[The following is the second part of Doctor Patrick Dowling’s presentation of the 15th G. Gayle Stephens Lecture, followed by a Question and Answer Session. The first part of Doctor Dowling’s remarks appears at: The Fifteenth G. Gayle Stephens Lecture – Patrick Dowling, MD, Part I.]
These are very impressive studies that Congress is beginning to look at now. The second part is Julian Tudor Hart. Dr Hart is a general practitioner in England. I think he must be around eighty.
I met him a couple years ago at a Society of Teachers of Family Medicine meeting. As far as I can tell, he’s been in private practice and he’s responsible for so many people in this industrialized community. On top of being a great doctor, all these years he’s done all these studies.
Thirty-five years ago he came up with this observation,, which he published in Lancet as the “inverse care law”, that says the availability of good medical care tends to vary inversely with the need for it in the population served. The greater the need, the less likely there are good doctors there (Slide 27).
I wanted to see if that still pertained and then, to round out the threesome I brought that cigar smoking guy, Winston Churchill, who said Americans will do the right thing, but only after they have tried everything else (Slide 28). You can see my argument here.
The question is: is there reason to be optimistic about this second battle. Because I thought Gayle Stephens was going to be here today and I was going to ask him, was he optimistic, but he’s not here.
I have concluded that he would be an optimist that I thought he was a spiritual man, because just reading his quote, he’s used the terms distributive justice, he uses the term humane and mercy. I think he’s optimistic that we might fall into the solution here by following Winston Churchill’s path (Slide 30).
Now, let me give you some factual reasons for optimism. Everyone who is based at a medical school knows the NIH increased its budget – doubled it, in five years, from 14 to 28 billion. Republicans and Democrats lined up to increase this budget. Every medical school around the country saw an increase in NIH funding.
Several schools, such as my own, started building research buildings. (We have a saying at UCLA that clinical dollars are worth fifty cents a grant dollar, but that every NIH dollar is worth two bucks a clinical dollar. We would do better not to see any patients, you know?
So everybody is geared up. Congress put up the money on the premise that what you would get is better care and lower costs. Well guess what! We have wide disparities, and the costs keep climbing. They’re saying ‘what happened?’ Then they found out several people in the NIH were on the drug companies’ payrolls. So they’re not too happy up on the Hill, as Denise knows.
Secondly, our president George Bush is out beating the bushes saying that Social Security is going to collapse. Well the truth is, Medicare will be in much worse trouble way before that. That’s very bothersome (Slide 31).
The third part of this, is the not well understood fact thatMedicare pays for training of physicians.
Look at the growth in docs in this country from 1970 to 2005. In 35 years, we almost tripled the number of doctors, while the population only went up by about a third.
There is an enormous growth in physicians – all of this paid for by the government – and we haven’t gotten the results that were expected.
In fact, it’s getting worse. An interesting study from a couple of months ago, looked at bankruptcies in the United States and it found an astounding fifty percent of all bankruptcies in the United States were people either being sick or for their medical bills (Slide 32.)
It turned out 75% of these people had health insurance, so this says the middle class is beginning to collapse under the weight of this healthcare system and there’s one case every sixty seconds.
Now lets get back to Dr Hart, and I want to take it back locally. All politics is local they say, and, thanks to Scott Christman for this map and I did the inverse care law in Los Angeles. Now there’s more to Los Angeles than Hollywood and rich people. There are ten million people in the County, 2.2 million have no health insurance, another 1.7 million have Medicaid (and if you saw the newspaper today, California is very cheap on expenditure for Medicaid we were 49th out of the 50 states, so we pay minimally. So we about four million people in Los Angeles County. This first slide is the poverty counties and the darker the areas the more poverty.
This is the South Central part of L A, this is the Harbor branch, where Harbor UCLA Medical Center is, and this is the Northeast Valley, the valley area, the city of L. A., once all orchard-like. Orange County was settled after World War II as a suburb, mainly all white folks. I showed you another map. The fastest growing area of the city now. It’s half Latino. it’s changed dramatically.
So this is where the poor people live. Then you ask, “where are the doctors?” The white area means very few doctors, so Julian Tudor Hart in 1970 got it right. Los Angeles 35 years later – in spite of all this expenditure, in spite of the workforce going from 300,000 to 900,000 – we hasn’t solved the problem.
Leonard Green’s got a map for the whole United States, which basically shows the same thing for rural and inner city. Though I think this is reason to be optimistic, because the present system isn’t working.
So I think were into a (something) period and for those of you who don’t read Latin that means there’s no free lunch (Slide 34).
Now Americans do like to get MRI’s on their knee when they sprained it, as long as someone else is paying for it, but we’re getting to the end. If you look at the budget deficits, it’s unbelievable. There is no free lunch left in the country.
Now why hasn’t this spectacular scientist, and I think it is great and I marvel at this stuff, for diseases for which cannot be prevented or unknown cures, this is great stuff, but we have to understand why people are healthy and sick and this is an epidemiological model but confirmed by others that says determinative health in the US in premature death defined as dying before age 75, what are the components (Slide 35)?
Well, genetics, what you’re born with. Thank your parents or grandparents, We are going to plow through the human genome, but I don’t think we ever want to substitute it, and change it greatly.
The second, I’ll put together social circumstances and environment, 20% that’s the neighborhood you’re born into, how much resources your family has, whether you’re impoverished, what’s your school like, whether you’re going to get shot in the neighborhood.
The third is behavioral choices – what you eat and drink, whether you smoke, or exercise. In this country it’s directly dictated by this – the poorer you are, the more likely your behavioral choices and medical care the 1.7 trillion dollar bonanza accounts for 10% at age 75. After that it begins to have a bigger impact, it cannot erase 50 years of bad behavior though. So if you want to cure 40-50% of the cancer in this country right now, it’s right into there.
Some pretty astonishing stuff. I have a couple more closing slides. If we were giving this talk in 1905, I guess I’d be up at a blackboard and it would only be white males in the room I guess.
If we are talking about mortality 1900, the leading causes of death are infectious diarrhea, pneumonia, influenza and TB. Fast forward 100 years, the leading causes are heart disease, cancer and stroke (Slide 36).
How are they different? 100 acute infectious disease, which had plagued humankind for millennia, through impressive public health, they started sanitation, potable water and then the great scientific advances – the magic bullets of immunizations and antibiotics we defeated this.
This was an enormous victory for humankind. It still hasn’t spread all round the world yet, but in this country now we’ve got chronic diseases – our diseases are all chronic.
Now why does that play to our advantage? Let’s go back to the Institute of Medicine. You’ve all seen the definition of primary care. It’s care provided by clinicians who are accountable for addressing the large majority of the needs (Slide 37).
The key words are sustained partnership and the context of family and communities – sustained partnership. The way you treat a chronic epidemic is a sustained attack over time. You want to change behavior, there’s no magic bullet – only primary care that’s based on a sustained partnership.
Now let’s look at the community. You’ve all seen this slide, the ecology of medical care, published in 1961 by Kurt White and again by Larry Green 2001.
If you haven’t seen it, it simply says, I looked at 1,000 adults in a month and what happens to them. 800 report a symptom, 327 consider seeking medical care, 217 see a physician half of whom are a primary care, 65 go to alternative medicine 21 visit a hospital clinic, 14 receive home health care, 13 ER, 8 are hospitalized and 1 is hospitalized in the UCLA’s of this world. So if you’re a medical student and your career’s down there in the medical center, you get a very jaded view of what healthcare is.
Even if you’re out in these hospitals, and Scott Christman said the State of California was only collecting data on hospital discharges. Now they’re going to get to the next realm at least to look at asthma but look at what’s all out there. This is where the glory and the money is, but it’s also where you spend all the money. The further you get out here, the more cost effective the intervention – so another reason to be optimistic.
Just another point. Another great man, Robert Graham, said we have spent time worrying about the wolf at the door – socialized medicine – while ignoring the corporate marketplace, which is the bear in the pantry (Slide 39). How true, how true!
I think the answer to that is no country int he world has ever succeeded in delivering universal healthcare through the market.
Markets by definition create winners and losers. The winners are already visible.
The losers are ourselves, our patients our communities. We cannot allow this to go on, it will not work.
Now there is some good news I think, and of all places, I found this on page 1 of the Wall Street Journal. Back in February (2005), a company in Wisconsin of 12,500 people, to trim health costs, started bringing primary care doctors right into their work-site and their costs dropped 30% – unbelievably.
People were happier, outcomes were better, and to quote the CEO “when primary care is done right, the results can be amazing. (Slide 41)”
Now if we could only get the US government and people to understand that, I think were on to something. So in closing I would say the new model of family medicine, I think the points that need to be stressed, a couple of points and part of this is the future of family medicine, and from my vantage point in L A, we’ve got to get beyond the one patient – one doctor in one room at a time. That’s a very expensive, very ineffective use when you’ve got chronic disease.
We’ve got to take public health – which is population health. They are good at acute disease, they don’t have a clue in L. A. as what to do about chronic disease. But you’ve got to integrate primary care and public health together and we’ve got to bring mental health in there also. Then you begin to develop a model to look at this stuff (Slide 42).
The chronic care group model, we’ve talked about some of you are already doing in this room. There’s a new term, I just heard it’s called fee for condition. It was published int he British medical journal on March 19th .
I bring this up. (I think there’s someone from Oregon), but the two authors were guys named Dave Sanders and Albert De Pearl, and one was a resident and one was a colleague at Harbor UCLA Medical Center and they’ve come up with this new model.
They say that “fee for service” pays you for tasks like answering the phone, blah blah blah. It doesn’t pay you for outcome. They want fee for condition that you can weigh… the acuity weighed on the person coming in and the condition, and you pay them to take care of that person and the outcome.
Thus, a very interesting team approach to care and I think that would do us well.
Finally, and we’ve talked about this today, the question of the underserved family and I didn’t know that was on the agenda, the FQHC. The Waco people are doing a fantastic job, and we’ve been talking about a “teaching FQHC” because we run this big family health center at UCLA and there’s no way we can cover all the costs.
But there is this enormous social benefit, so we’ve got this idea across and it sounds like somebody in Boise, Idaho was working on this and several people. So I think this is part of the answer. In closing I want to get back to Dr Tudor Hart (Slide 43).
He said January 1, 2000 thirty years apart. Every thirty years he makes an announcement on the inverse care and he said “the inverse care law is not a law of nature but of dehumanized market economics. it could be unmade by a re-humanized society. I think that’s the charge for all of us.
I’ll end by saying a quote from the Berlin wall: “He who wants the world to exist as it is does not the world to exist at all.”
I think that sums up the state of health care in the United States. It’s unsustainable to continue what we’re doing. There was an old saying, “What is good for General Motors is good for the nation.” Well, if you saw General Motors, they’re in big trouble for two reasons. Number one they’re making ugly big dinosaur SUV cars, which you can change.
But number two, their health care costs are just soaring off the map. They are now making more cars in Windsor, Ontario across the border from Detroit, Michigan in Canada than in the whole State of Michigan. Why? Because Canada has a healthcare system. So what’s good for GM is good for the nation, well GM has got a real crisis in healthcare and that’s another reason I’m optimistic.
I want to thank, I thought he was going to be here today, to thank Dr Stephens for his insight, eloquence and inspiration of thirty years in family medicine and invite all of us to proceed with the second battle. I think there’s much ahead for all of us, thank you.
William Burnett, Coastal Research Group: Thank you Pat. I just wanted, for those of you who are confused as to why Gayle isn’t sitting there, Gayle’s wife, EJ, of sixty years or whatever it has been, was hospitalized a few days ago. She is OK as far as we can tell. He’s doing some care giving at home, but he is going to be with us tomorrow, not in person, but through the miracles of an interrelationship between Bell South and SBC to get him in the celebration of the Gayle Stephens lectures tomorrow. so you will hear from him tomorrow. Remember your thoughts because you can attack him electronically tomorrow.
Dr Dowling: I trust his wife is one of those females over age eighty, so she’s benefiting, and that is good indeed.
Dr Freeman: Dr Dowling, would you be willing to take a few questions from the floor?
Dr Dowling: Sure, certainly.
Dr Freeman: All right, well I’m not letting anyone go to lunch unless there’s at least two good questions up on that-
Dr Dowling: There’s no free lunch as we say, right?
David Blandino, MD, University of Pittsburgh Medical Center, Shadyside Hospital Family Medicine: First of all, thanks Dr Dowling and thank you for pointing out that the primary care community is broader than ourselves.. But I think you pointed out some of the authors, I think the Barbara Starfield article from a month ago ought to be–everyone ought to get it, read it and send it to everybody they know in healthcare because it’s a powerful, powerful article.
I have a copy but mine is so dirty, I’ve written all over it, it’s not worth copying. But it’s on the web, it’s a web exclusive I think, so people ought to send it. It’s very, very powerful. She’s a pediatrician and Wendberg and Elliot, are general internal medicine folks and I think we shoot ourselves in the foot when we don’t ally with them more effectively and so maybe it would be a comment on how we can better ally with, probably our general internal medicine folks primarily, but also the general pediatricians. when we do these kind of future family medicine studies they can be more future of primary care studies, because that’s where the best evidence is when we are lumped together at least from the medicare data and Barbara Starfield’s data.
Dr Dowling: I would agree and thank you for pointing that out. I would just also add that talking to Barbara Starfield, she’s worried that the next generation of researchers won’t be there to pick this up. My own department research division, NIH funded people, they are not looking at this kind of stuff, much to my consternation because the funding trails are for other things they look at, but this has got to be looked at and I would agree this is a family of primary care. We want all the people at the table who can solve the problem with us and it’s just not family physicians, so I thank you for the comment.
John Testerman, Loma Linda University, Loma Linda, California: I want to express my appreciation for this powerful talk here. I have a
question I want to ask you. In many of the discussions around universal access one hears talk of single payer and other kinds of plans – many of which may simply end up freezing in place the current specialty-based individual practice-based broken system. I’m wondering if you have some ideas or thoughts that you’ve had regarding a different paradigm for doing this, for delivering universal care that would make it possible to fund such a thing other than simply an enlarged Medicare or Medicaid program?
Dr Dowling: A great question! I have this argument with people whether they’re an idealist, or pessimist. I said I’m a pragmatic idealist and I think the single payer system would…i think is the best way to go. It was on the ballot in California five years ago and it lost 74% to 26%. I’ve come to conclude as I mature, that all things get settled in the middle of the political spectrum. and for that reason, as much as I would prefer a single payer, I don’t think it’s going to pass because the oppositional forces are too strong in this country. What I would do is look at New England Journal of Medicine about ten days ago, in which Victor Fuchs from Harvard had a very good article on vouchers in which low income people get a voucher and can use it in a system and you’re going to build the system this way for universal coverage. And I think that’s…He said it’s not politically ready yet, but I’m hearing both sides of the aisle that are interested in something with that. That still doesn’t answer the workforce issue I agree. We’ve got to have a primary care orientation and that’s why the Starfield article and the Weinberg stuff is so important. We’ve got to do our duty to educate our local legislators, state and national that it does matter how you deliver this care. So that’s my two cents worth, but if you haven’t seen the New England Journal article on vouchers – it’s a very,very good article.
Virag Shah, MD, Presbyterian Intercommunity Hospital, Whittier, California: You partially answered my question already I’m an associate family medicine director residency in Whittier California near Los Angeles
– Dick Nixon’s hometown I should add –
Dr Dowling: Yes…He’s a hero. Actually he had a pretty progressive health program that if it had gone through, we’d be in much better shape. Isn’t’ that right Jerry (Rodos)?
Dr Shah: We had a resident last year graduate and take a job for $85,000 in an over-served area according to your map, which is to be expected. Last year I got married and saw my medical school roommate who took a job as a radiologist starting at $360,000 working four days a week with 12 days vacation and only one call a month.
As far as medical education in a capitalist economy…during your talk it seemed to me that…it didn’t seem like we could work to make everything equitable in a capitalist economy as far as medical education is concerned. Do you have any suggestions? How can we attract people?
Dr Dowling: That’s a great question. One of my kids is at third year medical school at UCLA, so I’m privy to what students really think and I’ve learned the alphabet ROAD, the road to happiness is Radiology, Ophthalmology, Anesthesiology, and Dermatology is what she tells me. And I say “Don’t’ you dare.” And I say are you aware that X-ray films now are being sent over to New Delhi and read during the night by night hawks that are U. S. trained and things may change?
I said that radiation oncology is a very lucrative field now, but I said that Ithink in ten years cancer therapy is going to be biological and antigen-based and we won’t be using radiation oncology (it’s like nuking somebody), that that technology is going to change.
I told her that primary care is always going to be there and that what we tell students is, and we have a family medicine interest group is the biggest student interest group at the UCLA School of Medicine and I think Dr Jimmy Hara here is from the Kaiser-Permanente system is a big part of that.
I tell my own daughter is you’re going to be doing something for the next forty years, you better do something you have a passion about and love and don’t count on the finances.
But you’re right, we are underpaid and this is a big problem and it’s going to have to be addressed head on. If this is a social good, why are we paying somebody who sat in the same row in medical school 85,000 and another person 360,000. It’s an imbalance and I don’t know the answer to that, other than to get that out.
Maybe Denise does, she’s a dean.
Denise Rodgers, MD, Robert Wood Johnson Medical School, New Brunswick, New Jersey: Let’s be clear, I’m not a dean I’m a dean-lette.
Dr Dowling: You’re a dean look-a-like, right?
Dr Rodgers: I had two questions Pat. One, how do we begin to bring this increasing body of knowledge about the importance of primary care into the medical school curriculum in an evidence=based way. You sit around curriculum committees these days and everybody’s talking about increasingly talking teaching evidence-based medicine, etc, etc, etc., and yet there’s this whole body of evidence related to primary care and it’s efficacy that the deans of these schools and many of our specialists wanted to ignore – partly I’m interested in there being a sort of an underground movement to do this, but I was wondering if you had thoughts about it.
II’ll ask both my questions quickly here. The second question is based on this thought: I’m not as convinced about the middle way yet in this country, I’m more convinced about the importance of PR. No matter how people in this audience felt about what happened with Terry Schiavo, the PR associated with her on life support was effective.
I think the thing that was most remarkable to me was that we had 45 million uninsured people in this country. We can motivate the US congress, and the President of the United States to do emergency legislation around the life of one person, and yet we blithely allow millions of people in this country to die and suffer incredible morbidity before their deaths because they don’t have access to adequate health care. Quite frankly I can’t feel like it’s not something that we’ve done wrong in terms of how we present this to the general public, so I guess I’m talking about maybe underground movements both in the medical school as well as with the general public. What are your thoughts and ideas on that.
Dr Dowling: Yeah, as far as reaching the deans. We send those articles to our deans all the time whenever this stuff comes out and they know who they are and Weinberg’s one of his zip codes as the west side of LA and UCLA is one of the institutions and now Blue Cross is wondering why costs are higher. So the issue is on the radar screen at least and they’re questioning the articles. But I guess the other forum is the AAMC which the deans all go to and to have some workshops and probably Weinberg and Starfield ought to be plenary speakers there. It might be the best way. I don’t know if they’ve ever been invited in that forum, but that would be a powerful presentation. The other…I think the former governor of Utah isw no head of the U. S. Department of Health and Human services, so I suspect he’s a close friend of Mike Magill’s and Mike ought to have the Secretary and Barbara over for lunch someday now that he’s got Dave Sundwall back in the state.
As far as the 45 million people, I’m in favor of getting them covered whatever way we can do it. But I think it’s a moral outrage, whether it’s the middle ground or whatever, I just want to get it done, so I haven’t settled on one way.
I agree with you it’s got to be done. I was trying to just build the case. Now people are in bankruptcy. Now GM is going under. So there’s going to be a coalition of people, I think, thundering for a change. What they end up with, I don’t know. but I would lave as many options open as possible and have people willing to back something they may not agree with entirely. The goal is can we move the boulder up the hill. That is what I would say.
Roxanne Fahrenwald, Montana Family Medicine: I have a couple of comments. I want to thank you for your talk. I think it was an outstanding overview of where we are, and partly how we got here. The costs of healthcare coverage, of providing healthcare, and of providing specialty care have been a huge problem in the affordability and the quality, as you pointed out, of health care in the country.
I guess a couple of things made me sort of stand up and comment. One was I appreciate hearing a – I don’t know if it is a centrist or compromise or pragmatic approach towards healthcare coverage. I think iwhen we take polarized stands – it must be this or it must be that, it must be the market or it must be the government – that we’re a pretty contentious country. I think that’s partly why we haven’t moved forward on this and I think we do need to look at the outcomes, look at what will work and not be so wedded to our individual stands that we can’t make something work.
What got me on my feet was the comment about reimbursement – that one person is making $85,000 a year and somebody in another specialty is making $300,000 dollars a year, and the thought that we’re under-reimbursed. I’m not so sure I see it like that, I think they are over-reimbursed. I think that’s one of the problems that underlies the cost of healthcare in this system.
You shouldn’t make $300,000 a year to sit a few days a week and look at pictures. It’s not a hard job. So I think the problem is, I think the money we make is fine, and I think that the money people make for doing subspecialty focused repetitive task types of care is wrong.
Dr Dowliing: Thank you. I’m not going to debate that.
Charles Q. North, MD, MS, Indian Health Service, Albuquerque: I got a couple of really good things from your talk, Pat. One is the thought that we should move the Canadian border right up to the Mexican border. Then Robert Ross wouldn’t have to move back to Canada and everybody who moved North would have healthcare coverage, so I think that would be a great solution. The second thought is that, unlike Arnold Schwarzenegger, we should drive a Toyota Prius and that would solve a lot of problems in Los Angeles, vecause I don’t know where they’re actually made anymore.
Dr Dowling: He’s working on a hybrid Hummer, That’s the answer.
Dr North: I have a daughter that’s a second year medical student, so I need some advice for the next year from you, but she’s doing a study on interviewing physicians in the Albuquerque area on social activism – why they are or are not socially active. It’s under the rubric of professionalism, I guess. So if she finds out that some people actually want to be socially active but aren’t because they aren’t sure what to do, what would you recommend at this point, we as knowledgeable physicians and presumably social activists too. Now that we’re armed with this information, who should we talk to in our local communities or state legislatures or national representatives to congress and industry too who are going to be supporting our residencies evidently?
Dr Dowling: So you want advice for your daughter, is that it?
Dr North: No, she’s going to be a radiologist and support me.
Dr Dowling: In response, one suggestion: a book “The Call of Service” by Robert Coles, who’s a social psychiatrist at Harvard, is worth reading, The other stuff is these legislators basically get into this work because they want to solve problems and I think just the basic information on the economics of health care and how you get better outcomes at lower rates. If people understood that it would inspire them enough I think. I think just some of this information has to get out by Starfield and Weinberg on the local level and the governors and everyone else. We have student groups at UCLA that eat this stuff up. They’re really into this.
We could feed it into our social activist groups. now are you going to post your talk on a website, or email it to us? We’re going to patent it and use it as a fundraiser. Bill, can that be done?
Mr. Burnett: Yes.
Dr North: You know, the talk was pretty good but the quotes were great and people understand soundbites, so I’d like a copy.
Dr Dowling: Well that’s blarney and the soundbites change every day.
Don McCanne, Physicians for a National Health Program, San Juan Capistrano, California: I just want to comment about single payer.
I knew you were not in the room when I made the comment, so I’m not taking this personally. You mentioned Victor Fuchs and his voucher proposal. He and I debated that at Stanford along with Dr. Amal. the president-elect of the California Medical Association. At the end of the debate it was pretty well decided that Dr Amal was out of the running, but Dr Fuchs asked me if I’d like to join him in supporting vouchers, and I asked him if he’d like to join me in supporting single payer, so it was an impasse.
But the point is that vouchers and single payer are the two models. The CMA/AMA model – consumer directed healthcare – is going nowhere It’s rhetorical nonsense and all of the policy makers are discussing this right now. Are we going to have a national single payer system or not.
In today’s Orange County Register is a guest editorial that I wrote. The Register is a libertarian newspaper. My editorial was in response to Bruce Bodacken, the President of California Blue Shield who said that if we don’t fix quality and cost in healthcare, we are going to have a single payer system. Well, of course I responded to that and it’s in today’s orange county register.
We have three different studies that, though they know doctors in general don’t’ support single payer, 60% of physicians say “yes, but I do”.
Don’t write off single payer. If you keep saying that it’s going nowhere, it will go nowhere,but even Hillary Clinton, and her long New York Times article said ‘maybe we do have to really look at a comprehensive public solution.’ so single payer has all of the health policy science behind it.