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 Cátedra UPF-SEMG-Grünenthal de Medicina de Familia y Economía de la Salud 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. Cátedra UPF-SEMG-Grünenthal de Medicina de Familia y Economía de la Salud 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 Cátedra UPF-SEMG-Grünenthal de Medicina de Familia y Economía de la Salud
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