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frank-cotham-he-s-too-uninsured-to-be-moved-cartoonThe last plenary I attended in Ottawa while at NAPCRG (pronounced Nap-Crag, the second A is invisible) was by David Williams. Entitled Building a Healthier Future: What Each of Us Can Do, it focused on disparities in our society with attention to the health related ones. One of the questions asked was whether the structural evidence of different health outcomes when measured exclusively by race was prima facie evidence of racism. A tool has been developed at Harvard (found here) to allow you to assess your contribution to the problem. Many of Dr Williams’ findings were covered in the series Unnatural Causes which I strongly encourage you to watch.

Dr Williams makes a pretty compelling argument for the continued existence of significant attitudinal differences regarding otherwise “equal” folks who differ only by skin color. He describes one study where resumes were identical except for a remote drug conviction were used by job seekers in a randomized fashion

It was a fairly dramatic study done in Milwaukee, Wisconsin where they sent black and white men, all with identical resumes to apply for 350 entry-level jobs. What this study found was that a black male with a clean record, no criminal record, was less likely to be offered a job than a white male with a felony conviction. So it was a dramatic example of – in the year 2004 – of the persistence of discrimination in American society.
He then goes on to cite another study where references to black and white folks in popular literature and the press were analyzed for modifier use. For example, the word most associated with black is “poor” and for white was “ambitious.” He was not against labels, per se, but pointed out that our cultural shortcuts almost certainly influence our clinical decisions. He cited, as evidence, a study done with physicians, several actors telling the same story, and the outcome (cath/no cath). Although that study was open to reanalysis, the evidence has consistently been that racism contributes to poor health outcomes.
Dr Williams suggested several systemic fixes (creating access and care opportunities independent of income) but also suggested we need to look inside ourselves and combat everyday, insidious prejudice. He suggested this is not easy. To do our part, we are going to ban the word “black” and “white” from the initial presentation of our residents when presenting a patient. If it is pertinent, it will be included in the risk factors but we are going to ask for occupation (This 33 y/o female brick mason) to force our residents to think beyond color.
I was even more struck by the need for us to change after reading the essay Dead Man Walking in this weeks New England Journal. Discussed in depth by my friend Josh Freeman, it is the very moving story of a man who died of a easily preventable and treatable-in-late-stages illness (colon cancer) as a consequence of his lack of insurance. This is particularly germane today as the Affordable Care Act is under fire from the left (OMG some people want to keep their sucky insurance and the website is broke) and the right (let the free market continue to rip people off and the website is broke because government sucks) following a rocky implementation (the website does suck). I have to say, though, that I am concerned that the ambivalence with the law isn’t about a website malfunction but is about a core belief that “sick people do it to themselves.” We as a country pay for almost 50% of births through Medicaid already, but we are fighting including birth control among Obamacare’s defined benefits (which some say will actually reduce costs) because of the misguided notion that contraception access unleashes the inner animal.
Most employer-based insurances are pooled risk. This means that I have to pay for Erin’s birth (even though I will never give birth) and she may have to pay for my prostate surgery (even though she will likely never have to have prostate care). Those of us with employer-based insurance have it because of the generosity of our boss or our spouses’ boss. The backlash from the efforts to bring affordable, accessible, and transparent coverage to those “other” Americans may have, as its explanation, that we think the word “uninsured” goes with the phrase “sucks-to-be-you.”

I interview approximately 60 prospective physicians for medical school over the course of the year and 40 physicians who are applying for the residency program. The pre-med students (almost all of whom are the age of my children) tend to have pretty good interview skills and are trying very hard to get into medical school (“I’ve wanted to be a doctor for as long as I can remember”) so the interviews tend to be somewhat predictable. Every so often I’ll get one who considers ObamaCare to be the devil’s work but for the most part they are good but non-controversial interviews.

The resident interviews are more fun for me. These are physicians-to-be who want to be in Family Medicine, want to see what our program has to offer, and have at least a passing understanding of the advantages our program might have over our competition. These are interviews with much more substance. The three on Friday were especially enjoyable.

One of the candidates was from Louisiana and grew up in a part of the state that my family is from as well. After a discussion regarding Cajun territory, the conversation veered towards Family Medicine and why he wanted to become a Family Physician. The candidate had done most of his clinical work in Lafayette, a regional clinical site where Family Medicine is taught. Like all good clinicians-to-be, on every clinical rotation the instructors not only focused on his clinical learning but also on his career choice. “Why Family Medicine” they would ask. He worried about the prestige factor as he was choosing a specialty. His decision was cemented, though, by a decision LSU made to place him with a rural Family Physician for an extended period. He saw this physician as a mentor and it was this relationship that cemented his decision to go into Family Medicine. He said “At the (teaching) hospital in Lafayette, the Family Medicine team is down here and the specialists are up here. Out in the community it is completely reversed.”

The second candidate was a student who had come for an interview the previous year. I remember the interview from last year very well. I was very surprised when I heard that this student selected Pediatrics instead of Family Medicine. She came back to re-interview because she said she had discovered her mistake and wanted to be a “Family Doc.” She said she was admitting a very young patient to the inpatient service for failure-to-thrive. It is uncommon for infants to fail to thrive and it is almost always a parenting problem and not an infant problem. In this case the mother seemed to the resident to be suffering from post-partum depression. Unfortunately, she was told that it was not her place to treat the depression, only the poorly fed infant. She said to me “I want to be able to treat the whole family.”

The third was a non-traditional candidate who was originally from Mobile. He left Mobile almost 18 years ago and after a roundabout life course ended up in medical school. He told me “I want to take care of people who are underserved in a holistic way and I want to do it here at home.” The fact that he was of African-American descent was meaningful. Traditionally we have had trouble attracting African-American candidates from Mobile into primary care, as have others, in part because there is a tradition in the community to encourage minority medical students to pursue limited specialty choices. I suspect this is a reminder of our racist past in this region, where African-American physicians were excluded from specialty training. Having Family Medicine seen as a “specialty” by this student is clearly a victory.

So three candidates and three conversations that give me hope for our specialty and the future of medicine.