Medicine IS Politics

As I sit here cramming in a few last hours of study before sitting for my American Board of Family Medicine exam tomorrow, my smart phone repeatedly lights up. The #saveGME campaign is underway.

While I should keep studying, I cannot. Over the past several days, I have been reading articles and blog posts about the most recent spin in the deficit reduction “circus”—cut GME dollars out of the Medicare and Medicaid budgets. Neither of these issues has gotten traction in the mainstream media, and I know why. None of the journalists had the knee jerk reaction I did to the news: how will we train new doctors? While it is bad enough that most Americans, many of them eager to cut “entitlement” programs, don’t appreciate that about a quarter of our insured population is covered under government insurance (http://www.gallup.com/poll/125417/americans-reliant-government-healthcare-2009.aspx), a.k.a. “socialized medicine”, I presume even fewer residents—doctors in training, a.k.a “medicine’s future”—realize that their paycheck and much of the funding that keeps their training program up and running, comes from the Medicare and Medicaid budget. And if you are in a primary care program, one that is unable to generate tons of income from your services due to a flawed, procedure-based reimbursement system, you are especially dependent on these government funds.

And if the money dries up, the programs close. The vulnerability of primary care programs has been outlined in other blog posts here and elsewhere. The pre-existing shortage of primary care physicians is well known. Heck, the ACGME even titled its 20^th report last year “Advancing Primary Care” (a title that sounds ironic at this moment), and mandated the U.S. increase its proportion of primary care physicians from the current 32% to at least 40%, the critical point at which health outcomes improve and costs decrease.

Despite this, GME funds are on the table.

So as the baby-boomers age, and the generation known as “the first to not outlive their parents’ life expectancy” enter adulthood and pile on their chronic, life-style-induced diseases, and as a morally just health reform law requires more Americans be given affordable health insurance, the roster will bloom with patients. These patients will be sick; they will have multiple disease processes, limited resources, and will demand increasingly complicated and expensive technology in their treatments. And if the GME cuts go through, and specialty programs survive by simply doing more procedures to generate more income for them and more debt for the American public, and the primary care programs shrink instead of grow, our nation’s health will suffer deeply.

The AAFP is mobilizing its members to contact their representatives. It has been lobbying members of Congress for a GME primary care carve-out that would send some funds directly to community-based primary care training programs (currently 100% of GME dollars are distributed to hospitals, who then decide which programs to fund), and it has iterated several more demands to the President directly. But it can do more. In my mind, the fact that most Americans, and most residents, don’t know that Medicare and Medicaid dollars are the key funding source for training all the doctors in this country is not acceptable. We need to use the media better and educate the public on how healthcare is delivered in this country. I think if they knew, they would be outraged.

Tomorrow I will be tested on knowledge that will allow me to say I am Board Certified in Family Medicine. Sadly, out of hundreds, there may only be a single question that tests my knowledge on the politics of medicine. And that’s too bad—because these days, medicine is all politics.

GME Funding for Family Medicine Residencies Must Be Preserved.. Now!

In a letter from the ACGME to the American Board of Medical Specialties, American Hospital Association, American Medical Association, Association of American Medical Colleges, and Council of Medical Specialty Societies, the ACGME warns of consequences that could occur due to proposed cuts in Medicare Graduate Medical Education (GME) funding. GME funding is the main source of financial stability for residency programs that train this country's medical interns and residents - the pipeline of production for physicians.

These cuts would threaten:

• The availability of residency positions to produce new physicians
• Access to care for the Medicare population
• Access to care for the underserved, underinsured, and uninsured
• Community-based primary care residency programs which produce primary care physicians that typically serve in rural and other underserved areas
• The distribution of primary care residency slots in multi-specialty institutions towards more lucrative sub-specialty training which reimburse the institution more for procedural rather than preventive care
• Residency training in general with the possibility of support from industry (insurance companies, pharma, etc) and/or implementation of tuition for residency training
• Entering clinical practice after one year of internship to repay student debt resulting in the undereducation of practicing physicians

The Association of American Medical Colleges provides a variety of resources explaining the importance of GME funding, including their advocacy to increase the amount of funding for GME in order to prevent/slow down a shortage of physicians. This includes a letter to President Obama sent on 5 July 2011 urging the President to preserve GME funding.

The American Association of Colleges of Osteopathic Medicine took it a step further by initiating a member-driven action alert. This alert allows members and non-members to submit emails and letters to their representatives in an effort to generate more than the usual auto-generated email response from our elected officials.  The AACOM also submitted a joint letter with the American Osteopathic Association to Congress opposing cuts to GME.

The American Academy of Family Physicians focus in on primary care, asking its members to take action on its Speak Out Grassroots Advocacy site by contacting legislators to specifically preserve primary care.

"The deficit reduction conversations continue. Lawmakers are re-thinking Medicare’s Graduate Medical Education (GME), and at this critical time, they should be reminded of primary care’s importance. Our representatives have an opportunity to change this program so that it encourages the innovations in primary care training that will help build a workforce our communities can count on."

So, where is the American Medical Association and the American Academy of Pediatrics?

Currently on the homepage of the AMA, they are worrying about the Independent Payment Advisory Board (IPAB) as well as a decrease in Medicare payments for diagnostic imaging.   It seems like CMS is starting to do the work that the RUC should be doing to decrease overvalued services?  Apparently this is more important than worrying about cuts to GME.  The AAP does not seem to be worrying about much of anything.  The ACP has submitted a letter to the President and Congress urging for a debt ceiling agreement which addresses GME, but nothing really focused on GME.

The AOA had no problem leading the way as one of the first medical organizations to take action.  The ACP continues its support for primary care, though it is easy to tell they do so very cautiously to keep its medicine sub-specialty members content.  Will the AMA step up at the sake of losing support from its specialty members to help save funding for primary care?  Or will they issue a blanket statement asking to preserve GME funding in general while still knowing that the preservation of GME funding does not necessarily mean the preservation of primary care training.  It may mean the shifting of more training towards specialties that get paid more for procedures...  who funds the RUC again?  Who makes money off of coding books with codes for procedures for which the RUC makes recommendations to CMS for reimbursement rates?  I digress...

Any cuts to GME that do not preserve funding specifically for primary care could be catastrophic, especially for programs that can barely get by with the current level of funding.  GME cuts that do not preserve or increase primary care residency funding will continue the current shift in our physician workforce that favors specialization and does not value primary care.  It is at times like these when I am most thankful for choosing a family medicine residency in the military - a health care system that actually appreciates and values primary care as its foundation for health care delivery.

Are We Providing Health Care, or Just Delivering Health?

As a medical student I have come to appreciate two core goals of Health Care:

1) Health: The delivery of medical knowledge, assessment or treatment to a patient

2) Care: The compassionate approach to any patient

As a medical student I have also witnessed clinical medicine practiced across a spectrum of situations. Taking my time to reflect on these experiences, I am not certain we are meeting our goals. Too often I have watched a flurry of attendings rush from bed-side to bed-side, witnessed residents spend far more time in front of a computer screen than holding a patient’s hand. I am not arguing the nature and necessity of our modern system, rather I hope to ask a major question:

Do we get so caught up in the delivery of our health care, that we sometimes neglect the care itself? Are we providing health care, or simply delivering health?

Allow me to frame this in another way. Have you considered the definition of the word “care”? One that I rather like defines care as a “watchful attentiveness”. How often are you watchfully attentive to your patients? What can be said about the nurses, residents or staff working with you?

At the same time that medical advances allow immediate, efficient, and direct monitoring of patients, these same technologies can so easily disrupt our watchful attentiveness. New systems, with built in redundancies and alerts have the potential to incentivize complacency and interrupt the patient-physician relationship. I often overhear residents or attendings say, “Don’t worry about the patient in room 246 until the lab results come back. There is nothing we can do until then.” The consequence of this attitude represents a negligence to the value and importance of physician compassion.

Nothing we can do? What happened to kind words, reassurance, and the offering of a comforting hand? Sure the electronic record may show normal cardiorespiratory monitoring, no new nursing communications, and no updated lab results – but there still exists a patient, sitting in a hospital bed. Possibly alone, likely insecure, and almost definitely in need of your care.

Again, I am not arguing that our current system is ineffective in delivering health, nor am I contending the decisions of my peers and superiors. I have a profound respect for the urgencies and constraints of our modern health system. But I believe that, in any area of life, self-reflection is necessary for growth.

Somewhere along our medical journey, as we agreed to see more patients then we could handle, and developed advanced technologies that separate patients from caregivers – we may have lost sight of a simple fact. Fifty percent of our mission as physicians delivering health care is to provide that care to our patients. To be watchfully attentive over them. Consider – are we providing health care, or just delivering health?