letters

No easy answers to "Ten Hard Questions"

The editorial "Ten Hard Questions About the Future of the Specialty," by Douglas Iliff, MD [September 2005], generated an unprecedented reader response, both in terms of the quantity and the enthusiasm of the comments we received. Below are excerpts from a sample of the letters, followed by a response from Dr. Iliff. - FPM

Thank you for publishing Dr. Iliff's editorial. These are exactly the kinds of things we should be talking about. Enough about the Future of Family Medicine project; anyone who actually believes that reimbursement for family physicians will ever approach that of our proceduralist colleagues, or that our cognitive efforts will be appreciated and appropriately compensated during our lifetimes, needs to be educated on the economic realities of today.

I particularly sympathize with Dr. Iliff's discussion of patients who are willing to leave a practice just to save a couple of bucks. Many of us are tired of chasing our tails to offer all the bells and whistles we are asked to provide (open-access scheduling, small family-oriented office, hand-holding, unpaid crisis counseling, hospital care, early morning hours, late evening hours, Saturday hours, staff development, etc.) only to be confronted by patients who demand diagnosis and treatment by phone because they don't want to pay a $10 co-pay, and who threaten to leave the practice if we don't oblige.

Family medicine is having a rough time attracting U.S. medical grads, and some of the best and brightest are getting out of traditional practice. I fear that the Future of Family Medicine project is going to be too little too late to save the specialty.

Amanda Heidemann, MD
St. Louis

I agree with Dr. Iliff that patients bearing more of the cost of their poor lifestyle decisions would make a positive difference in our health care system. However, I don't agree that health savings accounts are the answer (and I don't pretend to have the answer). We are not
currently rationing care; we are rationing patients. Too many people have no reasonable access to medical care. This costs much more than it would cost to provide that care. Until we provide basic health care for all, we will continue to rank low in health care among industrialized countries, despite spending three times more per capita.

Anna Bittner, MD
Richmond, Va.

Our society is fixated on getting Cadillacs for the price of a Yugo, and, unfortunately, the average health care consumer can't judge the difference! As long as poorly supervised, second-tier providers masquerade as equivalent, comprehensive providers, payers will continue to devalue family medicine. Meanwhile, as we pontificate about computerized records, etc., Rome burns around us. Our professional societies would do well to enlist spokesmen such as Dr. Iliff to sell the real story to the entities that shape the future of American health care.

J. Vogus, MD
Redding, Calif.

Thank you for giving Dr. Iliff the space to vent what many of us are feeling. The American public no longer perceives computers as technology but as infrastructure. We do not appear technologically advanced because we have them, only backward if we do not. We have carried the banner for higher quality health care and evidence-based medicine, but this matters little with the public. Our patients care about money and convenience. They worship technology and specialization but only when they do not have to pay for it, and they rarely know what the true costs are.

J.E.B. Johnson, MD
Port Lavaca, Texas

I couldn't agree more with Dr. Iliff's editorial. My group has implemented health savings accounts for our employees, and I can tell you that as a consumer, it absolutely changes the way you approach medical care.

Rich Harover, MD
Dayton, Ohio

How many uninsured Americans are there? How much do we already spend on health care? Do we really believe that we can provide this kind of care for at least another 40 million people? Who's going to pay for it? I believe our society is making decisions that keep affordable, high-quality, widespread health care out of arms' reach. We continue to create an environment that cannot provide the type of health care we think we deserve, for the price we think we should have to pay, using a finite pool of resources. Frankly, I think we've decided that universal health care is less important than fast-food dollar menus, leather seats and nationwide wireless phone service.

Jerry Bruggeman, MD
Columbia, Mo.

The professional organizations that are set up to help defend us against aggression by the government and other third-party payers are failing and have been for two decades. Our leaders are like the ministers in the pulpit who don't believe what they are preaching but know their job depends on continuing the same old rhetoric. Dr. Iliff has it right, but I suspect he is too busy taking care of patients to have the effect he might. If he runs for the Senate, I will contribute to his campaign!

Joseph J. Baum, MD
Floyd, Va.

Dr. Iliff is on the money. When patients are responsible for a significant portion of their health care, they are far more cost-conscious. I will soon need two surgical procedures and will have them done in a surgery center in the next town because it will cost me half as much. I have a health savings account and am footing most of the bill. I am the chief of staff of the local hospital and have been on the active staff for 29 years, so I would prefer to use the local hospital; however, when the cost is half and the care will be equal, going elsewhere is a no-brainer.

Douglas Morrell, MD
Rushville, Ind.

Thank you so much for Dr. Iliff's editorial. I thought I was the only crazy person out there adding up the numbers and finding lots of zeros. But then I'm also a farmer. Talk about losing causes. The only way to explain family doctors' (or for that matter small farmers') behavior is to think of it as a form of obsessive-compulsive disorder based on relationships. Unfortunately, we can't get anyone else to buy into our little addiction.

Yusuf Harper, MD
Norwich, N.Y.

I thought Dr. Iliff's editorial was excellent. So much of the advice given to me about family medicine seems to come from doctors who went directly from a residency to some type of bureaucratic job, having seen their last patient 20 years ago. Dr. Iliff at least spoke from the true front lines.

David Granite, MD
Greenbelt, Md.

Although I agree with many of Dr. Iliff's observations, I was disturbed by his reference to moral hazard as justification for change in payment mechanisms. As a family physician who has spent most of my career caring for patients in underfunded settings, I find this generalization concerning. Although there is a great deal in the actuarial and financial literature about the shortcomings of this theory when applied to health care, one of the best insights for physicians who recognize that part of our problem is that we are not created equal appeared in a recent issue of the New Yorker (see http://www.newyorker.com/fact/content/articles/050829fa_fact).

Kevin M. Hepler, MD, MBA
Mechanicsburg, Pa.

Author's response:

Dr. Hepler cites an article by Malcolm Gladwell, which is well worth reading, dealing with the limitations of moral hazard as motivation for the uninsured. Similarly, Dr. Bittner refers to the problem of the uninsured as a matter of rationing.

I did not outline my thoughts for applying the carrot-and-stick of health savings accounts to national health policy, but here they are (nothing is original to me; credit John Goodman of the National Center for Policy Analysis):

Every American should be covered by a high-deductible insurance policy with specified mandates, open for bidding among private companies. Whether by employer or government contributions, every family or individual would be given a yearly stipend to manage as a health savings account.

It has taken half a century to train Americans to misuse health care resources through the perverse incentives of our present non-system. Health savings accounts would start the re-training process, as Drs. Morrell and Harover testify from personal experience. Furthermore, I have found poor people to be every bit as shrewd at managing their money as anyone else; but first, they have to have the money.

Douglas Iliff, MD
Topeka, Kan.

Your clinical questions answered

"How to Answer Your Clinical Questions More Efficiently" [July/August 2005] was a welcome exhortation to ask well-structured clinical questions - and, of course, to answer them efficiently.

In answering foreground questions, busy clinicians want rapid access to the best available evidence. This need points to a potential pitfall in using resources such as those the authors cited (PubMed, InfoPOEMs, ACP Journal Club) that provide abstracts or summaries of individual articles. With this approach, clinicians must read through the multiple identified articles and either synthesize information ourselves from the larger body of relevant and valid evidence, or be made aware of a published synthesis, perhaps a systematic review (e.g., a Cochrane review). The synthetic approach requires more work, but is essential, lest we run the risk of "medical gossip" (to use Slawson and Shaughnessy's term).

Clinical Evidence and DynaMed are two additional resources that provide ready answers to most clinical questions based on the best available evidence and also synthesize that evidence. I have no financial interest in either of these entities. Clinical Evidence covers 200+ topics and is based on randomized-controlled trials, which makes it most useful for treatment questions. DynaMed offers a systematic literature surveillance approach, which is an alternative to systematic search-based resources like those mentioned by the authors. DynaMed covers more than 1,800 topics. Topics contain a digest of summaries, emphasizing the clinical conclusions and grading the quality of evidence cited, which is useful for answering foreground questions. The DynaMed Web site describes the surveillance methodology and bibliography, which includes over 100 journals monitored directly, more than 400 journals monitored through multiple journal review services, and collections of systematic reviews, guidelines and drug information. This breadth, along with many direct links to other reviews such as American Family Physician articles, also make DynaMed ideal for answering background questions.

Richard O. Schamp, MD
St. Louis

Authors' response:

We were unable to include many worthy resources because of space limitations. Clinical Evidence and DynaMed attempt to answer higher-level questions using medical literature and are best thought of as resources to answer foreground questions. We agree that the strength of these two resources is that they synthesize evidence about covered topics. Synthesis of information is an important part of evidence-based medicine (EBM). In their landmark book on EBM, Evidence-Based Medicine: How to Practice and Teach EBM, authors David Sackett et al note, "The practice of evidence-based medicine requires integration of individual clinical expertise and patient preferences with the best available external clinical evidence from systematic research." Physicians answering a clinical question must always evaluate the new information in the context of the known medical literature, their clinical expertise and patient preferences, whether it comes from a single article or synthesis.

Jeffrey M. Weinfeld, MD
Washington, D.C.

Kate Finkelstein, MLIS, AHIP
Washington, D.C.