Wednesday, February 25, 2015

A doctor and lawyer walk into their Congressman’s office…

…And tell her they actually agree on something—no joke!

Think of it: two learned professions, which in popular lore don’t really like each other (thus, the dismissive jokes each make about the other), agreeing on a public policy response to a pressing national priority?  Two professions, often at loggerheads with each other, whether it is on tort reform or facing each other down in court of law, yet finding something they can agree on?

Well, this is precisely what happened this week when the American Bar Association joined with ACP and 7 other health professional organizations in a call to action, published in the Annals of Internal Medicine, on preventing deaths and injuries from firearms.   The physician organizations that co-authored the paper—ACP, American Academy of Family Physicians, American Academy of Pediatrics, American College of Emergency Physicians, American Congress of Obstetricians and Gynecologists, American College of Surgeons, and American Psychiatric Association, representing the vast majority of U.S. physicians, were joined by the American Public Health Association and the American Bar Association to “advocate a series of measures aimed at reducing the health and public health consequences of firearms. The specific recommendations include universal background checks of gun purchasers, elimination of physician ‘gag laws,’ restricting the manufacture and sale of military-style assault weapons and large-capacity magazines for civilian use, and research to support strategies for reducing firearm-related injuries and deaths.”  

This paper is, to my knowledge, the first interdisciplinary agreement among the largest and most influential specialty organizations representing the medical profession, the legal profession, and the public health community to take on one of the most vexing problems facing this country:  that each year “more than 32,000 persons die as a result of firearm-related violence, suicides, and accidents in the United States; this rate is by far the highest among industrialized countries.”

Each organization approached the issue from a position of credibility on the aspects of firearms policies for which they had the most standing: physicians and public health advocates on the impact of firearms on the individual health of patients and on population health, the lawyers on the Constitutional issues involved.  The ABA confirmed that the policy recommendations proposed in the paper are well within the right to bear arms as established by the Second Amendment:

“These recommendations do not come solely from a group of health organizations without expertise in constitutional law but have been developed in collaboration with colleagues from the ABA, which has confirmed that these recommendations are constitutionally sound. For 50 years, the ABA has acknowledged the tragic consequences of firearm-related injury and death in our society and expressed strong support for meaningful reforms to the nation's gun laws, as well as for other measures designed to reduce gun violence that do not fall under Second Amendment scrutiny. Because the courts have repeatedly held that the Second Amendment is consistent with a wide variety of laws to reduce gun-related deaths and injuries in our nation (yet confusion exists among the public about whether the Second Amendment is an obstacle to sensible laws), 1 mission of the ABA has been to educate its members, as well as the public at large, about the true meaning and application of the Second Amendment. . . No ruling of the Supreme Court (or any other court, for that matter) calls into question any of the specific proposals that we recommend.”

The origins of the ABA joining with ACP and the other health professional associations go back to a year ago, when the ABA first informed ACP of its interest in the working with the College on firearms policy, following the publication in Annals of ACP’s own paper on reducing deaths and injuries from firearms, written on behalf of the College’s Health and Public Policy Committee, chaired by Dr. Thomas Tape.  At the ABA’s invitation, Dr. Tape presented at an educational seminar for lawyers at the ABA’s annual conference in August 2014 on 'Combatting Gun Violence, A Role for Lawyers and the Bar.' Renee Butkus, ACP’s Director of Health Policy and co-author (with me) of the ACP’s 2014 position statement, participated in the Fall of 2014 in the founding meeting of the  Prosecutors Against Gun Violence, prosecutors from 23 jurisdictions who “formed to combat gun violence by sharing information on programs that work and copying effective state laws,” reported USA Today.

Both the ACP and the ABA decided that it would be even more effective to broaden the effort to include other major physician membership organizations and public health advocates—leading to the joint statement published on Tuesday.  The plan now is to seek endorsements of the paper by an even broader universe of physician, public health, health services researchers, and consumer and public advocacy groups over the next several months.

I think the combined credibility of doctors and public health professionals on the health impact of firearms, and the lawyers on the constitutional issues, will give this new effort more credibility than any one organization, or any one profession, could bring to the firearms debate on their own.

It will need it, given the pervasive influence the gun lobby has over public policy in the United States.  In an editorial accompanying the joint paper, Drs. Darren Taichman, Executive Deputy Editor, and Christine Laine, Editor in Chief of the Annals of Internal Medicine, argue that it will take the engagement of the 500,000 plus members of the health professional organizations that signed the statement to make the difference:

“What if the more than one half million health care professional members of these organizations contacted their federal and state government representatives to tell them that they believe firearm-related injury is a public health crisis that we need to fix? We just did. It took less than 1 minute to find contact information for our state government legislators (we searched “e-mail my PA legislator”). You may contact your Congressional representatives at or We provide a copy of the letter we sent (Supplement), and you can modify it or write your own to convey your thoughts on the public health threat of firearms.

"We, as health care professionals, are trusted, expected, and paid to prevent harm to our patients and discover solutions to public health problems. Have we done our jobs? Can we? The answers are no and maybe: No, we have not sufficiently reduced the firearm-related harms our patients suffer, but maybe we can, if we demand the resources and freedom to do so.”

Today’s questions: What do you think of the joint paper by ACP, the seven other health professional organizations, and the ABA?  Do you agree with Drs. Taichman and Dr. Laine that physicians have not “sufficiently reduced the firearm-related harms our patients suffer, but maybe we can, if we demand the resources and freedom to do so?"  What are you willing to do?

Thursday, February 19, 2015

I used to fear mad scientists. Now I fear mad anti-scientists.

This is how I titled my guest blog post for the Philadelphia Inquirer, on how the proclivity of many Americans to deny science is endangering the rest of us, whether it is parents refusing to vaccinate their kids, or the more than one out of four Americans who deny that the earth is warming and/or that humans have anything to do with it.  Here is my entire post, as it appeared in the Philadelphia Inquirer:

“When, as a teenager, I first watched the groundbreaking Stanley Kubrick satire Dr. Strangelove, it scared the heck out of me. The final scene, when Dr. Strangelove’s Doomsday Machine sets off worldwide nuclear (brilliantly set to the pop tune “We’ll meet again” . . . some sunny day), captured the anxiety of a generation that grew up fearing that mad scientists and their complicit politicians, would end up getting us all killed.

Today, I fear that it’s the mad anti-scientists, and their complicit politicians, who may end up getting us killed. Because of science-denying people who refuse to vaccinate their children and themselves, the United States is experiencing a measles outbreak that so far has infected at least 121 people, mostly children, in 17 states, including Pennsylvania and Delaware. As the Philadelphia Inquirer’s editorial board observed in a February 8 editorial, Vaccinate Your Child, Pennsylvania “is particularly susceptible to” measles, mumps, and rubella (MMR), because only 87% of its kindergarten-age children are vaccinated against these diseases, among the lowest in the country. In New Jersey, 97% of kindergarteners are vaccinated.

Make no mistake about it: measles not only is highly infectious, it kills.  In the late 1950s, before the first licensure of a measles vaccine in 1961, “an average of 150,000 patients had respiratory complications and 4000 patients had encephalitis each year; the latter was associated with a high risk of neurological sequelae [harm] and death. These complications and others resulted in an estimated 48,000 persons with measles being hospitalized every year.”

I have no doubt that the anti-vaxxers are sincere in wanting to protect their kids against what they believe are ‘dangerous’ vaccinations, except that their beliefs are directly contradicted by the scientific evidence.   My Philadelphia-based employer, the American College of Physicians, is the largest physician specialty membership society in the world, representing 141,000 internal medicine physician specialists and medical student members.  On February 4, the College issued a statement declaring that: 

‘The scientific evidence clearly supports the benefit of the MMR vaccine and the lack of any association with autism. Physicians have a duty to provide the best care for their patients, as well as to protect the public health. At the same time, the profession has a duty to advocate based on accurate scientific data. Patient/parent autonomy is not absolute when it has the potential to compromise both individual and public health. Thus, we urge all Americans to embrace the sound preventive medicine practice of both routine pediatric and adult immunizations.’  

The American Academy of Pediatrics, Centers for Disease Control and Prevention, and the World Health Organization have affirmed the same: the MMR vaccine is safe, doesn’t cause autism, and saves lives.

It doesn’t help, though, when parents’ anxieties about vaccine safety are stoked by pandering politicians. Or when a small, yet influential, number of physicians spread falsehoods about the safety of vaccinations, which one prominent medical ethicist argues should be grounds for having their licenses revoked.

My fear about the impact of the anti-science movement though, isn’t limited to vaccinations.  Because of people who deny the science of climate change and oppose policies to mitigate it, we are looking at a future of “extreme heat waves, rising sea-levels, changes in precipitation resulting in flooding and droughts, intense hurricanes, and degraded air quality,[which will] affect directly and indirectly the physical, social, and psychological health of humans. . . climate change can be a driver of disease migration, as well as exacerbate health effects resulting from the release of toxic air pollutants in vulnerable populations such as children, the elderly, and those with asthma or cardiovascular disease.”

In a free country like the United States, everyone is entitled to their opinion.  But when your opinions put us all at risk, it is time for the rest of us to speak out, and demand public policies—and politicians who will carry them out--that are grounded in science, not mad anti-science denialism.”

For readers of this ACP Advocate blog, I think there are some important questions about what the medical profession’s role should be in challenging science deniers:

What should physicians say to patients who refuse to vaccinate themselves, or their children?

Should physicians decline to see patients who refuse vaccinations that put others at risk, as some pediatricians are being pressured to do? Would refusing to see such patients constitute patient abandonment?  This is what ACP’s Ethics Manual has to say about physicians discontinuing a relationship with a patient:

“When the patient's beliefs—religious, cultural, or otherwise—run counter to medical recommendations, the physician is obliged to try to understand clearly the beliefs and the viewpoints of the patient. If the physician cannot carry out the patient's wishes after seriously attempting to resolve differences, the physician should discuss with the patient his or her option to seek care from another physician.

Under rare circumstances, the physician may elect to discontinue the professional relationship, provided that adequate care is available elsewhere and the patient's health is not jeopardized in the process.”

Should physicians who give credence to the views of those who believe that vaccinations cause autism have their licenses revoked?

Should physician membership organizations, including ACP, exert more leadership in warning the public about the health risks of climate change?  Should physicians be encouraged to advocate for public policies to mitigate global warming?

What about other manifestations of anti-science denialism, like the millions of Americans who reject evolution? Should physicians advocate that evolutionary biology be taught to pre-med students and in medical schools as one of the basic sciences, as a consensus group convened by The National Academy of Sciences recommends, because “Evolutionary biology is not just another topic vying for inclusion in the curriculum; it is an essential foundation for a biological understanding of health and disease?”

As members of a learned profession grounded in the scientific method, physicians should be expected to stand with science, especially when the views of anti-science dissenters threaten public health.  But when physicians take stances on hot-button issues—vaccinations, climate change, evolution—it puts the medical profession in the challenging position of going against the views of the millions of Americans (and elected politicians) who reject the scientific consensus on these issues, including many of the physicians’ own patients. What is the right balance between the medical profession being respectful of the views of people who don’t agree with the scientific evidence, and advocating for public policies, as supported by science, that are necessary to mitigate health risks to individual persons and populations?

Today’s questions: What are your responses to the questions I posed above?

Tuesday, February 10, 2015

Killing the Goose

Last week, I attended a briefing about a new policy report, issued by the influential Brookings Institution, calling for reforms to accelerate the transition to value-based physician payment.  Brookings’ report builds on the framework recommended in a bipartisan, bicameral (House and Senate) SGR repeal bill that was agreed to last year by the congressional committees with jurisdiction over Medicare.

There are some very thoughtful concepts in their proposal, like improving and simplifying quality measures.  Some of their ideas gave me pause, like requiring that physicians in a Patient-Centered Medical Home, or another alternative payment model (APM), accept direct “downside” financial risk for meeting quality and efficiency measures. Brookings could be setting the bar so high that few physician practices could qualify or be successful in achieving the required savings even if they were able to qualify as an APM.

Beyond the specifics of their report, though, one thought kept going through my head: as policymakers keep coming up with well-intentioned ways to “reform” physician payments, we might be at risk of killing the goose that lays the golden egg.  The goose being primary care, and the egg being high quality, patient-centered, accessible, compassionate and cost-effective care, which can only come from a patient having an established relationship with a primary care physician that they know and trust.

We know from hundreds of studies that primary care is highly associated with better outcomes and lower costs.  We also know that relatively few medical students are choosing to go into primary care.  We know that many established primary care physicians are frustrated and discouraged, leading some of them to leave medicine altogether or downsize their patient panels by going concierge.

And we know why this is so.  Primary care physicians are under-paid and over-worked relative to other physicians.  Many are dejected because they feel so disrespected.  Everything they do is being measured, but how often is what they do truly treasured by society?  We stick them with dysfunctional electronic health records that make their lives miserable, and then penalize them with payment cuts if they don’t use their records in a way that the government considers “meaningful.”  We dangle out more money to them—but only if they are willing to work ever harder and ever longer, in “alternative payment models” that involve spending more time on administrative processes (like reporting on measures) and less time with their patients.  Meanwhile, many of their colleagues in other specialties that can bill for highly compensated procedures can still do quite fine under conventional fee-for-service (FFS)—and when they too have to jump through hoops to prove their value to payers, they start out with a much higher FFS compensation baseline than primary care.

Readers of this blog know that I believe that fee-for-service hasn’t been a good deal for primary care—if it was, why has primary care been so underpaid under FFS compared to other specialists?  I also believe that if done rightly, new payment and delivery models, like Patient-Centered Medical Homes, offer the tantalizing possibility of  valuing primary care more highly while improving patient and physician satisfaction, with better outcomes and lower costs.  And just saying no to value-based payments isn’t going to be a winning strategy for primary care.  It is better to mold the changes that are coming than to cling to a hope that it will all just go away.

At the same time, though, a great deal of caution is in order.  When someone comes up with a new plan to change the way that primary care is going to be organized and compensated, we should ask:  Will it add to the administrative burdens of primary care physicians?  Take their time away from patients?  Will they have to run harder just to stay in place?  Will it make them feel even more beleaguered and less valued?

If the answer to any of these questions is yes, then we need to stop and re-think what we are doing to primary care, and come up with a better way.

 Real value-based payments should assign the highest value to the patient-physician relationship. Everything else is secondary.  Because otherwise, in our zeal to re-invent how physicians are paid and care is delivered, we will have killed the goose that laid the golden egg:  the goose being primary care, and the egg being high quality, patient-centered, accessible, compassionate and cost-effective care, which can only come from a patient having an established relationship with a primary care physician that they know and trust.

Today’s questions: do you think policymakers may be at risk of killing the goose, primary care, that laid the golden egg  of high quality, patient-centered care?  And if so, what should be done to make them stop?