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Resident: This is an 85 year old woman who presented in sepsis from a multilobar pneumonia. Her temperature was 103.2 and she had a blood pressure of 100/60. Her chest x-ray showed pneumonia. Two hours after the antibiotics, she is up and around and wants to go home.

Me: Wow

Resident: I know, based on the CURB-65 criteria her predicted mortality is about 50%

I give away a lot of advice, that people may or may not want.  People come to me not for information regarding their disease but for a cure. They want to feel better. This is in part an residual of the miracles of the antibiotic age that I was a part of this weekend. Pneumonia, the “old man’s friend” is now, if treated efficiently and effectively, almost always curable as attested to by my patient form this weekend. The proliferation of “urgent care”s and “immediate care”s is partly because people want to feel better immediately (it isn’t Dr. Perkins I need, it is a prescription and a steroid shot) and partly they don’t want to miss a pneumonia and die (it isn’t pneumonia, is it?).

The antibiotic model is that it works great for pneumonia in old people in part because the outcome is so dramatic. The older person is still old but the pneumonia is now gone. It is a lousy model for chronic illness. Take insulin for 4 days for your diabetes and you still have to take it the 5th day. And the 365th day for that matter. Unlike the pneumonia, which if untreated will kill you quickly, the high blood sugar of diabetes rarely kills. It is the aftereffects, the sequelae, of diabetes that kills with heart disease, stroke, infection, and blindness.

The New York Times covered a science story regarding the differences in premature mortality between the rich and the poor (found here). In it they point out that the differences can be explained by smoking (the poor are much more likely to smoke, now) and prescription narcotic abuse (just because it came with a prescription doesn’t mean it is safe). The third contributor is obesity. The rich are less likely to be obese than the poor, but not that much less (31% vs 37%), so why is obesity more of a problem for them? The investigators didn’t know why, exactly.

We had another patient this weekend who was admitted for her diabetes that explains why obesity isn’t so bad for the poor but the sequelae of obesity is. Her diabetes is well controlled when she has her insulin. Her job provides her insurance. Unfortunately her job doesn’t pay enough to cover the copay for the insulin, her grocery bill, and her housing expenses. So often, she has to make a choice between food and insulin, especially if her job doesn’t give her enough hours. So it isn’t the obesity per se. It really isn’t the diabetes, per se. It is the need to choose between a warm place to stay, food for her family, or her insulin that forces her to neglect herself. The sequelae of being poor in America.

 

 

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Donald Trump and Hillary Clinton were walking down the street when they came to a homeless person. Trump gave the homeless person his business card and told him to come to his office for a job. He then took $20 out of his pocket and gave it to the homeless person.

Hillary was very impressed, so when they came to another homeless person, she decided to help. She walked over to the homeless person and gave him directions to the welfare office. She then reached into Trump’s pocket and got out $20. She kept $15 for her administrative fees and gave the homeless person $5.00.

Joke” on the internets

Chronic homelessness is a complex problem. In 2006 Malcom Gladwell told the story of “Million Dollar Murray.” Murray was a gentleman who lived in Reno, Nevada, and had a major substance abuse problem. A veteran who learned to cook while in the service, Murray had two personalities. When drinking, he drank a lot. He was arrested a lot. He ended up in the emergency room a lot and, in fact, someone did the math and it was calculated that during one binge he cost over $1,000,000 in services. When supervised, sober and in housing supplied by an agency, he cooked well. He made money. He would be released on good behavior and go back to drinking. A lot.

Malcolm Gladwell points out that most people who are ever homeless are homeless for 1 day. The second most popular number for “days homeless” is 2 days. Murray’s case, though not typical for homelessness, was typical for expensive homelessness.

It’s a matter of a few hard cases, and that’s good news, because when a problem is that concentrated you can wrap your arms around it and think about solving it. The bad news is that those few hard cases are hard. They are falling-down drunks with liver disease and complex infections and mental illness. They need time and attention and lots of money. But enormous sums of money are already being spent on the chronically homeless, and Culhane saw that the kind of money it would take to solve the homeless problem could well be less than the kind of money it took to ignore it. Murray Barr used more health-care dollars, after all, than almost anyone in the state of Nevada. It would probably have been cheaper to give him a full-time nurse and his own apartment.

As told in this article, the George W. Bush administration looked into the chronic housing problem with the lens described by Malcom Gladwell. They found that $10,000 targeted towards these hard cases through housing subsidies could save the government several hundred thousand dollars. This money did not go to making them less dependent on substances. It did not go to giving them employment skills. It went to housing…and it worked:

In terms of impact, the number of chronically homeless people living in the nation’s streets and shelters had dropped by about 30% – to 123,833 from 175,914 – between 2005 and 2007, which policy makers attributed in part to the effectiveness of Housing First

Today that number is a little more than 100,000 with the number of homeless vets (not necessarily chronically homeless) being 40,000.

Why are we not celebrating this success?

From the right side of the aisle, it was seen as a “give away.” It reflected a paradigm shift in housing, the movement away from emphasizing “housing readiness” to offering low demand permanent housing solutions. Though it fixed the problem, it fixed it by giving housing to those who could not control themselves, thus exacerbating the feelings of unfairness amongst those who “play by the rules.”  From the left, Housing First has been criticized on its failure to address broader service outcomes, particularly substance abuse issues. It was seen as a market based solution (these folks cost us less money now) which didn’t address broader issues of equity and values.
John Maynard Keynes said “there is nothing a politician likes so little as to be well informed; it makes decision-making so complex and difficult.” The appeal of many of the current politicians is their willingness to ignore evidence as they pursue policies which have broad, superficial appeal. Homelessness rises to the level of public awareness when the tourists feel bullied or otherwise threatened (see comments following this article). One can only hope that our core values will come through as we work through this election cycle.
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What should be huge medical news is that the mortality rate (the rate at which people die) for white men and women aged 45 to 54 with less than a college education is rising in this country. This despite all the money that is spent on health care. This just does not happen. Why is this? Per the Washington Post:

“Drugs and alcohol, and suicide . . . are clearly the proximate cause,” said Angus Deaton, the 2015 Nobel laureate in economics, who co-authored the paper with his wife, Anne Case. Both are economics professors at Princeton University.

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And we are talking about a lot of excess deaths

Based on the findings, Deaton and Case calculated that 488,500 Americans had died during that period who would have been alive if the trend hadn’t reversed.

There is a lot of speculation about the exact why and more studies are certain to follow, It is clear that the economic recovery has left these people behind and it is also clear that the safety net, including mental health but also including meaningful retraining, has not been effective for this group of people. For now, as a physician I need to do a better job of screening for pathological substance use and mental illness, As citizens we all need to advocate for more, not less, support services for this at risk population. As people, we can all say out neighbor “Is there anything I can do to help?”

How can Dr Carson be leading in a national poll for president and get a pass on a some, well, scientifically suspect beliefs such as “his statement in the wake of the Oregon mass shooting that it would be advisable to attack an armed gunman during a mass shooting ‘because he can’t get us all‘?” Or. how can folks want a president who is doing infomercials on neutraceuticals which misrepresent scientific fact and when called on it, deny having been paid for what was almost certainly a paid gig?

The New York Times gives a plausible answer to this question today. Ishani Ganguli, a Boston internist with an interest in health policy, points out that, pretty much, physicians get a bye:

  • He points out that we are trained to speak authoritatively regardless of the certainty of the situation or the strength of the evidence. In other words, as I tell my residents, “patients and attendings smell fear.”
  • He points out that surgeons are trained to believe that their skill is what stands between the patient and death and the loss of that faith leads to a crisis, one that a successful surgeon may never experience. He or she may not be good (and there is now a scorecard to look at) but will never admit defeat.
  • Doctors should never be politically correct, or so they are portrayed in the media (see House, MD),
  • There is a long line of physicians who are given a pass (see Dr Oz for the latest example)

Dr Ganguli points out that we as a society feel the need to ascribe trust to the MD. Our Hippocratic sales pitch has been an effective marketing strategy. He goes on to point out that self reflection and knowing our limits are keys to maintaining this trust. I am afraid that these are qualities Dr Carson does not have.

139263_600Ben Carson on setting up health savings accounts in a post Obamacare world:

“You also give people flexibility to transfer money within a family. So if you were $500 short, your wife could give it to you, your daughter could give it to you, your uncle, your cousin.”

Me in conversation with a fellow who is homeless and suffers from a terminal illness last week:

“Can you give me a ride? I sleep in a cot in the shelter down the way. I worked all my life until I got sick. Just got discharged a week ago from the hospital. Can walk about a half a block before I have to rest. I spend my morning walking to the this place for food.”

Me: “How long does it take you?”

“Oh, all morning. It’s about 3/4 of a mile. I spend the afternoon walking back. The give me a lot of medicines but when I run out I end up back in the hospital”

From a blog on population health

…..success (in lowering healthcare costs and increasing quality of healthcare/better outcomes for patients) …will require the ability to embrace the messiness of disease and the complexity of patients, rather than providing idealized solutions that impress in the boardroom but flop in the examination.

It is refreshing not to have a wonkish campaign for the Republican nomination. Both 8 years ago and 4 years ago terms like “bending the cost curve” and “medical loss ratio” were being used by the actual candidates. Voters don’t want to hear that. They want common sense solutions for common sense problems. For healthcare, the answers are simple—after all, we’ve all been to the doctor, right? Make the sick folks make choices. Get ’em out and working. Since Dr Carson is, well, a doctor, his common sense answers are just the prescription for our sore ears.

As found here, he feels that Health Savings Accounts for almost all are just what the doctor ordered:

ObamaCare, he opines, is way too restricting. Why should people need to have the details of what they purchase?

A major problem is that many people in our entitlement society see nothing wrong with forcing others to provide for their desires. In a free and open society, anyone should be able to purchase anything they want that is legal.

Given enough freedom, the invisible hand will sort things out:

Most people will want to get the biggest bang for the buck and will independently seek out both value and quality. That, in turn, will bring all aspects of medicine into the free-market economic model, thus automatically having an ameliorating effect on pricing transparency and quality of outcomes.

In addition, the miracle of compound interest will overcome the human predisposition to become sicker as we get older:

If accounts are established at the time of birth, they will be even more potent because the vast majority of people will not experience catastrophic or even major medical events until well into adulthood. By that time, a great deal of money will have accumulated.

Lastly, Americans are generous to a fault and will contribute to a fund if it goes to those who are deserving:

The 5 percent of patients with complex pre-existing or acquired maladies would need to be taken care of through a different system, similar to Medicare and Medicaid, but informed by the many mistakes in those programs from which we can learn. Even this kind of system should have elements of personal responsibility woven into it.

Problem is, facts really get in the way of an attractive market-based narrative:

  1. Healthcare in this country costs about $8,000 annually for each man, woman, and child, of which the government currently pays around $5,000.- President Carson would put $2,000 into everyone’s account. Already he’s saved us money!
  2. Five percent of the population accounts for almost half (49 percent) of total health care expenses with most of those people being on Medicare or Medicaid.- Um, does that mean we bonus everyone $2,000 and then have to pay the same amount for folks on Medicare anyway? Or does their account magically grow? 
  3. The lower 50 percent of spenders accounted for 3 percent of the total national health care dollar.- Uh, oh, here’s a problem. We have taken this money out of health care and moved it into a savings account for healthy people.
  4. High spending persists over multiple years for many patients, while others return to more normal spending levels after an expensive episode. There is also evidence that high spending occurs near the end of life for many patients, particularly within the Medicare population- Well, this is a problem…what happens when the savings account runs out? I guess they are walking to the homeless food site.

Interestingly, Dr Carson performed operations that cost the patient’s insurance $3,000,000 on a routine basis. He never published his results, but the operation he became famous for (separation of twins joined at the head) apparently has a mortality of 50%, and an unknown but high rate of severe disability. It is clear that informed consent remains a real problem regarding outcomes without surgery. Since these operations occur in the first year of life, the twins could kick in the first $4,000 from their HSA. Wonder if having to collect $2,996,000 from the health savings accounts of 1498 of the parent’s closest friends and family would make a difference?

Me, I’m now into the Donald’s plan:

Trump said that the Affordable Care Act has “gotta go” and that he would repeal the law and replace it with “something terrific.”

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Me (while in the military): Well, why can’t we do it this way. This person is malingering and really needs to be “not in the Marines.”

My superior: You really don’t want to. This person might be a screw-up but he is well connected and you really don’t want to start a “congressional.”

In Hawaii, where I was stationed, we lived in fear of “congressionals.” Some enlisted person or another would get what he or she perceived as bad care and before you new it, a letter from a congressperson’s staffer would appear on the commanding officer’s desk.

Dear Captain (blank),

This is to inform you that one of our constituents feels that the care they received  was substandard. Please provide in writing the circumstances surrounding this incident. 

Signed, 

Congressman Foghorn Leghorn

This letter would initiate a chain of events that resulted in all productive activity stopping until all of the minute details could be compiled into a mountain of paperwork and sent “up the chain.” The reality was that the Congresspeople probably could care less about what actually happened but, being the representative of the people, wanted to respond (or be seen as responding) to their constituent. The actual effect was to keep us from doing what we were being paid to do, provide quality care to the troops, and instead focus on the distraction.

This past week our Congressman, Bradley Byrne, responded to what he perceived his constituents wanted. He voted aye on a blank check for congress to “investigate” Planned Parenthood’s role in, I don’t know, having a disturbing lunch conversation regarding embryonic tissue donation. (If you want an in-depth discussion on the ethics of the use of cells in scientific discovery, a good source is this book.)

The investigation, though, seems not to be investigating the use of embryonic tissue in medical advances (think rubella and varicella vaccine) but, very specifically:

Requires the Panel to investigate and report on:

  • medical procedures and business practices used by entities involved in fetal tissue procurement;
  • any other relevant matters with respect to such procurement;
  • federal funding and support for abortion providers;
  • the practices of providers of second and third trimester abortions, including partial birth abortion and procedures that may lead to a child born alive as a result of an attempted abortion;
  • medical procedures for the care of a child born alive as a result of an attempted abortion; and
  • any changes in law or regulation necessary resulting from such findings

Congressman Byrne, please don’t let them turn this into an expensive distraction. Let’s investigate how to make it REALLY difficult for these entities to procure fetal tissue by making pregnancy termination rare. I would ask that Congress use the  “any other relevant matter” clause to investigate the real causes of our abortion crisis and these should include:

  1. In states that have not expanded Medicaid, working parents are only eligible for Medicaid if their incomes are below 61 percent of the poverty line (about $11,900 for a family of three), and jobless parents must have incomes below 37 percent of the poverty line (about $7,200 a year for a family of three). In most states, Medicaid coverage is not available at all to adults without children. This large group of people does not have easy access to long-term effective contraception and thus is more likely to have an unwanted pregnancy and seek out pregnancy termination. How are these states responding to the challenge?
  2. Health coverage during the period before pregnancy allows women to receive preventive care like regular doctor visits, birth control, information about making healthy food choices, tobacco cessation programs, and substance abuse services that decreases their own health risks and makes it more likely that their babies will be born healthy if and when they become pregnant. For example, research shows that prenatal care for high-risk pregnant women reduces the incidence of costly premature births. In states that have not expanded coverage. these people only seek care after they become aware of their pregnancy and make a conscious decision to go to the doctor’s office. They are more likely to have a fetus with a problem and seek out termination. What are we doing to provide access to women prior to conception in the states that have not accepted expansion?
  3. By accepting the Medicaid expansion and eliminating gaps in coverage, the state administrative costs are reduced because the states  no longer have to process enrollment and disenrollment for women who move on and off Medicaid coverage based on pregnancy, thus reducing the size of government and saving the state needed tax revenue that could be returned to the taxpayers. In those states not accepting the expansion, how are they justifying this needless expansion of bureaucracy?

I expect my response soon.

Signed, your constituent and a taxpayer.

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I look marvelous, but I don’t feel marvelous. Which is hokie-dokie for me, because, as you know, my credo is “It is better to look good than to feel good.”

Billie Crystal as Fernando Lamas

In 1948 some investigators from Boston University decided to take on conventional wisdom. They went to a nearby town  (Framingham, a 20 minute train ride away) and talked everyone in the town into giving a little of their personal data, blood, and health habits. They did this because conventional wisdom was that heart disease was brought on by personality  (“Type A”) and plain bad luck. What they found was not only was personality non-contributory in and of itself,  but they discovered a whole host of factors that actually did contribute to heart disease and were modifiable. The modern treatment of hypertension, diabetes, and high cholesterol, as well as the importance of physical activity and smoking cessation to the prevention of heart disease, all came form this study. The identification of the cause of 1/3 of strokes, atrial fibrillation, was made as a result of these serial observations as well. It has been estimated that the number of lives impacted as a result of these findings is in the millions and the amount of money saved in the billions.

These types of observational studies are important. Health care providers, stuck in the forest as we are, need someone to point out the trees. These types of observational studies on large populations are an important aspect of the forest-tree dialogue. Unfortunately the are also very expensive (current costs are several million dollars annually). In addition, the timeline is measured in decades making it an academic career killer for the first 20 years or so.

It appears that some folks in Britain have taken up the longitudinal study baton. The UK Biobank has taken information on 500,000 folks (with their permission) and committed to tracking these people over time. The first major report from this data bank came out in the Lancet this week. Having almost a decade of data, they looked at who died and what was associated with death. More usefully, they have put the data on a website so you can see whether or not to purchase a long-playing record.

They only enrolled folks between 37 and 70 and of the 500,000 only 2% died. Because of the length of the study, the model only works for 5 years out (Framingham has good data for 10 years out for most things they look at and longer for some). For guys, they found that if a guy said his health was excellent, it was. That was the single best predictor of 5 year mortality. For women, a history of cancer was associated with an increased risk of death, For both men and women, a slow self reported walking pace was associated with an increased risk of death. A history of smoking? Still bad news for both sexes and current smoker even worse. Things that didn’t have an effect at 5 years? Blood pressure, Average monthly beers. Cell phone use. Beef intake.

I fully expect more to come out of this effort. As of today, though, my UBBER age is 40 and I feel marvelous. What’s yours?

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Law 13: THE DELIVERY OF GOOD MEDICAL CARE IS TO DO AS MUCH NOTHING AS POSSIBLE

Samuel Shem, House of God (Quoting the Fat Man’s Laws)

On rounds a while back in the hospital, we had a patient who had come from ICU and was being cared for by our team. He was a little older than our average patient (he was in his mid 80s), a little sicker (his kidneys and liver were failing), and a lot scared (I don’t want to die, doc. I want to feel better. I want to go back to how I was. Don’t let me die). He was getting a lot of blood draws, had a catheter in, and was getting IV fluids and a strong diuretic. Thanks to “big data” we now have calculators that we can plug in certain data and determine the likelihood of the patient being alive at 3 months, 6 months, and a year. In this patients case, there was a 50% chance that he would be alive in 3 months. As much as I wanted to, I was not ever going to be able to put him back together. I was also sure that he would have at least one or maybe two more trips to the ICU before he died. The sad thing is, those trips to the ICU might just cause him to die sooner.

Americans have believed that the US Healthcare system is the best in the world despite the fact that we consistently rank last among wealthy countries in almost every category measured. We are the most expensive in the world, spending twice what the next highest country spends.. It appears, that we have mistaken excess for quality. It also appears that we physicians are complicit in selling this belief to the public.

I often have patients say to me “do everything.” Often, they make that statement as the end of life is rapidly approaching. In this country, everything comes with a steep price-tag. Part of that price is monetary, For example we spend $1.25 billion in Medicare recipients for cancer care with 25% of that occurring in the last month of life. Part of that price is in shorter life-spans (from the Dartmouth Atlas):

Ironically, research has found that in patients with chronic illnesses, more aggressive interventions result in shorter life expectancy, probably because of the risks associated with hospitalization. This indicates that the best strategy for extending the life of people with chronic illness is to focus on those activities that provide a survival benefit – better control of blood pressure for people with diabetes, for example – rather than on “heroic” end-of-life care.

It turns out that the Fat Man was right. For a lot of people, symptom management (What would you like to be able to do?) with the reduction of aggressive care actually leads to a longer, better life.

What can you do? Take advantage of being well and determine what you would like others to do for you when you are sick. The CDC has some good information on advanced care planning. Only 20% of Americans have done so. If you suffer from chronic illness, have a conversation with your physician about what your expectations are regarding your last year. Only 25% of physicians report having such a conversation. Limit your care seeking behavior to what really is necessary. One in three Americans who die have seen over 10 physicians in the last 6 months and yet they still died (and perhaps sooner than they might have). When it is clear that a cure is not possible, seek symptom relief. Programs providing palliative care improve length and quality of life. In Alabama, only 20% of hospitals have such programs. Makes it hard to follow the Fat Man’s advice.

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Dr Perkins, can you come see this baby? Something about it just makes me feel uncomfortable.

I walk into the exam room to evaluate the week-and-a-half-old baby that was being seen by our new nurse practitioner. The child had a late morning appointment, the mother having called at 8 because the baby “wasn’t feeding.” No fevers, nothing else out of the ordinary per mom (although the baby did up having a fast heart rate). But as soon as I walked into the room, I quickly agreed with the nurse practitioner. The child was sent to the hospital for a “septic work-up” and was indeed septic.

Dr Perkins, I just don’t feel good. I have this chest pain when I go to sleep at night. Not during the day, mind you, only at night. That’s right, it hurts right there when you mash down.Why, yes, I have been getting a little short winded when I walk the golf course but isn’t that just weight gain?

Despite the reassurance that reproducible chest wall pain brings, based on reduced exercise tolerance we went ahead and obtained an EKG. To make a long story short, 3 vessel disease.

It was quite the Monday.

Despite running a busy department, I do a lot of clinical medicine. Trained in the underserved environment where I continue to practice today, I care for all ages, do some minor procedures, deliver babies (and now the babies of the babies I delivered). As my practice has aged with me, I see a lot more older than younger folks and find myself diagnosing more dementia and less strep throat the older I and my patients get.

Being comprehensive defines my specialty along with continuity, coordination, and first contact care. We preach to our learners the importance of these attributes, we test our graduates on the comprehensiveness of their knowledge, and we criticize ourselves for allowing our scope of practice to shrink. Now there is one more piece of evidence that should make us think twice about that cushy outpatient job ($50,000 signing bonus, no call, no hospital, 15 minutes to the beach). The Graham Center has authored a very elegant study that links scope of practice with actual practice. They found that doctors who were able to do more (were more comprehensive in their approach) had Medicare patients who were less likely to be hospitalized and who had better care-seeking behavior. By better, I mean that they cost the system about 15% less.

Not measured in this study were quality and patient satisfaction. This is important. As one of the commenters points out, sometimes comprehensiveness can be misused.

[F]or some populations with higher disease burden, high comprehensiveness (or scope, as we say) may be counterproductive. PCPs that maintain “too much” comprehensiveness for patients who need more contributions by other providers may be doing so because of lack of coordination with specialists, inadequate supply of alternative providers, an inability to recognize limitations, or resistance to “letting go”. Whatever the reason, the decreasing value of expanded scope in high risk individuals is a phenomena we have seen in numerous populations.

Despite these limitations, this is important.  In the words of Kevin Grumbach (one of the smartest people I know) on NPR (one of the best sources for information I know)

the new study confirms a belief that had long been suspected, but has rarely been proven: Coordinated care, led by a family doctor who is judicious about referring patients to specialists, leads to cost savings.

“It goes from a matter of philosophical preference to actually showing that this saves money,” Grumbach says.

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Remember back in the 1990s? Clintons were in the White House. Bushes wanted to be in the White House. Health care reform was fresh on everyone’s mind. As the French say, plus ça change, plus c’est la même chose, I guess.

The care delivery reform vehicle of the 1990s was to be Health Maintenance Organizations. Not particularly liked by physicians, these were groups of physicians and non-physician providers (hospitals and other health care entities)  who were tied by a common goal of delivering quality care at low cost. The problem is the definition of quality on the part of the HMO (low use of services that were not proven to be effective) was not the same as that of the patient (immediate access to services felt to be necessary by a prudent lay person).

In 1998, 3200 graduates of US medical schools went into Family Medicine.

The HMO movement eventually receded, as a consequence of consumer and physician revolt, although some remained (Kaiser and Group Health Puget Sound are the most well known from that era). For most Americans in the ensuing years, health care consumption was considered a matter of personal choice and, as Americans, we opted for convenience and technology. Insurance companies obliged us by limiting out-of-pocket cost. One could eat at the health care buffet and it only cost a couple of dollars.

As  physicians, we opted to provide these services in as efficient a manner as possible, with this efficiency being manifest as immediate access for folks with insurance. What happened was fairly predictable. Physician salaries skyrocketed. Health care inflation soared. Consumption was increased in areas of surgical procedures and high cost medications. Use of opiates such as Lortab dramatically increased.  If the analogy was one of restaurant dining, it is as if everyone with insurance in America got a free dining card with unlimited dessert.

For those without insurance (about 15% of adults under 65), care was not readily accessible unless they had significant cash to spend. Their dining card allowed them to stand by the dumpsters and wait for table scraps.

In 2004, only 1100 US grads went into Family Medicine.

Medical students in this country started talking about the ROAD to success, getting a position in a Radiology, Ophthalmology, Anesthesia, or Dermatology residency. Relatively easy work, really high pay. The pastry chefs of medicine.

American medical school in 2006 stood ready to respond to this new market reality, as encapsulated in this report from the era. They recommended a strategy of increasing enrollment in medical schools by 30%, supporting it with evidence of an aging workforce and the fact that physicians were not located where they needed to be (areas of shortage). In addition, they pointed to increased demand for more convenient access by an aging population.

If you fill the bucket to overflowing, they figured, student physicians could not help but go to places of need and select specialties of need. The market would sort things out. The aging population would get the doctors they needed, more Americans could catch the brass ring of “my son/daughter the doctor,” and we could continue to allow the market to set the tone. Or, to use the restaurant analogy, everyone who wants to be a pastry chef can be, and certainly someone will want to clean the dishes.

Did it work? We have increased the number of medical students from 14,000 in 2006 (the year the AAMC decided that the answer was to increase the number of doctors) to 22,500, an increase of 66%. The number of positions offered for training after medical school has increased from 24,000 to 27,000. Of those new US grads, the number electing to do radiology is up 200% and anesthesia is up 300%, Physical medicine and rehabilitation (one of the “new road” specialties) is up 300%. Family medicine, the specialty that goes to rural areas, the most rapidly aging specialty—how are we doing? Up 20%. The rest of the Family Medicine training slots? Filled by folks who went to medical school  in other countries

American students, it seems, are betting that we as a country are going to continue to allow people to eat unlimited dessert and they all want to be the pastry chef. So much for allowing our country’s workforce policy to be set by 25 year-olds. Heck of a way to run a restaurant.

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