Dialogue with...
Barbara Starfield. 1932-2011
Pediatrician and Professor of Health Policy
at Johns Hopkins University in Baltimore
(USA).
Barbara Starfield, (Brooklyn - New York
City, December 18, 1932) Distinguished
Professor
of
health
policy
and
management at the Johns Hopkins
Bloomberg School of Public Health, passed
away on June 10 at the age of 78. Always
committed with the need for a strong
primary care system all over the world,
her last two years have been occupied
with the lecture/seminar “circuit”:
WONCA (Crete; Philippines; Pan American
Health Organization (Caribbean); Italy
(Pisa); Spain (Zaragoza, Barcelona,
Madrid), Middle East (Qatar and Oman);
Denmark, Norway, South America(Brazil,
Argentina, Uruguay), Canada, New
Zealand on the topics of primary care,
multmorbidity, quality of care, and related
topics.
Looks like we have similar problems in the
medical degree that influence the
upcoming election of general medicine:
faculty specialists, high rents and income
differences between primary health care
professionals and other specialists,
prestige. Is primary health care a hero´s
path?
Primary care should be the pathway of
heroes, as it is becoming more important
over time because of the changes in
medicine that are occurring. Largely as a
result of the successes of modern medicine
over the most recent century, the natural
history of diseases is being altered by a
wide variety of types of interventions.
Most of these interventions succeed in
postponing death but leave the individual
(and population) altered, biologically,
emotionally, and socially.
Biological
changes result from an increasing variety
of foreign substances, some (if not most)
of them toxic to a greater or lesser degree,
but always altering the way in which the
body evolved genetically over hundreds of
thousands of years. The way in which
humans respond to the changing
environments
is
largely
unknown,
unanticipated, and unexplored, as is the
impact of the internal and external changes
on emotions and cognition. Likewise,
society is changing as a result of
technologic innovation, most of it lifeenhancing, but also with unknown adverse
effects.
Unfortunately, the practice of medicine is
not changing to meet these new
challenges. It is still ‘stuck’ in an era where
the major tasks were to diagnosis and
manage discrete diseases that mostly had
discrete causes associated with the impact
of single external agents (‘germs’),
resulting from degradation of cellular
function of unknown causes, or from
premature aging of body organs..
The structure of medical teaching has been
based on knowledge about anatomy
deriving from coroners reports in the
1800s; they are the genesis of the division
Cátedra UPF-SEMG-Grünenthal de Medicina de Familia y Economía de la Salud
of medical personnel largely by organ
system (e.g. pulmonology) or by type of
intervention on organ systems (e.g.
surgery).
But ‘pathology in the modern era is no
longer disease and organ system based.
“Causes’ are no longer discrete. For the
most part, deviations from ‘health’ rapidly
become multisystem dysfunction, because
of the myriad exposures to and
interactions among the biological, the
environmental and social influences. The
complexity of modern living is reflected in
the complexity of pathology and the
increasing variation in manifestations of
what once were specific diseases but now
constitute “multimorbidity’.
“Primary care should be
the pathway of heroes,
as it is becoming more
important over time”
The future of health services must be in
dealing with multimorbidity —interactions
among diseases. This is why primary care
physicians must be the mainstay of
doctoring in the future. If medical
education does not realize the need for a
shift in focus from a disease-orientation to
a person-orientation, medical care will
become increasingly irrelevant.
Let's talk about salaries. Nowadays and
concerning general practitioners, "more is
o should be better? Health Affairs
mentioned the income gap between
family physicians and specialists as one of
the as one of the reasons for not choosing
family medicine.
The problem is that specialists are paid too
much. In the US, medical education is very
costly, and much of the cost is born by the
students themselves. Over time, it is the
power of the specialties that has been
responsible for the disparity between what
specialists and primary care physicians are
paid-----scores of different specialties
negotiating for what their fees should be
and too-few primary care physicians means
that specialists have much more power in
decisions about who earns what. Students
naturally gravitate toward high-earning
specialists, in order to pay back their debts
from medical training. What happens in
the US heavily influences what happens in
the rest of the world; the prestige of high
earnings conveys the sense that they are
‘worth more’. Governments have been
reluctant to challenge professional
prerogatives in decisions about what they
are ‘worth”. Competition within and across
countries for the medical workforce leaves
this situation unchanged. It will take
international agreements to begin to
address this issue. Organizations like
WONCA need to be much more active in
advocating for primary care worldwide.
Ironically U.S. primary health care is
limited because access to specialists is
straightforward, however there are
excellent universities all of them with
departments of family medicine, and in
Spain, with a strong focus on primary
health care (as politicians say), their
presence at university is null.
It is not true that all universities/medical
schools have family practice units. In fact,
the most prestigious schools in the US
(Harvard, Johns Hopkins) do not. And even
in the ones with family practice
departments, the one family medicine
department is routinely out-voted in
decisions by the vast majority that are
specialty departments. So the curriculum
at most medical schools (perhaps with the
exception of some very new ones) is mostly
disease and specialty oriented.
Most
rotations are through specialty clinics. The
faculty are overwhelmingly specialists and
they actively discourage students from
even thinking about going into primary
care because they are ‘too smart’. Every
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medical student will confirm having this
experience. It is a very brave medical
student who applies for a family medicine
postgraduate training. It is the active
efforts of specialists to discourage primary
care that is the problem in training.
There is evidence that more is not always
better. With much less percentage of GDP
devoted to health care, similar results are
achieved, sometimes better, investing in
other ways to achieve health. Any lessons
for countries (including Spain) that have
increased their spending on health in the
last decade?
The main issue for costs of care is to avoid
interventions that are unnecessary. There
is a large literature on how to decide on
which interventions are worth their costs,
but some interventions are not worth ANY
costs. Some countries (such as the NICE
agency in the UK) have well-developed
efforts to make decisions on which
interventions are not indicated in any
circumstances. In the US, about one third
of excess costs are a result of unnecessary
or contraindicated interventions. (An
additional third is a result of high
administrative costs because of private
health insurance, and one third is a result
of very high prices for services in the US)..
Part of the problem is a result of a poor
evidence base for deciding on which
interventions are useful and which are not.
Even the best conducted (internally valid)
‘gold standard’ evidence based on
randomized clinical trials (RCCTs) usually
lacks external validity; that is, it is not
widely generalizable to populations
because the study population was selected
by specific age, by absence of comorbidity,
or by other characteristics that are not
similar to the general population. For
example, the results of most RCCTs are not
applicable to the elderly, or to children, or
to people with more than one disease--which are most of the people on whom the
intervention will be used!
“The problem is that
specialists are paid too
much”… “the prestige of
high earnings conveys
the sense that they are
worth more”
Moreover, interpretation of RCCTs and
their incorporation into guidelines usually
does not take into account the fact that
VARIABILITY in results is generally
neglected in forming guidelines. That is,
even in RCCTs, not everyone responds in
the intended way, yet when guidelines are
applied, everyone is expected to respond
in the same way. Furthermore, the DEGREE
of likelihood of adverse events needs
consideration in interpreting the results of
RCCTs before new treatments are accepted
for use in populations.
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Thus, in order to deal with the issue of
rapidly rising costs, it is increasingly
necessary for policy makers to insist on
better evidence of utility and with minimal
likelihood of adverse events.
In time of recession and although the U.S.
begins to grow very slowly, moving from
private insurance like yours to a universal
public health insurance seems a little
complicated. Do you think it´s possible to
maintain public insurance commitments?
“Obama´s reform”, a remedy to control
the expansion of health care spending
(although
the
experience
of
Massachusetts in the absence of primary
care was the opposite) or opportunity for
universal health care?
Many people in the US are in favor of a
‘single payor’ system. The US already has a
‘single payer’ system for the elderly; it is
called Medicare. It was formed in 1965
and is very popular because the
government uses a social security system
to pay for much of the care for all of the
population of ages 65 and over (please
note that people still have to pay part of
the costs.) Although many Congressmen
were in favor of making single payer part of
the reform, the health insurance
companies lobbied hard to remove this
possibility from all proposed legislation
(because it would be a threat to put this
industry out of business) so that it is not
even permitted to be considered by
individual states in their attempt to make
state-based reform.
“Obama’s reform” is primarily an attempt
to bring universal health insurance to the
only industrialized country that does not
now have it. It is NOT a primary care
reform. It mandates that everyone have or
buy health insurance, giving some financial
help to those who cannot afford to buy it.
It is not primarily an attempt to reduce
costs, although the thought is that people
who have insurance are more likely to have
a primary care doctor. The thought is that
more use of primary care will lower costs
although there is nothing that, in itself,
mandates where people seek care. The
problem in Massachusetts is that there are
not enough primary care physicians to
serve the population. As the same is the
case in the country as a whole, mandating
insurance will, most probably, increase
costs as more people will have access to
specialists. There are provisions in the law
for encouraging the production of more
primary care physicians, but very little
money is allocated to do this.
“It is important to find
a way for public health
and primary care to
find ‘common ground’ “
While it is true that greatly improving
health, and especially equity in health,
would require better social, environmental,
and educational policies, we know that a
good health system, built on the
foundation of primary care, can improve
the situation. That is why any reform
proposal that has the goal of improving
Cátedra UPF-SEMG-Grünenthal de Medicina de Familia y Economía de la Salud
overall health and equity in health has to
be heavily focused on good primary care in
addition to financing reform (which is what
the Obama plan really is)
The challenge of the XXI century, moving
from a “national sick system” to a national
health system, giving more importance to
prevention and health care determinants?
What about a “joint venture” between
primary health care and public health,
both in the driver´s seat?
Yes---it is important to find a way for public
health and primary care to find ‘common
ground’. Dr Francisco Sevilla in Spain and I
did a study of several countries about ten
years ago. We found that the countries
varied greatly in who had responsibility for
various aspects of prevention (see REV ESP
SALUD PUB 2004; 78:17-26). We found
there was great variability.
“In Spain, family
physicians are a
relatively new
profession; with time
and with an active
Society, the family
physician should gain
stature”
Deciding who should do what is very
difficult. It seems clear that for
interventions
that
concern
health
protection, health promotion, and primary
prevention that apply to ALL people (such
as advocating for laws and regulations on
food safety) the responsibility is public
health. Where the intervention is for
specific individuals with individual needs,
the responsibility is for primary care, but
public health needs to play a role by:
establishing health policy to facilitate the
provision of services in primary care and to
establish and support information systems
and community support personnel that
help primary care physicians to provide
better and more timely care. I believe that
public health agencies have NOT yet
learned how to do this. They need to be
encouraged to do this.
Any recipe for overcoming the discredit of
the family physician in Spain?
Family physicians as a group need to
engage the press to better understand
what family physicians do. Television
programs like Marcus Welby MD did a lot
to raise the esteem of primary care, but
there are few if any such programs now.
Family physician groups also need to
participate in research efforts to obtain
knowledge about primary care issues (like
multimorbidity) to show that they have
their own area of special expertise.
In many places (like the UK and Canada),
the family physician is held in high regard.
Particularly in England, the Royal College is
very visible, and there is a long history of
building of the GP profession in that
country. I think the same is true in
Denmark and Norway. In Spain, family
physicians are a relatively new profession;
with time and with an active Society, the
family physician should gain stature.
PLEASE NOTE THAT Dr. Starfield's
powerpoint book on primary care is now
freely available on the website:
http://ocw.jhsph.edu/courses/starfieldcou
rse
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