584
Editorials Health Care Reform-Another View HEALTH. Health care. Access to health care. Access to health care for all. Access to good health care for all. * Now is the time. What will it take? It will take accepting limits. Although we can do many things for patients, we cannot do everything. Bodies and souls cannot always be fixed. Genetic damage, abuse of some sort, bad luck, our own lack of knowledge and technology, or, simply, error can devastate. Perfection may be our preference, but it is an unattainable and unaffordable luxury. As we acknowledge limits, and as we let the public know that medicine has limits, expectations and costs should decrease. I suspect that "accepting limits" will mean that everyone, physicians and patients and all other participants in health, will give up something so that everyone can get something. What else will it take to establish good access to good care? We will save time and energy by eschewing the temptation to blame and to criticize. There is no reason to blame the villain who caused the current state of affairs; there is no villain. It will also take respecting the public and regaining its respect and trust. If physicians are to play an important part in planning for improved access-and we must-we will listen carefully. As individuals and organizations, we will act as an honored profession, not as a special interest. We will speak up on behalf of patients for, if we do not, who will? The public holds in high regard those who serve it well. Our ability to affect the difficult decisions ahead depends heavily on public trust. It will take hard work to prevent disease and damage, pain and suffering. Finally, lest we forget, Justice Louis D. Brandeis wrote, A profession is an occupation for which the necessary preliminary training is intellectual in character, involving knowledge and to some extent learning, as distinguished from mere skill. It is an occupation which is pursued largely for others and not merely for one's self. I(p2) Science is our particular intellectual underpinning. As we restore and heal our profession and remember what our profession is about, we need to teach. We need to teach ourselves and our students about excellence. We need to teach the public, patients, and families about risks, responsibilities, choices, benefits, limits, about staying healthy and getting
healthy. Knowing what it takes, we need to describe good health care for all. It should be * Compassionate * Culturally acceptable * Convenient * Reasonable and appropriate, indeed, excellent * Comprehensive. Care should range from preventive through acute to rehabilitative, including care for individuals and families and communities, including care for the psyche and soma; * Based on continued, enhanced basic and applied research. We need to know more about molecular biology, *See "Costs and Coverage-Pressures Toward Health Care Reform," by P. R. Lee, D. Soffel, and H. S. Luft on pages 576-583 of this issue.
organ systems, and behavior; about growth and aging; about women and men; about ways to prevent harm. What elements will be necessary in the newly forming, newly reforming health care system? * We need more primary care professionals-physicians, nurses, community workers. * We need quality assurance by education, not search and destroy. Quality assurance needs to be managed by the profession and not as a for-profit enterprise. * The system should function smoothly for patients and physicians. This means that forms should be simple. Payment, reviews, and appeals should be fair and fast. * There should be incentives for patients and physicians to use the system wisely. * The structure should be flexible and not monolithic. We need to take into account geography, gender, patient needs, health professional availability, special circumstances, and special opportunities. * There should be joint involvement, joint management, and joint ability to affect the system by all participants: patients, families, physicians, payers, hospitals and other health facilities, pharmaceutical companies, policymakers. * It is essential to rethink the fundamentals of professional liability. The emphasis should be on healing. While we are reforming, we need to reform Workers' Compensation, a system that means well and usually does well but has been justifiably criticized for sometimes downright dishonest practices by attorneys, physicians, and patients. Any discussion of the foundation, function, and form of our health system needs to iterate values commonly held in the United States. In 1776, Thomas Jefferson set forth our inalienable rights of "life, liberty, and the pursuit of happiness."2 To secure these rights requires vigor and enthusiasm. Working together, moving ahead, we can renew the optimism that fuels progress. Fairness and evenhandedness are also important to all of us, as is paying attention to the vulnerable among us. Our profession has its own values. William Osler said, "Do the kind thing and do it first."3tP'"8 We also affirm altruism and provide ethical care. Arnold Relman, editor emeritus of the New England Journal of Medicine, wrote recently, "From its earliest origins the profession of medicine has steadfastly held that physicians' responsibility to their patients takes precedence over their economic interests (A. S. Relman, "What Market Values Are Doing to Medicine," Atlantic Monthly, March 1992, p 99). Now, however, "At every turn in the road physicians both in practice and in academic institutions are being attracted by financial arrangements that can compromise their professional independence (Relman, Atlantic Monthly, March 1992, p 105). If "caveat emptor" gets the upper hand and undermines trust, "tincture of physician" as a main element of healing is doomed. What else will it take to establish access to good health care for all? We will need to experiment. We will need to ensure fiscal soundness. We will also need to attend to issues that may seem more social than medical: drugs, guns, violence, poor nutrition and housing, and long-term care. We will need to harness the energy we have, driven by the shared conviction that Americans deserve to have good health and
THE WESTERN JOURNAL OF MEDICINE
o
NOVEMBER 1992
e
157
*
good health care and by the awareness that health care spending is sapping our country of vitality and options. We do have limits. We also have remarkable abilities to heal. We need to claim, to proclaim, to reclaim the basicsscience, education, respect, and trust. LINDA HAWES CLEVER, MD REFERENCES 1. Brandeis LD: Business-A Profession. Boston, Mass, Small, Maynard & Company, 1914 2. Thomas Jefferson, Declaration of Independence, July 1776 3. Beeson PB: On becoming a clinician, In Reynolds R, Stone J (Eds): On Doctoring. New York, NY, Simon & Schuster, 1991, p 178
Getting Some Breathing Room-Persuading Patients to Stop Smoking ABOUT 35 YEARS AGO when I was participating in a summer internship in chronic disease research methods sponsored by the California State Health Department, a discussion took place about how to "prove" that cigarette smoking was responsible for the development of chronic obstructive pulmonary disease (COPD). Randomized controlled clinical trials were relatively new, and concerns ranged from whether there were sufficient data to suggest that any controlled trial was necessary to whether any trial was ethical. Could one, with what was known at that time, ethically randomly assign consenting adults to take up smoking or not provide all patients with the contradicting information that smoking was or, as some suggested at that time, was not harmful? Little was said or known about how difficult it was to actually get subjects to stop smoking. Most of the studies of that era related to highly motivated people who had just suffered a major illnessmostly men with stomach ulcers or myocardial infarctions. Primary prevention was rarely mentioned. In one sense Browner and co-workers in their report elsewhere in this issue of the journal have attempted, using data from the Multiple Risk Factor Intervention Trial (MRFIT), to do such a study in the only way ethically possible.1 As part of a randomized trial designed to reduce the risk of heart disease in what most would agree was a high-risk group, the investigators took advantage of data being obtained to assess heart disease to evaluate the effects of cigarette smoking cessation on the change in lung function. More than 12,800 men aged 35 to 57 years were enrolled in the MRFIT study. These men were randomly assigned to either an intensive integrated program of smoking cessation or usual care. Of those entering the trial, 6,347 were smokers for whom acceptable repeated pulmonary function measurements were obtained during the course of the trial. In general, acceptable pulmonary function data were available only for the latter half of the six-year follow-up study. Thus, the analysis was based on the change in pulmonary function as measured by the forced expiratory volume in one second (FEV,) expressed as an annual rate of decline over two to four years. Unfortunately, for the hypothesis to be tested in terms of pulmonary function change, the subjects most susceptible to the effects of cigarette smoking (those with diagnosed chronic respiratory disease) were systematically excluded from the sample. Yet, even after excluding the group likely to be most sensitive to the effects of smoking cessation-that is, those with COPD whose pulmonary function is declining fastest2-the investigators interpret their findings as showing a beneficial effect of stopping smoking.
585
5
585~~~~~~~~
The authors are appropriately cautious in discussing the limitation of their findings; nevertheless, the results are important in adding to the evidence that, no matter when a patient stops smoking, the effect, at least in terms of nonmalignant respiratory disease, is beneficial. These results were recently summarized by the United States Surgeon General's 1990 Report entitled The Health Benefits of Smoking Cessation.3 A relatively large body of evidence from crosssectional, cohort, and interventional studies mostly indicates less morbidity and, in some cases, greater levels of pulmonary function among former smokers than among those who continue to smoke. The pathophysiologic correlates of these epidemiologic findings support some postulated mechanisms for the measured responses. Generally, the earliest lesions found in smokers' lungs involve the small airways. When these are noted there may be no changes in pulmonary function as measured with the FEV1. Changes in mucus production, however, brought about by the direct irritant effects of cigarette smoke on goblet cells in the larger airways, may result in partial obstruction, which will reduce the FEV1. In fact, it is this mucous hypersecretion that is initially affected by a reduced exposure to cigarette smoke, with the subsequent decline in goblet cell number and a reduced production of
mucus. In humans the effect of reduced smoking on the production of mucus can be measured by reduced sputum volumes both in general population samples and in those with chronic bronchitis. A corresponding improvement in pulmonary function in patients with severe COPD can be detected within three months of stopping smoking.4 Similarly, in normal populations (adjusted for pack-years of smoking), an improvement of about 5% in the FEVy is noted in both men and women after three years of smoking cessation (the interval between measurements). As long as the subjects continue not to smoke, they maintain that 5% difference from those who continue to smoke.5 Some studies have found a reduced rate of decline in the FEV1 in former smokers; others have found that, once the initial improvement has occurred, the decline continues at a rate similar to that in current smokers. Although it is clear that the initial improvement is maintained, few studies to date have been carried out long enough to show with certainty that, once the initial improvement is taken into account, further slowing of the rate of decline in the FEV, occurs. Without detracting from the importance of the MRFIT findings, I should note that the study suffers from this same difficulty of not having observed the patients long enough to be certain that the effect on the FEV1 is not all due to the immediate effect of stopping smoking rather than an ongoing slowing of the rate of decline. As previously mentioned, the Surgeon General's report on the health benefits of stopping smoking refers to several studies, contributing to a similar conclusion that for nonmalignant respiratory diseases, stopping smoking is beneficial. In addition, that same volume reports on a wide body of data that speak to a variety of health benefits of quitting smoking that extend beyond concerns related to the development of COPD. As indicated by the Surgeon General, "Cigarette smoking is the most important preventable cause of death in our society . . . and is responsible for approximately 390,000 deaths each year in the United States, or more than one of every six deaths."3 Such statistics, in fact, do not consider all the effects related to smoking.
Editorials Health Care Reform-Another View HEALTH. Health care. Access to health care. Access to health care for all. Access to good health care for all. * Now is the time. What will it take? It will take accepting limits. Although we can do many things for patients, we cannot do everything. Bodies and souls cannot always be fixed. Genetic damage, abuse of some sort, bad luck, our own lack of knowledge and technology, or, simply, error can devastate. Perfection may be our preference, but it is an unattainable and unaffordable luxury. As we acknowledge limits, and as we let the public know that medicine has limits, expectations and costs should decrease. I suspect that "accepting limits" will mean that everyone, physicians and patients and all other participants in health, will give up something so that everyone can get something. What else will it take to establish good access to good care? We will save time and energy by eschewing the temptation to blame and to criticize. There is no reason to blame the villain who caused the current state of affairs; there is no villain. It will also take respecting the public and regaining its respect and trust. If physicians are to play an important part in planning for improved access-and we must-we will listen carefully. As individuals and organizations, we will act as an honored profession, not as a special interest. We will speak up on behalf of patients for, if we do not, who will? The public holds in high regard those who serve it well. Our ability to affect the difficult decisions ahead depends heavily on public trust. It will take hard work to prevent disease and damage, pain and suffering. Finally, lest we forget, Justice Louis D. Brandeis wrote, A profession is an occupation for which the necessary preliminary training is intellectual in character, involving knowledge and to some extent learning, as distinguished from mere skill. It is an occupation which is pursued largely for others and not merely for one's self. I(p2) Science is our particular intellectual underpinning. As we restore and heal our profession and remember what our profession is about, we need to teach. We need to teach ourselves and our students about excellence. We need to teach the public, patients, and families about risks, responsibilities, choices, benefits, limits, about staying healthy and getting
healthy. Knowing what it takes, we need to describe good health care for all. It should be * Compassionate * Culturally acceptable * Convenient * Reasonable and appropriate, indeed, excellent * Comprehensive. Care should range from preventive through acute to rehabilitative, including care for individuals and families and communities, including care for the psyche and soma; * Based on continued, enhanced basic and applied research. We need to know more about molecular biology, *See "Costs and Coverage-Pressures Toward Health Care Reform," by P. R. Lee, D. Soffel, and H. S. Luft on pages 576-583 of this issue.
organ systems, and behavior; about growth and aging; about women and men; about ways to prevent harm. What elements will be necessary in the newly forming, newly reforming health care system? * We need more primary care professionals-physicians, nurses, community workers. * We need quality assurance by education, not search and destroy. Quality assurance needs to be managed by the profession and not as a for-profit enterprise. * The system should function smoothly for patients and physicians. This means that forms should be simple. Payment, reviews, and appeals should be fair and fast. * There should be incentives for patients and physicians to use the system wisely. * The structure should be flexible and not monolithic. We need to take into account geography, gender, patient needs, health professional availability, special circumstances, and special opportunities. * There should be joint involvement, joint management, and joint ability to affect the system by all participants: patients, families, physicians, payers, hospitals and other health facilities, pharmaceutical companies, policymakers. * It is essential to rethink the fundamentals of professional liability. The emphasis should be on healing. While we are reforming, we need to reform Workers' Compensation, a system that means well and usually does well but has been justifiably criticized for sometimes downright dishonest practices by attorneys, physicians, and patients. Any discussion of the foundation, function, and form of our health system needs to iterate values commonly held in the United States. In 1776, Thomas Jefferson set forth our inalienable rights of "life, liberty, and the pursuit of happiness."2 To secure these rights requires vigor and enthusiasm. Working together, moving ahead, we can renew the optimism that fuels progress. Fairness and evenhandedness are also important to all of us, as is paying attention to the vulnerable among us. Our profession has its own values. William Osler said, "Do the kind thing and do it first."3tP'"8 We also affirm altruism and provide ethical care. Arnold Relman, editor emeritus of the New England Journal of Medicine, wrote recently, "From its earliest origins the profession of medicine has steadfastly held that physicians' responsibility to their patients takes precedence over their economic interests (A. S. Relman, "What Market Values Are Doing to Medicine," Atlantic Monthly, March 1992, p 99). Now, however, "At every turn in the road physicians both in practice and in academic institutions are being attracted by financial arrangements that can compromise their professional independence (Relman, Atlantic Monthly, March 1992, p 105). If "caveat emptor" gets the upper hand and undermines trust, "tincture of physician" as a main element of healing is doomed. What else will it take to establish access to good health care for all? We will need to experiment. We will need to ensure fiscal soundness. We will also need to attend to issues that may seem more social than medical: drugs, guns, violence, poor nutrition and housing, and long-term care. We will need to harness the energy we have, driven by the shared conviction that Americans deserve to have good health and
THE WESTERN JOURNAL OF MEDICINE
o
NOVEMBER 1992
e
157
*
good health care and by the awareness that health care spending is sapping our country of vitality and options. We do have limits. We also have remarkable abilities to heal. We need to claim, to proclaim, to reclaim the basicsscience, education, respect, and trust. LINDA HAWES CLEVER, MD REFERENCES 1. Brandeis LD: Business-A Profession. Boston, Mass, Small, Maynard & Company, 1914 2. Thomas Jefferson, Declaration of Independence, July 1776 3. Beeson PB: On becoming a clinician, In Reynolds R, Stone J (Eds): On Doctoring. New York, NY, Simon & Schuster, 1991, p 178
Getting Some Breathing Room-Persuading Patients to Stop Smoking ABOUT 35 YEARS AGO when I was participating in a summer internship in chronic disease research methods sponsored by the California State Health Department, a discussion took place about how to "prove" that cigarette smoking was responsible for the development of chronic obstructive pulmonary disease (COPD). Randomized controlled clinical trials were relatively new, and concerns ranged from whether there were sufficient data to suggest that any controlled trial was necessary to whether any trial was ethical. Could one, with what was known at that time, ethically randomly assign consenting adults to take up smoking or not provide all patients with the contradicting information that smoking was or, as some suggested at that time, was not harmful? Little was said or known about how difficult it was to actually get subjects to stop smoking. Most of the studies of that era related to highly motivated people who had just suffered a major illnessmostly men with stomach ulcers or myocardial infarctions. Primary prevention was rarely mentioned. In one sense Browner and co-workers in their report elsewhere in this issue of the journal have attempted, using data from the Multiple Risk Factor Intervention Trial (MRFIT), to do such a study in the only way ethically possible.1 As part of a randomized trial designed to reduce the risk of heart disease in what most would agree was a high-risk group, the investigators took advantage of data being obtained to assess heart disease to evaluate the effects of cigarette smoking cessation on the change in lung function. More than 12,800 men aged 35 to 57 years were enrolled in the MRFIT study. These men were randomly assigned to either an intensive integrated program of smoking cessation or usual care. Of those entering the trial, 6,347 were smokers for whom acceptable repeated pulmonary function measurements were obtained during the course of the trial. In general, acceptable pulmonary function data were available only for the latter half of the six-year follow-up study. Thus, the analysis was based on the change in pulmonary function as measured by the forced expiratory volume in one second (FEV,) expressed as an annual rate of decline over two to four years. Unfortunately, for the hypothesis to be tested in terms of pulmonary function change, the subjects most susceptible to the effects of cigarette smoking (those with diagnosed chronic respiratory disease) were systematically excluded from the sample. Yet, even after excluding the group likely to be most sensitive to the effects of smoking cessation-that is, those with COPD whose pulmonary function is declining fastest2-the investigators interpret their findings as showing a beneficial effect of stopping smoking.
585
5
585~~~~~~~~
The authors are appropriately cautious in discussing the limitation of their findings; nevertheless, the results are important in adding to the evidence that, no matter when a patient stops smoking, the effect, at least in terms of nonmalignant respiratory disease, is beneficial. These results were recently summarized by the United States Surgeon General's 1990 Report entitled The Health Benefits of Smoking Cessation.3 A relatively large body of evidence from crosssectional, cohort, and interventional studies mostly indicates less morbidity and, in some cases, greater levels of pulmonary function among former smokers than among those who continue to smoke. The pathophysiologic correlates of these epidemiologic findings support some postulated mechanisms for the measured responses. Generally, the earliest lesions found in smokers' lungs involve the small airways. When these are noted there may be no changes in pulmonary function as measured with the FEV1. Changes in mucus production, however, brought about by the direct irritant effects of cigarette smoke on goblet cells in the larger airways, may result in partial obstruction, which will reduce the FEV1. In fact, it is this mucous hypersecretion that is initially affected by a reduced exposure to cigarette smoke, with the subsequent decline in goblet cell number and a reduced production of
mucus. In humans the effect of reduced smoking on the production of mucus can be measured by reduced sputum volumes both in general population samples and in those with chronic bronchitis. A corresponding improvement in pulmonary function in patients with severe COPD can be detected within three months of stopping smoking.4 Similarly, in normal populations (adjusted for pack-years of smoking), an improvement of about 5% in the FEVy is noted in both men and women after three years of smoking cessation (the interval between measurements). As long as the subjects continue not to smoke, they maintain that 5% difference from those who continue to smoke.5 Some studies have found a reduced rate of decline in the FEV1 in former smokers; others have found that, once the initial improvement has occurred, the decline continues at a rate similar to that in current smokers. Although it is clear that the initial improvement is maintained, few studies to date have been carried out long enough to show with certainty that, once the initial improvement is taken into account, further slowing of the rate of decline in the FEV, occurs. Without detracting from the importance of the MRFIT findings, I should note that the study suffers from this same difficulty of not having observed the patients long enough to be certain that the effect on the FEV1 is not all due to the immediate effect of stopping smoking rather than an ongoing slowing of the rate of decline. As previously mentioned, the Surgeon General's report on the health benefits of stopping smoking refers to several studies, contributing to a similar conclusion that for nonmalignant respiratory diseases, stopping smoking is beneficial. In addition, that same volume reports on a wide body of data that speak to a variety of health benefits of quitting smoking that extend beyond concerns related to the development of COPD. As indicated by the Surgeon General, "Cigarette smoking is the most important preventable cause of death in our society . . . and is responsible for approximately 390,000 deaths each year in the United States, or more than one of every six deaths."3 Such statistics, in fact, do not consider all the effects related to smoking.
