Can Free Med. Schools save Primary Care?

My brother showed me this interesting op-ed in the New York Times today arguing that the primary care dilemma in America can be saved by a simple solution: subsidize medical school for doctors!

Okay, okay - so it's more complicated than simply letting future rich doctors go to school for free.  The reality is clear: there's a severe shortage of primary care docs in America because there's no $$.  If you're a physician in training, why settle for only giving patients physical exams (open your mouth, say ahhh!, etc.) and referring the sick ones to other docs when you could be a specialist?  There's a financial incentive for every prospective doctors to be a surgeon, cardiologist, or some other kind of specialist because - ka-ching! - that's where the money lies.  

So, what do the columnisst propose?  Let everyone go to med. school for free.  Now, if after you finish med. school you decide to continue your primary care training - that's also free.  But, if you want to become a specialist, you pay (instead of being paid, as the system currently is).  The best part?  The plan subsidizes itself - the money the specialists pay for further training covers the cost of medical school for all doctors.

With a simple switch, there's an incentive for all students to go into primary care.  

Ethics, Enlightenment Thought, and Global Health - Thoughts from Josiah Littrell

A scholar of psychology and philosophy, Josiah is a great friend who wanted to share his reflections on the tension between medicine and public health. A former Master's student at Duke, he is currently working at UNC-Charlotte - though he still remains a rabid Duke basketball fan at heart. 


As I read Sanjay’s post about the tension between helping individuals and implementing more broad-brush policy changes, I couldn’t help but think that it encapsulated the tension brought about by the way the Enlightenment shifted our ethical framework. An odd thought process, I know. When you change your major once a year as an undergrad and drop out of grad school twice after that, I guess that’s just the way your mind works.


At any rate, the ethicist Alasdair MacIntyre contends that Enlightenment thinkers sought to create a rational justification for moral thought and behavior. In so doing, these thinkers abstracted moral decision-making and removed it from any broader familial or social context.


We see this all the time in the thought experiments we all have to undertake in philosophy classes. It usually follows the line of, “You are standing by a set of train tracks, and a passenger train is approaching a broken track. You can pull the switch and divert the train to another set of tracks, saving the lives of everyone on board. But if you divert the train, it will run over the 4 men working on that section of track. You can’t get their attention to warn them of the approaching train.” Of course, most people say to pull the switch and save several hundred lives while sacrificing 4 people.


This kind of utilitarian, greatest-good-for-the-greatest-number social ethic is exactly the product of such de-contextualized ethical thought. Most of us, though, rarely hang out by train tracks. Fewer of us still will find ourselves located by a track switch and forced to choose between saving a passenger train or saving 4 railroad employees.


But we DO find this type of ethic writ into the fabric of contemporary society. This is the voice of the “cost-effective,” wondering why anyone would medivac one patient out of the developing world when so many vaccines could be purchased for the same price. This is the proponent of just war, claiming “collateral damage” is a necessary sacrifice for national security.


In context, though, those lives mean a great deal. The family of the patient and the doctor treating him or her certainly value the investment made in saving the patient’s life. They would consider it $20,000 well-spent. The people who lose wives and sons and sisters and uncles to stray bullets or errant bombs view such “collateral damage” as more than the mere detritus of a utilitarian “just” war.


The alternative, I think, is an ethic of virtue. This is an ethic that asks how we go about building a better world—an ethic that views our small and large decisions as either contributing to or detracting from building that world. It is an ethic that lives in context; it says, “Yes, we do live in a violent world of suffering, famine, disease, and hard choices. But we also live in a world where the life in front of us is precious and worth saving.”


The rebuttal, of course, is that this is a horribly impractical approach, and that is why we need the abstraction. I will unabashedly say that virtue can be impractical. But would you be practical if it involved the lives of your parents? Of your spouse or partner? Of your closest friends? Can you impose that practicality on other people? Should you?


That is why contextual ethics matter. Life doesn’t happen in thought experiments.


What if we paused to mourn the loss of any life, no matter how cost-effective or justified in the abstract? What if we celebrated the saving of any life, no matter how expensive? What if we lived in a world that invested as much in life as it does in death?
We start by building that world together through conversations such as this.

Doctors for America National Conference - May 23, 2011

For any folks in the D.C. area, wanted to give you a heads-up about an interesting conference taking place in the city next week! 

Doctors for America, an advocacy organization that started out as Doctors for Obama during the 2008 campaign, is hosting it's first-ever national leadership conference to discuss legislative priorities in medicine for the upcoming year.  As a collection of over 15,000 young physicians and a subsidiary of the Center for American Progress, this group has real potential to make a difference.  Within its first years, they helped pressure the AMA (American Medical Association - a traditional opponent of healthcare reform) into endorsing Obama's reform package by rallying the voices of medical students and young physicians.

Attending the conference will be Fmr. Senate Majority Leader (and key architect of Obama-care) Tom Daschle as well as Don Berwick, Head of the Center for Medicare and Medicaid Services.  Check it out!
http://act.drsforamerica.org/survey/NLCmedstudent/

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Political vs. Civic Engagement

A few days ago I attended the mandatory DukeEngage Academy for my participation in the program this summer. During the academy’s second day we were presented with fifteen or so topical panels and given the opportunity to attend three of our choice. A particularly interesting session I went to was led by Eric Mlyn, the director of DukeEngage, and was titled “Where is the Political in Civic Engagement.”

He talked about the important relationship between political and civic engagement and about connecting whatever passions we may find to some sort of policy or political advocacy, exactly what we're tying to do in Medvocacy! He showed us recent data on how people our age are much more involved in civic rather than political engagement. Yet as we age this relationship reverses and adults tend to be more engaged in politics over service, evidenced by the demographics’ higher voting rates and involvement in political issues.

We discussed reasons for this strange relationship, such as the fast-paced nature of current young lifestyles and the need for tangible and gratifying immediate rewards. Civic engagement typically produces these rewarding experiences while political action often doesn't result in visible effects until the long-term, which many of us are unwilling to wait for. Another reason could be our lack of faith in current government and its role. We’ve experienced high military spending, prolonged wars, budget deficits, faltering economy, huge debates over any compromises towards progress, and a range of other issues; with constant mention of our governments inefficiency in the media and other outlets. Maybe all these reminders of federal ineptitude have led young people to just lose trust in effecting any change through political means.

Or yet another reason could be that most college students only advocate for social issues they’re directly affected by or have a uniquely strong passion for. For us maybe the extensive amount of opportunities for civic engagement and thus an inherent separation of service concentrations may actually hinder attempts to organize a large movement for political impact. Do we need to first relate many forms of civic engagement to each other before taking on politics or policy change?

How do we bridge the divide between service and political action?
Eric Mlyn summed up the dilemma very well in his introduction with his metaphorical question; it concerned education improvement and went along the lines of ‘is it better to tutor children in schools or lobby for educational reform?’
Or is the solution a combination of both, and if so how do we find that right balance to achieve beneficial lasting reform.

Thoughts?

Development: Health, Education, and Poverty

Health, education, and poverty are all intricately linked to one another. For example, someone with poor health may have an impaired ability to be productive at work and may therefore not earn the wages needed to keep him or herself out of poverty. Additionally, a child with chronically poor health may not be able to attend school as frequently as his or her healthy counterparts, which in the long term could lead to lower education levels. While poor health is correlated with decreased income and lower education levels, can we make any assumptions about causality?

These three factors are so intimately interconnected that it is difficult to discern if these factors are merely correlated with one another or if an elevation in one factor may cause an elevation in another factor. Though this distinction between correlation and causation may seem petty and insignificant, I feel like it is important to pinpoint some sort of causality in order to make strides in global development.

Let’s look at Kerala, a state in India that has experienced unparalleled progress in healthcare and education. The high literacy rates and life expectancies of Kerala rival those found in high-income countries. The state also has some of the lowest infant and maternal mortality rates in the country. Interestingly, while Kerala may boast elevated health and education levels, the state has experienced relatively slow economic growth. In fact, the unemployment rate in Kerala is almost three times that of the overall unemployment rate in India.

In this scenario, elevated levels of healthcare and education did not cause economic growth. In fact, in reaching many of the millennium development goals, Kerala was left with limited money for other investments like highways and cheaper colleges. Therefore, the state of Kerala produced many healthy and educated, but unemployed, individuals.

I feel like it is important to understand the nuanced relationship between the three variables so that a region can experience growth not only in healthcare and education, but also in the economy. Maybe, we could look more closely at economic development as having a larger causal role in shaping health and education than vise versa. I have no idea if this is true, but I’m just throwing it out there. It would seem logical to me that increasing someone’s income level would empower that person to seek better health services and educational opportunities.

http://news.bbc.co.uk/2/hi/south_asia/8546952.stm

Moving Mountains: the tension between medicine and public health

After exam week, finally got a chance to read Mountains Beyond Mountains - the best-selling biography of Paul Farmer.  Very legit, an inspiring tale of how a student (and former Dukie!) can revolutionize health with passion, intelligence, and reckless ambition.  Farmer's tale of defying the status quo serves as an empowering reminder that current protocol in domestic/global health is by no means ideal - that all it takes data and compelling reason (even if it comes from 20-year olds) to change the direction of an entire field.  

From the book, you can tell Farmer's impact originated from source: dedication to individual patients.  While he changed WHO policy left and right, that didn't matter to him as much as the one TB patient who needed help in Haiti.  Rather than sit in conference rooms debating language for declarations, he would instead prefer hiking 7 hours to check whether his impoverished patients were taking their meds.  This was his fuel - these faces and stories were his motivation.  Sometimes, his solutions weren't "cost-effective" - why spend $20,000 on a Med-Evac for one patient when that could buy 1,000 vaccines for others?  In a world of limited resources, Farmer's approach diametrically opposes that of public health - which aims to maximize health benefits or utility (or some other econ jargon) over a population.  

This conflict is an important one for us students to figure out.  Sure, it's easy to say that the best doctors will be both centered on the individual and cognizant of the population.  But what will we care about more?  As someone that's passionate about policy, I lean towards the public-health, "cost-effectiveness" side of spectrum - it's practical and realistic.  But, maybe Farmer has a point.  Maybe before we start talking like we know something, we need to get grounded in a community (whether that's Haiti or Durham).  Perhaps that's the only way we'll know what social justice actually looks like.  

Farmer caught a lot of flak for his position on treating individuals.  There can't be possibly be enough resources to do that, right?  Yet, maybe if we all had his collective "naivete", we could make his realization come true.  

Social Justice - Should diseases compete with each other?

The following post originated from a student trip to D.C. called "Advocacy in Action" in May 2011, where 10 Dukies met with interest groups and policymakers on the Hill and chatted about health policy.  This post is copied from our trip blog. 

In a time when our nation's saddled with a $3 trillion deficit, the reality is pretty clear: the healthcare pie can only be so big, right?  It's a pretty simple realization - but, as students, we saw the repercussions of that first-hand today at Housing Works.

After learning that a D.C. councilwoman was planning on re-distributing HIV/AIDS funding to support efforts against diabetes, heart disease, and hypertension, we helped compose a letter in response urging the councilwoman to not touch the AIDS money.  After all, HIV/AIDS is still a huge problem in D.C., where many citizens are still being infected with both the virus and social stigma attached to it on a daily basis.  The city's even hosting the International AIDS Conference next year - I mean, why cut funding now?  Instead of putting health money in different pots - some for diabetes, some for cancer, etc. - why not just create a better health system that prevents this stuff in the first place?

Yet, maybe the councilwoman had a point.  Ideally, this stuff about health systems is the right action - but how long will it take to implement?  Who's going to restructure our delivery infrastructure?  When will D.C. citizens actually feel the effects?  Who's paying attention to folks with other diseases right now?  The health community does not want to overtly compete with each other for resources and attention for policymakers, but our money crunch might be forcing all of us to do so.  The reality is, most health interest groups are built upon a narrow but definitively clear mission: cure HIV/AIDS, end cancer, give everyone insurance, etc.  It's simple: highlighting the tangible oppression of a diseased patient is way more effective than marketing the abstract notion of health system strengthening .  We all care about health, but in a world full of small pies where there's not enough slices to go around, our interests by default compete. 

Maybe, just maybe, there's room for students to induce collaboration.  To unite folks in the stand for health as a human right.  To show that, at the end of the day, we collectively need access, quality, and cost of healthcare to improve in America.   Massaging this inherent competition may be difficult, but it has to be possible.  To settle for less would be an injustice to us all.