Blog posts

“You’re wasting your life.”

By Dr. Evan Saulino
. 3 Comment(s)

That’s the “encouragement” I got as a 4th year student when one of the attending physicians at my research-focused medical school found out I was going into primary care. 

Of course I was convinced I was going to do something important – and most definitely was NOT wasting my life.  But I couldn’t point to much objective information to know that was true.  Would I really be “saving lives” in primary care?

I knew I liked the idea of working with individuals and families over time, and recognized the theoretical benefit of having a comprehensive rather than a partial/organ-specific approach to patients.

And I knew through my epidemiologic training in microbiology and experiences working in less-developed nations that the biggest bang for our buck has always been in preventing illness through public health measures and behavior change.  How many lives have been saved just by having clean drinking water, getting vaccines, and washing our hands?

So I ignored my attending’s comment and went with my gut.

But it wasn’t until 2007, after several years in primary care practice, that I heard about and read Barbara Starfield’s incredible research and ideas.  Through her work I realized the true importance of my choice of primary care – specifically family medicine - as a specialty that does indeed “save lives”. 

Originally trained as a pediatrician, Barbara Starfield was known for vigorous investigation and thorough data analysis during the course of her long career.

Here are just a few highlights from her data and reviews that are mind-blowing when you think about the policy and practical implications:

-          In the United States, a 20 percent increase in the number of primary care physicians is associated with a 5 percent decrease in mortality (40 fewer deaths per 100,000).  But the benefit is even greater if the primary care physician is a family physician. Adding one more FP per 10,000 people is associated with 70 fewer deaths per 100,000, which is a 9 percent reduction in mortality (Starfield et al, 2005). 

-          Areas with higher ratios of primary care physicians to population have substantially lower health care costs than areas with lower ratios.  This may be the result of the better preventive care and lower hospitalization rates associated with good primary care (Starfield et al, 2005).

-          Adults with a primary care physician rather than a specialist had 33% lower costs of care AFTER adjusting for demographic and health characteristics (Starfield et al, 2005, original research done by Franks and Fiscella, 1998).

Don’t get me wrong, I definitely do rely on my specialty colleagues – and there are some specific ones that we are in real need of – general surgeons just to name one.

But understanding the basic findings of Barbara Starfield’s research should offer policymakers and health professionals a clear view of the closest thing we have to a “silver bullet” to control health care costs and improve health outcomes.  In order to be successful, learning from her evidence about the promise of primary care is even more critical as we move forward with health reform in the coming years.

Though I barely met her, she gave me a reason to stay in primary care – and to work to make it much better than it is now

I was lucky enough to talk with her last year, when my state Academy of Family Physicians and a statewide rural research network brought her to Oregon for a conference focused on the “Medical Home” model of care.

She was a feisty woman with quick comebacks.  I have no doubt she would have handled my medical school professor with the verbal equivalent of a wrestler doing a body slam. 

Her critique of our state’s “Medical Home” definitions and measures as “nearly perfect” is a badge of honor I know many who were involved are very proud of.

Sadly, Barbara Starfield died on June 10th at the age of 78.

Below is an excerpt from the message the Dean of the Johns Hopkins Bloomberg School of Public Health sent out:

“Dear colleagues,

I have very sad news.  

Barbara Starfield, professor of Health Policy and Management, died Friday evening of an apparent heart attack while swimming - an activity that she dearly loved.  Our School has lost one of its great leaders.  Barbara was a giant in the field of primary care and health policy who mentored many of us.  Her work led to the development of important methodological tools for assessing diagnosed morbidity burden and had worldwide impact.  She was steadfast in her belief that a quality primary care system is critical to the future of health care in this country and worldwide…”

It is now left to us to put her research into practice.

Share Your Comments


  1. Linda Burke-Galloway, MD

    What a wonderful testimony to a life well lived. Thanks for sharing.
  2. Fred Matthies

    Thanks, Evan. I met Barbara twice, the first time in Bethesda, MD at the AAFP annual meeting 1993. Had a chance to thank her in person for the cross national comparisons article of 1992 (dates may be off). I share your high regard and praise for her research, and she helped me with some of my articles and essays on reform of medical education. Barbara's incisive analytic powers and rigorous research were almost intimidating. All family docs will miss her.
  3. Andrew Johnstone RPh/MD

    Too bad the "medical home" concept is being so bureaucratized and micro-managed though. Pretty much every innovation we come up with that increases efficiency or improves patient care, winds up not being the same innovation that some bureaucrat decides to mandate as an element of 'quality'. So we have to choose between tossing out what has worked for us and our patients, and doing something which often works less well, but earning 'points' with the insurers and government regulators, or doing what actually works well, and ignoring them.

Your Comment


Join Doctors For America


or skip signup