Friday, May 29, 2009

Do internists have confidence in their own training when compared to NPs?

Last week, ACP President Joseph W. Stubbs, MD, FACP, joined with other
primary care physician and nursing organizations to endorse the Preserving Patient Access to Primary Care Act, H.R. 2350, introduce by Rep. Allyson Schwartz (D-PA).

H.R. 2350 now has more than 100 co-sponsors in the House of Representatives, and Senator Maria Cantwell (D-WA) plans to introduce a companion bill in the Senate. In a press release issued yesterday to announce her plans, Senator Cantwell quotes ACP: "According to a report issued by the American College of Physicians, 'primary care, the backbone of the nation's health care system, is at grave risk of collapse.'"

Unlike other bills that address the primary care crisis in a piecemeal fashion, the Preserving Patient Access to Primary Care Act addresses the issue in a comprehensive way. It will fund more primary care training programs through the National Health Service Corps and Title VII primary care programs, provide scholarships and loan repayment for primary care physicians and other primary care professionals in critical shortage facilities or geographic areas, break down regulatory barriers to training medical students and resident in primary care clinics; increase primary care Graduate Medical Education slots; raise Medicare payments for primary care; pay primary care physicians for care coordination; allow savings in Medicare Part A associated with primary care to be put back into primary care; and give primary care practices the option of receiving additional care coordination payments for becoming Patient Centered Medical Homes (PCMHs).

Yet, despite all of what the bill does for primary care physicians, its treatment of advance practice nurse is a sticking point for some. It would allow NP-led practices to qualify as Medicare PCMHs, within the limits of their state licenses and if they meet the same standards as physician-led practices.

ACP policy recognizes the important contributions nurse practitioners make to primary care but makes the case that the training and skills of each profession are complimentary, not equivalent. In the PCMH model, "care for patients is best served by a multidisciplinary team where the clinical team is led by a physician" says ACP, but "given the call for testing different models of the PCMH, ACP believes that PCMH demonstration projects that include evaluation of physician-led PCMHs could also test the effectiveness of nurse practitioner-led PCMH practices in accord with existing state practice acts and consistent [with meeting the same eligibility and qualification standards as physician-led practices]."

H.R. 2350 goes beyond ACP policy, in that it would allow NP-led practices to qualify as PCMHs, not just for demonstration projects as proposed by ACP, but under a permanent Medicare PCMH benefit, starting in 2011. ACP's top physician leadership made the judgment that H.R. 2350 merits the College's strong endorsement, even with the more expansive NP language, since perhaps 95 percent of the bill is based on ACP policy.

In the days since ACP endorsed the bill, some ACP members have expressed concern that ACP's support will further blur the lines between general internal medicine and advanced practice nursing, making it even harder to persuade young people to go through the extra years of training to become a physician But if internists truly believe in the value of their training, shouldn't they also be confident that they will be able to show such value in a medical home model where the outcomes of care can be measured?

My bet is that the PCMH will help support the value of internal medicine training by providing a consistent way to measure the outcomes, effectiveness and efficiency of care provided by internists, even when compared to nursing-led PCMHs that operate within the limits of their licenses and against the same evaluation benchmarks. And, as I've written about before, our chances of getting primary care legislation could be irreparably weakened if physicians and nurses are viewed as being in competition with each other, rather than as allies on the need for more of both.

Today's question: Do you believe that internists will be able to demonstrate the value of internal medicine training, even when compared to NP-led medical homes using the same evaluation benchmarks?

Tuesday, May 26, 2009

Are physicians truly on board with health care reform?

The Portland (Oregon) Register-Guard reports that physicians "are as eager as their patients" to reform health care, with surveys revealing "that overwhelming numbers of physicians resent the current crazy patchwork health care system, which fixes their reimbursements, regulates and too often denies patient care, and piles physicians with paperwork so unending and from so many directions that the average doctor has little time left over to challenge the status quo." The authors write, approvingly, that the American College of Physicians is "the medical organization perhaps most vocal in support of universal health care coverage."

Most of the physicians I know are hugely dissatisfied with status quo. ACP has channeled such frustrations into a powerful call for a better health care system that provides all Americans with access to affordable coverage and to a primary care physician.

Still, I wonder if physicians will be on board with health care reform when Congress begins producing the details of legislation. My sense is that most physicians urgently want health care reform and believe strongly that all Americans should have affordable health coverage. But they worry that instead of improving "the current crazy patchwork health system, which fixes their reimbursements, regulates and too often denies patient care," health care reform will be more of the same, or worse.

Physicians' hearts and minds are still very much in play, and it would be a huge mistake for President Obama and Congress to take them for granted. Democratic and Republican pollsters alike tell us that physicians' views on health care reform could be decisive in determining if the public will be behind the effort, because voters are much less likely to support health care reform if told that it will result in the "government" taking decisions away from their own doctors.

There are two specific questions that I think could make or break health care reform with physicians:

1. Will health reform pay them fairly for their services? No, physicians don't care only care about money, but they do expect to be paid a fair rate. They will be much less likely to support health care reform if it fails to put an end to the annual cycle of Medicare payment cuts caused by the Sustainable Growth Rate (SGR) formula. Primary care physicians may turn away from health care reform if it offers only a token increase in payments, instead of re-structuring payments to make primary care a competitive career option. Other specialists may balk if increased pay for primary care comes solely out of their pockets. Physicians of all stripes are less likely to support a bill that includes a "public plan" option if the public plan would pay them based on these same flawed Medicare payment rates, and drive other payers to do the same.

2. Will health care reform reduce the administrative burdens and paperwork requirements that drive physicians mad? Physicians will wildly embrace health care reform that streamlines billings and reduces the hassles associated with health plan interactions and second-guessing of clinical decisions. But health care reform that adds more pre-authorization requirements, second-guessing and paperwork, all in the name of controlling costs, will drive doctors away in droves.

If President Obama and Congress want the support of physicians, they will produce health care reform that pays physicians fairly for their services, restructures payments to support primary care doctors, reduces hassles and second-guessing, and yes, provides all Americans with access to affordable health coverage. I think they will also be more likely to have the support of the general public, which pollsters say will be taking their cues from doctors as they make up their own minds.

Today's question: What could make doctors turn for or against health care reform?

Thursday, May 21, 2009

What a difference a week makes!

I don't typically use this blog to advertise what ACP is doing for its members, since this blog is about stimulating discussion of key health policy issues, not marketing ACP membership. Today, I am going to make an exception, because I think those of you who are ACP members need to know about the extraordinary things that this organization is doing for you. Please read this excerpt of a note I sent this morning to my ACP staff colleagues in Washington:

"I want to thank everyone for the incredible amount of work that each of you contributed to ACP's effectiveness over this past week. We just concluded what was certainly the most successful and effective Leadership Day, generating an extraordinary amount of excitement among our attendees and inspiring a new generation of medical students and associates. It was evident that they felt that ACP's priorities had risen to the top of the national priority list and that they were making a difference by being here.

We worked diligently with Rep. Allyson Schwartz on introduction of a comprehensive bill to support general internal medicine and primary care that was based directly on ACP policy. This bill was officially unveiled yesterday and received endorsement from the other primary care physician organizations, AAMC, and major nursing organizations. We worked closely with her office on preparations for yesterday's press conference. The bill has nearly 100 co-sponsors in the House of Representatives, and Senator Maria Cantwell's staff has told us that she will be introducing a Senate version of the same bill within days.

As all of this was going on, we developed joint recommendations on payment reform with the AAFP and AOA that have been presented to the Senate Finance Committee. We provided detailed comments to the Senate Finance Committee under a very quick deadline on payment and delivery system reform. We prepared for and provided staff support for two major ACP policy committees, our Health and Public Policy Committees and the Medical Service Committee, and helped them move forward on several new ACP position papers that will enable us to continue to influence the policy debate on health reform. We have drafted analyses and responses to two other Senate Finance Committee options papers, again with a very short period of time to meet their deadlines, which need to go out to them within days.

I wish I could tell you that we can all sit back and enjoy the fruits of our labors, but the pace of legislative activity is such (the major Senate committees expect to pass major health care reform legislation through their committees in June) that we will continue to be challenged to influence the process at every stage of activity, but I have every confidence that we are up to the task. Each of you, including those of you who were not directly involved in these specific efforts but contributed in your own ways, should share the enormous pride I have in the work of the Washington office."

It is not just the ACP staff that made all of this happen: my pride and appreciation also goes to 300 practicing internists and 100 medical students and IM residents who came to Washington this week to learn about the issues and to take our message to Congress; to the visionary leadership of ACP, which has given the policy direction and priorities needed to be viewed by policymakers as credible and effective advocates for better patient care; and to the ACP membership, which has reached an all-time high of 128,000 internal medicine physicians and medical student members - the life-blood of the organization.

I know that ACP still has our work cut out for us; there are no assurances that the progress we've made will materialize into the kinds of health care reforms needed by internists and their patients. When you read this, I hope you are able to share a bit in the spirit of energized optimism that pervaded ACP's Leadership Day on Capitol Hill, and that your day may be brightened as a result.

Today's question: Do you think most ACP members are aware of what the organization is doing for them? If not, how do we get the message out?

Wednesday, May 20, 2009

"This is the start of making primary care cool again"

So says Dr. Ari Silver-Isenstadt, a young pediatrician associated with the National Physicians Alliance. He was one of a broad spectrum of organizations - representing physicians, nurses, nurse-practitioners, and medical colleges - that joined today with Rep. Schwartz to announce support for the Preserving Patient Access to Primary Care of 2009, H.R. 2350.

"It is critical that comprehensive reforms to halt the crisis in access to primary care be included in any legislation to expand health insurance coverage," said ACP President Joseph W. Stubbs, in announcing the ACP's support for the bill. "Providing everyone with affordable coverage is essential, but coverage alone doesn't guarantee access if there aren't enough primary care physicians to take care of patients. And without primary care, the costs of covering everyone will be much higher and the outcomes much poorer."

Earlier in the day, Rep. Schwartz spoke to the 400 plus attendees of ACP's Leadership Day on Capitol Hill about her efforts to support primary care. She noted that the bill already has the support of nearly 100 members of Congress, and she asked for ACP's help in lining up more supporters. We also learned that within days, Senator Maria Cantwell (D-WA) will be introducing the bill in the U.S. Senate.

Would the Preserving Patient Access to Primary Care Act really make primary care cool again? My teenage girls would tell you I am the last person to know what's cool, but I think it would be cool if the U.S. Congress officially declared that primary care is essential to a better performing health care system.

It would be cool if Medicare started paying primary care doctors more, and giving them credit for helping to keep people out of the hospital. It would be cool if medical students who go into primary care could graduate without debt. It would be cool if primary care physicians could be compensated for providing patient-centered care through a medical home. It would be cool to reduce the cost barriers to preventive services. And how cool would it be to reduce the paperwork hassles associated with Medicare drug formularies and claims adjudication?

All these, and more, are included in the Preserving Patient Access to Primary Care Act of 2009.

I know that some will not agree with me on this, but I also think it is cool that the Preserving Patient Access to Primary Care Act has the support of both doctors and nurses. Rep. Schwartz believes (and the evidence supports this) that the United States needs more primary care internists, family physicians and pediatricians, and also needs more nurse-practitioners and physician assistants.

I fully understand that primary care physicians and NPs don't always see eye-to-eye on each one's respective roles in primary care or in the medical home. But as I have written about on other occasions, a political split between NPs and primary care physicians could be fatal to getting meaningful primary care legislation enacted. Wouldn't this be the most un-cool outcome of all for the patients who desperately need access to primary care?

Today's question: What do you think needs to be done to make primary care cool (again)?

Tuesday, May 19, 2009

Where have all the medical students gone?

I write this blog from a briefing for medical students and internal medicine residents attending ACP's Leadership Day on Capitol Hill. They are learning what they can do, with their colleagues in internal medicine practice, to get Congress to support ACP's priorities:

Ensure that all Americans will have access to affordable health insurance coverage and access to a general internist or other primary care physician.

As I look around the room, I am encouraged that so many energetic and optimistic young people - more than 100 in all - took time out of their studies and residency programs to learn about health policy. No one can make a better case for health care reform than the next generation of physicians.

Yet, if asked a few years hence, "Where have all the medical students gone?" it won't be general internal medicine, family medicine, or pediatrics. That is, unless something big happens to make primary care more appealing.

Right now, about one out of three doctors in the U.S. are in primary care specialties, compared to the 50/50 mix found in other countries with higher performing health care systems. This would be bad enough, but unless next year's graduating class (and the ones that follow) are given a reason to look more favorably on primary care, fewer than one in five physicians will be in primary care. We know this because only 17% of U.S medical school graduates in 2008 expressed a desire to go into primary care, an all time low. We also know from studies that without more primary care physicians, the American people will experience higher cost of care and lower quality.

I don't write this to put a damper on the eagerness of the medical students in this room. The fact that so few of them are thinking about going into primary care isn't a statement about them, but a statement about us, as a nation. If we really believe that patients should have a personal physician who is trained in comprehensive and longitudinal care, then we would show this to our medical students. We would pay primary care doctors better, reduce the paperwork and hassles (see yesterday's blog) associated with primary care, pay off their debt, and expose them to the joys of primary care in their training.

Tomorrow, I will be writing about a major new piece of legislation to be unveiled by Rep. Allyson Schwartz (D-PA) that will offer a comprehensive plan to realign federal health policy to produce more primary care physicians.

If this bill were enacted into law, as ACP hopes it will, we may soon be able to report that medical students are going into general internal medicine, family medicine and pediatrics. And the country will be better off as a result.

Today's question: Do you think that medical students' lack of interest in primary care is something that can be remedied by the federal government?

Monday, May 18, 2009

How much health care might be purchased with the $31 billion spent annually by physicians on health plan interactions?

I will be blogging this week from ACP's Leadership Day on Capitol Hill, which is ACP's annual event when internists from around the U.S. come to Washington to meet with Congress. As Congress begins to draft legislation to meet its promise to produce comprehensive health reform legislation by the August, there is no better time for internists to make their case to elected lawmakers.

One issue - which is not getting the amount of attention it should - is the enormous amount of money and time physicians spend on health plan interactions.

The issue, if it comes up at all, is usually in arguments over single payer health insurers. Single payer advocates point out, correctly, that the U.S. spends much more on health care administration than most other countries. This is a macro-level debate, though, that doesn't really tell us much about how much it costs physicians, at the micro- and practice-level, to comply with health plans' rules relating to drug formularies, pre-authorizations, retrospective review, et al. One can imagine, for instance, a U.S. style single payer plan that imposes enormous administrative costs on physician practices (think Medicare Part D).

Late last week, the health policy journal Health Affairs released a web exclusive study on what it costs physicians to interact with health insurance plans. These are among the sobering findings.

Physicians reported spending almost a half hour each day, three hours each week, and three weeks per year, interacting with health plans. Primary care physicians spend significantly more time (3.5 hours weekly) than other medical specialists (2.6 hours) or surgical specialists (2.1 hours). Clerical staff spend 7.2 hours per physician each day, for a total of 35.9 hours per week. RN/MA/LPNs employed by physicians spend 19.1 hours per physician per week.

Solo or two-person practices spend 3.5 hours weekly interacting with health plans, significantly more than practices with 10 or more physicians. Physicians spend more time dealing with formularies than any other heath plan interactions.

Translated into dollars, the authors estimate that the national time cost to practices of interactions with health plans is a stunning $23 billion to $31 billion, or $68, 274 per physician, per year. Primary care practices spend $64,859 annually per physician - "nearly one-third of the income plus benefits of the average primary care physician." They note that the "interactions that generate these costs may produce benefits as well."

Maybe so, but the study doesn't address a key policy question: how much health care could be bought if the U.S. were to reduce the amount of time and money that physicians and their staff spend on health plan interactions? Let's say for discussion purposes we could cut in half the average of $68,000 annually and 3.5 hours per week that physicians spend on health plan interactions (even leaving out, for now, the time that their employees spend on these tasks)?

This could be enough to pay the annual health premiums for three families, multiplied by every practicing physician in the U.S, based on average premium cost of $12,000 per family. It would allow each primary care physician to see another four or five patients per week, thereby reducing wait times and easing the primary care shortage. It would increase primary care physicians' incomes by an equivalent of $32,000 per year - more than many of the ideas for increasing primary care pay being considered by Congress.

It would reduce one of the chief frustrations of primary care physicians, which gets communicated down to young people as a reason to stay away from the field. As Star Trek's iconic Dr. "Bones" McCoy might have said, "I'm a doctor, not a paper-pusher!"

Yet I think there is a real risk that Congress not only won't reduce the paperwork on doctors, but add more pre-authorizations and medical review requirements, all in the name of cutting costs.

Today's questions: Does the Health Affairs study accurately reflect your experiences with health plan interactions? What would you recommend be done to lower the costs of health plan interactions, and prevent Congress from adding new ones?

Thursday, May 14, 2009

Should ACP survey its members before taking controversial stands?

Health Affairs has been hosting an ongoing debate about the Patient Centered Medical Home, initiated by Caroline Poplin, MD, a fellow of the ACP. Dr. Poplin has been highly critical of the PCMH and ACP's support for the model. In a posting co-authored by me and my colleague, Michael Barr, MD, FACP, we tried to respond to Dr. Poplin's concerns. Dr. Poplin subsequently responded to our comments, and among other things, posed the following question:

"Finally, I have a question for the ACP. I have been a loyal member since I passed my Boards, and a Fellow for a good part of that. Why didn't the ACP canvass its membership, general internists in particular, before adopting such an important, controversial proposal?"

First, let me say that ACP values the loyalty of ACP members like Dr. Poplin, and we welcome debate about our positions (which is the main reason why I write this blog). I applaud Dr. Poplin for expressing her concerns about the PCMH, even though critical of ACP's positions.

But to her suggestion that ACP should canvass its membership before adopting positions on controversial issues ... well, we don't ... and I am glad of that. As any pollster would tell you, opinion polls provide some useful information, but cannot substitute for a deliberative discussion of policy options based on review of the evidence and considering the diverse views of those we represent.

The more complex an issue is, like the PCMH, the less reliable a canvass of opinion will be. Polls can be manipulated to tell the surveyor what they want to hear. For example, if ACP was to ask our members, "Would you like to be paid for the work involved in care coordination that you do outside of an office visit?" (one of the key attributes of the PCMH payment model advocated by ACP), I bet we would get a very positive response. If we were to ask the question, "Do you think primary care physician practices should have to go through an independent evaluation and qualification process in order to be paid more for care coordination?" I expect we would get a more negative reaction.

This does not mean that ACP does not care about its members' views; we wouldn't survive as a membership organization if we didn't.

Our policy process is designed to ensure that the diverse views of members are considered, but we also consider evidence from published sources and the views of non-physician experts. Everyone of our position papers, including the paper on the Patient-Centered Medical Home, is written and approved by ACP policy committees made up of internist-members; after first being reviewed by ACP's Board of Governors (elected state leaders); ACP's councils representing medical students, associates, young physicians, and subspecialists; and the Board of Regents. A position paper, like the one on the Patient-Centered Medical Home, usually takes up to a year before it is published, allowing many opportunities for views, including dissenting views, to be expressed.

ACP's policy process is our principal strength, making us different from most other membership organizations. The inclusiveness of our deliberations ensures that the positions reflect the wide range of views of ACP's membership, are respectful of those who have different opinions, take into account the views of others outside of ACP, and are supported by published evidence whenever possible. I don't believe our policies would have the same degree of respect among policymakers if they were based on membership opinion polls.

ACP also needs to be able to respond rapidly to changing legislative and policy developments, relying on our policy papers to the extent possible. This will especially be true over the next several months, as Congress works to meet President Obama's deadline of passing health care reform before the August recess. It will not be possible to canvass our members on every controversial issue before taking a position.

Finally, I doubt many of us would want President Obama or the U.S. Congress to make decisions by canvassing public opinion. We want them to do what they think is right for the country, taking into account polls but also considering the evidence on what actually will work and their own values and expertise. Would we expect anything less of ACP as it advocates for what it believes to be right for internal medicine?

Today's question: Do you think ACP should canvass its membership before taking positions on controversial issues?

Monday, May 11, 2009

To boldly go where no one has gone before?

Maybe it's because I saw the new Star Trek prequel this week (great movie, by the way, at least in the view of this lifelong Trek fan), but today's announcement that major stakeholders have agreed to reduce health care expenses by two trillion dollars reminds me of the alternative universe scenarios popularized by the series. Just alter the time-space continuum, and you can change the past, present and future to meet a screenwriter's preferred ending, even if it conflicts with everything that had gone before. In this alternative timeline, many of the groups that opposed past efforts to rein in health care costs have joined together to promise major cost reductions.

The co-signers of the agreement, conveyed in a letter to and a meeting with President Obama, are the American Medical Association, America's Health Insurance Plans, Service Employees International Union, Pharmaceutical Research and Manufacturing Association, Advanced Medical Technology Association, and the American Hospital Association. The groups pledged "to do our part to achieve your Administration's goal of decreasing by 1.5 percentage points the annual health care spending growth rate - saving $2 trillion or more. This represents more than a 20% reduction in the projected rate of growth." The letter is short on details ("we are developing consensus proposals") but focuses on four areas: administrative simplification, standardization and transparency; reducing over-use and under-use of health care by aligning quality and efficiency incentives among providers and across the continuum of care; encouraging coordination of care, adherence to evidence-based best practices, and proven clinical prevention strategies; and improvements in care delivery models, health information technology, workforce deployment and development, and regulatory reforms.

President Obama, called the agreement "remarkable" noting that, "some of these groups were among the strongest critics of past plans for comprehensive reform. But what's brought us all together today is a recognition that we can't continue down the same dangerous road we've been traveling for so many years; that costs are out of control; and that reform is not a luxury that can be postponed, but a necessity that cannot wait."

It truly will be remarkable if this agreement leads to concrete steps to lower health care costs and l certainly hope that it does. To do so, though, will require that each of the stakeholders do things that go well beyond anything that they've done so far. For instance:

Will the medical profession go beyond pilot-testing of new payment models to embrace reforms to hold physicians accountable for achieving better outcomes and lower costs, improve payments for primary care, and correct the mis-valuation of services, even if this comes at the expense of some physicians who are doing pretty darn well under the status quo?

Will the drug and medical device manufacturers be willing to negotiate with the government on the prices of their products? Will they be willing to allow comparative effectiveness research to be used to make coverage decisions or accept other limits on coverage of new drugs and devices?

Will the health insurance industry agree to reductions in overpayments to Medicare Advantage plans, to transparency in their own industry practices, and to reductions in the administrative tasks they impose on physicians?

Will unions agree to reforming the medical liability system to lower the costs of defensive medicine or subjecting their own rich health insurance benefit packages to income taxes in order to pay for coverage for others with no insurance?

Will the hospitals agree to reforms to penalize those with high readmission rates, to regulatory controls on excess capacity, or to delivery system reforms to keep people out of the hospital?

I ask these questions not because I am a cynic, but because I know that controlling costs will involve sacrifice from all of us. Emphasizing things like prevention is nice, but even if we all live longer and prosper as a result, health care is still going to be extraordinarily expensive. True and effective cost controls will involve all of us - physicians, hospitals, drug and device manufacturers, health insurers, and yes, John Q. Public, giving up something we like for the greater good.

Like all Star Trek fans, I believe in the power of rewriting the past to create a better future, but it remains to be seen if the co-signatories to today's agreement are really ready to take their members where none have gone before.

Today's question: Do you believe that this agreement will lead to concrete and shared sacrifices to control costs?

Wednesday, May 6, 2009

Health professionals and torture

A new report by Congress finds that health professionals helped design coercive interrogating practices, including techniques like water-boarding, considered to be torture under U.S. and international law.

According to the Senate Armed Services Subcommittee "'interrogation team psychologists' [at Guantanamo Bay] discussed interrogation approaches, including use of 'religious oriented superstitions, varied schedules, shame, various disruptions of daily routines, and using ethnic interrogators.'" And this: "Two psychologists [named in the report] reviewed the materials, and generated a paper on al Qaeda resistance capabilities and countermeasures to defeat that resistance."

ACP's ethics manual states that:

"Physicians must not be a party to and must speak out against torture or other abuses of human rights ... Under no circumstances is it ethical for a physician to be used as an instrument of government to weaken the physical or mental resistance of a human being, nor should a physician participate in or tolerate cruel or unusual punishment or disciplinary activities beyond those permitted by the United Nations Standard Minimum Rules for the Treatment of Prisoners ... Interrogation is defined as a systematic effort to procure information useful to the purposes of the interrogator by direct questioning of a person under the control of the questioner. Interrogation is distinct from questioning to assess the medical condition or mental status of an individual."

In keeping with the obligation of physicians to "speak out against torture", ACP wrote to President Bush in October, 2003, to call for investigations into allegations that the U.S. may have engaged in unlawful interrogations including torture. ACP sent a follow up letter, on May 17, 2004. The White House responded as follows:

"As the President has said, Americans stand against and will not tolerate torture. American personnel are required to comply with all applicable United States laws, including the Constitution, Federal Statutes, and our treaty obligations with respect to treatment of detainees ... The United States will continue to take seriously the need to question terrorists who have information that can save lives, but will not compromise the rule of law or the value and principles that make our country strong. Torture is wrong no matter where it occurs, and under President Bush's leadership, the United States will continue to lead the fight to eliminate it everywhere."

In 2004 and 2005, ACP introduced two resolutions to the AMA House of Delegates to ask the AMA to support investigations into alleged torture and to reaffirm the AMA's opposition to physician involvement in unlawful interrogations. Both resolutions were adopted by the AMA with some modifications. The AMA's Council on Ethical and Judicial Affairs has issued an opinion that states, among other things, that "Physicians must neither conduct nor directly participate in an interrogation, because a role as physician-interrogator undermines the physician's role as healer and thereby erodes trust in the individual physician-interrogator and in the medical profession."

ACP also submitted comments to revisions in the Department of Defense's field manual on lawful interrogations, and also supported an amendment by Senator John McCain (R-AZ) to ban torture. The McCain amendment subsequently was enacted into law by Congress.

On March 3 of this year, ACP joined with the American Medical Association and American Psychiatric Association to support President Obama's executive order to ban torture.

So far, there has been no documented evidence that physicians (MDs/DOs) were "used as an instrument of government to weaken the physical or mental resistance of a human being," which speaks well of the medical profession. Yet it remains deeply disturbing to find that the U.S. government did engage in interrogation tactics that U.S. and international law define as torture, and that some non-physician health professionals were a party to it.

I know that some ACP members will question why the College involves itself in controversial issues like torture, especially given the risk our opinions will be politicized. But I think that it is admirable that ACP speaks out on human rights issues that are central to what it means to be a health care professional. And what is more central to professionalism than honoring physicians' ethical obligation to speak out against torture?

Today's question: What do you think?

Tuesday, May 5, 2009

A primary care doctor by any other name ...

Would still smell as sweet, right? Yet some internists argue that the description "primary care" is one of the reasons why younger physicians are not choosing general internal medicine, and why some established ones feel disrespected. This is what Dr. JH07 had to say in response to my recent post:

"I sensed respect from all of the colleagues I interacted with at IM '09, last week. I sensed love and enthusiasm for our specialty, Internal Medicine, at that conference by its diverse group of attendees. So what is not respected? Answer: "primary care". Primary Care is a label that some physicians were dubbed with in the late 80's, early 90's with the rise of managed care. It's a moniker that, like HIV to the mononuclear cell, like a worm virus to the code of a computer program, some physicians are inextricably and incurably infected with. When these physicians became "PCP's, with the second P standing for provider, we lost our identity as medical specialists, and we became something less than physicians, at times indistinguishable from other providers of medical care who are not physicians. The only way out of this is to throw off the yoke of "primary care" and become the physicians/medical specialists that we are, again. This will not be easy because "primary care" is now well known to the public, the legislators, the insurers, and various medical/surgical specialists, and like many infamous nick-names in the history of our culture, will not be easy to shed."

Dr. Bob Centor, an ACP regent, makes a similar point on DB's Medical Rants:

"Words matter. Hospitalists have succeeded in part because their name carries instant recognition. Primary care suffers in part because so few decision makers really understand how complex primary care is. So I recommend that we no longer use the phrase to describe this important, complex and rewarding profession. The phrase has suffered semantic drift. Until "primary care" physicians understand that the nomenclature is at least half the problem, we will not be able to solve the problem."

I can understand the desire to shed the words "primary care", but I think this would be unwise at a time when politicians and policymakers alike seem to buy into the idea that "primary care" is the keystone of a high performing health care system, as Senate Finance Chair Max Baucus (D-MT) has famously described it. Whether legislators will do enough to live up to primary care's billing as the "something on which other associated things depend" is still to be determined.

The word "primary" itself has many meanings. One is to be first, such as in primary school. General internal medicine, pediatrics and family medicine are about first contact, continuous and comprehensive care. Primary also can mean most important - as in lack of health insurance is a primary reason why people do not have access - and I think this also fits.

What is wrong with being the "first" and "most important" physician in the health care system? Here is how ACP's recent "solutions" paper on primary care defines it:

"The IOM defines primary care as 'the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.' Primary care physicians provide not only the first contact for a person with an undiagnosed health concern but also continuing care of varied medical conditions, not limited by cause, organ system, or diagnosis. The hallmarks of primary care medicine - first contact care, continuity of care, comprehensive care, and coordinated care - are going to be increasingly necessary in taking care of an aging population with growing incidence of chronic disease and have proven to achieve improved outcomes and cost savings. Without primary care, the health care system will become increasingly fragmented and inefficient - leading to poorer quality care at higher costs."

The paper goes on to describe the unique training of internists:

"General internists provide long-term, comprehensive care in the office and the hospital, managing both common and complex illnesses of adolescents, adults, and the elderly. Internists receive in-depth training in the diagnosis and treatment of conditions that affect all organ systems. General internists are specially trained to solve puzzling diagnostic problems and can handle severe chronic illnesses and situations where several different illnesses may strike at the same time. They are also trained in the essentials of primary care internal medicine, which incorporates an understanding of disease prevention, wellness, substance abuse, and mental health. Internists' training is solely directed to care of adult patients; consequently, internists are especially focused on the care of adult and elderly patients with multiple complex chronic diseases."

I would think that the above descriptions of primary care physicians and general internists are something we should be proud of, instead of demeaning primary care by associating it with a lower and less important level of training and patient care.

Today's question: What do you think - should internists define primary care on our terms? Or would you describe yourself as something different?

Friday, May 1, 2009

Time to get real on primary care

As I've written in many blog posts, policymakers seem all to be in agreement that primary care is essential to a high performing health care system. Capitol Hill is alive with the sounds of lawmakers promising to enact major reforms to increase the numbers of primary care physicians, a goal that is expressly mentioned in the budget resolution passed yesterday by Congress.

The problem, though, is so far the modest policies being considered don't seem to be equal to the stakes involved. In a new policy paper, ACP lays out in stark terms why primary care medicine is in crisis, and what needs to be done now to reverse it. The now must include substantial changes in Medicare payment policies to make primary care a viable career path compared to other specialties.

My concern is that the legislative process could result in minimalist policies that throw a few dollars primary care's way, but not enough to make a difference. Politicians might then think they've done something to solve the problem, while meanwhile, young physicians will continue to vote with their feet and pursue other specialty fields. Deeply disheartened established primary care physicians will wonder why the political system has once again left them behind. And patients will wonder why they can't find a primary care doctor.

Politicians need to hear from voters that saving primary care demands a wholesale revamping of federal policies, including paying primary care doctors what they are worth. Happy talk about primary care is well and good, but happy talk won't get more doctors to go into primary care or keep struggling primary care practices from closing their doors.

Today's question: Do you think politicians understand what is really needed to save primary care? If not, how do we get them to understand?