One recent Tuesday, a physician named K. Allen Greiner paid a house call. Greiner has known the patient for eight or 10 years, but the home visit was a first.
The two had met at a clinic in Kansas City, Kansas, where Greiner was working as a volunteer. The patient came in with an infection. He had recently been released from a state prison.
Greiner continues to see the patient at a clinic at the University of Kansas Medical Center. The patient has emphysema, and his health has declined to the point that he requires in-home nursing care. "He's really smoked himself to death," Greiner says.
His lungs shot, the patient likes to pretend that Greiner's lack of expertise is what's keeping him from getting well. It's an absurd premise. Greiner is a professor and the associate chair for research in KU Med's Department of Family Medicine. He is a principal investigator on two projects that have received nearly $12 million in grants from the National Institutes of Health.
The titles and grants don't mean anything to Greiner's patient, who some days lets his physician have it for 15 minutes. The patient tells good stories — about the military, about prison, about urban life in KCK — which helps Greiner put up with the abuse.
"Sometimes I just like talking to him," Greiner says, "even though he's just yelling and screaming and complaining."
The home visit lasted 30 or 40 minutes. Before he left, Greiner sprayed for roaches.
House calls are an infrequent but important part of Greiner's work. Seeing the way his patients live, he says, helps him become a better caregiver and researcher.
Also, his patients seem to like it. "People appreciate that stuff, and doing it once doesn't kill you," Greiner says.
From the time he was a medical student, Greiner has been thinking about how to improve his profession. There's room for it, to be sure. Health care accounts for about 18 percent of the U.S. economy. But the resources, vast as they are, deliver only mediocre results. Babies born in the Czech Republic and New Zealand, for instance, are more likely to reach their first birthdays than their American counterparts.
Greiner says it's outrageous that U.S. health care consumes so much wealth when millions of people lack insurance.
"We're wasting insane amounts of money on medicine and health care now, and we're not providing anything to large chunks of our population," he says. "And we've just chosen to do that."
Greiner's ideas for repairing the system make some of his colleagues gasp. Doctors, he says, make too much money. He would also like to change the way physicians interact with their patients. Is it unreasonable to ask family doctors to give out their e-mail addresses? Greiner doesn't think so. "I've been doing it for years," he says.
Greiner's admirers include Dr. Sharon Lee, the executive director of Southwest Boulevard Family Care. Greiner volunteered at the safety-net clinic when he was a medical student. His intelligence and compassion stood out even then, Lee says.
"He became the student that we sort of judged everybody else on," she says. "He became the gold standard. It made it hard for others to compete."
Greiner's work has also caught the attention of business executives. Emil Peters, a senior director at the Cerner Corporation, a health-care information technology company, met Greiner through a mutual friend. They talked at lunch about ways to improve the health of underserved populations.
"If medicine and health care could be administered by guys like Allen Greiner," Peters says, "we'd have no problems."
Greiner hated medical school. "I was totally miserable," he says. "I couldn't stand it here."
Greiner enrolled in medical school at KU after earning a degree in anthropology from Brown University in 1991. As a teenager in Topeka, he did not dream of becoming a doctor. At Brown, he took courses in neuroscience that made a medical degree seem like something worth pursuing.
At first, Greiner resented the way his instructors made medical school feel like boot camp with a lot of Latin.
"They start shoving all these facts at you, and the sort of underlying message is, if you don't memorize all these facts about biochemistry and physiology and anatomy, then you're going to kill people," he says. "You're going to fuck up, and people will die, and it's going to be your fault."
In addition to his issues with the way he was being taught, he felt the profession was generally too cold and paternalistic. "Health care and medicine is very dehumanizing and, I think, has a lot of problems," he says. Greiner set out to memorize the necessary facts and ace the necessary tests because he wanted to be able to change the system from within.
Greiner, who is 42, gravitated toward public health, a field that recognizes that there's more to medicine than diagnoses and cures. With his anthropology background, he responded to the idea that culture, environment and behavior affect disease and health in important ways. He chose to do his residency in family medicine, seeing it as a logical place for someone with an interest in public health. Family docs, after all, are anthropologists of sorts, forming a picture of their communities with every new patient who walks through the door.
At the time, family medicine was a popular specialty. By 1993, a majority of workers with employer-sponsored health insurance received some form of managed care. Family docs were seen as the quarterbacks in this system, which was designed to reduce unnecessary medical costs
Alas, capitation — health maintenance organizations paying doctors a fixed sum to cover each patient in a practice — was rejected by the public.
"They thought doctors were getting money and then withholding care and then profiting more by withholding that care," Greiner says. "So they saw it as a conflict of interest to do less to people."
Today, the system is biased in the opposite direction. Insured patients generally receive more care than they need. Physicians receive payment for the services they perform, not for keeping people well. The model rewards a doctor who, for example, orders tests on a mole that looks benign. "I might just say, 'Well, let's just cut it out and send it to the pathologist,'" Greiner says.
Greiner would like to see a system that puts more emphasis on prevention and helping people live better, healthier lives.
"Most of what we do in medicine and health care is sick care," he says. "We wait until people get sick, and then we try to do heroic things to get them OK for a while. And a lot of that, we're only getting them OK for a short period of time, and their quality of life is going to suck."
As Greiner sees it, the challenge is to deliver the best health to the largest number of people. To test for possible solutions, he's going into areas where sickness and disease are most prevalent.
It's a Tuesday in May, and Greiner and a team of students and researchers are assembling at KU Med for a trip to an American Indian reservation.
Greiner is dressed in a blue button-down shirt and tan pants. The team members wear red T-shirts bearing the logo of the American Indian Health Research and Education Alliance, an effort supported by KU Med's Department of Preventive Medicine. Equipment necessary to stage a health fair is being packed into the vehicles that will make the trip to the reservation of the Ioway Tribe of Kansas and Nebraska.
As the name implies, the reservation straddles the two states. Greiner sits in the back of a white van as it follows the Missouri River to White Cloud, which is 90 miles north of Kansas City, Kansas.
Last year, the National Institutes of Health awarded KU Med a $7.5 million grant to expand its work addressing the health disparities in American Indian communities. American Indians are more likely to die from tuberculosis, chronic liver disease, diabetes and pneumonia than members of other ethnic groups. Greiner and Christine Daley, an assistant professor of preventive medicine and public health, are the project's principal investigators.
In White Cloud, the van passes a small casino before reaching the tribe's community center. Greiner and his team spread their blood-pressure monitors and other devices on folding tables. The cholesterol testing station requires a team member who is willing to perform a moderately invasive procedure. "Are you comfortable doing finger sticks, or would you rather not?" Angel Cully, a community outreach coordinator in the newly created Center for American Indian Community Health at KU Med, asks another member of the team.
At 3 p.m., Greiner takes a look around the room. "All right," he says, "we just need people."
The 40 tribe members who show up for the health fair receive "passports" when they register. If they fill their passports with a stamp from each station, they are eligible for a raffle to win a Foreman grill and other prizes. The idea is to create an incentive for visiting all the stations. Greiner does not want the cigarette smokers to skip the lung test. "It works," he says of the ploy. "It really works."
A woman with long brown hair reaches the station that tells fairgoers their body mass index. She seems apprehensive about putting her feet on the scale. "I probably already know what that test is going to tell me," she says.
Greiner spends most of the afternoon at a table with an "ask the doc" sign taped to the edge. It's his custom at health fairs. Earlier this year, he manned an "ask the doc" table in the basement of a church in Garden City, Kansas, which has a large Hispanic population. Greiner is the principal investigator on another National Institutes of Health-funded project, one designed to improve cancer survival rates for American Indians and rural Latinos.
Greiner says he learned a lot in the church basement about the Latinos who live in western Kansas. "It was just great being able to sit there and talk to people all day long about the different doctors they'd been to, or the fact they couldn't get to any doctor at all, or the fact they were going back to Mexico next month, and they'd totally run out of their medicine and didn't know what to do," he says.
Greiner hopes to improve the level of communication with the Latinos he meets in the course of his work. When he's in his car, he listens to CDs that teach Spanish.
In White Cloud, Greiner's "ask a doc" station is located near a table that offers colorectal-cancer screening kits.
American Indians do not, in fact, report higher rates of colorectal cancer. This is partly because they're less likely to be screened for the disease.
The lower incident rate is also a function of the fact that American Indians have a shorter life expectancy that other populations in the United States. (Most cases of colorectal cancer are diagnosed in people ages 50 and older.) In addition to higher rates of tuberculosis and alcoholism, American Indians are more likely to die in car crashes, commit suicide and be murdered.
On the trip back from White Cloud, Greiner works on paperwork related to his duties as the chief medical officer for the Unified Government of Wyandotte County. In this role, Greiner is more of a technical adviser than an administrator. He focuses on the medicine and allows Joe Connor, the director of the Public Health Department, to manage the operation.
Connor is grateful for Greiner's expertise and his willingness to share it with the community. "He does way more than the minimum for us," Connor says.
Greiner has worked with Connor's staff to make the Public Health Center, a three-story concrete building attached to City Hall, into a doctor's office that can function without a doctor being present. Greiner has designed protocols, for instance, that allow the clinic to treat sexually transmitted infections (STI) without his having seen anyone.
"No one leaves here without a scrip," says Greg Stephenson, who heads the community health unit. "They leave here with medicine in their bellies or in their veins."
Wyandotte County has the highest STI rate in Kansas — the Unified Government buys penicillin in bulk. The Public Health Center meets the high incident rate with an aggressive approach. If a woman comes to the clinic and is diagnosed with chlamydia, her partner can obtain medicine without an exam. "He doesn't even have to unzip," Stephenson says.
Stephenson and others at the Public Health Center appreciate that Greiner treats them as peers. Nurses who suggest ways to improve the protocols receive e-mails from Greiner, signing off on the change. "He always listens to us," says Jeanne Bennett, a nurse at the clinic. "And if it's for the patient, he's all for it."
Empowered by Greiner, the Public Health Center performs a range of tests and provides a variety of services. Greiner and Bennett collaborated on protocols to encourage vaccination against the human papillomavirus (HPV). More than 5,000 patients who came through the STI clinic received vaccines for hepatitis A and hepatitis B. The clinic manages the prenatal care of pregnant women and inoculates international travelers against yellow fever and other infections.
The Public Health Center is able to deliver this care at a reasonable cost. A gonorrhea case that might cost $1,000 to treat in an emergency room can be handled for about $65. Stephenson says the clinic is a model for health-care reform.
"We're probably doing this for five cents on the dollar or less," he says.
Working with the Unified Government allows Greiner to be a physician and public health official at the same time — the kind of doctor who can undertake the systemic changes that Greiner has wanted to make since he was in medical school.
"If we really want to say that what we care about is improving people's health, it can't just be doing procedures on people and tests on people in here," he says, sitting in his office inside a new building at KU Med. "It needs to be bigger, broader and messing around at all those levels."
Too often, Greiner says, doctors can't see past whatever organ system is their specialty.
"We're always reducing our level of focus, lower and lower," he says.
In 2002, Greiner wrote a book review that appeared in Journal of the West, a literary magazine. Greiner commented on Quinine and Quarantine: Missouri Medicine Through the Years, a book by a surgeon and professor named Loren Humphrey.
The review was negative. Greiner thought the book made doctors seem too heroic.
"Its wandering themes return most often to the triumphs of the medical profession and scientific technologies," Greiner wrote. "This has the unfortunate effect of reducing three centuries of Missouri struggles with illness and disease to a formulated pat on the back for doctors, hospitals and researchers working in the last half of the 20th century."
A better book, Greiner went on, would have featured more stories of "osteopathic medicine, of women and minorities and of rural citizens."
Greiner continues to be suspicious of the power and authority vested in his profession. Modern medicine, he says, is in many ways a story of accidents, greed and selfishness.
"I would argue we all need to make less money," he says. "It's a little ridiculous to pay teachers almost nothing and pay physicians insane amounts of money."
Greiner believes that U.S. health-care costs could be cut in half if the right structures were put in place. His ideal system would put a premium on the most effective forms of care. It is relatively cheap, he notes, to treat high blood pressure and diabetes. Once the chronic illnesses were paid for, there would be plenty of money left to remove gallbladders and treat skin cancers. But experimental chemotherapy for people likely to die in six months? Greinercare can't afford it.
Not surprisingly, primary care physicians and public health workers are playing significant roles in this more efficient system. Greiner would like it if family doctors had time — that is, got paid — to communicate with patients via e-mail.
Of course, doctors are not the only ones who would have to accept change. Insurance companies, drug and device makers, and consumers would all have to put "skin in the game," as the saying goes.
"It just takes the willpower and everyone sort of feeling the pain of the change," Greiner says.
A grown-up discussion about controlling costs and expanding care seems unlikely in the current political environment, though. Large segments of the population lead difficult lives and have terrible health, Greiner says. Yet state lawmakers act as if they have it made. Greiner was appalled when Missouri instituted drug testing for welfare recipients.
"Do we not realize that if you're on welfare, your life really sucks already? And now we're going to go after these people and see if they're using drugs or not and yank their welfare benefits for three years? It's amazing how we think," he says.
Greiner is not retribution-minded. Rather, he's drawn to people who lead complicated lives, like the ex-con who likes to complain. And he continues to fit patient care into his increasingly busy schedule. Some of his patients have been with him from the time he was a resident. Greiner says he has a soft spot for the people of Kansas City, Kansas.
"To me, the worlds people live in there are interesting," he says. "And I know that they need a lot of help."