“Is there a doctor in the house?” is a Hollywood cliche.  But when it comes to the houses of the United States Congress, the answer is always “Yes.”  Physicians have served in every Congress from the first in 1789 through the current 111th Congress.(1)

Currently, there are 16 physicians who serve as members of Congress (1), 14 in the House of Representatives and two in the Senate (2). With health care reform a pressing issue currently facing the United States, several additional physicians are seeking election to Congress this year in races across the country (3).

Dr. Ami Bera

The Student Doctor Network recently spoke with physician candidate Ami Bera about what health care professionals bring as candidates, and what life is like on the campaign trail for a physician.

Dr. Ami Bera is a Clinical Professor of Medicine and former Associate Dean of Admissions at the UC Davis School of Medicine. He also served as former Chief Medical Officer for Sacramento County, CA where he directed SacAdvantage, a program providing access to care for 200,000 uninsured.

Tell me about the office that you seeking.

I am running for the Democratic nomination for the 3rd U.S. Congressional District in California. The seat is currently held by Republican Congressman Dan Lungren, who has served eight terms and is a former California attorney general. There are three candidates running in the Democratic primary so far: myself, Elk Grove City Councilman Gary Davis and Sacramento Municipal Utility District Director Bill Slaton.

What motivated you to enter the race?

Honestly, it was never a stated goal for me to run for elected office. But after I stepped down from my position as Associate Dean of Admissions at UC Davis, I found myself looking for a way to serve. In the past I have done service behind the podium and have been disappointed by the follow-up on important issues by our elected officials. I realized that I have a desire to change the political conversations we have been having: to move away from doing what is best for one’s polling and promotion to advancing some of the great work on issues that is done by those behind the scenes and at non-profits.

What steps did you take before entering the race?

The idea of entering this race first occurred to me last October. I decided that I would explore the idea instead of focusing on “why shouldn’t I do this.” I started by speaking with some friends who are in the state legislature. They told me I had a great resume on healthcare, and that my experience growing up in an immigrant family would make me a compelling candidate. But they encouraged me to run for city council first and to work my way up the political escalator.

I had no desire to be a career politician and when looking at the race from an intellectual perspective it seemed like the time was right for me to enter. This district is now 40% Republican and 38% Democratic. The demographics have shifted with an increase in minority voters and migration from the Bay Area. With approval ratings for elected officials at record lows and the focus on healthcare, this is the perfect election to run as a non-career politician and a physician. It is a potentially winnable race, an opportunity for me to change our political conversations, and to fix healthcare.

What is your day-to-day life like as a candidate?

After filing in April, the first phase in a campaign was to establish legitimacy. A sad reality of the U.S. political system is that legitimacy is measured by fundraising ability. Generally a day starts around 5:30 am with email and internet communication. I meet with people for coffee and lunch. It is essential to build relationships with potential donors. Also, we have focused on getting people engaged with the campaign and on collecting small donations of $5-$20.

This next quarter ends September 30 and we are still focused on fundraising. I am going to Washington, D.C. to meet with Democratic leaders and to build a buzz about the race.

We have been able to focus more on voter outreach through townhalls and house parties. In the evening I usually attend multiple events. I am working as hard as I did during residency and I do miss having some quiet evenings at home to relax. But I love what I am doing.

What do you love about being a candidate?

When I first started in the race I had to see if I enjoyed being a candidate. I very quickly found that I love it. Being a candidate and talking with voters is a lot like what we are trained to do as physicians. I listen to other people sharing their suffering, ask questions, listen, and reflect back to them. As a physician I am trained to engage with people in tough subjects and this has been an asset as a candidate, especially when discussing controversial topics that can inspire passionate responses in voters.

What have been the most rewarding and challenging aspects of the campaign so far?

It has been very rewarding to put my ideas out there and to see them resonate with people. I try to present my ideas in an authentic way and I want to understand where people in the community are coming from. I have found that by doing this communities have really let me into their lives. This has been a very humbling experience.

The greatest challenge with campaigning is that it involves a lot of talking about myself. I know I have a healthy ego, but I always want it to be less about myself and more about the voters. So I try to find a balance by focusing on my values, telling my story, and presenting the stories of other people I meet. It has been hard because I am not a “sound bite” guy. How do you focus on a topic as complex as healthcare reform in a sound bite? But I have focused on stories and hope that they will stick better than sound bites.

How has being a candidate affected your work as a physician and educator at UC Davis?

I took a leave of absence from UC Davis at the end of June to focus on the race. The medical school has been supportive but as an apolitical organization, they cannot overtly support me.

The students are mostly aware that I am running. I would love to get the students more engaged in the race because I think it is a unique opportunity. But I am very conscious not to push myself on them. I will be teaching periodically, but am largely removing myself from the medical school’s daily activities.

How have your wife and daughter responded to your candidacy?

When I first verbalized my idea to run this past December and January, Janine, my wife, was in disbelief. But after she realized I was serious, she raised questions about how it would impact our family. Would we have to move to Washington, D.C.? To split time between two locations? She did not embrace it at first, but as she has seen it unfold she is in it with me to win. Janine is my best asset and I expect that as we get busier she will represent the campaign at events.

My daughter just started 7th grade, so she does not fully grasp the implications of my candidacy yet. As we get further along we will have lots to talk about and some big decisions to make if I win. In the end I am most concerned about being authentic and running as hard as I can. If I do that and I lose, it is okay. But I am not willing to compromise my self, my values, or my family to win.

Have you always had an interest in politics?

Most of the people in my life who have known me well are not surprised that I am running. I have always been engaged in politics, mostly focused on the politics of change and how to move forward on issues that I care about. My mom would say that I was a pain as a child, always questioning and exploring new ways of doing things. I was very fortunate to grow up in a family that allowed exploration and offered safety and support whenever I fell down.

How have the positions that you have held in the past helped to prepare you for elected office?

My experiences as a physician have given me perspective on all aspects of healthcare delivery. My life has unfolded unexpectedly and I have taken opportunities as they have presented themselves. As chief resident I realized I was interested in working on systems issues. After residency I spent four years in practice at the county medical clinic and as the medical director of care management for the five hospital Mercy system. This experience allowed me to focus on systems issues and way to increase efficiency in care delivery.

I then served as the Chief Medical Officer for Sacramento County and worked on ways to increase coverage for the uninsured. I was then offered the opportunity to look at how we train the next generation of physicians by serving as the Associate Dean of Admissions at the UC Davis School of Medicine. While I never planned to set up these experiences, they have built upon each other and given me a very unique perspective on healthcare.

Tell me more about the program you started to increase coverage for the uninsured.

Using two million dollars from the county and one million from the federal government, we created a program called SacAdvantage that targeted low wage workers and small businesses with two to fifty employees that had not previously offered health insurance. It was built on the employer-based model of care and provided a subsidy from the county to make it affordable for small businesses to cover their employees.

The main problem I see with it now is that it still ties coverage to employers and people could lose coverage if they moved to another state or changed jobs. I now favor offering all Americans a compassionate baseline of health care that is not tied to employers. Additional coverage could then be provided by employers or purchased by individuals.

What do you see health professionals being able to bring to elected office?

All of the training that we have will help us in politics. What makes a good doctor—having compassion, good listening ability, the ability to make hard decisions quickly, and leadership skills—are all essential in politics. As physicians we have a particular ability to articulate the story of healthcare in this country. If voters ask me about “death panels” at a townhall I can tell them about what happens in the ICU regarding end-of-life issues. I find it embarrassing how silent physicians are given that we are held in high esteem by many. As a group physicians need to step up to the plate on healthcare.

If health professional students have interests in politics what do you advise they do to pursue a career in this realm?

I think it is most important for students to discover their passions and what is most important to them. Too often students look decades into the future and try to plan out every step of their career. But it is better to focus on the present than to try to be calculating. Look at what you are passionate about today and work on issues within your sphere of influence, for example resident work hours. It takes courage to address these issues and the skills you build will help if you choose to run for office later. You will learn by doing.

It is also important to know your strengths and weaknesses. Embrace your flaws and your ignorance. That way you will know when to delegate tasks and to let others with greater knowledge take over for you.

How can health professionals with limited time get involved in politics?

I would advise that they find a local organization that does work on an issue that they really care about. Focus on finding one project that can be done to really make an impact. The skills that one builds working at the local level are the same ones that are used in elected office. In politics there is just a bigger stage.

References

1. “Doctors on Hill seek voice in reform debate”, June 15, 2009, AMEDNEWS.com, http://www.ama-assn.org/amednews/200…5/gvl20615.htm

2. http://www.ama-assn.org/amednews/200…3/gvsa0223.htm

3. http://www.beraforcongress.com/, http://www.trivediforcongress.com/, http://www.jayfleitman.com/,  http://wargotzforussenate.org/

Dr. Al Berg

by William Burnett

Alfred O. Berg, MD, MPH, is a professor at the Department of Family Medicine at the University of Washington in Seattle.  He is board certified in Family Medicine and General Preventive Medicine and Public Health.

Dr. Berg’s research has focused on clinical epidemiology in primary care settings.  He has served as chairman of the United States Preventive Services Task Force, co-chair of the otitis media panel convened by the Agency for Health Care Policy and Research, chair of the CDC STD Treatment Guidelines panel, member of the AMA/CDC panel producing Guidelines for Adolescent Preventive Services, member of the Institute of Medicine’s Immunization Safety Review Committee, and chair of the Institute of Medicine’s Committee on the Treatment of Post-traumatic Stress Disorder.

He currently chairs the CDC’s panel on Evaluation of Genomic Applications in Practice and Prevention.

He recently spoke with the Student Doctor Network about evidence-based medicine and health care reform.

You have been associated with the concept of “evidence-based medicine [EBM]”. Would you explain the term, and its relevance to the current debate on health care and health insurance reform?

The average person imagines that medicine has always been “evidence-based”, but there is quite a difference between the older ways of thinking about evidence and the systematic approach to evidence that is now considered the state of the art.

In the past, if you were a medical student, resident, or practicing physician trying to find answers to a specific problem, and your attending or your consulting physician said “this is your answer” you assumed it to be true.

What has changed is that we now ask who or what is the authority for the evidence. We are now more systematic about deciding when something is authoritative.

The most important characteristic about the new approach is that the evidence is scrutinized in standard ways, leading to more accountable and transparent clinical recommendations.

Unfortunately much of current medical practice still uses the “it’s true if I say so” approach, so a lot of medical practice is not evidence-based by current standards.

EBM is one of the “under the radar” features of the current health care reform debate. Would you see it as a major change, if it ends up in any form of the final legislation?

EBM could have a huge impact on reform. It could lead to more transparent and accountable practice, and would change the ways things are done now.

One of the likely outcomes of health care reform, in whatever final form the legislation takes, is that clinical practices and outcomes will be monitored and behaviors that depart from evidence-based standards of care will not be acceptable.

Over time, evidence-based practice has potential to reduce the huge variations in procedures and interventions we have now when there are no medical reasons for the differences.

You have been a member of and chaired advisory bodies on EBM for both the Institute of Medicine [IOM] and the U.S. Department of Health and Human Services [DHHS] over the past two decades.  How did you come to be involved with these advisory bodies?

My interest began as a fellow in the Robert Wood Johnson Clinical Scholars Program where I first learned basic epidemiology, health services, and biostatistics.  I made some connections with one of the DHHS committees that existed in the late 1980s, in which I had expressed skepticism whether a guideline released for treating asthma was supported by the published evidence – there was too much expert opinion.

In 1989 I was appointed to the Preventive Services Task Force, my first real assignment in this area. I was then asked to chair the Centers for Disease Control committee that published the 1993 Sexually Transmitted Disease guidelines, and co-chaired a committee for the Agency for Health Care Policy and Research on otitis media with effusion.  I have gone on to other committees on vaccine safety, genetic testing, post-traumatic stress disorder, and genetic tests, sponsored by various agencies.

What qualifications led to your appointments to such a diverse group of committees?

Being a generalist on clinical topics and a specialist in critical appraisal and systematic review has led me to be involved in a variety of clinical questions. As a non-specialist on any given clinical topic, I do not come into the process with preconceptions about what our conclusions should be.

And, because of the experience in reviewing the basis of evidence in dissimilar clinical areas, I have developed some general expertise at managing the committee processes that are designed to reach clinical and research conclusions.

You are a member of the Institute of Medicine.  What does it do?

It is an organization of around 1,700 elected members, part of the National Academy of Sciences which was chartered by Congress during President Lincoln’s administration, although the IOM formally began just in 1970. It receives no direct federal appropriation, but does accept contracts from federal agencies when an agency wants answers that are unbiased and evidence-based.

For example, the VA commissioned the IOM to do a study to advise them what interventions work in treating PSTD — a controversial topic where some might have questioned the conclusions if the VA had done the study on their own.  The agency negotiates the contract with the IOM, but once the project begins the IOM works independently. The IOM accepts broad input but its internal processes are confidential. The IOM also takes extraordinary steps to limit conflict of interest on its committees so that the conclusions are not tainted.

How does one determine what kinds of medical interventions are “evidence-based” and what kinds are not?

Medical students, residents, and physicians need to be moving towards asking that question more often. I have become wary of what I call the “journal club approach” to medicine where a single article is discussed hoping that it might be a “silver bullet” that will change practice. From where did the article come? What were the clinical questions asked? Are the questions relevant to my own practice?  Where does this fit in the body of evidence already available?

Medical schools are beginning to do a good job of teaching how to evaluate individual studies, but there is a parallel list of questions on how to evaluate evidence-based clinical practice guidelines. I believe this skill is as important as being able to evaluate a single research article.

How much of a problem are health care disparities in your opinion?

The folks at Dartmouth have shown how the same condition is managed in different ways at different costs in different parts of the country, when there is no apparent reason for difference.  If we were following evidence-based practice more uniformly, a patient with the same characteristics would be managed the same way in rural Texas as in New York City.

A New Yorker article (”The Cost Conundrum“) looking at the highest Medicare costs in the U.S. showed that over-treating and over-diagnosing have negative consequences. If one wants to maximize health, the “sweet spot” is when you use only as much health care as you need. When you use more medical services than you need it can lead to poorer outcomes.

If we have high standards for evidence-based practice, we could decrease costs and make health care more rational, regardless of who you are, who your doctor is, or where you are.

How do you assess President Obama’s health care reform efforts?

I believe his heart is in the right place. What I think he is finding is that EBM is important. He is also finding that science is not what is driving the system, but rather the economic benefits enjoyed by lots of people in the healthcare industry. EBM threatens the profits of some very powerful special interests. I believe that all the special interests are willing to bend on some issues, but their second best position tends to be keeping the status quo.

I hope the public will figure out that they are getting neither good value nor good health from its money, and we’ll finally be able to move ahead.  EBM has potential to help in that process.

Are there models in other countries of how EBM would work?

Much of the rest of the developed world is ahead of us on EBM. In many countries, there is a process for deciding when there is enough evidence about an intervention’s efficacy to make a product or intervention available to the public at public expense. Interventions considered experimental or not achieving a level of confidence in the outcome are generally not paid for with public funds. The U.S. is quite unique in that evidence of an intervention’s proven effects can take a back seat to other concerns.

Can you employ EBM techniques to determine if less invasive therapies work, such as those advanced by, for example, holistic health practitioners?

Of course. We should move toward a single standard of evidence that is blind to the kind of therapy being promoted.  We should be able to objectively assess the balance of benefits and harms of any test or intervention, whether performed by an MD or a naturopath.

How do you see the future widespread use of the Electronic Health Record (EHR) interfacing with the idea of EBM and federal funding of evidence based preventive care?

That is something I’m working on at the moment. One of the issues of EHRs is the proliferation of products that cannot talk with each other. The business incentives are not aligned to make this easy. The feds have been trying to come up with a list of common data elements, but EHR vendors are dragging their feet. At the University of Washington, we would like to develop ways to use EHRs across practices for disease management and prevention within the practice and for collaborative research regardless of the particular EHR being employed.

What are things do you believe have a chance of going right?

President Obama has made it clear that he is interested in science and objectivity. I have faith that in the long run being open and transparent about evidence supporting medical practice will result in desirable change. There are many examples of where the EBM approach has made a difference in the outcomes of patients and where it has nudged the funded research agenda. People like me continue to hope that focusing on the evidence will eventually improve the public’s health. 

If you haven’t already voted, go to the polls today and vote.  Be sure to follow these 4 steps:

1. Check your voter registration card (or sample ballot) for the location of your designated polling site.
2. Bring photo ID and proof of address.
3. Get in-line before the polls close.  Even if the polls close, as long as you are in-line you cannot be turned-away.
4. Vote carefully – review your ballot for accuracy before turning it in.

In this election season, healthcare has been an increasingly pressing issue for American voters.

In an August 2008 TNS Healthcare survey, nearly 60% of voters age 18-29, and 75% of voters over the age of 65 agreed that healthcare issues would play a major role in their presidential election choice.

The feeling that our current system is a “failure” predominates, and thus healthcare reform is seen by many as a mandate for the new president.

Healthcare professionals must understand the issues involved in the politics of health in order to move towards reform – and that brings us to one of the most contentious issues, that of single payer healthcare.

A single payer system would clearly be a radical change. In the current system, private insurance companies independently negotiate payments with healthcare providers, which are different than the payments made by government programs like Medicare and Medicaid. These, in turn, are different than the payments that a patient would make out of pocket if uninsured. This system has made the costs of healthcare services seem mysterious and fluid in nature, numbers drawn out of a hat.

Those from the left side of the political spectrum tend to advocate single payer systems as a curative solution for this bureaucratic nightmare, pointing out that eliminating complex billing and administrative procedures from healthcare offices and centers would be a huge cost-saver and tool for simplification. Those who approach the issue from the right tend to advocate transparency in billing as a free market approach to the problem, reasoning that if patients were able to act as customers of a healthcare business, they could then shop around for lower cost services and understand far more clearly the actual cost versus benefit equation for proposed therapies.

There are major challenges to both these views. For example, though a single payer system might be able to greatly reduce healthcare costs through elimination of complex billing procedures, many suspect that it could just as easily reduce healthcare costs through reducing payments to physicians and other providers. Medical professionals, already angered by the inability of Medicare to cover the costs of patient care, are understandably fearful of the idea of governmental disbursement of all patient care costs.

Though Medicare is efficient in terms of administration and billing, it is often accused of reducing access to healthcare. Many doctors already have stopped taking Medicare patients in their practices, and more are poised to do the same. In fact, the AMA has estimated that 60% of physicians would limit their Medicare patients if the payment cuts continued. The current political situation is that there will be a meager 1.1% raise in payments in January 2009, which seems unlikely to keep pace with inflation. Since the underlying formula that directs payment increases and cuts has not been corrected, a 20% cut is pending for 2010. The Medicare and Medicaid programs already cover a third of Americans, and with costs on the rise, they already consume 40% of our federal budget. Single payer is often referred to as “Medicare for all” – clearly not a thrilling prospect considering the challenges the program has faced.

To look critically at the conservative viewpoint, it is difficult to see how a free market philosophy could be easily applied to the healthcare industry. After all, sick patients are often not in a position to shop for the cheapest care. A patient often is geographically limited in terms of the healthcare facilities that are available. And a patient who chooses to “save” by shunning preventative healthcare or by avoiding purchasing health insurance can drive up costs for others by then incurring an avalanche of unpaid costs when disaster strikes. Thus the idea that we can exist as independent healthcare consumers is a bit misleading, since in fact we may have an interest in keeping our neighbors healthy.

So what is single payer, specifically? Conservatives who disapprove of increased government intervention into healthcare often refer to single payer as socialist. As Michael Moore pointed out in the documentary “Sicko,” common public institutions such as police departments and libraries are more truly socialist than a single payer healthcare system because they are not only government financed, they are also government run. But they don’t generate the same amount of controversy. Some countries, such as Cuba, have a socialist healthcare system run by the government. Single payer specifically refers to a system that is paid for by one entity, generally understood to be the government, but does not specify how the healthcare system is run. A proposal in the United States for the government to run all hospitals and medical offices seems unlikely to meet with success.

Even single payer itself seems less than mainstream. Democratic presidential candidate Barack Obama does not have it as part of his platform (he has stated, though, that he would support single payer for building a healthcare system “from scratch”). But if single payer healthcare becomes a reality, strict accountability and quality measures will be crucial to track how taxpayer money is being spent.

Single payer is gaining popularity as a concept. A 2003 Pew poll found that 72 percent of Americans favored government-guaranteed health insurance for all. Whether it could realistically be successful in the United States, where employer-based, private health insurance is an entrenched concept, is another question. Look for increasing debate on the pros and cons of single payer as healthcare reform looms as a legislative priority.

by Lee Burnett

A recognized pioneer and leader in family medicine, John Geyman, MD has written a number of articles and books on American healthcare. He has just released his latest book on the health insurance system, Do Not Resuscitate.

Dr. Geyman’s books are known for detailed research and facts. Do Not Resuscitate is a natural follow-up to his earlier texts, deftly tackling the latest and most complex data and concepts and distilling them into a captivating and quick read.

This book could be compared to the writings of Noam Chomsky with Dr. Geyman delivering a searing indictment of today’s health insurance companies and the US Government. This book has a single point: the insurance industry has failed America and it should be replaced with a single-payer nonprofit fund.

The book starts with a fascinating historical review of the development of health insurance and how it evolved from a nonprofit enterprise to a massive for-profit industry. Most interesting is why the United States is the only western country without national universal healthcare. He then analyses industry tactics such as risk avoidance through cherry picking, policy cancellation, denial of coverage, and deceptive and even fraudulent marketing practices.

Dr. Geyman presents compelling data illustrating tactics the insurance companies use to perpetuate the status quo and retain control in the face of increasing calls for comprehensive change. He details how the insurance industry is dying and demonstrates that incremental reforms will not save it. The book concludes by showing how national single-payer health insurance could work for the US.

Being that the topic of healthcare reform is very timely in this campaign year, I would highly recommend Do Not Resuscitate to students going on interviews.

The Student Doctor Network spoke with Dr. Geyman, who lives on San Juan Island near Seattle, Washington.

Why is the U. S. the only western nation without single-payer health care?

For a number of historic, cultural and economic reasons, the U. S. is the “odd man out” among industrialized countries around the world in not having some kind of public financing system for its population.

The idea of national health insurance (NHI), however, is not new. It was first raised by Teddy Roosevelt and the Progressive Party in 1912. After a bitter fight it was finally defeated in 1917 by an alliance between employers and organized medicine.

Since then, American worship of open markets, our culture of individualism, and the political power of private stakeholders in what has become a medical-industrial complex, have successfully opposed publicly financed universal coverage on the basis of claimed American exceptionalism.

Although public opinion for more than 60 years has favored NHI, an ongoing coalition between market stakeholders, an increasingly powerful, largely investor-owned insurance industry, and most of organized medicine continues to oppose NHI.

The AMA fought hard against Medicare and Medicaid during the mid-1960s, It was marginalized politically, however, when the American Hospital Association joined forces with Blue Cross (which as an intermediary would process all claims for hospital services) to assure passage by Congress of these public programs. The AMA then quickly switched to profit from these programs as poor and elderly Americans became consistently paying patients.

Private stakeholders in our deregulated market-based system use their political power and money to preserve open markets against public will on the basis of claimed market “efficiencies”(untrue) and the threat of “socialism” if NHI were to be implemented (also untrue, since NHI is social insurance combined with a private delivery system).

It is claimed that the U. S. has the best health care system in the world. Why would we want to change this for-profit model?

It is pure mythology that we have the best health care system in the world.

Many cross-national studies show the opposite, as these examples show:

• 42nd in life expectancy, 41st in infant mortality
• last among 19 OECD countries in mortality from amenable causes (deaths that could be avoided by timely and effective care)
• 15th out of 25 countries for such indicators as disability-adjusted life expectancy and child survival to five years
• 11th out of 11 industrialized nations on 11 criteria for performance of its primary care base

We do have the most expensive and bureaucratic system in the world. One that siphons off 31 percent of the health care dollar on administration, overhead and profits.

The profit motive distorts incentives, encouraging many providers to deliver inappropriate and unnecessary services. It is well documented that the more specialists there are in higher reimbursed parts of the country, the more unnecessary care is provided with worse outcomes.

Investor-owned care has been demonstrated to cost more and to be of lower quality, whether hospitals, HMO’s, nursing homes, dialysis centers, or mental health facilities.

With NHI, we can transition to a not-for-profit system which assures universal access to necessary and cost-effective care of higher quality and greater accountability, which still incorporates the strengths of a private delivery system.

What about the for-profit pharmaceutical and medical device companies?

There is not anywhere near as much competition in our health care system as market advocates would have us believe.

The drug and medical device industries, as well as other medically-related industries, have wide latitude to set prices at what the market will bear, and lobby strongly to defend their price-setting prerogatives and avoid price controls.

They claim that any effort by the government to constrain costs by bulk purchasing (as the Veterans Administration does so effectively in gaining discounts on prescription drugs of about 45 percent), would stifle innovation. This is a false argument.

Most current medical research is publicly financed through the National Institutes of Health. The drug industry spends two or three times as much on marketing as it does on R and D. Many new technological advances have been made abroad by countries with national health systems (egs., CT scanning in England, laparoscopic cholecystectomy in Canada).

Manufacturers know that most demand for health care is not price-sensitive. Chemotherapy for cancer gives us a classic example of inelastic demand. Driven by hope, cancer patients will spend enormous amounts of money on chemotherapy drugs (some now costing $50,000 to $100,000 a year), even for those of questionable or marginal clinical benefit.

Many new drugs have no competition until their patents expire. As an example of predatory price-setting, Ovation Pharmaceuticals raised the price of Cosmegen, its drug for Wilms’ tumor in children, by 3,436 percent (not a typo!) in 2006.

What happens to physician income and quality of life if there is a single-payer system?

The growing gap between procedure-based reimbursement and cognitive, time-intensive physician services has led to serious specialty maldistribution of physicians in this country. We now have an oversupply in many procedure-oriented specialties and critical shortages of physicians in primary care, geriatrics, and psychiatry.

NHI can provide a structure for reimbursement reform based on system needs. Physician incomes in family medicine, general internal medicine, general pediatrics, geriatrics, psychiatry and other shortage fields will see increased incomes, while those in surplus specialties are likely to be reduced, especially if providing inappropriate or unnecessary services.

When Canada went to its single-payer system, physician incomes changed little. Today, generalist physicians in England are better paid than their counterparts in the U. S.

Physicians’ quality of life will improve with NHI. With simplified billing through single-payer, their overhead and administrative hassles will be much reduced. Their time will be mostly involved with direct patient care, what they went into medicine for and were trained to do, and they will have more clinical autonomy.

The intrusive bureaucracy of 1,300 private payers, with their different requirements, will be a thing of the past.

Do you hold much hope that single-payer health insurance can be implemented within the current political system?

The current political system is a challenge, but many forces are gathering that give me optimism that single-payer NHI can be finally enacted in this country. Here are some data points that point in that direction:

The present health care system is falling apart – fast. Access is getting worse, costs are becoming unaffordable for much of the middle class, quality of care is spotty, many of the services being provided are either inappropriate or unnecessary (some even harmful), and all incremental attempts to reform system problems have been failing.

Our market-based system is not self-correcting, as its proponents claim. The private insurance industry is on a death march, and has demonstrated its obsolescence in these ways:

• inefficiencies compared to public financing
• fragments risk pool by medical underwriting
• increasing epidemic of underinsurance
• excessive administrative and overhead costs
• profiteering – shareholders trump patients
• pricing itself out of the market
• unsustainable and resists regulation

So, as things get worse, as they are, the pressure for real reform of health care can only increase. Here are some signs that this is underway:

• the crisis in health care costs and access now affects at least one half of our population
• a sizable majority of the public has favored publicly-financed universal coverage for 60 years
• the electorate is changing, with many across party lines seeing the failures of conservative policies of the last 30 year
• the mismatch of the business model of health insurance with the public interest is raising concerns of sustainability among industry insiders and some Wall Street analysts
• with the exception of privatization in recent years, the overall success of Original Medicare since 1965 shows that publicly-financed health care works
• organized Labor is rapidly getting behind single-payer NHI; employers may not be far behind, as shown by the economic difficulties of many employers (eg., the auto industry) in competing abroad with countries with social insurance
• there are now 92 co-sponsors of HR 676 in Congress, a bill for NHI as a “hidden solution in plain view” for the failures of our health care system
• recent studies are now showing that a majority of physicians support NHI (egs., 59 percent of 2,200-plus physicians in a national sample this year; over 60 percent of physicians in Massachusetts and Minnesota)

The 2008 elections are likely to alter the political landscape with probable control by Democrats of Congress and the White House

Although organized medicine, as exemplified by the AMA, has been a reactionary and often marginalized player in the national debate over health care for 90 years, this was not always so. It is of historical interest that the social insurance committee of the AMA passed a resolution in 1917 calling for serious study of various forms of social insurance in order to avoid “ leaving the profession in a position of helplessness as the rising tide of social development sweeps over it.”

The new generation of physicians can play an important role in reversing the reactionary mode of organized medicine and moving it to one of leadership toward a health care system that meets the needs of the country.

Rather than have government create the single-payer system, do you see any other options such as a government-backed for-profit insurance company (along the lines of Fannie Mae and mortgage lending)?

The possible role of a government-backed for-profit insurance company along the lines of Fannie Mae and mortgage lending is discredited by recent events.

The business model doesn’t work as a way to finance health care. Original Medicare operates with an overhead of about 3 percent, while the average overhead for commercial insurers is 18 percent and 26.5 percent for investor-owned Blues. High overhead costs just take money away from direct patient care.

Experience has shown that the health insurance industry cannot be effectively regulated. Although some states (eg., Massachusetts) try to regulate health insurers through such requirements as guaranteed issue and community rating, public not-for-profit financing still offers more value and reliability to enrollees, as demonstrated by Original Medicare.

The insurance industry has successfully avoided regulation for many years. It maintains a very large lobbying presence in state capitols across the country, often with revolving doors and conflicts of interest with state legislatures.

All self-insured employee benefit programs (ie., most large employers) are exempted from state regulations by the Employee Income and Security Act of 1974 (ERISA). If insurers don’t like regulatory policies in one state, they just move to a friendlier state. Another approach being touted by the industry and conservative policymakers involves association health plans (AHP’s), which are exempt in most states from state rate-setting regulations.

Private and institutional shareholders of for-profit insurance companies would not take kindly to the idea of national healthcare. How do you address their concerns?

This is true, but the policy goal should not be to prop up a failing industry through government subsidies. Instead, the goal should be to build a health care system that best meets the needs of our entire population for affordable coverage of necessary health care of good quality.

The NHI program includes a major effort in retraining and job placement for many administrative and insurance worker positions displaced by NHI. There will be new needs for many to become involved in expanded programs in home care, public health, and other areas.

John Geyman, MD is Professor Emeritus of Family Medicine at the University of Washington School of Medicine in Seattle, serving as Chairman of the department from 1976 to 1990. He served as founding editor of the Journal of Family Practice (1973 – 2000) and editor of the Journal of the American Board of Family Practice from 1990 to 2003.

SDN: Gary, your resume is pretty awesome. You currently hold the position of Medical Director of the East Dayton Health Center, a community health center with federally qualified health center status; and you are simultaneously Associate Dean for Student Affairs and Admissions at Wright State University’s Boonshoft School of Medicine in Dayton, Ohio.

Yours is a unique postion, with major responsibilities in a community health center serving the disadvantaged, and as the dean of students for a medical school, which will include lots of students from more privileged backgrounds. 

From the perspective of these two different worlds, what do you see as the major health care issues that medical students should be considering?

GL: Sometimes students look at the world from the perspective that they are familiar with and grew up in; and get some degree of culture shock when they come across patients who do not think like they think nor share their world-view. Most students do not know what it is like to live in poverty and see health care as a luxury of life instead of a commodity that is always available to their household.

I see three issues of major importance – all inter-related. The first is that we are approaching a majority of persons in this country that simply cannot afford health care – at least with its current cost structure. Second, the aging of the population will place far more demands on the health care system than anyone seems to planning for. Third, we as a society are under-investing in primary and preventive care. A lot of people believe that the answer is political – simply elect the right people to run the government, have them mandate universal insurance coverage for everybody and the problem will go away. I think that is an illusion.

SDN: How so? Why wouldn’t universal health coverage work?

GL: It might work with fundamental system reform, and some of the proponents of universal health coverage include the idea of a single payor system of a kind that might wipe out whole industries. I personally don’t think our political structure will produce THAT type of change. But I do think some kinds of changes will come, and perhaps quite rapidly.

Even if you give people full access to care with our current system, it has be appropriate access. It is inappropriate for emergency rooms to be dealing with most primary care problems, and it would inappropriate access to care for a person with a stomach ache to show up at the office of a gastroenterologist as the first point of contact. What we have to address as a nation is a bottom up approach where primary care is the anchor of a health care system dedicated to providing quality health care for all.

SDN: What kind of changes do you foresee, and what should medical students be thinking about?

GL: I think there are parts of the health care cost structure one can think of as a bubble. We have the example of what happened to the technology sector at the beginning of this decade. Students were in computer sciences curricula dreaming of their high incomes. A lot of computer science graduates ended up bitterly disappointed. This isn’t to say there is not a lot of money in technology, but those who made it often had to work much harder than they thought they would, and some found the high salaries were not the cinch they thought they would be.

Students have to aware that modern medicine is constantly changed by innovations in technology, pharmaceuticals, and evidence-based changes in standards of care. Students could choose a specialty that is technologically lucrative and relevant at this time, but changes in community standards of care may limit the numbers of subspecialists needed in that field.

SDN: You advise medical students. How do you suggest that they prepare for the kind of systemic change that you see?

GL: First, to be very suspicious of the idea that you make specialty choices on the basis of perceived income or “lifestyle” of the specialty. Of course, if a specialty attracts you because you really like doing what that specialty does, you should pursue it. But, if you are thinking that this is a good specialty for you, because you will have a high income for a 40 hour work week or less, and can pay off your student loans rapidly, you could find out this is as much a bubble as the dot.com industry experienced (and more recently mortgage banking and investment banking) and that neither that super-high income nor the easy lifestyle will materialize for you.

If medical students know that a specialty gets high remuneration for not that much work, everyone else knows it too, and that can be perilous when everyone in a society is trying to figure out how to rein in health care costs.

SDN: But aren’t physician salaries determined by the marketplace?

GL: Not the kind of marketplace you learned about in economic classes. Our system is neither a planned system, nor a market-based system. Basically, it is a group of arbitrary pronouncements that prices will be set a particular level, and more often than not it is simply a group of physicians that has recommended what those price levels should be to some government entity that can agree with them, or do something else entirely.

If your income is based to a large extent on an arbitrary policy that can be changed more or less at will, I think that should give you pause. Probably, the most important health care financing agency is Medicare. When it sets a pricing policy, the rest of the system follows, often very rapidly. As an example, when it developed “diagnostic related groups” in the 1980s, it completely changed the ways that hospitals were reimbursed, and created great pain for many institutions.

SDN: Do you think Medicare might impact the incomes of sub-specialists?

GL: All projections of Medicare is that there is not enough money in the future to handle the aging of the population without significant change in the budget, either through increased revenues, decreased benefits or decreased costs in the current system. I don’t see much change in the benefit structure, nor a vast increase in revenues. These changes would require a consensus in our national politics. I do see Medicare changing rules of how it reimburses physicians and hospitals, and I would not be surprised to see a Congressional mandate that it do so. It will have to find a lot of cuts to keep the budgets reasonably balanced. The low-hanging fruit of those could well be those physician services where medical students see high incomes for comparatively little work.

The deepest cuts are very unlikely to occur with the primary care specialties, in part because that’s not where the money is, and because Medicare and other health agencies are understanding that the primary care infrastructure needs attention and infusion of more resources. The major studies of the cost-effectivenss of health care expenditures, all tend to highlight the value of preventive services, early treatment of acute illness, and comprehensive and continuous approaches to chronic disease. All of that is the arena of primary care.

SDN: What do you advise medical students to do?

GL: One of the lessons of economics is that if there is manifest need, and previous underinvestment in resources, that could very well be an area in which to expect rising incomes and other positive changes. I think there are several things that favor choices in the primary care specialties right now – especially family medicine, but also general pediatrics and general internal medicine as well.

SDN: The primary care specialties in the United States have had lower remuneration that such specialties as, say, radiology, orthopedics, anesthesiology, dermatology and surgery. Why should your student advisees consider primary care?

GL: If you think in terms of lifetime instead of annual earnings, even in our current system primary care does better than when you compare the average annual remuneration of physicians in established practices by specialty.

Remember, you still can become board-certified in family medicine after three years of residency, and can negotiate a pretty decent beginning income in a group practice. General internists and pediatricians also can be in established practices while their sub-specialty colleagues that entered residency at the same time still have years of residency ahead of them. Opportunities exist for primary care physicians throughout the nation, some enhancing the income with loan repayment.

What is more, some of the specialties that you might have several extra years to be able to enter, may turn out to be vulnerable to revenue decreases through technological innovations (since pharmaceutical and medical equipment manufacturers are always seeking to develop products that change the way care is provided), changes in reimbursement policies of such third payers as governments and insurance companies, or simply because too many of a given specialist are being produced not to affect the marketplace for that kind of a physician..

SDN: But isn’t the knowledge base required for primary care pretty bewildering, if someone wants to do it well?

GL: Primary care is intellectually challenging, but that is why it always has attracted a portion of the brightest medical students. I find family medicine very rewarding, and always have. However, this is an especially wonderful time to choose primary care, because the technology of being a primary care physician is advancing along with the rest of medicine. The electronic medical record permits the effective incorporation of chronic disease management and quality assurance guidelines into primary care practice. Practices are being transformed in other ways, to enhance the relationship between physician and the persons for whom he or she cares.

In quite a few medical schools and teaching hospitals, the faculties seem to believe the world revolves around the practices of the referral specialists. But that simply is not how the world works. Primary care practices tend to be one of the most important businesses in any neighborhood. When you are in medical school or in residency at an academic medical center, there may be little understanding of how much respect you have as one of your community’s local primary care physicians and how professionally satisfying are the long term relationships you develop with your patients. When you leave the teaching hospital and academic medical center, you find that in most communities there is a great respect and comfortable working relationship between the community’s primary care physicians and the subspecialty colleagues to whom they refer and with whom they collaborate.

For several years, a majority of medical students have chosen to enter the referral specialties. As a result, if you are a medical student with good clinical skills, you may find that some of the most prestigious of the primary care residency programs may be willing to interview you.

SDN: What is it like to be a family physician in an Internet age?

GL: Well, it’s fun. It helps in relating to people. Of course, some of my patients are not as Internet-savvy as others and some just want me to do something to make them feel better. Other patients have self-analyzed their symptoms, surfed the Internet, and come to me as their coordinator of care with pages of information.

There is a consensus emerging that people need a “medical home”. In my view, the primary care physician’s office has been the gold standard for the medical home in every part of the world., and the past 40 years we have seen an extraordinary enrichment of the primary care infrastructure, principals and practices in this country. I see these primary care improvements as becoming increasingly valued over the next few years.

Many of the primary care practices are already set up to use Internet extensively, including assymetrical communications such as e-mail, and even are set up for patients scheduling their appointments by computer. This can help keep patients out of emergency rooms, when they should not be there, which is good for the whole society. For Internet-savvy patients collaborating with a primary care physician, it can help in the patient receiving comprehensive and continuous health care.

SDN: Is the Internet not a mixed blessing?

GL: The downside I see is one that is analogous to pharmaceutical advertising on TV.

SDN: How so?

GL: Most patients who need any kind of physician intervention have conditions that are appropriately managed at the primary care levels, and, except in a true emergency situation, those that need sub-specialty consultation or treatment are best identified by a primary care specialist. Television (and Internet) advertising helps promote the idea of the general public working directly with referral specialists. There is a current advertisement that suggests that you “consult your rheumatologist”. In fact, if the referral specialists had to handle any significant part of the primary care workload, it would erode their effectiveness as referral specialists. It is in the referral specialists’ interest also to promote the re-invigoration of the primary care system.

In fact, almost everyone, whether they are rich or poor, working class, professional or retired, should have a personal physician to help them navigate the health care system and to provide them or assist them in getting whatever services they need to meet their health care needs. It is very heartening for me to be the personal physician for whole families, as well as individuals. It is a great career choice in medicine, and one that will be ever more relevant, regardless of what changes occur in medicine.

Almost 1,000 medical students from over 90 different countries gathered in Canterbury this August to tackle inequities in health care across the globe. The 56th August Meeting of the International Federation of Medical Students Associations returned to the UK with the theme, “Access to Essential Medicines.” It proved to be a fascinating, tumultuous, and at times controversial week.

The IFMSA is the largest student body in the world, founded in 1952 to provide a cohesive voice for medical students across the globe. Its biannual general assemblies aim to educate and inspire its members to take action on international health issues, each centered around a chosen theme. The decision by the UK to focus on “Access to Essential Medicines” (AEM) was taken in light of its key relevance to both the developed and developing worlds. More than 10 million deaths each year can be attributed to lack of access to life-giving medications, in direct contravention of the Universal Declaration of Human Rights, entitling every citizen the right to “health and well-being of himself and his family, including … medical care and necessary social services”.  

The Assembly was opened, with customary vigor, by Dr. Richard Horton, chief editor of the Lancet. He spoke of the “collective failure” of medical institutions to produce doctors engaged with society, both domestically and globally. Increasing inequality in access to health care, he argued, demands that the moral contract between the medical profession and society be rewritten such that doctors come to see the assertion of justice as a fundamental part of their duty. It requires that doctors and medical students are prepared constantly to “disagree and quarrel with, object to, dissent from and disapprove of, resist, disbelieve, refuse, oppose, challenge, contradict and defy (their) governments” as and when the need arises. Justice in health, he concluded, should be paramount to all medical practice: “The social pathology of globalization, inequity and epidemic human misery that we face today demands nothing less.”

The spirit of revolt continued throughout seven days with a series of lively debates, speeches and seminars from experts as diverse as Hans Hogerzeil (director of Department of Medicines Policy and Standards, WHO), Parveen Kumar (chairman of the BMA), Richard Smith (CEO of United Health Europe and former editor of BMJ) and Richard Barker (chairman of Association of British Pharmaceutical Industries).

Informal lunchtime sessions on “Systems,” “Activism” and “How Students Relate to the Pharma Industry” encouraged students to take a personal stand. Videos on AEM ran throughout the week and computer-assisted learning packages provided real and well-argued evidence to back the rhetoric. Representatives from a range of non-governmental organizations, including Medecins Sans Frontieres and Oxfam, attended, tirelessly explaining their work and encouraging hundreds of medical students to consider work overseas. For, as Prof. John Yudkin (former director of the International Health Medical Education Centre) observes in the AEM film, “It is not just about access to drugs, it is about access to people who can prescribe and safely deliver those drugs.”

Record numbers of travel bursaries to the UK were distributed to students from economically-less developed countries who would have been otherwise unable to attend the Assembly. The sheer number and diversity of students encouraged a variety of viewpoints, and debates could be heard echoing through the corridors long after the speakers had finished. Projects and campaigns were coordinated from opposite sides of the world and many exchange schemes initiated.

The week culminated in the creation of “The Canterbury Declaration” and its formal adoption by the IFMSA. The Declaration supports the WHO Access Framework and, while recognizing the need for trade-related intellectual property rights legislation, advocates for countries making full use of its flexibilities. Importantly, its adoption lends the IFMSA a clear and consistent voice on the matter of “Access to Essential Medicines.” The Declaration encourages student protest and pledges support to all campaigns aimed at increasing governmental spending on AEM, challenging cases where essential medicines are priced beyond the reach of the poor and promoting transparency within the pharmaceutical industry.

The voice of the IFMSA is a powerful one and has in the past informed both national and, through its affiliation with the World Health Organisation, international policy. Its work is mainly directed into five main areas, recognised as peripheral to core medical curricula but central to the reality of health care. These are reproductive health (including AIDS), human rights and peace, public health, professional and research exchange, and medical education.

The UK branch of the IFMSA, Medsin-UK, is especially active and has branches in 28 different medical schools across the country, involving hundreds of health care students in its projects, campaigns and educational events. Its network aims to connect innovative projects and enthusiastic students to work together in addressing the broader determinants of health.

If you would like to know more about the IFMSA or Medsin-UK, or to get involved in the campaign for Access to Essential Medicines please see www.ifmsa.org or www.medsin.org

By SDN Staff, in collaboration with IFMSA

Almost one thousand of medical students from over 90 different countries will gather in Canterbury this August to address critical inequities in healthcare provision across the globe. The 56th August Meeting of the International Federation of Medical Students Associations will return to the UK with the theme “Access to Essential Medicines”.

The International Federation of Medical Students Associations (IFSMA) is the largest student body in the world and the official voice of medical students across the globe. Its biannual General Assemblies aim to educate and inspire its members to take action on Global Health issues through a combination of projects, training and campaigns. The UK team beat off fierce international competition for the opportunity to host the 2007 Assembly, which will be held August 4-10 at the University of Kent, Canterbury.

The decision to theme the event as “Access to Essential Medicines” was taken in recognition of its relevance to both the developing and developed worlds. More than 10 million deaths per year can be attributed to lack of access to life-giving medications, in direct contravention of the Universal Declaration of Human Rights, entitling every citizen the right to “health and well-being of himself and his family, including … medical care and necessary social services”. However, as pharmaceutical companies and health services defend their own rights and obligations, the issue has gained both increasing notoriety and key relevance to all those intent on practising within the medical community.

Professor Richard Horton, editor of the Lancet, who will give the opening address to the Assembly, has said of the issue: “Access to medicines has become the test above all others by which the rich world will be judged in its dealings with the poor” (Lancet 2002 vol 359:1605).

On Wednesday 8th August, the Assembly will host “Access Denied: the Big Debate” in which Jon Sowero (Univerisities Allied to Essential Medicines), Tom Ellman (Medecins Sans Frontieres), Catherine Royce (Drugs for Neglected Disease Initiative) and Richard Barker (Association of the British Pharmaceutical Industry) will be expressing their views on the role of “Big Pharma” in securing Access to Essential Medicines, and defending them both to one another and the student audience.

Other speakers throughout the week will include Hans Hogerzeil (Director of Department of Medicines Policy and Standards), Michael Wilks (Chairman of United Body of the British Medical Association) and Richard Smith (CEO of United Health Europe and former Editor of the British Medical Journal).

Informal seminars will encourage students to explore, among other things, the mechanics of Public-Private partnerships, the flooding of the third world with counterfeit medications and access denied to minority groups in the “developed” world, such as asylum seekers and the elderly.

The Assembly also aims to motivate and train its delegates to take positive action on Global Health issues themselves through a wide variety of campaigns and community-based projects. An extensive Training and Resource Development component has been integrated in the program, providing the participants with new skills needed in their work, but seldom found in the traditional University curricula. Such skills include Project Management, Media Skills, Strategic Planning, and Campaigning.

The UK was one of the 6 member nations involved in founding the IFMSA in 1952 and its UK member, Medsin, remains highly active with branch in over 28 medical schools. It has not, however, hosted an Assembly since 1964 and it was therefore with huge excitement the UK team secured the bid in August of last year. The team set out with the aim of hosting an ethical, environmentally sustainable and accessible Assembly in the UK. Fundraising has been exclusively from companies compatible with Medsin’s ethical policy, rejecting sponsorship from tobacco, pharmaceutical and private health insurance firms.

Procurement of all resources has been organized, along with the Assembly gathering itself, to minimize adverse impact on the environment.

Recent efforts have been aimed at increasing access to the Assembly to students across the globe. An international publicity campaign was launched at Christmas and, in coordination with embassies abroad, since then has secured visas for delegates. In addition to the traditional travel bursaries, a new scheme of sponsorship by UK medical schools of foreign students, has further widened access to students from economically developing countries.

More information can be found at www.ukam2007.org and www.ifmsa.org

To discuss this article visit the discussion thread located here:

http://forums.studentdoctor.net/showthread.php?p=5387965#post5387965

We present this article to highlight the debate currently in progress over use of animal labs in student education. SDN has no formal or informal position on animal labs. Our volunteer members have a diverse view on this topic and have worked together in an attempt to cover this topic fairly and evenly.

Jeff Tomasini likes dogs. That was one of the reasons that prompted the first-year student at the Medical College of Wisconsin (MCW) to opt out of a course he considers barbaric and unnecessary. During the three-day class that took place last month, Jeff’s classmates anesthetized 60 dogs obtained from the local pounds, opened up their chest cavities, examined their hearts, and then euthanized the animals.

“Killing an innocent animal is unethical,” Jeff says. “The top medical schools produce some of the country’s best physicians without ever harming an animal.”

And he is not the only one to protest the course that is fueling heated debates among students, physicians, and medical school educators across the country: do live animal labs have educational merit for medical students, or are they relics of the past?

At the center of the polemic is MCW’s physiology class that gives first-year students a rare opportunity to see a live, beating heart. MCW is currently one of only 14 medical schools in the United States offering a live animal lab.

Opponents of animal labs argue that technology – such as the widely used, life-like human patient simulators – eliminate the need to experiment on live animals. Proponents insist that such methods are effective teaching tools, especially since a dog’s cardiovascular system resembles that of a human.

“Computers cannot replicate the complexity of living systems,” Richard Katschke, Associate Vice President of Public Affairs at MCW told SDN. “Physiology, by definition, is the study of living systems. The live animal lab enables students to draw on the knowledge they have learned to date, and apply the information in a real-life situation. In student course evaluations, this lab receives higher ratings than any other course for first-year medical students.”

Indeed, in Jeff’s class of 204 students, only 12 opted out of the dog lab. And a few months ago three students wrote an editorial for their local paper, the Milwaukee Journal Sentinel, praising the course. “Based on our experience with this lab, the majority of our classmates agree that placing one’s hands on a beating heart, seeing live lungs inspire and expire, and seeing textbook knowledge literally come alive is an invaluable experience,” they wrote in an article endorsed by over 100 MCW students. “Our professors believe this teaching laboratory will make us better doctors, and of this we have no doubt.”

On the other side of the debate are organizations such as the Physicians Committee for Responsible Medicine (PCRM), a Washington D.C.-based group that promotes non-animal educational alternatives. PCRM has been criticized by consumer and professional watchdog groups, including the Center for Consumer Freedom, as being a “fanatical animal rights group” and serving as a front group for the People for the Ethical Treatment of Animals (PETA).

“Using live dogs is a pitifully inadequate way to teach,” says John J. Pippin, Senior Medical and Research Adviser at PCRM. “Are students likely to encounter an open-chest dog in the clinics or their practices of medicine?”

He questions MCW students’ contention that seeing live organs in an anesthsized animal is an educational experience. “The students get one shot at the dog, can test at most a few drugs, can only see responses under the rigid and unnatural conditions of anesthesia and intubation, occasionally kill their animal or watch him die before they are finished, [and] get no do-overs after the animal is dead.” Pippin also questions the ability of inexperienced students to assess the usefulness this course would have for their future careers.

The American Physiological Society (APS), a Bethesda, MD-based organization for science and medicine professionals, disagrees. “This is a matter of educational quality,” Dr. Martin Frank, the APS Executive Director says in a published statement. “Students benefit from the hands-on learning approach that animal laboratories offer.”

That comment is echoed by many of the nation’s physiologists who see substantial educational merit in live animal labs. “These laboratories have provided medical students with an opportunity to directly observe the physiology, anatomy and response of both internal and external environmental stimuli on a live organism that responds in an identical or very similar fashion to the human,” James E. Smith, Professor and Chairman of Physiology and Pharmacology at Wake Forest University School of Medicine is quoted on MCW’s website. “This is an invaluable educational opportunity that too many medical schools have abandoned.”

That position is endorsed on MCW’s website by several other physiologists from various medical schools, who say live animals provide experience and insight that other teaching methods do not.

“Physiologists and their professional organizations have a strong self-interest in preserving the use of live animals, because it’s what they know and sometimes one of the main reasons they are on faculty,” Pippin counters. “Live animal physiology may have applications to study comparative physiology or a particular animal’s systems, or for individual physiologists’ research interests, but not for students training to be medical doctors rather than physiologists.”

Rooshin Dalal, a student at University of Virginia School of Medicine, and a vocal opponent of animal labs, points out that “the argument about animal labs allowing students to touch living tissues is baseless. All of the same demonstrations can be easily observed in the human operating room – with the important advantage of learning about human anatomy and physiology – and surgeons will likely allow students in their third and fourth years to handle living tissue as well,” he says. “And, if there were some benefit to animal labs, wouldn’t most schools be using them?”

Currently 111 allopathic medical colleges in the United States no longer maintain animal labs. Pippin states that an ongoing PCRM survey, which includes top universities such as Pennsylvania, Mt. Sinai and Cornell, shows that replacing animals with simulation technology has had no adverse effect on curriculum or student performance.

“These (simulation) tools are so much better than using animals,” says one of the responders to the survey, Martin Eason M.D., J.D., director of the Patient Simulation Laboratory at East Tennessee State University Quillen School of Medicine. “No school should be depriving their students of them.”

In fact, most schools don’t. According to American Association of Medical Colleges, simulation and other technologies are now being used by 79 percent of U.S. medical colleges. MCW has top-of-the-line simulators as well, but offers the dog lab as an optional course.

Supporters of eliminating live animal experimentation scored one victory last week, when the American Medical Student Association (AMSA) passed a resolution encouraging the replacement of live animal laboratories with non-animal alternatives. The 65,000-member umbrella organization for premedical and medical students, interns, and residents also condemned the use of household pets from pounds, shelters, or random source dealers, thus reversing its earlier position, which endorsed pound seizures.

According to the U.S. Department of Health and Human Services, about 20 percent of the nation’s population – a hefty 60 million – live in the parts of the country designated by the government as Health Professional Shortage Areas. Those are primarily rural regions, or specific population groups impacted by the shortage, such as migrant workers.

On a global scale, the U.S. averages 2.3 doctors per 1,000 residents, well below the 2.9 recommended by the Organization for Economic Co-operation and Development, and adhered to by most industrialized nations.

What these figures mean is that, although we now have about 800,000 active physicians — up from 500,000 two decades ago – that is not enough to fill the needs of the growing and aging population. As a result, millions of Americans are finding access to convenient and quality health care limited. And, they have to wait longer for diagnostic procedures and medical treatments.

“People are waiting weeks for appointments; emergency departments have lines out the door,” said Phil Miller, a spokesman for Merritt, Hawkins & Associates, a national physician search firm. “Doctors are working longer hours than they want. They are having a hard time taking vacations, a hard time getting their patients in to specialists.”

In other words, the supply — 25,000 new doctors every year– is not keeping up with the growing demand. “The public expects good, innovative health care,” says Richard Cooper, director of the Health Policy Institute at the Medical College of Wisconsin. “But we’re not producing enough physicians to provide it.”

And the prognosis for the foreseeable future is grim. Cooper notes that currently the new crop of physicians just about compensates for those retiring every year. Within a decade, however, a large number of doctors licensed in the 1960s, 1970s and 1980s will no longer practice, creating a hard-to-fill void.

Studies show that an estimated 3,000 to10, 000 more physicians are needed to boost the ranks of active doctors every year to meet the needs of not only the population at large, but also of the increasing number of retiring baby boomers.

But producing doctors is not as simple as it may sound, for it is more a political than an academic process. Congress provides federal funding for medical residencies, and Medicare reimburses hospitals for the cost of resident training. The government currently spends an estimated $11 billion a year on 100,000 medical residents. The financially strapped Medicare already pays 3% of its shoestring budget on physician training and does not have the resources to increase the spending.

At least some of the responsibility for the current and looming crisis lies on the shoulders of the medical profession itself. Several decades ago the American Medical Association (AMA) warned of an expected “oversupply” of doctors, leading to an almost 20-year moratorium on new medical schools. The oversupply theory was reiterated as recently as 1994, when the AMA Journal predicted an excess of 165,000 physicians by the year 2000.

The predictions did not pan out, but the damage was done. “We face at least a decade of severe physician shortages because a bunch of people cooked up numbers to support a position that was obviously wrong,” Cooper said. “This is a desperate situation. And we need to act now because it takes a long time to train a doctor.”

The good news is that the Association of American Medical Colleges dropped the long-standing “oversupply” view in 2002; Florida State University’s College of Medicine, the first new allopathic medical school to open since 1982, graduated its first class of new doctors in 2005. Other states are considering expanding their medical schools as well.

The question of whether there will be enough doctors in the house to provide medical care to all those who need it, remains open. But now at least the alarm has been sounded – and heard.