Yes, our society must urgently address the “output variables” to ensure that students who choose primary care can earn a reasonable proportion of what other specialists do (some studies indicate that 70% of mean specialist income would be sufficient to eliminate that as a reason for not choosing primary care). Indeed, medical schools need to address the “process variables” by having explicit curricula on health disparities, social determinants of health, and community and preventive health, and ensure there is not a “hidden curriculum” mitigating against primary care. But they also urgently need to ensure that most of their admissions, not a token number, are students whose characteristics mean they are more likely to meet America’s healthcare needs. These include demographic characteristics, such as rural or minority origin and lower socioeconomic status of their family, and individual characteristics identified by past performance (not sentiments in an essay). This is primarily significant volunteer service, especially major commitments like the Peace Corps, Americorps, Teach for America, etc.
Everyone dies; what we can only hope for is a death unaccompanied by pain and unpleasantness. Infections like pneumonia which should be treated in an otherwise healthy person in whom a return to health is likely probably should not be in a person who is terminally ill, bed bound, demented. They are nature’s exit door. The same could be said for starvation, a relatively benign way to go, and almost always better than the alternatives of feeding tubes or intravenous nutrition, which carry high risks of complications of aspiration and infection and discomfort.
setting in which health care takes place), done first by Kerr White in 1961 and replicated by the Graham Center of the AAFP in 2003 with remarkably similar results. In a community of 1000 adults, in any month about 800 have a health problem or injury, 217seek attention from a doctor, 8 are hospitalized, 5 see subspecialists, and 1 or less is admitted to an academic medical center teaching hospital, which, of course, is where we train most medical students and residents, and where they get a skewed view of the prevalence of disease. They begin to see unusual or even rare things as common, and develop habits of ordering tests that are perhaps appropriate in that setting, but dramatic overuse in ambulatory practice.
I have often written about why the US needs a comprehensive national health system to cover all of its people, and my preference for a single-payer system similar to that in place in Canada. I believe that this is necessary for our country to address its poor health statistics. You can’t have lots of people without financial access to health care and have a healthy country. When financial obstacles exist, we have artificial and unnecessary suffering, pain, and death.
The problem is not that our system is not working, but that it is. Paul Batalden is famous for saying “every system is perfectly designed to get the results that it gets”, and ours is. The results that we get are relatively poor health outcomes on a population basis, large numbers of people excluded from health care coverage (even after ACA), many people getting unnecessary care because someone can make a profit on it, and the bizarre concept that there are not only people who are preferable to provide care for (because of their wealth or insurance status) but even diseases that it is preferable to provide care for (because the profit margin is better). Our system is not designed for people’s health; it is designed so that some (providers, insurers, drug companies, etc.) can make profit. It gets the results it is designed to get.
But the National Health Service was established, not as largesse in a time of plenty, but as a way of meeting the needs of the British people. In the US, a different story unfolded; with its industrial capacity intact and the need to shift from war to consumer production, the demand for labor exceeded the number of workers. Prevented from increasing wages because of wage and price controls, large companies found offering health insurance (non-taxable) a significant inducement, and found common cause with labor unions who could then offer these benefits to their members; a win-win that led to the employer-based health system that has characterized the US since.
A classic story taught in most introductory public health classes is of the person who finds the body floating in the river, and pulls it out. Then there are more, and he pulls them out. Then more and more and he gets friends. Then so many that the whole town gets involved, developing a highly efficient system for removing bodies from the river, moving them up and out to the graveyard. Until someone says: “Maybe we should go upstream, and try to find out what is causing all these people to die and fall into the river. And maybe do something about it.”
“Upstreamers”, then, are those who try to find out why the bodies are getting into the river as compared to those who are focused on addressing problems much later; often too late. Upstreamers recognize social determinant and other barriers that can shape outcomes. For the bottom 30 to 40% of Americans, the outcomes can be shaped substantially by various determinants and not by school, teacher, physician, nurse practitioner, etc. Most of the studies regularly promoted in major journals or reports fail to understand social determinants and patient situations.
Our leaders are not listening to the upstreamer family physicians, teachers, public health, military, nurses, and front line public servants. Leaders need to listen to those who have the perspectives that can help to better understand normal Americans and those facing numerous dimensions of challenges. This perspective is often shaped because front liners tend to arise from lower and middle income and upper middle income Americans, rather than the top of the socioeconomic heap. Our top leaders, on the other hand, tend to come more from the exclusive sector, and such upbringing makes it difficult to understand the daily lives of most Americans.
Few want to take responsibility for poor child well being, failures of investment in child development, numerous errors in the production and retention of important health care workforce, health costs that are too high for the outcomes, and other broken designs such as school funding mechanisms. It is easier to blame teachers or physicians rather than to make the investments that can make a difference. It is hard to see how these increasing costs and distractions prevent the investments that we need to make in our children – and our future.
How Do Declining Opportunities for Most Americans Shape Lack of Health Access?
Asian Indian choice of FM was 2% for the 1990s – the population segment most representative of highest income, most urban, children of professionals in census and in AAMC data. All such populations are 3 – 10 times more likely to gain medical school admission in the US compared to the average. Advantages of child well being from the start of life are evident.
It is not about artificial markers of race or ethnicity – it is about highest income, most urban, highest property value, and other characteristics associated with advantage (or concentrations). Those more normal and representative are falling behind of all races and ethnicities. The same is true in studies of college students. Asian and white populations are populations of advantage and as Barr demonstrated at Stanford, for students who planned to go to medical school when they were freshmen, these students of advantage had 100 – 110% actually apply to medical school, while the rate for underrepresented minorities, even in a select school such as Stanford, was only 50% remaining to apply for medical school. Advantage involves concentrations or combinations of concentrations as compared to normal. Those left behind are no small segment of the United States. Most Americans do not have the concentrations or combinations of concentrations needed for better opportunity, better cost of living, better health care quality, or easy health access.
Recovering Health Care Cost, Quality, and Access
We cannot do better as a nation with so many left behind from the earliest ages by design.
Health professionals such as family physicians can do Upstream work at the community level.
We need similar professionals working entire careers like we do to improve child development.
We need primary care and public health nurses that were trained specifically for primary care and public health – and who remain in such careers.
How we invest in our children and work locally in teams will determine our future.
 Rabinowitz HK, Diamond JJ, Markham FW, Hazelwood CE. ”A program to increase the number of family physicians in rural and underserved areas: impact after 22 years.” JAMA. 1999 Jan 20;281(3):255-60.
e professional role of a physician is – e.g., working in the community or not. They need both individual and institutional role models.
it is dwarfed by the phenomenal increase since then, as shown in the full graphic:
- “The diseases and injuries with the largest number of YLLs in 2010 were ischemic heart disease, lung cancer, stroke, chronic obstructive pulmonary disease, and road injury.
- Age-standardized YLL rates increased for Alzheimer disease, drug use disorders, chronic kidney disease, kidney cancer, and falls.
- The diseases with the largest number of YLDs in 2010 were low back pain, major depressive disorder, other musculoskeletal disorders, neck pain, and anxiety disorders….
- The leading risk factors related to DALYs were dietary risks, tobacco smoking, high body mass index, high blood pressure, high fasting plasma glucose, physical inactivity, and alcohol use.”
Just because you want to get rich quick, or avoid needle sticks, or find the magic cure for your arthritis or cancer that has been denied you, and someone is selling something that claims to do it, doesn’t make it true. If you think so, I’ve got a couple of bridges to sell you.
Now, why would we expect, or want, our young people to “grow out” of the idea that this is a good thing?