Tuesday, July 24, 2012

Paul D. Simmons, MD, FAAFP
Family medicine is a young specialty, a mere forty-three years old (1).  Unfortunately, family medicine will be extinct before it reaches its 70th birthday if current trends continue and—although I write as a family physician who educates family medicine residents and loves the idea and ideals of family medicine, I say—this might not be a bad thing.  Several forces, both from within and external to family medicine, are conspiring to make us irrelevant, unnecessary and obsolete.  We’ve all seen the Match Day trends (2).  Each year until 2010, fewer medical students pursued training and careers in family medicine, and the slight increases over the last few years are largely attributable to more family medicine residency positions available.  We cannot fill our available positions with US graduates.  Many of those who match in family medicine are trained in a shrinking spectrum of skills.  Many new graduates quickly jettison any broader skills they may have had in the name of work-life balance (3).  Across the country, specialists and insurers implicitly or explicitly argue that family physicians cannot and should not be doing surgical (or non-surgical) obstetrics, endoscopy, minor surgery, ICU care or hospital medicine (4).  We are often complicit in this effort to minimize our domain of practice, again in the interest of lifestyle or avoiding liability.  
As our skills and practice scope are diminishing, a wave of mid-level practitioners (i.e., physician assistants and family nurse practitioners) are moving into primary care medicine (5,6,7).  They share many of our same skills, are able to prescribe and order just as we are in a growing number of states, and are paid less.  Most of these so-called “physician extenders” do excellent work and are viewed as equivalent to physicians by many patients.  It is inevitable that health systems, policy-makers and third-party payers will soon realize—with dollar signs in their eyes—that these practitioners are inexpensive physician substitutes rather than physician “extenders.”  All of the skills, more empathy and a similar scope of practice without the egos or paychecks of physicians.
Sadly, family physicians are ill-equipped to resist our own demise because we lack a clear sense of what, exactly, it is we do.  Not only does the public have little sense of how a “family doctor” differs from an old-fashioned “GP” or an internist, many of us have a difficult time explaining the distinction apart from defensively sputtering, “We’re a specialty, too!”  Family medicine, some say, takes care of 90% of medical problems that present in the outpatient setting.  Of course, so do internists (for adults), pediatricians (for children), and emergency physicians (for everyone).  Family medicine, some say, provide continuity of care over the lifespan.  Perhaps thirty years ago this was true.  Now, however, vanishingly few family physicians will spend a career in the same location, taking care of the same population.  
Even more troubling, however, is a deeper sense of inadequacy within the family physician’s psyche.  Yes, I take care of adults, but can I really do so as well as an internist?  Yes, I take care of children, but can I really do so as well as a pediatrician?  I may deliver babies, but can I really provide the same quality of care as an obstetrician?  If the reader balks at these questions, consider:  if your wife were to experience a pregnancy complication, and you had the option, would you ask for an obstetrician or a family physician?  If your child was suddenly struck with serious illness, would you bring her to a pediatrician or a family physician?  We claim we are “equal” to our specialty colleagues—yet when serious or complex illness strikes those we love, we may find we have been playing doctor and we want a Real Doctor to step in to save us.  Do patients sense this as well?
The larger medical world certainly seems to have detected our impotence.  Family physicians exert minimal or no influence in determining our own payment structure, nor are our protests taken seriously.  The Accreditation Council of Graduate Medical Education (ACGME) frequently ignores or delays our specialty’s recommendations or intentions (8).  The AMA/Specialty Society Relative Value Scale Update Committee (RUC) continues to perpetuate an unjust payment model despite our protests (9).  Family physicians are not the doctors that come to mind when patients think of disease-detecting, mystery-solving “experts” at the Mayo Clinic or Cleveland Clinic, nor do many tertiary- and quaternary-care institutions see a significant role for us in their delivery of medical care.  Our medical journals are of comedically dubious quality, and we seem to be best at publishing, if anything, within the review article genre (10).
Our support for the Patient-Centered Medical Home (PCMH) model, for example, while predicated on admirable ideals, could easily be speeding our demise.  The PCMH model rests on the idea of team-based care, where many of the functions previously carried out by physicians are delegated to nurses, medical assistants and case managers.  This is intended to free up the physician to deal with the “hard” cases for which we are best suited.  The problem is: we are not best-suited.  The endocrinologist is best-suited to deal with the complicated, uncontrolled diabetic patient that cannot be brought under control by the nurse practitioner’s efforts.  Similarly, the cardiologist is best-suited to deal with the refractory hypertensive; the gastroenterologist with the complicated hepatitis C patient.  The family physician, in the PCMH model, is an unnecessary (and expensive) middle-man who has very little to add to the best management efforts of a high-functioning team operating with evidence-based protocols and guidelines.  Inevitably, someone in authority will realize this cost-saving, simplifying fact.
While our specialty shrinks and delegates itself out of existence, some of us take refuge in the ridiculous romanticism of “biopsychosocial” or “patient-centered” or “holistic” flag-waving—as if patient’s would rather have sympathetic hand-holding than competent, efficient, expert medical care.  That’s all fine, of course.  We’re generally nice people.  But while we’re spending our collective efforts on patient focus groups, learning acupuncture, satisfaction surveys, lifestyle balancing acts and “restoring the mystery” to medicine, our colleagues in internal medicine, pediatrics, obstetrics, critical care, surgery and emergency medicine are taking care of actual seriously sick people and showing that they can do a better job of it than we can.  Perhaps we should step aside and let them get back to work.
1.  Piscano, NJ. (n.d.) History of the Specialty. From American Board of Family Medicine website.  Retrieved from https://www.theabfm.org/about/history.aspx.
2.  Porter, S. (2012) Family Medicine Match Rates Increase Slightly.  AAFP News Now, American Academy of Family Physicians.  Retrieved from http://www.aafp.org/online/en/home/publications/news/news-now/education-professional-development/20120316matchresults.html.
3.  Kotmire S. (2012) Shrinking Scope of Practice Raises Questions About Future of Family Medicine Training.  Leader Voices Blog, American Academy of Family Physicians.  Retrieved from http://blogs.aafp.org/cfr/leadervoices/entry/shrinking_scope_of_practice_raises.
4.  Should Colorectal Surgeons and Family Doctors Perform Colonoscopy? (2012).  Gastroenterology.com, retrieved from http://www.gastroenterology.com/featured/should-colorectal-surgeons-and-family-doctors-perform-colonoscopy.
5.  Rough G.  (2009).  For many, a nurse practitioner is the doctor.  Arizona Republic.  Retrieved from http://www.azcentral.com/news/articles/2009/02/21/20090221nursepractitioners0220.html.
6.  Horrocks S, Anderson E, Salisbury C.  (2002).  Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. British Medical Journal 324: 819-23.  Summary retrieved at http://apps.who.int/rhl/effective_practice_and_organizing_care/SUPPORT_Task_shifiting.pdf.
7.  Flanagan L.  (1998).  Nurse practitioners:  growing competition for family physicians?  Family Practice Management 5(9): 34-43.  Retrieved from http://www.aafp.org/fpm/1998/1000/p34.html.
8.  Wood J. (2012).  Changing training standards for maternity care. Leader Voices Blog, American Academy of Family Physicians.  Retrieved from http://blogs.aafp.org/cfr/leadervoices/entry/changing_training_standards_for_maternity.
9.  AAFP Opts to Remain in the RUC (2012).  AAFP News Now, American Academy of Family Physicians.  Retrieved from http://www.aafp.org/online/en/home/publications/news/news-now/inside-aafp/20120313rucdecision.html.
10.  Van Driel L, Maier M, De Maeseneer.  (2007).  Measuring the impact of family medicine research:  scientific citations or societal impact?  Family Practice (2007) 24 (5): 401-402.  Retrieved from http://fampra.oxfordjournals.org/content/24/5/401.full.

Thursday, March 1, 2012

Smallpox Eradication: Public Health One-Hit Wonder?

“It is my opinion that we never should have landed a man on the moon. It's a mistake. Now everything is compared to that one accomplishment. Now everybody goes ‘I can't believe they could land a man on the moon . . . and taste my coffee!’ I think we all would have been a lot happier if we hadn't landed a man on the moon. Then we'd go, ‘They can't make a prescription bottle top that's easy to open? I'm not surprised they couldn't land a man on the moon. Things make perfect sense to me now.’”

- Jerry Seinfeld (1994)

The eradication of smallpox was such an enormous scientific and humanitarian success that it has forever raised expectations for public health interventions--perhaps, as Jerry Seinfeld might point out, to the overall detriment of public health! If we can pool our resources, overcome political differences, make a commitment and eliminate a disease that once caused 10% of all deaths (Friedman and Issacs, 2009), then why can’t we eradicate malaria, malnutrition or HIV?

Smallpox presented a unique opportunity to the planners and leaders of eradication efforts. As Friedman and Issacs (2009) describe:

- Human beings were the only known reservoir for the virus.
- No asymptomatic carrier state existed.
- An effective vaccine was available.
- Vaccination of contacts resulted in prevention or modification of disease.

These features made smallpox eradication a feasible outcome objective and provided workable answers to key managerial questions:

Where are we? The problem was a virus that was (a) endemic in every country in the world and (b) had a 30-50% mortality rate. However, with no natural reservoir other than humans, eradication was possible. Variolation (AD 10th century India and China) and vaccination (Jenner in 1796) had been proven effective in mitigating or preventing infection.
Where do we want to be? The goal was complete, universal elimination of smallpox. Lesser goals were unacceptable both because of the severity of disease and the feasibility of eradication.
What should we do? Interestingly, the WHO Smallpox Eradication Programme is most accurately seen as a successful bottom-up effort, in that it appropriated techniques from successful local efforts, including those of the Soviet Union in the late 1950s (during the Cold War, no less!) (Tulchinsky and Varavikova, 2009). The WHO effort learned and adjusted rapidly, keeping in mind its overall outcome objective and avoiding the pitfall of “outcome displacement” (i.e., satisfying itself with activity measures and process objectives alone).
How do we know that we are getting there? The worldwide effort to eradicate smallpox was only as effective as its information was accurate. Without local-level surveillance efforts and case-reporting (exemplified by India’s 1975 Operation Smallpox Zero assessment index (UCL, 2006)), the WHO could not have known whether its vaccination, surveillance and isolation efforts were actually working.

Although the success of international efforts to eliminate smallpox cannot be directly translated to other infectious diseases (which have natural reservoirs, mutate more quickly or have asymptomatic carrier states), or to non-communicable public health problems (e.g., malnutrition, which has multiple contributing factors and determinants), some lessons are certainly applicable to all public health programs:

- Clearly identify the problem and the outcome objective to improve the chances of success. Furthermore, avoid the temptation of “outcome displacement” - do not substitute a surrogate outcome for the outcome of interest.
- Be willing to adopt effective local methods. There is almost always more than one process by which impact objectives can be reached. Let the local people work out their own solutions, so long as the overall objective is not compromised.
- Timely, accurate measurement and feedback is essential. To remain flexible and adaptive, any program has to have access to up-to-date and reliable information.

We may not land on the moon or eradicate smallpox’s equivalent health problem anytime soon, but lessons in successful management are nevertheless applicable to more modest projects.


Cherones T. (Director). The Dinner Party, episode 77 (1994, February 3). Seinfeld [Television broadcast]. Beverly Hills, CA: Castle Rock Entertainment.

Friedman H. M. and Issacs S. N. (2009). Smallpox. In Basow D. S. (Ed.), UpToDate. Waltham, MA: Wolters-Kluwer Health.

Smallpox (2003). in Encylopaedia Britannica (15th ed). (Vol. 10, pp. 887-888). Chicago, IL: Encyclopaedia Britannica, Inc.

Smallpox control in India (2006). University College London (UCL). Retrieved from www.smallpoxhistory.ucl.ac.uk/India/IndProject.htm.

Tulchinsky T. H. and Varavikova E. A. (2009). The new public health (2nd ed.). Burlington, MA: Elsevier Academic Press.

Turnock B.J. (2009). Public health: What it is and how it works. (4th ed.). Sudbury, MA: Jones and Bartlett Publishers.

Tuesday, January 31, 2012

A Gun To Our Head: The 1976 Swine Flu “Debacle”

For a nationwide effort deemed--in the perfect vision of historical hindsight--a “debacle,” the coordinated efforts of multiple federal agencies, state health departments, and local volunteer organizations and individuals to prevent a “strongly possible” (Neustadt, et al., 1978) swine influenza epidemic in the winter of 1976-77 were uniquely successful from several perspectives. Prior to 1976, there existed no organized, efficient way to rapidly manufacture and deploy hundreds of millions of doses of vaccine, no way to perform nationwide disease and adverse-effect surveillance in real time, and no appreciation for the legal and logistical challenges that would result from such an effort. The lessons our public health infrastructure learned from the 1976 “debacle” are important tools we still use today.

The story starts with the sudden appearance of a respiratory disease outbreak among Army recruits returning from Christmas break to Fort Dix, New Jersey, in January 1976 (Gaydos, 2006). Martin Goldfield, a civilian epidemiologist (who would later strongly and publicly criticize the vaccination campaign), sent samples from the Fort Dix patients to the Centers for Disease Control (CDC), where on February 12th, lab director Walter Dowdle reported that a previously unidentified viral vector was swine influenza antigenically similar to the virus responsible for the 1918 pandemic. On Feburary 14th, CDC director David Sencer met with representatives from the Food and Drug Administration’s Bureau of Biologics (BoB) and National Institute for Allergy and Infectious Disease (NIAID) (both of which were responsible for licensing and testing vaccines), the Army and Dr. Goldfield to discuss the potential early outbreak.

By March, all reported cases (500 total, all in young, previously healthy recruits) were still confined to Fort Dix, but Sencer and his colleagues knew three worrisome facts so far: (1) human-to-human transmission was occurring, (2) no “herd immunity” existed in patients younger than 62 years old, and (3) traditional “high risk” groups did not apply--this virus was attacking the young and healthy, just as in 1918. On March 13th, Sencer sent an “action-memorandum” to the Secretary of Health, Education and Welfare (HEW) that became the motivating declaration for the nascent national immunization campaign. In the memorandum, Sencer wrote of a “strong possibility” that a swine influenza epidemic would occur during the 1976-77 season, and that the government must act swiftly and decisively to prepare. Although the memorandum was moderate in its tone, it argued that “less than 100% coverage” by vaccination would be “socially and politically unacceptable.” In subsequent meetings with Secretary Mathews (HEW), Sencer boldly argued with even more certainty that an epidemic would occur. Mathews took Sencer’s memo to the White House, where it was felt to be “a gun to our head” -- the social and political fallout of failing to prepare would indeed be a nightmare. President Ford chose to act and announced his decision to the public, flanked by vaccination luminaries Salk and Sabin, on March 24th.

The CDC, with limited time and resources, focused on encouraging planning by state health authorities, setting standards, allotting administrative funds to the states, purchasing vaccine on their behalf, conducting surveillance of disease and adverse effect activity, and encouraging involvement of private physicians and volunteer organizations. In comparison, the state and local public health organizations were responsible for planning the logistics of vaccine distribution and administration, injection gun acquisition and other details, using CDC-written educational materials to prepare the public. The CDC was simply unequipped to work on a state or local level, except to help in defraying costs and advising.

On the vaccine side of the effort, the NIAID and BoB acted as liaisons between the federal government and private vaccine manufacturers. These organizations conducted field trials and testing, and were instrumental in the decision to stop manufacture of the Victoria flu strain vaccine (which had been responsible for the 1975-76 flu season, including the majority of Fort Dix cases). Instead, it was decided to use all available resources to manufacture swine flu vaccine and combine it with the existing 30 million doses of Victoria vaccine to create bivalent vaccine doses for those at highest risk.

The coordination of these organizations across the federal, state and local levels was unprecedented and, in many ways, worked well. The first doses of swine flu vaccine were given in October 1976 and before the campaign was stopped, 40 million doses were given (over twice as many as had ever been given in any previous flu season) (Zimmer, 2009). However, the epidemic never materialized. Furthermore, 532 cases of Guillain-Barre syndrome occurred (and were reported “upstream” from local to federal authorities, in almost real-time, to the CDC’s first-ever computerized epidemiologic surveillance system), prompting cessation of the campaign in December (Turnock, 2009). In a sense, the rapid cessation of the program was as much a success of multi-level public health coordination as was the initiation of the 1976 swine flu immunization campaign. There is reason for optimism that the skills the public health system learned from 1976 will be useful the next time a metaphorical gun is held to its head.


Gaydos J.C., Top F.H., Hodder R.A., Russell P.K. (2006). Swine influenza A outbreak, Fort Dix, New Jersey, 1976. Emerging Infectious Diseases. Atlanta, GA: Centers for Disease Control.

Neustadt RE, Fineberg HV. (1978). The swine flu affair: Decision-making on a slippery disease. Washington, D.C.: Government Printing Office.

Turnock B.J. (2009). Public health: What it is and how it works (4th ed). Sudbury, MA: Jones and Bartlett Publishers.

Zimmer S.M., Burke D.S. (2009). Historical perspective--emergence of influenza A (H1N1) viruses. New England Journal of Medicine. Boston, MA: Massachusetts Medical Society.

Monday, January 30, 2012

What’s So Bad About Socialized Medicine?: The British National Health Service

The health care reform debate in America seems to reliably raise the specter of “socialized medicine,” complete with fears of long lines, “cookbook medicine,” rationing and--a more recent canard--the Death Panel. However, the United Kingdom has been somehow surviving under a system of universal, publicly-funded health care since 1948. Riding the post-World War II election of the Labour Party, social reformer Lord William Beveridge’s plan for a National Health Service (NHS) was passed in 1946. A son of generations of poor coal miners, parliamentarian Aneurin “Nye” Bevan then implemented the plan with his unique mix of political strong-arm tactics and artful compromise, achieving the cooperation of insurance companies, hospitals, general practitioners (GPs) and other stakeholders.

Now entering it’s seventh decade, the NHS is still widely popular with the British public. Its organization and governance has changed, but the experience for the patient has not - almost all medical care, from a common cold to a coronary bypass graft, is free. As originally designed, the NHS was divided into three main branches: (1) government-owned hospitals with salaried specialists; (2) GPs and dentists practicing in independent offices, but paid by the NHS; and (3) the public health authority. Reforms in the 1970s and 1980s under Thatcher’s Conservative government simplified layers of administration and improved integration and coordination of services. Further reforms in the 1990s created Regional Health Authorities (RHAs) which received disbursement of tax funding from the Department of Health. The RHAs then distributed funding to smaller District Health Authorities (DHAs), which contracted with hospitals and specialists, and Primary Care Trusts (PCTs), which contracted with GPs for services. More recent reforms have increased competition between hospitals for GP referrals, decreased waiting times, and resulted in improved physician and patient satisfaction.

The philosophy behind the NHS seems to be that, in a system into which everyone pays (with 15-17.5% sales taxes, and higher income and social security taxes than in the US) and by which all are served, it benefits everyone to stay healthy. The NHS incentivizes primary and secondary prevention. Primary prevention is encouraged by a system that pays GPs for implementing proven preventative strategies (e.g., “flu jabs [shots]”). Secondary prevention is promoted by a system that ensures universal access, very low cost (e.g., although a $10 fee is “required” for prescription drugs, this fee is waived for children, pregnant women, anyone over 60, and the chronically ill--that is, 85% of those who take prescription drugs), and evidence-based screening strategies vetted by the National Institute for Clinical Excellence (NICE).

In contrast to the US system, which spends one-sixth of its GDP (the greatest proportion of any industrialized nation) on care heavily weighted toward tertiary and hospital-based care, the NHS salaries specialists--the average specialist in the UK makes less than the average GP! Furthermore, 60% of physicians in the UK are GPs, whereas only 35% of physicians in the US are generalists. The NHS’s distribution of resources and specialties removes the incentives for high-cost tertiary care and shifts the emphasis toward cost-saving (and life-saving) preventive, public and primary health care.

But does it work? The NHS is certainly popular with the British public. As journalist T.R. Reid writes in The Healing of America, “There are private health insurance plans in the United Kingdom, but few people bother with them. Nine of out ten Britons get all their health care from the NHS.” The culture of “no medical bills” is also a point of national pride, as evidenced by the resounding defeat of a 1990s suggestion by the British Medical Association to institute a low copay for all patients. Not only is it popular, the NHS is also cost effective: it provides care for a population one-fifth the size of the United States, for one-fifteenth of the cost. Yet the UK has lower child mortality rates, longer healthy life spans and better recovery rates for most major illnesses.

Not that the UK or NHS are perfect, by any means. Before the reforms made by the Blair administration, a common complaint about the NHS were long waits to see consultants (i.e., specialists). There were several British popular press reports of patients dying while they waited for speciality treatment. However, this problem has been largely ameliorated by Blair’s infusion of funds into the NHS and the implementation of payment-for-results to hospitals and competition among hospitals for GP referrals. The UK, like the US, also continues to suffer healthcare disparities between its social classes--and also as in the US, these health disparities are greater than would be predicted simply from health factors alone. The NHS has not yet closed these gaps.

Despite these shortcomings, the NHS experience would seem to belie the notion that “socialized medicine” is an evil to be avoided. And how un-American can it be? The Veterans Administration system and the Indian Health Service in our own country are quite similar to the NHS: government-paid physicians working in government-owned hospitals for patients who pay little to nothing for the care they receive. It works there, it works here, it lowers costs, it improves outcomes, and it shifts the focus from tertiary to primary prevention.


Turnock BJ. Public Health: What It Is and How It Works. 4th ed. Sudbury, MA: Jones and Bartlett, 2009. [Chapter 3: Public Health and the Health System.]

Safra JE, et al. Encyclopaedia Britannica. 15th ed. “National Health Service,” vol 8, p 534. Encyclopedia Britannica Publishing, 2003.

Tulchinsky TH, Varavikova EA. The New Public Health. 2nd ed. Elsevier, 2009. [“Chapter 13: National Health Systems,” pp. 482-486.]

Reid TR. The Healing of America: A Global Quest for Better, Cheaper and Fairer Health Care. New York: Penguin Press, 2009. [“Chapter 7: The UK: Universal Coverage, No Bills,” pp. 103-124.]