presenting your research agenda. I would like to see if you can help us see a little integration.
Dr Berg: With all due respect, I think I may beg off because these are actually fairly new ideas for me and I have not thought through what common ground might look like. It is a very good question.
David Pepper, MD: Back to the concern of patient education, maybe the final question relates to death . I think that one of the things that specialists or sub-specialists have done is de-personify death in the sense that we now know that 80 percent of the people die in the hospital, and death for many has become an ugly charade of tubes and pretense that we can somehow prolong things.
I guess it goes back to patient education, but I think that one of the rules would be, that with the family doctor in hospice, the patient’s death would be the good death. I do not know where the comments lie and how that would tie into cultural sensitivity. But to me, you know we talk about death as tobacco or as accidents. I often say to the residents that a thousand years ago that everybody who was born died, and everybody who is born now is going to die. Somewhere in this discussion, and I am not sure where it fits, we lose that, and I think that is been something we hold close, because hospice is family medicine and that is the end of life.
Dr Berg: One of my favorite journals is the Journal of Irreproducible Results. There was a wonderful article in there a couple of years ago on the inheritance pattern of death that showed a genogram, that went all the way through. I agree with you. It is a topic that speaks to the heart of what many of us do in family practice, especially with our older patients. I actually have quite a group of elderly group of patients in my practice. I find myself spending less and less time hammering on them about whether their dose of a specific medicine is right or not, and much more time trying to figure out with them what their goals are for the next five years and sort of where medical care might fit into that.
I think that is a very appropriate place for primary care providers of all types to be spending time in and I think there are ways to study that. One of the things that we have not examined, or that I did not mention here at all is the whole business of qualitative research as opposed to quantitative research. Some of the work that is going on in primary care is to develop those methods, so that the conclusions from those research projects have the same weight and the same general visibility as the p-values and the statistical values that you see in the New England Journal articles.
So I agree with you and I actually had this conversation with Gayle Stephens a few weeks ago. He is sort of into death, if I may say so. He’s read a lot about it. We had a long conversation about the controversy surrounding Dr. Jack Kevorkian and many things. I think at a subsequent meeting he could probably do a much better job than I certainly could on where those end of life issues fit into clinical medicine, especially for us in primary care.
Dr Clasen: I think Gayle would have certainly liked this morning. Thanks to everybody.
Last Updated (30 May 2005 09:12)
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