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The Best Science Writing Online 2012
Showcasing more than fifty of the most provocative, original, and significant online essays from 2011, The Best Science Writing Online 2012 will change the way...
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The U.S. outspends all other industrial countries on health care, and yet we do not enjoy better health. Quite the opposite: an American baby born in 2006 can expect to live to 78—two years less than a baby born across the Canadian border. Out of the 30 major industrial countries, the U.S. ranks 28th in infant mortality. A large part of the gap in infant mortality can be traced to high infant death rates in certain populations—particularly African-Americans, who make up about 13 percent of the total population. In 2005 infant mortality for non-Hispanic blacks in the U.S. ran to 13.6 deaths per 1,000 live births compared with 5.76 deaths per 1,000 live births for non-Hispanic whites. The root causes of such disparities—which include differences in education, environment, prejudice and socioeconomic status—are notoriously intractable.
An easier fix may be under our noses: primary care. The idea is to have a clinician who knows your health history, will continue caring for you over the long term, and can recommend specialists and coordinate your treatment if you need to see them. Primary care can handle the health problems that most people have most of the time.
Research confirms the value of such care for the general population. The greatest benefits come to poor and socially disadvantaged groups, but they also extend to the well-to-do. Indeed, the need to strengthen primary care in the U.S.—making it more available—is one of the major tenets of the health reform laws that were enacted this past spring. A decline in availability in recent decades is a big reason why U.S. health has lagged behind that of so many other wealthy nations.
Primary care used to be the only game in town. In the late 19th century a family would rely on the same person (not always a doctor) to deliver babies, monitor and treat coughs and fevers, salve pain, comfort the dying, and assuage the grief of loss. Only the poor and the desperate went to hospitals. That changed in the 20th century, as advances in medical technology and in the education of physicians and nurses made hospitals safer places to be.
After World War II, Americans began associating medical progress with specialization. (In Europe, by contrast, the rebuilding effort led many nations to focus on general care—an emphasis that continues today.) The phrase “primary care” was invented in the U.S. during the 1960s in an effort by pediatricians and general practice physicians to resist the pull toward specialists. That effort failed; now only one third of U.S. physicians are primary care doctors—compared with about half in other industrial countries.
Primary care increases life span and decreases disease burden in part because it helps to prevent small problems, such as strep throat, from becoming big ones, such as a life-threatening infection of the heart. Having a regular clinician of that kind makes you a better patient because you trust the advice you receive and so are more likely to follow it; it also gives you access to someone who attends to the whole person, not just one body part. In addition, having someone to coordinate your care can be critical if you have multiple providers—as, for example, when you leave the hospital. (This coordination task is very different from the managed care trend of the 1990s that, under the guise of care coordination, turned many providers of primary care into gatekeepers who, in fact, mostly denied care.)
The many benefits of primary care show up in a range of research. Studies in the 1990s showed that those parts of the U.S. that had more primary care physicians for a given population had lower mortality rates for cancer, heart disease or stroke—three major causes of premature death—even after controlling for certain lifestyle factors (seat belt use, smoking rates) and demographic attributes (proportion of elderly people). By the 2000s researchers had linked access to such clinicians to lower rates of specific conditions, such as ruptured appendix (which requires emergency surgery) and low birth weight (which causes health problems in many infants).
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31 Comments
Add Commentas a retired physician and one of specialist(non-primary physician), I strongly feel this country needs major overhaul of medical field soon before we go bankrupt. government has to enforece minimum of 50%, even 90% reduction of medical specialty. physicians blame all medical legal system as a major cause of over-run of health care cost run-away train. when a patient admitted to then intensive care unit(ICU), it is routine to have five or six consultants from various specialists who ordered scores of unnecessary tests to impress their co-worker or party buddies and the waste is mind boggling when more than half of the patients in ICU don't even qualify to be in ICU. pay system to medical care need to be changed. buddy system in medical community is horrifying as well such as party goer, ethnic connection, fishing buddies etc which routinely inter-connect as a form of consultations.
Reply | Report Abuse | Link to thisAs a retired patient I agree wholeheartedly, but how can multimillionaire specialists be convinced to work as primary care physicians for 'minimum wage'?
Reply | Report Abuse | Link to thisFrom the article: "The root causes of such disparities—which include differences in education, environment, prejudice and socioeconomic status—are notoriously intractable."
Reply | Report Abuse | Link to thisI believe the author forgot alcohol and drug abuse, smoking and violent deaths. These factors likely predominate.
And where is the proof for your comment? Again, people spouting off their 'beliefs' and hoping they are accurate.
Reply | Report Abuse | Link to thisYou have made my point exactly. The author, writing in a supposedly scientific magazine, has made a sweeping assertion which is totally without any basis and has ignored some important factors. I'm not the one writing the article, just someone who has read it and feels there are glaring errors of omission.
Reply | Report Abuse | Link to thisThe author clearly states the study was controlled for certain lifestyle factors, with smoking being specifically stated. Now who's making sweeping assertions without any basis?
Reply | Report Abuse | Link to thisI find this article extremely interesting and agree entirely. Access to care is vital to good health and longevity. Primary care providers need to be at the forefront of the new healthcare changes of 2010. The estimated new 32 million patients must be handled by some form of primary care provider for not many lay persons know when they must see a genitourinary specialist, neurologist or a vascular surgeon. It is up to the provider to help navigate these individuals through the healthcare labyrinth. In addition, if these individuals are properly and consistently taken cared for most of these specialist visits will never be necessary. As a chiropractor I see these very forces tugging on my profession. The state of New Mexico has added an advance practices specialty to chiropractors in their state in order to address this primary care shortage. These chiropractors will be able to write prescriptions and inject medications. There will obviously be additional training for these individuals. The Council on Chiropractic Education (CCE) is also trying to delete the "without the use of drugs and surgery" provision in our definition as well as changing our D.C. (doctor of chiropractic) degree to a D.C.M (doctor of chiropractic medicine) degree. It seems that all these changes within the profession are setting chiropractors up to fill this deficit in primary care. Chiropractors are already portal of entry providers and you can see a chiropractor without a referral from a M.D. The chiropractor can refer you to a neurologist, orthopedist or an internist if your ailment falls outside of his/her scope and should do so. The chiropractic profession is torn by these new proposals with some for and others strongly against these changes. In my opinion the need for primary care providers will be so great that many states and associations will lean towards filling the needs of the people by allowing these advance practice degrees.
Reply | Report Abuse | Link to thisI also am a semi-retired specialist physician, and I can say that every assertion or conclusion contained in comment number one is "not even wrong". Those of you who don't recognize this quote will get a kick out of it when you look it up!
Reply | Report Abuse | Link to thisThe "problem" with medicine is complexity itself. And since there are a number of fine books on this subject available now I will simply recommend that all the social engineers should read up before trying any of their grand schemes on us. Hint:the schemes won't work.
Here is another assertion: Healthcare has little to nothing to do with longevity. That's right. The main factors affecting longevity are:
1. Clean chlorinated water (civil engineers)
2. Adequate food (farmers/agricultural chemists/agronomists)
3. Window screens and/or living in a malaria free zone
4. Vaccines to childhood diseases (pharma)
5. Antibiotics (pharma)
6. healthy lifestyle factors
I guarantee you that nothing but availability of those 6 factors accounts for >90% of the first world's population longevity gains.
As to "disparities" in health - one would find out very quickly that all the usual victim suspects would be the sickest and most downtrodden if everyone were simply forbidden to see the Doctor.
selforganized...i think the usa does a good job at 1 thru 5...just wonder if number 6 can account for our ranking so low in the developed countries....
Reply | Report Abuse | Link to thisRE:Self-organized, "Those of you who don't recognize this quote will get a kick out of it..."
Reply | Report Abuse | Link to thisI indeed got a kick out of it. THANKS!
In my experience with cardiologists and gastroenterologists is that many have very comfortable practices in which they provide routine monitoring of patients' conditions and occasionally perform critical major surgeries to save lives.
Reply | Report Abuse | Link to thisNow, in my case, about three years ago I spent three months near death while my gastroenterologist tested and retested as he debated with a series of two cardiologist whether my unusual critical symptoms were produced by my identified heart condition or a problem with my liver. My third cardiologist prescribed the standard medication used to treat my heart condition and my symptoms were immediately and 'miraculously' relieved. Shortly thereafter my gastroenterologist (perhaps inappropriately, except considering what we had been through together) confided in me that "the last time I saw you I looked like I was near death: I was."
So I certainly appreciate my third cardiologist, and appreciate the value of having a specialist who understand his particular patients' conditions. I don't wish to have to find another cardiologist who can recognize my condition if/when it reoccurs.
On the other hand, as I mentioned, I now see my cardiologist every 3 months, receiving an EKG along with an annual echocardiogram, as he monitors my now stable heart condition and the status of potentially dangerous medication levels.
I appreciate my current cardiologist, but it occurs to me that the maintenance of my conditions might could be much more economically performed by a general practitioner with perhaps an annual review of my files by my cardiologist. Frankly, I think I would know if I was having a recurrence of acute heart symptoms, and would not wait for my three month checkup if I was having problems.
However, the medical community seems to be upside down. No competent medical doctor would chose to earn much less supporting many more patients in less comfortable settings subject to the same legal issues as specialists. As a result it seems to me at least that there are not enough GPs while there may be a glut of millionaire specialists. I think this was the message of this article and I agree wholeheartedly. However, short of socializing medicine and paying doctors a standard wage I can't think of a cure for the current condition of the medical industry.
You really make it seem so easy with your presentation but I find this topic to be really something which I think I would never understand. It seems too complicated and very broad for me. I am looking forward for your next post, I will try to get the hang of it....<a href="http://www.evirtualservices.com/seo_service%20.aspx">Website Promotion</a>
Reply | Report Abuse | Link to thisThe main reason people in this country are in worse health than in other industrialized countries has more to do with the data on the graph on page 104 than a lack of primary care docs. Americans are just too fat, and don't care. More primary care docs, or NPs, or PAs, will have little to no effect on the obesity epidemic. Taxing sodas and foods like Twinkees, as was shown with cigarette taxes, will ultimately be much more effective in the long run.
Reply | Report Abuse | Link to thisFor those who keep making rude comments about "rich specialists," I would like to point out that the vast majority of primary care docs who see patients in an office setting in this country no longer admit to hospitals, thus, they are not on night or weekend call. Call most Family Practioners' telephones after 7 pm and you will get a recording to go to your closest Emergency Room if you need immediate treatment. And guess who they call once the patient is in the ER? The "overpaid" specialist! I am 54 Y/O and still on call 7 nights a month. I go in at 2am to admit heart failure, chest pain, hypertension, and atrial fibrillation when the Family Practioner is in bed asleep. And, of course, I get to work the next day too. Something non medical people don't realize, including the author of this rather lopsided poorly researched article, is that a cardiologist makes just as much for a specific level of office visit/hospital admission/hosptial visit on a patient as a primary care doc. Charges are based off documentation of level of service, regardless of specialty. We make more because we do procedures which took years to learn and also work more hours.
And does anyone else see the irony in citing a primary care doc (Dr. O'Malley) who would rather do research on "Health Care System Change" than actually practice primary care medicine full time?
shockdoc:
Reply | Report Abuse | Link to this"Charges are based off documentation of level of service, regardless of specialty."
I was presuming higher charges for cardiologist check-ups - I agree in this case there'd be no financial benefit for GP heart exams. Thanks for the correction.
I am actually stunned that Christine Gorman did not even mention the largest strictly primary care organizations in this country. They are The American Academy of Family Physicians, a group that has existed since the 1940's, and the specialty Board, the American Board of Family Medicine (which is recognized by the American Board of Medical Specialties). Family practice is the specialty in the US that is devoted solely to primary care. Other specialties have been forced to perform the role of primary caretaker through the years for a number of reasons, but all these specialists historically felt much more comfortable in the consultant role. Even Pediatricians are consultants in a well functioning primary care setting.
Reply | Report Abuse | Link to thisBut equally embarrassing is the situation that Family Practice has not promoted it's unique position better to the general public.
I ask Christine Gorman to take a look at the websites www.aafp.org and www.abfp.org. I look forward to her response.
Thank you for your hard work and long hours. I hope that you feel comfortable enough with your grueling work schedule that you can continue to provide excellent care for your patients without being overwhelmed with resentment. Perhaps it's time to take on a partner to share that call schedule.
Reply | Report Abuse | Link to thisI am a family physician who greatly appreciates the input and service of my consultants. I feel a partnership with them in the care of my patients. I am sure you are aware of the development by both government and industry to develop Accountable Care Organizations. In partnership with Hospitals and other institutions, every sub-specialty will be needed by these organizations while the backbone of care will be done by family physicians and their associated mid-level providers. The hope is that patient care will excel because of the practice enhancing communication and cooperation. I predict the satisfaction level of practitioners will rise over time. No doubt there will need to be some give and take during implementation. Best of luck as you cultivate those relationships that will be valuable in the future.
First of all, the comments seem to accurately reflect the state of our healthcare: Mixed reviews, support for more primary care, and the inevitable health promotion for penis enlargement in one of the comments.
Reply | Report Abuse | Link to thisThat aside, I do take exception to the author's using the uncommon occurrence of a complication of a cardiac catheterization as part of her argument against specialty care. First of all, the procedure benefits many many more people and leads to lifesaving and symptom improving treatments in many many more people (bypass surgery, angioplasty or even confirmation that all is NOT bad). The author could have also mentioned that of late we in the USA are moving away from the groin approach which is the source of her reference and to the wrist where bleeding is a nonfactor! That is science, which after all, is the purpose of this journal. And yes, of course, I am a cardiologist. I do agree however with the gist, namely more primary care is and would be a good thing.
Sorry, of the three, only bypass has shown to increase life expectancy after the procedure and the chemical eluting stents have shown a marked increase in mortality after placement. 5 years ago, BXBS was paying doctors $900 for an angioplasty but $5,000 if as stent was placed, what do you suppose the doc was going to do if it were close? Don't confuse technology and health. Most of what a FP doc can do can be safely and adequately done by a NP or FP (well baby checks, giving antibiotics for a viral bronchitis, med checks for BP or asthma, etc). Pay doc's for keeping people healthy would help a bunch and keep drug companies away from health care policy before every teenager is on lipitor. If you want FP's, give them cheaper medical school tuition. The fact is the decrease in CV disease still doesn't have an answer as to why, but because something happens coincident to it, doesn't make it the cause.
Reply | Report Abuse | Link to thisNice job of highlighting a problem, why not discuss the solution.
Reply | Report Abuse | Link to thisPrimary physicians don't get paid enough in comparison to specialists, and they have a harder job. If everyone paid for their own care out of pocket or their Healthcare Savings Accounts they would want to go to primary physicians and avoid specialists if possible. Specialists would lower their fees and primary doctors could raise theirs a little. Institutional providers would also compete to lower fees.
Healthcare Savings Accounts are available now. Start one and save money, get all your friends to do the same and save the country.
Oh my. Misinformation of the worst degree sir/madam. I wish you were correct with your numbers and your clinical points but that, like so much else, is "truthiness" at its best.
Reply | Report Abuse | Link to thisthere is evidence that ihk888 (the first post here) is right on track. and dr roberto vargus is also right. the medical/pharmaceutical/insurance cartel has a vested interest in maintaining the status quo. there are chiropractors, accupuncturists, naturopathic doctors who are especially trained in treating most common ailments and who are well versed in proper referral to medical primary care and medical specialists.
Reply | Report Abuse | Link to thisthe medical society has spent years maintaining an artificial shortage of 'doctors' and in actually maintaining a conspiresy to 'contain and eliminate competing professionals; (see the 1980's federal antitrust suit where the ama, ass. of hospitals, radiologists, and orthopedists were convicted of antitrust in trying to contain and eliminate chiropractic). actually the best and most economical and most satisfying primary care is by these competing professionals. (canadian, british, new zealand, and swedish national studies).
I live in an area where the economy is stagnant, population is decreasing and many commercial buildings stand empty. Yet in every suburb new medical offices or entire "medical campuses" are popping up, many with quite elegant architecture.
Reply | Report Abuse | Link to thisSo where do all the new patients come from in this shrinking area? That's just it; there are not more patients just more referrals and more appointments with more specialists for each patient. Kind of like doctor's office pinball - the patient is the ball and each bumper strike rings another cash register bell.
I, for one, do not mind paying more to my general practitioner if he is willing and competent to handle my particular ailment right there. In my experience, the benefit of a specialist's expertise is often negated by that specialist's lack of familiarity with my history, narrowness of scope and inefficient sharing of information between the GP's and specialist's offices (the latter being a particular problem between HMO's). In most cases, I prefer a GP who takes time to reason deductively and consider my condition more scientifically than a hurried expert looking from just one angle.
If many of us want to see more health care administered by our general practitioners, perhaps the first step may be to let them hear this directly from us patients.
My blood boils everytime the US infant mortality statistics are compared with those from other nations. It is a fact that the US includes premature babies (and extremely premature babies) and late term stillbirths in our mortality count, whereas many other countries do not. As a result, our higher number includes these additional deaths. This is a comparison between apples and oranges. Calling these statistics comparable, and using this to promote the view that Americans pay too much for not-so-high quality care, is a liberal talking point to denigrate the excellent healthcare most of our citizens obtain.
Reply | Report Abuse | Link to thisI have no criticism of the premise of the article that primary care availability will improve overall health in this country. Ms. Gorman, however, did leave out one important cause of racial disparity. In addition to differences in education, environment, prejudice and socio-economics, there is a racial (ie genetic) differences. As we learn more about genomics and its application to individuals, we might be able, one day, to level the playing field on this matter. I also would say that a major factor in health is compliance with one's doctors' advice. It will take a shift of cultural paradigms to make this happen, something the government should be promoting.
Lastly, primary care doctors are in a bind, and the PPACA is actually going to make it worse for the country and the 32 million or so people who will be better able to afford health insurance. Medicare and Medicaid reimbursements are ridiculously low, so much so that many physicians cannot gross enough to pay their staff, rent, and overhead, much less take home a decent salary. We have seen the trend that commercial health insurers follow Medicare in their levels of reimbursements. If this trend continues under PPACA, many primary care doctors will have to close their doors, and then access will be worse than before. Already, in my area, it is very difficult to find a doctor to take Medicaid. Insurers, including M & M, must pay for care at a rate that encourages physicians to choose, and continue to work, in primary care.
Check out the latest "Health Affairs" for more data on this topic. Researchers at Columbia compared US to European populations on smoking, obesity, population diversity, etc and found these factors still don't account for the lagging health gains in the US. Indeed, US population smokes less, on the whole, than the European one. The investigators kept coming back to overspecialization and fragmentation of the medical field as a primary cause for US falling behind. http://bit.ly/9OHnTx
Reply | Report Abuse | Link to thisRe international infant mortality rates IMR. Take a look at the CDC's analysis of differences between the US and European countries on infant mortality. http://www.cdc.gov/nchs/data/databriefs/db23.htm
Reply | Report Abuse | Link to thisIn short, the US is not the only country that reports all live births, no matter gestational age or weight. So do the European countries of Austria, Denmark, England and Wales, Finland, Germany, Hungary, Italy, Northern Ireland, Portugal, Scotland, Slovak Republic, Spain and Sweden. The biggest reason for the difference in IMR is the number of premature births in the US--which is quite high by any measure. The CDC concludes that whether you include live births under 500 grams in the statistics makes little difference in explaining why the US still lags other countries.
For those skeptics who believe Ms. Gorman's thesis about the value of primary care is "not even wrong" (not subject to proof or disproof by evidence), please go to Google Scholar at http://scholar.google.com/ and search for Starfield, Barbara. Dr. Starfield's publications showing the evidence go back a few decades. The "fluff" in this subject area belongs to the offhand skeptics, not to the followers of the evidence.
Reply | Report Abuse | Link to thisI agree that expanding primary care may be the best way to resolve chronic disparities in health care outcomes. I have a “modest proposal” for implementation that should satisfy both conservatives (who believe that health care is a market commodity) and liberals (who believe that all people deserve equal health outcomes). My proposal is based on three observations: (1) primary care providers are generalist specialists (and, vice versa, other specialists’ expertise is limited to a part of the body - let’s call this “partialist” care), (2) low socioeconomic status (SES) is a major determinant of poor health outcomes (and, vice versa, high SES is associated with better health outcomes), and (3) primary specialist care is associated with better population health outcomes (and, vice versa, exclusively partialist care is associated with poorer population health outcomes). I therefore suggest the following two-tiered US health care system: Let the poor have primary care-based universal access; and let the rich shop for exclusive partialist care on the open market. This should optimize health outcomes for the poor, and minimize health outcomes for the rich, thus ensuring equality.
Reply | Report Abuse | Link to thisWho can argue with this?
I agree that expanding primary care may be the best way to resolve chronic disparities in health care outcomes. I have a “modest proposal” for implementation that should satisfy both conservatives (who believe that health care is a market commodity) and liberals (who believe that all people deserve equal health outcomes). My proposal is based on three observations: (1) primary care providers are generalist specialists (and, vice versa, other specialists’ expertise is limited to a part of the body - let’s call this “partialist” care), (2) low socioeconomic status (SES) is a major determinant of poor health outcomes (and, vice versa, high SES is associated with better health outcomes), and (3) primary specialist care is associated with better population health outcomes (and, vice versa, exclusively partialist care is associated with poorer population health outcomes). I therefore suggest the following two-tiered US health care system: Let the poor have primary care-based universal access; and let the rich shop for exclusive partialist care on the open market. This should optimize health outcomes for the poor, and minimize health outcomes for the rich, thus ensuring equality.
Reply | Report Abuse | Link to thisWho can argue with this?
Oh puhleeze. At least base your arguments on evidence, not ideology. The effect of socioeconomic status goes both ways (being sick can also make you poor). I didn't say that expanding primary care is the best way to deal with chronic health disparities. Rather, it is often overlooked and may produce better results (for both rich and poor) than most people realize.
Reply | Report Abuse | Link to thisI believe you misunderstood the intent of my satirical "modest proposal" a la Jonathan Swift:
Reply | Report Abuse | Link to thishttp://en.wikipedia.org/wiki/A_Modest_Proposal
I happen to be a supporter of primary health care, and each of the three observations I made are evidence-based.
Okay dlhahn, I missed the literary reference (even though I studied Swift's "Modest Proposal" to eat Irish children as a way of dealing with famine when I was in college). But in my defense, Swift's satire was a lot more obvious than yours. :)
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