The New York Times editorial on September 9, 2012, “Simple treatments ignored”, is a commentary on a report in the September 7 issue of the Centers for Disease Control and Prevention (CDC) publication Morbidity and Mortality Weekly Report (MMWR) that many Americans with hypertension (high blood pressure) were not being adequately treated. The Times notes that the study “found that 67 million Americans had high blood pressure and that 31 million of them were being treated with medicines that reduced their blood pressure to a safe level. The remaining 36 million fell into three groups: people who were not aware of their hypertension, people...
0 Physician advocacy: for patients and for social change
A recurring question for physicians and others in the health profession is what degree of health advocacy is expected or appropriate. For those of us in medical education, the question becomes how much of the training (and evaluation) of medical students and residents should be based on advocacy for their patients or populations. Sarah Dobson and colleagues provide a useful formulation of this question in a “Perspective” in the recent Academic Medicine, “Agency and activism: rethinking health advocacy in the medical profession”.[1] They note that “Health advocacy appears in various forms in professional charters and standards”; however, as Canadians...
0 Abortion and women's health: who truly has a conscience?
“Conscience clauses” have become increasingly common in laws about health care as state legislatures seek to limit people’s access to services that they don’t approve of but have not, as yet, been able to make illegal. Of course, it started with abortion care, with doctors being allowed to “opt out” of training requirements for abortion (not that anyone was ever required to “opt in”), and gained momentum with the development of mifepristone (formerly RU-486), the abortion pill, ensuring that pharmacists would not have to fill prescriptions for it if they opposed abortion.Of course, mifepristone is only sold directly to providers, so pharmacists...
0 Primary care, specialty care: what about health?
Three “Perspectives” in the September 6 issue of the New England Journal of Medicine address different, but clearly related, aspects of the transformation of health care. I have previously discussed one of them, “Becoming a physician: the developing vision of primary care" by Barnes, and Comfort in Social determinants key to the future of Primary Care (September 22, 2012). The two others are "What business are we in? The emergence of health as the business of health care"[1], by Asch and Volpp from the Wharton School of the University of Pennsylvania, and "From Sick Care to health care -- re-engineering prevention into the US health system" by...
0 Social determinants key to the future of Primary Care
A "Perspective" in the September 6 issue of the New England Journal of Medicine, "Becoming a physician: the developing vision of primary care"[1] by Kathleen A. Barnes, Jason C. Kroening-Roche, and Branden W. Comfort*, addresses the change in the practice of primary care enabled by changes in payment and structure and how this is more attractive to medical students. All three are medical students (although Kroening-Roche already has both his MD and MPH) from schools in different parts of the country (Harvard, Oregon, and Kansas); they met at the Harvard School of Public Health, and all of whom seem to be interested in being primary care...
0 Research basic and applied: we need them both
“Not every mystery has to be solved, and not every problem has to be addressed. That’s hard to get your brain around.”This statement was the coda of a very good article, “Overtreatment is taking a harmful toll”, by Tara Parker-Pope, in the NY Times, August 28, 2012. The topic of the article, and the implication by the speaker, who was talking about her own family’s health care and unnecessary testing, is one that I have written about several times recently, in terms of both screening tests (“The "Annual Physical": Screening, equity, and evidence”, July 4, 2012) and investigation and treatment of disease (“Rationing, Waste, and Useless Interventions”,...
0 Financial Incentives, maybe; corporate profit, no!
If we truly wish to move toward a healthcare system which delivers high quality in a reliable manner, one of the great flaws of our current system is that incentives are not always lined up to achieve that goal. Indeed, we could make a strong argument that incentives, particularly financial incentives, often lead healthcare providers (sometimes individuals, but certainly large organizations such as hospitals, nursing home and hospital chains, pharmaceutical companies, device manufacturers) in the wrong direction. That is, they pursue financial profitability rather than the highest quality of care for our people. Sometimes these two run together,...
0 Quality and price for everyone: Bigger may be better in some ways, but not all
Atul Gawande, MD, a Harvard surgeon at Brigham and Women’s Hospital in Boston, regularly contributes significant and provocative articles to the New Yorker under the head “Annals of Medicine”. In recent years I have written about several of these, including the “The Cost Conundrum”, June 1, 2009 (my comments in Medicare Costs: "All Politics are Local", June 11, 2009), “The Hot Spotters”, January 24, 2011 (Freedom abroad, health at home: experiments in preventive health care, February 13, 2011 and Camden and you: the cost of health care to communities, February 18, 2011), and “Cowboys and Pit Crews”, May 26, 2011 (EMRs and Primary Care:...
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