Corporate control corrupts medicine and reduces healthcare quality

Medicine and health care is always changing, and the pace of change seems to be accelerating. Some of this change is good for people -- some of the new drugs that come out actually help, either a lot of people, or more commonly a few people. Sometimes new treatments are more effective, less painful, shorter, or less debilitating than older ones. And, sometimes, they are not. One thing we can be sure of, though, when we see a new treatment advertised, whether on TV or in a magazine or on a billboard, is that someone is making a lot of money on it.

There has been a great deal of coverage of two of the most important and egregious industries in which large corporations make lots of money at the expense of our health: pharmaceuticals and insurance. They deserve it, and I have written about them often. But another extremely important area where corporatism and corporate culture has taken hold and is expanding is in the ownership and management of hospitals. The most important thing about this increasing corporatism is that it is about making money (even in “non-profit” hospitals), not primarily about providing the health care that people need; of course, if what you need (or can be persuaded to buy) is profitable for the hospital, they’re all about it. For example, new surgical techniques and imaging, and particularly high-margin, low risk procedures like joint repair and replacement in otherwise relatively young healthy people (let’s go for that high school quarterback or 40-something weekend warrior). Not so much problems that occur in people who have multisystem disease, are old, are high risk, or are poor and uninsured. And some stuff – like psychiatric treatment for the most needy, or trauma care, are big money losers. Hate that if you’re a CEO, although might be good if you are a person who needs it.

This trend has been going on for a long time, particularly in large metropolitan areas, where most big hospitals are, and most of them are now part of hospital systems. Of course, big hospitals were always big, but the overemphasis on making decisions based upon money rather than people’s health has been accelerating. And more recently the process has taken over hospitals in smaller communities, including Critical Access Hospitals in rural areas. The Critical Access designation is meant to reflect the geographic isolation of a community, such that travel to the next-closest hospital creates real health risks for the population, and so even if operating it is inefficient, it receives federal support.

This is discussed in an outstanding editorial by Andrea Wendling in the October 2018 issue of Family Medicine, “Times Are Changing”. Dr. Wendling focuses on two major areas, the reinterpretation of the “value” of physicians and the role of family physicians. Family physicians are the most common specialists in rural areas, in part because they can have such a wide scope of practice. They can care for the medical problems of adults and children, deliver babies, provide care for many musculoskeletal problems, mental health, women’s health care, and provide many procedures. At least as important to patients, they can see them in all the venues where they need to be seen – the office, the hospital, the nursing home, and even the patient’s home. Dr. Wendling notes that this is threatened by the corporate perception of physicians’ value, which is their value to the system, measured financially, rather than their value to the health of the community. Yes, you might find it beneficial to have a doctor who knows you, who has cared for you and your family for years, be able to see you in whatever setting you find yourself in, but the system has decided it is more efficient (read “more profitable”) to have your doctor be only an ambulatory care provider, or only a hospitalist.

It is not only family physicians who are affected, although they predominate in rural areas. While some specialists – those that provide care that is not necessarily the most important, but is the most profitable – have always been more highly paid and more sought after by health systems, even they are seeing decreases in their pay and status. It is hard for the family physician to cry for slight cuts in the income and power of doctors (like orthopedists and radiologists) who are making many times what they do, and in fact it is hard for most Americans to cry for the plight of even the lowest-paid doctors. Perhaps it feels like crying for the white men who bemoan their loss of privileges (real and desired) because women and minorities are finally moving the playing field to being, at least a little, more equal. But the corporate influence is far more malignant.

Family doctors believe that their contribution to people’s health is relatively greater than their income. Doctors believe that, whatever their income, they are working to improve people’s health. CEOs and corporations believe that health is a good thing to try to sell, provided we sell the kind that makes money. They do not put the health of the community first; they put the financial well-being of the corporation first. And, not surprisingly, this affects both poor and rural communities the most, because of the limited access to services they had in the first place; an arrogant and self-serving corporation taking over the only hospital in a community does not bode well for the overall health of the people who live there.

And, adding insult to injury, it is not only the dollar-centered approach that is a problem, it is the egos of the local leaders who, emulating their corporate bosses and our political class, think that they as individuals are important and deserve respect and obeisance. I have a friend who led the physician group at a rural hospital when it was taken over by a larger system, and helped negotiate the criteria for bonuses for the medical staff. Soon after, that physician was fired by the local CEO for “embarrassing them”! The doctor got their job back with the help of lawyers, but imagine the gall of that CEO! If what they were doing was right and good, they had no reason to be embarrassed; if they had reason to be embarrassed because what they were doing was corrupt, self-centered, not good for the physicians or for the community’s health, what they were doing was wrong and should have been exposed. I have no doubt that if the people in that town were asked who they valued more, the physician who had cared for them for years or the new CEO put in by a corporation, which one would get more votes. Maybe the CEO would get that of their spouse.

So we have a health care system that is structured to be corrupt, from the insurance companies, to the drug and device makers, to the big health systems, all geared to profit. We have many physicians, in all specialties from the rich and powerful subspecialists to the family physician, who are trying to figure out how to stay on the “good side” of these corporate systems and of the local martinets. We have physician leaders, in hospitals and medical societies and academic departments who often are looking mostly at themselves and how to show that they as individuals are important (like that rural CEO), maybe believing that what is good for them is somehow good for people. Sadly, this is even true in family medicine, no longer the ‘counterculture’[1]its founders, like Gayle Stephens, wrote about, but now often simply other supplicants for corporate largesse.

All of this is at worst immaterial and at best subsidiary. The criteria for whether a healthcare system or aspects of it are good is whether it improves the health of people and the community. We have a long way to go in our healthcare system. And it’s long since time to get started.

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[1] Stephens GG. Family Medicine as Counterculture. Fam Med 1989; 21(2):103-9.

Free tuition in medical school is only one step toward producing the doctors America needs

The NYU School of Medicine shook the world of medical education recently by announcing that tuition would be free. The NY Times article about it says that ‘Rising tuition and six-figure loans have been pushing new doctors into higher-paying fields and contributing to a shortage of researchers and primary care physicians.’ Certainly, it is easy to understand that a $55,000 per year tuition bill is going to be way beyond the ability of most medical students and their families to pay, and that a total indebtedness that is often over $250,000 may well affect the specialty choice of medical school graduates. While physicians in any specialty make far more than the average American, compound interest makes the payments a lot more than $25,000 a year for 10 years; often more, indeed, than that average American income (think about the payments on a $250,000 home loan, which usually has a lower interest rate). This may tip the balance between choosing betwee, say, family medicine or anesthesiology, when the latter choice can be expected to result in an additional $7 million in lifetime income.

The other, presumably obvious, impact of free tuition could be the ability of the school’s admissions committee to take more students from lower income families than they currently do. Note “lower income” is not necessarily the same as “low income”, as 80% of medical students now come from the top 20% of income. And, yet, they still have a lot of trouble paying for school, tuition plus the Times’ estimated $29,000 a year in living expenses (in NYC). It is not necessarily true that ability to pay is a significant criterion in the admissions decisions of medical schools, but rather that there are confounders. A big one is that being from a high-income family is associated with having the higher grades and test scores that are so valued by medical school admissions committees (probably especially those, like NYU, that are very interested in producing MD/PhDs and other laboratory researchers). Free tuition, however, might mean that those students from lower-income families who do gain admission will be under less financial pressure to take paying jobs while in school (a really bad idea when trying to succeed in medical school). In addition, those students who have started their own families or whose families of origin have counted on them helping to support them, would have one big less thing to worry about.

We definitely need more family physicians and other primary care doctors than we are producing now (and NYU has produced one of, if not the, lowest number family physicians of all US medical schools). We also need far more students from lower-income and underrepresented minority and rural backgrounds. The reason is not just for ethical or moral, or making up for past practices. It is directly about providing quality healthcare to all the American people, because physicians are most likely to practice in settings like those in which they grew up and feel most comfortable. Thus, students from upper-middle and upper income, primarily white (and Asian) suburbs are most likely to practice in those settings – which are precisely those least in need of more doctors. Students from rural or low-income or minority communities are much more likely to practice in such communities, and these are the places most in need of more doctors. Of course, the correlation is far from 100%, but the trend is overwhelming. Thus, to the extent that free tuition can increase either of these goals, it would be a great thing.

So what is the problem? Well, it is far from certain that free tuition will lead to these desirable outcomes. This point is made by family physician (and NYU medical school graduate) Kenny Lin, MD, in his Common Sense Family Doctor blog. Although Dr. Lin’s 2001 class had only four graduates entering family medicine, it was a larger number than any class since. He points to the fact that NYU has never had a Department of Family Medicine (one of the few such schools, almost all of which are “elite” private and on the East Coast). He also notes that in terms of producing other primary care doctors (general internists and general pediatricians), NYU has also done very poorly.

More important, Dr. Lin cites a study published in the JAMA Network by Grischkan, George, Chaiyachati, et al., that demonstrates that students entering family medicine (one of the lowest paying medical specialties) have a higher average debt load than those entering fields such as radiology, dermatology, and ophthalmology. He writes

These findings suggest, paradoxically, that physicians with the highest debt burden are preferentially choosing a specialty with among the lowest income expectations - why on earth would that be? What it says, actually, is that students from less well-off backgrounds are more likely to be attracted to primary care in the first place.

This is a very important point. Dr. Lin, focused on the critical issue of producing more family physicians and primary care doctors, believes that eliminating tuition and thus taking students from more diverse backgrounds “will likely have a small, but measurable, positive effect on primary care.” He urges that NYU and other schools increase their “pipeline” programs to help students from less advantaged background gain the skills that they need to be both admitted to and successful in medical school. I agree, but I would go beyond that.

Medical schools should train the doctors America needs. This means fewer subspecialists, and more primary care doctors. This means a smaller percentage of doctors practicing in the suburbs of big cities, and a larger percentage practicing in rural areas and underserved inner-city communities. This is not going to happen if we keep taking the same students we currently do, no matter how nice they are, no matter how high their grades are, and no matter how much they are like (or often are) the children of the faculty of the medical school. If you don’t think this is important, a recent paper from the National Bureau of Economic Research by Alsan, Garrick, and Graziani titled “Does Diversity Matter for Health? Experimental Evidence from Oakland” (reported in the Times article “The Secret to Keeping Black Men Healthy? Maybe Black Doctors”) demonstrates that it does: a significantly higher percentage of black men received important tests, took medicines, and made lifestyle changes when advised to by a black doctor rather than a white or Asian one. Importantly, this comes from more than a knee-jerk reaction to the race of the physician; it has a lot to do with how they were treated. While the ‘white and Asian doctors often wrote comments like “weight loss,” “tb test” and “anxiety” — cryptic notations that referred to medical recommendations…black doctors often left more personal notes, like “needs food, shelter, clothing, job’. This goes beyond race, and suggests that both our overall medical curriculum focuses too much on the disease and not the person, and further that minority physicians may be more likely to realize that it is a person who needs to be treated, and identify the social determinants of health.

Indeed, Elisabeth Rosenthal, the editor of Kaiser Health News, argues in an Op-Ed in the Times that medical school should be free only for those who make a firm commitment to entering specialties and practicing in areas that have real need:

…if a student chooses to become an ear, nose and throat surgeon in suburban New York or a private cardiologist in Miami, fine. He or she can pay back what has been borrowed. But if that doctor chooses to deliver babies in rural Oklahoma or practice pediatrics on the South Side of Chicago, then he or she should get to keep every penny of salary.

I agree, and believe that to make this likely, medical schools, both private “elite” schools like NYU, and certainly state-supported schools, need to take a much higher percentage of students from the lower half of the family income scale, from rural areas and from groups that have been historically underrepresented in medicine. And not just a few more, not just a pilot program with 2% or 5% or 10% of the class. These programs must be far more extensive. The entire classshould be composed either these groups of students or of students who, while perhaps from wealthier, whiter, more suburban backgrounds, have demonstrated an extended commitment to service to others. Extended, like the Peace Corps, or Teach for America, or VISTA, or working abroad for years in service programs, not a car wash fundraiser one Saturday.

Some, and sadly this may include many in the administration of medical schools, particularly “elite” ones, will say this can result in the exclusion of the “best” applicants. It may, in fact, lead to the exclusion of some of those with the highest grades, and may even require additional work on the part of the faculty to help students with less rigorous academic preparation. Or, perhaps, elimination of much of the nonsense memorize-detail coursework of the pre-clinical curriculum. But while “best” can mean many things, if the definition is not “most likely to make a positive difference in the health of all the American people” it needs to change, and soon.

Free tuition, at NYU, or other private schools, or state-sponsored schools, may be a terrific idea, and one that should be widely imitated. But it is only one part of an overall strategy, including changes in the selection of applicants, the curriculum of the schools, and the reimbursement of primary care, to significantly change the kinds of doctors that are produced so that they meet our nation’s needs.

"The Child is the father of the man: family physicians' screening for adverse childhood experiences

"The Child is the Father of the Man: Family Physicians’ Screening for Adverse Childhood Experiences", my editorial accompanying an excellent article on Adverse Childhood Experiences (ACEs) in the latest issue of "Family Medicine", at 
http://www.stfm.org/FamilyMedicine/Vol49Issue1/Freeman5