The Fifteenth G. Gayle Stephens Lecture – Patrick Dowling, MD, Part I

[The following is the introduction and first part of Doctor Patrick Dowling’s presentation of the 15th G. Gayle Stephens Lecture. The second part of Doctor Dowling’s remarks appears at The Fifteenth G. Gayle Stephens Lecture – Patrick Dowling, MD, Part II.]

Joshua Freeman, MD, University of Kansas, Kansas City: It’s my honor to introduce Patrick T. Dowling M.D. M.P.H, as a fifteenth speaker in the series that began fifteen years ago with Gayle Stevens himself.

Patrick Dowling, MD, MPH

Dr Dowling is the Chairman of  Family Medicine at UCLA in Los Angeles, one of the Commissioners of Public Health for the County of Los Angeles, and a member of the Board of Trustees of the Charles R. Drew Medical  Center. More importantly, he started his career at Cook County Hospital in Chicago. I have known Pat for over thirty years, since we went to Kindergarten together. (Not really.)

When I was interviewing at cook county hospital for my residency, Pat was a resident there and because he was a (something french) genius he was the chief resident when I was an intern, even though he isn’t older than me. I left to go into the National Health Service Corps in Arizona and Pat recruited me back to Cook County Hospital when he was the associate chair of that department. He helped encourage me to write a faculty development grant which was certainly the start of my academic career.

When Jorge Prieto, the Chairman of Family Medicine at Cook County Hospital – who was a mentor to all of us there – left (I won’t go into all the details), Pat left soon thereafter to Brown University. Then thanks to his sinuses California got him out of Rhode Island and he became head of the family medicine residency program at Harbor General Hospital in Los Angeles.

From thence he was dragged kicking and screaming to become Chair at UCLA. Pat is exemplary in terms of his commitment to the care of undeserved people in the United States.  I think that’s the  finest thing you can say about anybody and Dr Dowling has represented that all the way through his career. He is a great speaker. He has this wonderful voice that could have gotten him a job as a Baptist preacher, had he not chosen this career path.  But more importantly than his intonation – although that’s great – is what he says. This has consistently been a voice for the people and a voice for the most disenfranchised people in our country. So I am pleased to introduce Pat Dowling, who will speak on the Second Battle of Armageddon.

Patrick Dowling, MD, MPH, University of California, Los Angeles: Thank you, Josh and good morning to all. It’s good to see so many new faces – especially out of state faces, because in spite of our bold governor the state is in big trouble here  and we need your dollars.  Second, I thought it was a fascinating discussion this morning about the money and the problems because about ten days from now were going to be facing our budget hearing with the vice chancellor and Dean and are short about 1.3 million dollars, so when he asks again why we need this I’m going to point to Michelle Bholat my colleague to answer the question based on everything we heard today.

Third, I want to salute three people here today.  First is Dean J. Jerry Rodos. We share careers in  both Chicago and Rhode Island. Second is Dean Denise Rodgers, the pride of Flint, Michigan  (We have a great job for you in Los Angeles!)

Third, I want to thank Josh Freeman for that kind introduction. I did meet Josh in 1976 (not in kindergarten), but he did go to grade school with a person who is now a Republican United States senator. It’s also the first time I’ve ever seen him clean shaven in the last thirty years.  I didn’t recognize him. It reminds me of the [1968] “Clean for Gene” McCarthy campaign. I hope he’s running for Senator Bob Dole’s spot. Josh is a  pretty unique guy and as I recall I think he majored in journalism and he went back to medical school later. There was a gap on his CV, so I asked him “What did you do there?” As I recall he went from New York City down to Cuba to become a harvester, so he’s had a long history of helping people.

Slide 1

So thank you. With that I have this title. Bill Burnett called me to give this talk and I said “what do you want me to talk about?” and I was told Gayle Stephens was planning to be here. [Editor’s note – Dr Stephens’ wife was hospitalized just before the National Conference commenced, preventing his participation in person. He took part via a telephone hookup.] I wanted to come up with something unique because we’ve been talking policy and economics this morning, but Dr Stephens is more historian and more poet, so I wanted… That’s what I’m going to talk about. I came up with this title and I hope it all fits in.

Slide 2

For those of you who don’t know Dr Stephens, I thought it would be good to focus on some of his very words. (I thought he’d be here today to either comment or refute or whatever, but he’s not here so we can say what we want.) The truth is he was one of the founders of family medicine and a great writer. He points out that our family tree in medicine had some real shady characters over the years (slide 2). There was a long battle with the clerics until medical orthodoxy – as he termed it – occurred. Then he said we didn’t really become a solvent profession until about a hundred years ago with the Pure Food and Drug Act passed in 1906 (slide 3).

Slide 3

After that medicine solidified and really fought every element of social reform until what Gayle calls the Battle of Armageddon 1965 [the passage of Medicare and Medicaid] – what John Geyman calls the great social contract this country passed. After being defeated three times, we passed Medicare and Medicaid legislation, 40 years ago.  That was the first battle of Armageddon and no small thing at that time and that’s what that was all about. Then Gayle goes on to talk about the birth of family medicine. (Slide 4) I think Jerry Rodos mentioned this that we were like pediatricians and psychiatry – we were really a specialty that came out of social reform, rather than science or technology.

Slide 4

We were basically committed to getting first class health care to everyone who needs it.  So we’re a little different specialty, probably closest to the pediatricians and psychiatrists. Gayle goes on to say that we were humble, benevolent family doctors, and the reason we enjoyed some success is we thought of something bigger than ourselves (Slide 5). It wasn’t just to pad our pockets. It was to help the whole community. We started as a sect. By 1978, nine years down the road, we were a church.  So we had some very early success thanks to many of the people in this room.

Slide 5

I think his key article is what he called “Family Medicine as Counter Culture”, published originally in 1978 and republished in Family Medicine in 1999 (Slide 6) He said family medicine on balance has more in common with the counter culture than it does with the scientific medical establishment, because we believe there is more to medicine than science and that all health problems cannot be solved by science alone. In fact – showing what a poet he was – he said ‘human illness and suffering happen to the entire human organism and the self that laughs and cries” and science is only applicable to part of that and so were part of that other side of that and hence the counter culture (Slide 7).

Slide 6

With respect to science he says for more than 100 years medical science has conducted a spectacular and costly crusade against death, the most constant reminder of the ultimate impotence of science. It’s too bad he’s not here.  At its deepest level family medicine, and this really hit home, is more concerned with life than death (Slide 8). We’ve had brilliant success in science, no question about it.  We come from academic medical centers but the question is: is it a monster?  at what cost is it coming? and can it bankrupt us?  and the question of the power and someone was speaking of the devil and we know how that fits in (Slide 9).

Slide 7

So we had this huge battle in 1965, after losing three times and progressive forces of reform won in 1965 so you would think that cleared the path for what Gayle said a thousand years of righteousness, but  guess what, it didn’t quite happen and those forces that had fought led by the AMA back there (Slide 10). He really likens modern medicine institutions to the medieval clergy of the past in maintaining their death grip on privilege and power and goes on to say that family medicine put its foot in its mouth in some respects by we changed our name so people got a little confused (Slide 11).

Slide 8

Then, to use a great adjective, we were suckered into “gate-keeping” by managed care.  We were all part of that (Slide 12).  That’s kind of the history of Gayle Stephens. If you haven’t met him you should read his stuff. He’s delightful. So which I wondered what about the, that should be H2O, water in Birmingham or is there something, Did Gayle get it right, or is there something polluting the water there? I think Gayle got it right/ Let me show you some data now. You don’t need to be a health economist to know that the health system in this country is in crisis.

Slide 9

In fact, we had the last four Secretaries of Health and Human Services bipartisanly all agree the system is flawed relies too much on high tech, rather than primary care (Slide 14).

We have a population that does a lot of things detrimental to their health. As far as the dollars – well, anyway you look at it we keep spending more and more.

This is per capita expenditure and if we graphed it out through 2002.

Growth in United States Per Capita Health Expenditures

We are up around $6,000 for every man, woman and child in this country. Enormous dollars!

Slide 10

The same time if you look at the decade of the 90’s, which is when managed care came in, it was really a…what did I push here, no?  OK. Anyway, at the beginning of the 90’s healthcare spending was…inflation was double digit, two to three times that of general inflation. Something had to be done, you saw managed care come in and was successful in decreasing those costs considerably.

By the middle of the 1990’s people began rejecting managed care and look what happened.  Now we’re up here. The way most people felt it was their yearly increase in health premiums and they were soaring seventeen percent a year look what happened.

Managed care was successful in that people rebelled and now were up here.

Selected U. S. Health Care Expenditures 1990-2000
Slide 11

The third thing, the cost of everything went down for a while. People rejected managed care and back to there.

So 2005 is like 1990 all over again, only we don’t have a strategy this time.

Now lets look at how some of our other colleagues western industrialized nations. What kind of spending do they have?

It turns out we spend much more than anyone else and that spending is accelerating.

Per Capita Healthcare Expenditures Selected Countries

In fact, it’s now, I think, around fifteen percent of the GNP, but in data just released it shows that for the last five years twenty five percent of all economic growth went into healthcare – an astounding cost expenditure when compared to the next item, defense. You know what’s happened to defense in the last five years. We’ve entered into two wars, we have internal security you would think there was enormous increases. Everyone agrees with that’s ten cents n the dollar.

Slide 12

Healthcare consumed twenty five cents on the dollar (Slide 18). That’s very accelerated growth, never seen before. So the question is, OK we spend twice as much as everyone else, yet we managed to have forty-five million people uninsured, including seven million people in this state, especially in the southern part of the state. Does more dollars mean better health?  If we were much better off than everyone then it’s a good investment, right? (Slide 19.)

Well, lets see the data we have. WHO data compares cross national and just a few things, infant mortality life expectancy etc….  There are actually twelve measures they use to look at across countries and we  are in the bottom third in most and the middle third in some.

Slide 14

We rank number one in one area and half the people in this room will be pleased to hear that if you’re a female at age eighty in the United States, once you hit age eighty you will outlive all females in any other country.

But that’s the only category, and there won’t be too many men around, so we’ve somehow managed to spend $1.7 trillion and if you’re a female at age eighty you’re going to eke out some more years. So there’s a marginal benefit.  So I, being a simple guy wondered “gee I wonder how the rest of the world gets better outcomes.

Slide 18

They don’t spend, they spend a lot less, what are they doing? One way to look at it is what do their doctors look like and as you’ve all seen in most of the industrialized countries, half the doctors are family doctors or general practitioners were at twelve percent.

In our country we have a broader definition of primary care, which I endorse, and, with general pediatricians and general internist, [all primary care doctors] were still just thirty percent (Slide 23). So we have a different physician workforce here so the question is, does it matter?  I think the best person to answer that question, and the two names I dropped today.

Slide 19

If you don’t know who Barbara Starfield is, if you can’t do a literature search to understand primary care, this is the one person I would read.

She’s at Hopkins. She is a pediatrician, a great woman, and she’s done this stuff and found among westernized industrialized countries with a primary care orientation, you’re going to have lower costs, higher satisfaction, better health levels and lower medication costs (Slide 24).

And if you look at the problems facing the United States today, we have soaring costs.

Comparative family doc/general practitioner to population ratios

We have people very dissatisfied with their healthcare, the healthcare levels are very disparate, we have huge disparities on racial and ethnic geographic regions, and we have drug costs that are going off the roof.  All you have to do is watch TV every night and see who’s sponsoring most programs.

Slide 23

So the other person to look at I think is a guy named Jack Weinberg at Dartmouth. He’s done a bunch of studies on the geographic variations in Medicare expenditures and Medicare is, I don’t know, a hundred and eighty billion dollar program to cover about thirty four million seniors and disabled people, and he began to wonder why some areas were spending much more than others. He found five zip codes in the United States where per capita expendables controlled for age and acuity were twice that of some average places.  One of the five areas was Manhattan, another zip code happened to be the west side of Los Angeles and the average areas happened to be towns like Portland and Minneapolis.

So what he found was the cost two times per capita when controlled and in the final six months of life the expenditures were three times as great.  So you might say OK but maybe they’re getting better outcomes. Maybe this is a good investment.

Slide 24

What he found was in the five areas with high expenditures, you’re much more likely to spend seven or more days in an ICU during your terminal six months, you had visits to five or more medical specialists, you had a higher mortality rate, and he’s adjusted this, and lower satisfaction than if you had just gone to a family doctor. So the problem here is not only eating up tremendous public resources, you’re getting higher mortality rates, and you’re getting worse outcomes.

Now the other study someone referred to this morning just was published on Health Affairs Online about three weeks ago.

Slide 25

Once again Barbara Starfield just looked at a simple thing. For all the counties in the United States, she calculated the number of primary care physicians. When she adjusted mortality for age, race, and percent poverty, she found that the more primary care doctors you had per county, the lower the mortality rate.

There was no relationship with specialists at all. Thus, very crucial data suggests that if you just put a primary care provider out there you run lower costs, increased satisfaction and lower mortality. (See Part 2, slide 26.)