Tuesday, December 20, 2016

Does Life Expectancy Matter?

U.S. life expectancy declined in 2015 for the first time in more than two decades, according to a National Center for Health Statistics study released last week. The decline of 0.1 percent was ever so slight ― life expectancy at birth was 78.8 years in 2015, compared with 78.9 years in 2014.  However, this reversal of a long-time upward trend makes these results significant.

While many researchers are scratching their dumbfounded heads in utter astonishment, I hypothesize the decline in life expectancy is partly due to the decrease in the primary care physician supply.  Studies have shown the ratio of primary care physicians per 10,000 people inversely correlates with overall mortality rate.  It is a well-known and reproducible statistical relationship that holds true throughout the world.  In the U.S., increasing by one primary care physician per 10,000 population, decreases mortality by 5.3%, ultimately avoiding 127,617 deaths per year.


Headlines last week highlighted how much these unexpected results left the researchers baffled.   Jiaquan Xu, a lead author of the study told The Washington Post, “This is unusual, and we don’t know what happened…so many leading causes of death increased.”   Age-adjusted death rates went up by 1.2 percent, from 724.6 deaths per 100,000 people in 2014 to 733.1 in 2015.  Death rates increased for eight of the ten leading causes of death, including heart disease, chronic respiratory illness, unintentional injuries, stroke, Alzheimer’s disease, diabetes, renal disease and suicide.  Differences in mortality were most prevalent in poorer communities, where smoking, obesity, unhealthy diets, and lack of exercise are ubiquitous. 

For fear of sounding like a broken record, I reference a post published on this site about investing more in primary care if the healthcare system wants more people alive and healthy.  Funding a system with a primary care focus is not an innovative concept; it is a well- accepted winning strategy on which to build the health of a nation.  In 2007, the Director-General of the World Health Organization, Margaret Chan, said “A primary health care approach is the most efficient and cost-effective way to organize a health system.  International evidence overwhelmingly demonstrates that health systems oriented towards primary care produce better outcomes, at lower costs, and with higher user satisfaction.”  A thorough meta-analysis by Macinko, Starfield, and Shi (2007) addressed the question of whether increasing the number of primary care physicians could improve health outcomes in the U.S.   In every health outcome analyzed, the PCP/10,000 rate was associated with improved results.  You cannot find a more definitive conclusion than that. 

Health policy experts, IT executives, and politicians jumped on the ACA, HITECH, and MACRA bandwagon while clinging tightly to their misguided belief that more electronic records, ACO’s, care coordinators, administrators, pay for performance schemes, and other fads or gimmicks would improve health outcomes; it turns out one of the most fundamental measures of healthcare quality, our life expectancy, is no better than before.  

Unfortunately, thanks to predatory insurers, lobbyists, and self-serving CMS directors plundering the private health care practitioner, now there is another obstacle looming on the horizon which will prove to be a larger hurdle than originally anticipated.  The primary care physicians we so desperately need are running from clinical medicine like their hair is on fire resulting in a supply that cannot meet demand.   

Based on statistics in 2000, increasing by one PCP/10,000 required 28,726 more primary care physicians.  The situation has worsened as the plight of the primary care physician has become more unpredictable and calamitous.  Considerable gains in population health could be realized if CMS focused their efforts on more adequately reimbursing physicians rather than penalizing them.  Coaxing more physicians to enter primary care or strategizing ways to entice those “retiring” physicians to rejoin the workforce would be worthwhile endeavors indeed.   It would be far better than waiting to crank out a new generation from medical school.  After all, only 7% of graduates choose primary care as a career for reasons that should be clear by now. 

Fifty years ago, just over half of the physicians in the U.S. practiced primary care; today that ratio sits at 30/70.  The U.S. has a lower life expectancy and higher infant mortality rate than many other highly developed countries where the primary care to specialist ratio far exceeds ours.  Evidence from studies of those countries indicates a primary care centric system results in better health outcomes, fewer medical mistakes, cost-containment, and higher patient satisfaction.  If I have said it 1000 times, I will say it again:  expanding insurance coverage makes no difference if there are not enough primary care physicians in the workforce to care for patients in need.  Paying primary care doctors adequately enough to retain them is the only way out of this mess.    

Neither researcher, health policy expert, politician, nor economist, I am just a primary care physician on the front lines seeing sick patients who are getting sicker.  A decline in life expectancy was not unforeseen by many of us.  What if life expectancy continues to decline in 2016?  What if my hypothesis is correct as to the reason life expectancy is heading in the wrong direction?  Will the political machine and predatory insurance industry wake up and pay attention?   My hope is researchers, economists, and politicians holding the fate of our healthcare system in their hands take my words to heart.  Decreasing life expectancy may be just the tip of the iceberg.    The dwindling primary care physician supply will matter more as the predicted physician shortage materializes.  Before primary care physicians go the way of the dinosaurs, make sure to establish a relationship with one of us.  In the future, there is no doubt your life expectancy will depend on it.   

Friday, December 9, 2016

The Price is Basically Right

Recently, President-Elect Trump selected Rep. Tom Price, MD to lead the Department of Health and Human Services.  Suffice it to say, this signals Mr. Trumps’ resolve and commitment to definitively repealing and replacing.  Dr. Price has already sunk his teeth into health care reform, having proposed alternative healthcare solutions in every Congressional session since 2009.  As a physician myself, I am delighted at the prospect of having another doctor at the helm of HHS. The last physician to lead HHS was Louis Sullivan, MD as part of the administration of George H.W. Bush.  Having a physician, who can understand the needs of physicians and patients, representing both in health policy decision making at the federal level gives everyone the best chance for meaningful and successful health care reform. 

Dr. Price is a third generation physician and a retired orthopedic surgeon with experience in clinical practice and academia before being elected to the U.S. House of Representatives.  At his core, he has been a fierce critic of Obamacare.  Dr. Prices’ most frequent objection to the ACA is the fact it hinders the ability of patients and physicians to be in control of medical decision making and puts the government squarely between doctors and patients.  Amen! He understands the subtle distinction that while expanding coverage may provide insurance, it is in no way akin to delivering patients unfettered access to health care. 

As I fend off increasing government regulations in my quest for survival as an independent physician, Dr. Price (and Seema Verma – Mr. Slavitts’ replacement at CMS) seem like an oasis in the desert.  Below are some basic tenets of the Price Plan, The Empowering Patients First Act. 

1.     Tax credits so individuals may buy insurance on the private market. It starts at $1,200 a year and increases with age, but is not adjusted for income. People on Medicaid, Medicare, and Tricare, could opt to buy private insurance and receive this tax credit.

  1. Expansion of health savings accounts, which allows people to save pre-tax money which can be used to pay for premiums, copayments, and deductibles.
  2. Individuals with existing medical conditions cannot be denied coverage if they had continuous insurance for 18 months before selecting a new policy. This continuous coverage provision incentivizes individuals to purchase insurance while young in the hope of creating a long-term insurance pool, (something Obamacare has been unable to accomplish.)

4.    Federal money would be given to individual States to create high-risk pools. These are government-run health plans for people with existing medical conditions who cannot obtain affordable health insurance on the private market. Price has suggested using $3 billion in funding for high risk pools—which comes to $1 billion a year.  This approach carries some inherent risk because cost predictions may underestimate reality.  Critics say high-risk pools have been tried in as many as 34 states and largely failed because they were routinely underfunded. It is possible the annual cost of high risk pools at closer to $2.5 billion a year. Fine, make sure we fund this adequately this time.

  1. Balance billing could be allowed, which evens the playing field for physicians and patients alike.  It would offset the exorbitant “facility fee” hospitals are allowed and independent offices are forbidden to charge.  Allowing physicians leeway on reimbursement could significantly alter the dismal trend of physicians leaving clinical medicine in droves. 

Dr. Price has criticized “government takeover of healthcare.”  I agree with him wholeheartedly.  His socially conservative stances have angered many; he is pro-life, votes against insurance coverage for women’s health issues, additional funding of CHIP (Children’s Health Insurance Plan), and LGBT issues.  However, the more I struggle to stay afloat in independent practice, the less these differences of opinion actually matter.  Sylvia Burwell and I probably agree on Womens, LGBT, and childrens’ health issues, but my bleeding heart, ironically, has worsened my chance for survival in a career I love.  Reality is what brought this very liberal physician to advocate a different approach to healthcare reform. 

Dr. Price recently stated, “Premiums have gone up, not down. Many Americans lost the health coverage they were told time and time again by the President that they could keep. Choices are fewer.”  He is correct.  Choice for all of us has evaporated from the system in many small rural areas suffering from physician shortages already. Frustration at the overwhelming increases in insurance premiums is palpable everywhere in this country.  Maybe it is time to give Dr. Price and Seema Verma a chance.  There will be many compromises as in all things, but allowing physicians and patients more control over their lives and livelihoods is a revolution worth celebrating. 

Tuesday, December 6, 2016

Nixing the Louse

It is about time I cover a well-known parental nuisance known as head lice.  This is one of those time-honored childhood rites of passage for many of us.  Some make it through childhood unscathed.  I was not one of the lucky ones.  The first time I was in 4th grade and itching like mad before my parents figured it out.  The second time I was a pediatric intern, unwittingly having had head-to-head contact with an unknown infected child. 

A few call nights later, I discovered I had contracted head lice. The hospital pharmacy only had Lindane in stock, which is an older shampoo-type remedy, with negative side effects; but I was desperate.  There was no hot water in the hospital to make matters worse.  Basically, I took an ice cold shower, put on the medicine, stood there crying and shivering for 10 minutes, and then rinsed it out.  That was the “longest ten minutes of my life.”  A fellow intern with experience working in inner-city clinics sat on the toilet in the ladies room “nit-picking” at me for three hours.  Bless her heart.  One week later, I used Nix (permethrin) to finish off the job. 

Over the last 16 years, I have been exposed countless times.  Whenever I am aware of contact, I pick up a bottle of Nix, take it home, and prophylactically fight the theoretical louse that might have hitched a ride.  This method has kept me lice-free for over a decade. 

Yesterday, I was accidently exposed by head-to-head contact with another child.   Our nanny planned to stop by the drugstore on her way home from my office, so I asked if she would pick up some more Nix for me.  She obliged.  After picking my children up after school, I had 1 hour to do a prophylactic treatment before evening activities began.  I anxiously opened the box ready to get things started and to my utter shock and dismay, both bottles were completely empty.  I did not know this was thing!

Apparently, someone had purchased Nix, used it at home, put the nearly empty bottles back inside the box, and glued the top shut (in hindsight, there was a lot of glue inside the box top.)  Sadly, I returned to the store, explained what had happened, purchased another two bottle package, and headed home for some “louse and me” time.  Hopefully, you are laughing because I was not last night heading back to the store. 

I have had more than my fair share of experiences with head lice and various remedies over the years.  Personally, I like Nix as it is the least damaging for my hair.  However, recent reports suggest the bugs are resistant to this particular chemical.  Malathion works well and 98% of lice are susceptible, but apparently this chemical is flammable, so I am not confident it is worth the risk.  There is new Ultra Nix, a product on the market using dimethicone type chemicals, which destroy the little bug bodies and the lice eggs as well without being a pesticide.  The hair looks greasy for about three days afterward but returns to normal after a few baths or showers. 

There are “other” remedies, such as tea tree oil (possibly more preventative than curative), mayonnaise, olive oil, dawn dishwashing soap, and additional homemade approaches.  The science is still out on these, but many patients swear by these methods so I include them here for completeness.  Finally, it is worthwhile to mention an antibiotic medication called Bactrim.  Taken twice per day, this medication damages the louse when it feeds on blood from the scalp.  Somehow it ruptures their intestines. They did not even teach us this good stuff in medical school!

Last but not least, the often overlooked, yet most effective way to treat head lice in children: manually pulling nits and combing out every single tiny little louse.  This can take hours and is mind-numbing work; however it is truly the best way to end an infestation in your child and in your home. 

While there are some hard lessons in contracting lice, I do hope you have more knowledge to rid your child of this pesky critter. “Nit-picking” could be considered spending quality-time with your child.  I know the return trip to Walgreens to exchange used bottles of Nix gives new meaning to the word ‘memorable’ for me and always will.      

Tuesday, November 29, 2016

Sometimes We Are Heroes and Sometimes We Are Villains.

My last story about a patient ended in sadness, so I am sharing one with a more uplifting outcome this week.  Two months into my private practice career, I was assigned a “No Doc” patient, a term referring to a child without a regular physician.  This one, in fact, did have a pediatrician, who called me to say “the family fired our group because we have not been able to diagnose the illness in their six week old son. He is your responsibility now.” 

If I have learned anything over the last 15 years, it is that our job is not an easy one.  That is not to make excuses, rather to emphasize the fact that success or failure can depend on circumstantial timing, making physicians look like heroes or villains.  Most doctors are doing the best we can, but sometimes it is not enough to heal an ailing patient.  It is the ambiguous nature of practicing medicine, and it is our perilous reality.    

Prior to that phone call, I had been on my way to the gym.  I was 27 years old and not much for formalities, which is still true today.  Dressed in a sweatshirt (clean), shorts (modest), and tennis shoes, I had my hair pulled back in a classic ponytail and wore no makeup when I first met these terrified parents. 

Studies have shown 75% of medical diagnosis is contained in the history, 10% in the physical exam, 10% on tests and 5% where there is no answer.  As I began to take the history, their six week old son started coughing.  He coughed and coughed until he turned blue, at which point I placed oxygen on his face and became more worried.  I knew all too well, he most likely had whooping cough.

Physicians can be “sugar coaters” who hide their concerns while gently reassuring patients and “bottom liners” who share the brutal truth (sometimes more abruptly than they would like.)   I try hard not to talk so much, but I cannot help myself.  Many patients like my “level with you” approach, but occasionally, eyes glaze over as I share diagnostic possibilities while brainstorming out loud.     

This is one of those times I was a definitive “bottom liner.”  As I managed his airway and called for help, I explained their son likely had pertussis (whooping cough) and required transfer to the local children’s hospital for pediatric intensive care.  As I discussed logistics, the father interrupts “How the #%&* do you know what is wrong with my son after less than 2 minutes?  He has been coughing for more than 3 weeks and doctors far older and smarter than you could not figure it out!”  He was extremely angry, which is understandable.    

My top priority was to arrange for transport to the closest intensive care unit quickly, so I reassured this father I would answer questions after stabilizing his son.  After speaking with the pediatric ICU, I returned to find both parents crying.  I had previous experience treating pertussis in this age group and knew a whooping cough spell when I saw one.  These parents understood the gravity of the situation watching me provide bedside airway support and answer their questions waiting for help to arrive. 

Timing has a role in everything and in this case, was on my side.  Their son’s symptoms advanced to the point where the diagnosis became more clear for me to look like the hero.  In a twist of fate, this same father was working in the ER when my husband got a piece of steak lodged in his esophagus which required invasive removal.   Life sometimes has a sense of humor and suddenly, he was our hero.

Every year when this child comes in for an annual check-up, I think back to the moments when I seemed like both hero and villain. This fragile infant recovered and has grown into a young man.  It is important that physicians be intelligent, caring, empathetic, and work hard, but sometimes timing can make all the difference.  While I do hope my future holds more days as a hero than a villain, this young man is a constant reminder for me to be grateful to those parents who place their precious children in my loving hands. 

Tuesday, November 22, 2016

At Thanksgiving, Do #OneKindAct.

“All men are created equal; endowed by their creator with the right to life, liberty, and the pursuit of happiness.”  This is as powerful a proclamation today as it was more than 200 years ago.  It remains one of the best philosophical, moral, and ethical statements in our history.  It is a core foundation of this great nation.  Let us be reminded of this timeless sentiment over this upcoming Thanksgiving Holiday. 
In 1621, the Plymouth colonists and Wampanoag Indians shared an autumn feast that symbolized the first Thanksgiving celebration.  Individual colonies and states carried on this tradition for more than two centuries.  Ironically, in the midst of the Civil War, President Abraham Lincoln proclaimed a national Thanksgiving Day to be held each November. 
The Civil War was perhaps this country’s greatest moral, constitutional, and political crisis.  In 1858, Lincoln said “A house divided against itself will not stand. I do not expect the Union to be dissolved -- I do not expect the house to fall -- but I do expect it will cease to be divided.”  President Lincoln ultimately saw this nation through its most divisive period and was able to preserve our Union.  Can we not put aside our differences and see the good in each other, if only for the holiday season?  
In 48 hours, families will gather around dinner tables everywhere in America and express gratitude for all of the things for which we are thankful.  There will be countless political discussions, arguments, disagreements, and rhetoric spilling from mouths far and wide.  Stop.  Change the conversation.  Instead, consider doing #OneKindAct for just one human being: a family member, friend, or even a complete stranger.   Do something that demonstrates support for one another no matter our race, religion, color, gender, national origin, creed, sexual orientation, or political affiliation.  Then Tweet it, Instagram it, or Facebook it to show you care. 
The anger, bitterness, and name calling have been unprecedented. Stop.  Members in the same family voted differently.  It has happened before and it will happen again.  Do not allow those dissimilarities to tear families apart. There are hurt feelings on both sides.  Acknowledge them and then stop.  Your loved ones did not change overnight; their ethics, values, and moral beliefs are the same as they were before.  Do not make blanket assumptions based on one single political decision without placing it in the context of shared family experiences over a lifetime.  Life is too short not to see the goodness in each other.    
In 1787, at the close of the Constitutional Convention, Benjamin Franklin was asked, “What have we got?” by a curious woman, as he left Independence Hall.  He replied, “A Republic, madam, if you can keep it.”  This is the vital task entrusted to us by our Founding Fathers.  We must keep it.  We are not a pure democracy, where the majority have unlimited power; we are a republic, where a written constitution places limitations on that power, thereby providing safeguards for individuals in the minority.  Without these checks and balances, those in the minority, whether by race, religion, color, gender, or even political affiliation, would suffer at the hands of the majority.  Our Founding Fathers created a representative republic government, which has served us well for the last 200 years.  It is not going to fail us now.   
The elections of 1876, 1888, and 2000 also produced an Electoral College winner who did not win the nationwide popular vote.  The outcome two weeks ago is not unprecedented for us as a nation.  We should search to find common ground and move forward.  Lincoln said, “A government of the people, by the people and for the people, shall not perish from the Earth.”  We can choose what we will become, as a country, as a family, and as a people.  We can continue to name call, bash, insult, and cast our anger far and wide.  Or we can choose to dust ourselves off, cast our conflicts aside, and rebuild by doing #OneKindAct at a time.   
Republicans, Democrats, and Independents collectively abhor the violent and discriminatory events that have occurred over the last two weeks.  No one can force another person to act out hate, bigotry, racism, and xenophobia; people are committing these reprehensible crimes of their own accord.  Do not let these rotten apples spoil the bushel.  We can change this by joining together and doing something constructive. 
Extending an olive branch is never easy, but it is necessary.  Commit to do just #OneKindAct.  Make it extraordinary.  Make it compassionate.  Make it a statement that we do not tolerate hate, bigotry, racism, violence or discrimination of any kind.  We are a people united in a common history and a common purpose; we are free to be kind to one another, philanthropic to those who are less fortunate, and patriotic toward citizens, non-citizens, and immigrant populations alike.  This holiday season our loved ones are depending on us for guidance, reassurance, and unconditional love.  Why can we not put our differences aside and do that for each other?  We should. We must.  We can. We will.  Do #OneKindAct and have a very Happy Thanksgiving. 

Monday, November 21, 2016

Call to Action by Margalit Gur-Arie and Niran Al-Agba, MD

On November 8th America elected a President who ran on the promise to restore government of the people, by the people, for the people (among other things). However, we cannot expect such a government to be handed to us on a silver platter, no matter who resides in the White House. We must build it ourselves, by definition. Government of, by, and for the people requires those people to stand up and do more than just vote every four years, do more than author clever blogs, do more than compose brilliant tweets, post cynical quips, or write constructive comments on the websites of power. Self-government requires informed citizens with a vision to organize, mobilize, and take purposeful action.

For the last eight years, we have engaged in all of the former and none of the latter. We know many of you are in the same predicament. We are the everyday people and frontline physicians everybody in government is supposedly trying to help. We do not entirely doubt the intent, but the end results have been so much less than we need, so much less than the American people deserve, and so much less than we know is possible. We come from vastly different backgrounds. We have diametrically opposed political ideologies. We have a broad and dynamic spectrum of thought for how health care in America should work. This is our strength. We must now build on that asset. 

You may be elated by the 2016 election outcome; you may be on the fence, indifferent, worried, depressed, despondent, or positively enraged. Whether you love it or hate it, you cannot deny that something extraordinary occurred on November 8th.  Whether you think disaster breeds opportunity or victory itself is the opportunity, let’s seize the present; trust tomorrow even as little as you may” and try to gain some control over our personal and professional fates.

Call to Action

We would like to propose that we organize a workgroup of physicians and people with interest in health care to create evidence and consensus based guidance and recommendations for the new administration as it undertakes major changes in health care policy, legislation, and regulation. Our initial thoughts are that we create an objective position paper to address the impeding changes to current health care legislation, free of political and partisan shenanigans. Our dreams are that this grows into a perpetual grassroots advisory group which brings real-world experiences, varied points of view, and wisdom from the frontlines of medicine and everyday life into the hallowed halls of government to inform the work of public servants.

If you think the American people and their doctors should have a voice in governance, if you believe the welfare of your patients stands above politicking, and if you want to amplify your voice and the voice of others, please join us. If you think you can contribute a small amount of time to such effort, we invite you to kick start this endeavor. You can remain anonymous if you so choose. You can contribute as much time as you have available. You can choose how, when, and what. Let’s leave the actual details open and brainstorm together how best to move forward quickly.

Let’s Roll

Are you all in? Would you prefer to dip your toes in the water?  Do you realize the possibilities if enough of us come together and collaborate in a meaningful way?  If so, please email us at mga111026 at gmail.com. We can communicate via email to set up a conference call and take it from there. We will do the housekeeping, bottle washing, and ashtray emptying to get us started. For those who already expressed enthusiasm (or guarded interest) on Twitter and on this blog and others, retweet, spread the word and let’s make this happen. It’s time.

Tuesday, November 15, 2016

A Vote For TrumpCare

The world is not going to end.  We witnessed a revolution earlier this week.  The people have spoken and they chose the anti-establishment, street smart, government shrinking candidate who bucks the status quo.  We find ourselves in uncharted territory, with an unpredictable President-elect, who has unclear plans for healthcare.  Here is what we do know.  Mr. Trump is a successful entrepreneur.  Forbes describes the entrepreneurship pathway as having no clear story line, but a “sense of chaos, hectic decision making, and moments of great fear and doubt.” Improving our broken healthcare system will involve decision making in the face of great uncertainty.  Mr. Trump has a well-developed tolerance for this sort of ambiguity and is likely the right man for the job. 

Mr. Trump won over the white working-class individuals in small rural areas.  Sluggish economic recovery in these areas played a significant role in his unanticipated victory.  It is these disenchanted individuals watching the American Dream slip through their fingers who voted for Mr. Trump.   Those same people want the freedom to buy the insurance they need, and not what the bloated government shoves down their throats.  25% of the population lives in rural areas yet only 10% of the physicians practice there.  Physicians are leaving the system in droves, closing their patient panels, and not keeping up with demand, thereby threatening patient access in these isolated locales. 

Independent practices have a better chance of survival than they did just a few short days ago.  Do not sit idle.  My son, who is in the second grade, was asked to write down his thoughts on this election. “If Hilary Clinton is elected, I will die.”  His teacher insisted he use facts to back up his dramatic statement.  “If Hilary Clinton becomes President, she will close my mom’s clinic, we will not have enough money for food, and I will die.”  While this is not exactly the conversation that took place over family dinner, my son did understand healthcare would change dramatically following this election.  You should have seen him on election night when the network called Pennsylvania for Trump, but that is another story for another day.  Private practice physicians must seize this opportunity to be involved in the “make things great again” conversation. 

Hillarycare was a known entity with a foregone conclusion.  Trumpcare remains a bit of an unknown.  His “plan” for healthcare was revealed a little more than a week ago, ironically, at Valley Forge.  It encompasses dropping the insurance mandate and allowing purchase across state lines,  making health savings accounts accessible, price transparency, Medicaid block grants to the states (which has certainly worked well for Head Start) to encourage policy innovation, and protecting coverage for those with pre-existing conditions.  The blank canvas is full of possibilities, which is markedly better than the universal health care plan we could have been facing had the outcome of the election been different.  

Every clever “fix” for healthcare so far has had unforeseen adverse consequences.   Providing marketplaces for consumers to shop for insurance did not improve health; instead, it padded the pockets of insurance company CEO’s, lobbyists, and administrators with special interests.  The statistics on rising insurance premiums could not have been released at a better time to facilitate a Trump victory.  I am overjoyed at the possibility disingenuous CMS employees and lobbyists for the American College of Physicians could be out of jobs.  As for MACRA, I hope it goes down with the Affordable Care Act ship altogether.  Physicians want to practice at the top of their skill set, without needless oversight by administrators telling us what is “best practice.”  

The system Mr. Trump is inheriting is full of obstacles.  Patients are disgruntled about paying exorbitant premiums they can ill afford.  Even Bill Clinton chimed in, “The costs are going up, coverage is going down, it’s the craziest thing in the world.”  Maybe not the craziest thing.  I say a man getting elected to the White House without having any previous political or military experience while most of the polls were predicting his loss is fairly extraordinary.  

Admittedly, there are no easy solutions.  My best advice is for him to familiarize himself with the game, the players, the field, and the score, and then develop his own blueprint for healthcare.  Most importantly, get back to the basics.  One hundred years ago healthcare started with fundamentals:  the physician, the patient, a stethoscope, and a conversation.  People were arguably as healthy then as they are today.  My additional thoughts are below:

1.      Invest and innovate, especially in primary care.  We are cost-effective and knowledgeable.

2.      Stop penalizing physicians who do not use Electronic Health Records.  Physicians are doing two hours of paperwork for every one hour of patient care and hiring ancillary staff to support this unnecessary infrastructure.   Let me do my job. 

3.      Shrink or Decentralize the Centers for Medicare and Medicaid bureaucracy.  None of these people are practicing health care providers.  Why are they in charge of 18% of the GDP, when they know little of practice on the front lines?

4.      Encourage innovation and competition amongst insurance companies.  If you want a low deductible, your children covered until they are 26, and exemption from pre-existing conditions, then pay for it.  If you want only catastrophic coverage, and pay for routine maintenance as you go, then pay less and save the extra money to go on a cruise. 

5.      Redefine high “quality.”  Reward physicians when they spend more time with patients, are more accessible, and able to prevent expensive hospital admissions and readmissions.  Eliminate patient satisfaction scores, immunization rate scores, and outdated HEDIS measure goals. 

6.      Require Medicaid recipients to contribute to their health insurance, on a sliding income-based scale.  Require small copays for insurance plans including Medicare and Medicaid.  Even a small personal investment ($3) for a visit has been shown to increase value in the eyes of the consumer. 

7.      Allow Medicare to negotiate with drug companies.  Pharmaceutical companies have been getting fat and happy while Americans have just been getting fatter and more ill. 

Our problems in health care have little to do with the patients or the physicians; rather it has to do with corruption of our administrators and nonessential healthcare players.   Beware of the snake oil salesmen touting their latest “solution” for the health care conundrum; instead, look to physicians with boots on the ground caring for real patients to provide tangible answers. 

The undecided policy agenda of Mr. Trump held the most promise to save private independent practices everywhere.  Time will tell if this gamble will pay off.   Now is the time to roll up our sleeves, get to work, and embrace transformation.  Success is where preparation and opportunity will meet.  I hope he leaves no stone unturned. 

Tuesday, November 8, 2016

How This Physician Grieves

As of Sept. 15, 85 children from 33 states, the District of Columbia and Puerto Rico have died due to infection with the flu during the 2015-2016 season. Piper Lowery, who was a healthy and vibrant 12 year old girl died from H1N1 Influenza almost one year ago.  Her mother, Pegy Lowery, has gone public with her daughters’ story, to urge more parents to get flu shots for their children.  I would like to help her spread this message, because I was devastated by the death of Piper and I miss her beyond words.   Below is my reflection on my own grief as her pediatrician. 

My Dearest Piper,

I remember the day you were born like it was yesterday as I gowned up to go into the OR and attend your delivery.  The OB placed you in my arms and you were so beautiful.  I loved you from the moment you took your first breath.  You were feisty, and had a good, strong cry.  I knew we were going to be special to each other. 

Over the last twelve and half years, I had the great privilege of watching you grow into a beautiful young lady.  Whenever your name appeared on my schedule, it always put a smile on my face.  You brought sunshine along no matter the reason you were visiting me.  Occasionally, I bribed you with chocolate from my personal stash to assuage my guilt at having given you immunizations.  I loved your hugs and your quiet smile.  I miss those things most of all.

Being your pediatrician was priceless.  I expected to take care of your children someday and knew you would make a wonderful mother by watching you care for your little brother.  There would be many stories to tell your children about you as a little girl.  I never thought it would end.

You are the first and only patient in 16 years of practice for whom I have signed the birth certificate and the death certificate.  100 years ago, country doctors did this sort of thing more frequently, but today, I suspect it is a rarer experience.  It is one of the hardest things I have ever done.   The last time I saw you, I knew you did not feel well.  You kept asking to go home; you were pale but still had your sparkle.  I repeated your vitals myself and spent extra time with you to ensure nothing was missed.  I treasure our hug as you left; not knowing it would be our last.

You were ill with influenza and I was so worried you might worsen over the weekend.  Your mom knew to take you to the hospital if you deteriorated and she sent me a message the following morning that you were headed there.   I told her I would be concerned all day until I heard back on your condition.  She messaged back that you had said you loved me.  Thank you for those final words dear child; they will be etched on my heart forever.  “I love you too, my little friend”, I thought to myself. 

You hated the thought of going anywhere but my clinic; you had never been to the hospital before.  You asked your mother if I would be there by your side in the ER.  You were disappointed when she told you I would not.  Upon arrival, you collapsed in the hospital parking lot and had to be carried in to the ER by strangers.  I wish I had been there, though the outcome would have been no different.  The doctors started trying desperately to save you.  I could hear the word ‘epinephrine’ in the background while on the phone with your mother during your resuscitation; I knew we might lose you.  

You were not mine to lose in the parental way, but you see, that is how I always thought of you.  My own daughter was not born until you were eight, so you were one of my “first” daughters.  I had two sons already when I became pregnant for the third time.  I assumed it would be yet another male child.  Do you remember telling me you absolutely knew in your heart it was a girl this time?  I can recall that conversation like it was yesterday.  You were right, my sweet friend.

When I received the call from your mother that you died, I was overcome with disbelief and wanted so desperately for the outcome to be different.  As I drove to your home afterward, I did not know what to say to your grieving family.  We sat together and cried for what felt like hours.  Your parents and brother felt more of a comfort to me than I was to them; though we were undoubtedly a comfort to each other.  We told so many stories about you and your shenanigans.  We laughed and cried that day.  I sobbed the entire drive home. 

At your funeral, I sat next to a mother of four whose children attended your school.  They kept handing me tissues as I sobbed uncontrollably while taking in each picture of your smiling face over the years.   I had known you at EVERY stage of your brief lifetime.  Halfway through the service, the mother leaned over and said “I wish my children had a relationship with their pediatrician like Piper had with hers.” 

I thought to myself that I was the lucky one; to know you and to love you.  I am so thankful to your parents for sharing you with me all these years and allowing me care for you.  Not one day has gone by since your passing that I have not thought of you and longed to see your smiling face one more time.  I will miss you more than you will ever know.

With Love,

Your Pediatrician and Friend.

Wednesday, November 2, 2016

Et Tu, Dr. Noseworthy?

Should patients fire their doctors if they suspect burnout?  In a recent PBS interview, Dr. Noseworthy suggested patients should “change physicians” when faced with non-empathetic doctors suffering from burnout.  His cavalier resolution to our occupational struggle feels like a betrayal, to both his esteemed colleagues across the country and our profession.  In my opinion, firing your physician is a risky proposition in light of the looming physician shortage.  After all, a bird in the hand is worth two in the bush. 

Burnout is an overwhelming sense of disillusionment a physician experiences when the practice of medicine holds no joy.  It is not a psychological problem, yet can lead to a downward spiral of impairment.  According to a recent article in US News, almost half of physicians have symptoms of burnout. Seven percent of physicians aged 29-65 contemplated suicide in the last year.  These statistics are troubling on many levels. 

Over half of current physicians state if given the opportunity to choose again, they would not choose medicine as a career.  Why?  Our once noble profession has lost its magnificence in an explosion of technology, nonsensical regulations, and increased clerical burden.  According to a study in the Annals of Internal Medicine, for every one hour of patient contact, a physician spends two hours doing administrative work.  Never-Had-a-Bad-Day-Noseworthy said, “EHR’s are not easy to use.”  Why are physicians being required [forced] to utilize useless technology if it does not reduce burnout while improving efficiency and care quality? 

Look, we sacrificed our youth seeking delayed gratification that may never come; physicians have responsibility, but no authority, and vast quantities of knowledge, yet no autonomy. Sadly, we have ceded it to arrogant administrators running amok in a system of unfettered capitalism.  Regrettably, this oppression has taken a toll on us all, patients included.

How did physician burnout become linked to increased medical errors?  A study examined the relationship between the burnout experienced by surgeons and frequency of medical errors.  The more exhausted and depersonalized your physician has become the greater your likelihood of experiencing a medical error. 

How common are these so-called medical errors?  Last May, the British Medical Journal released a study ranking medical errors as the third leading cause of death in the U.S., after heart disease and cancer, killing 250,000 people a year. From my perspective, an overwhelming workload also plays a significant role.  A recent study in JAMA found increasing a nurses’ workload from four to six patients increases the death rate by 14 percent, while going from six to eight patients is tied to a 31 percent increase in death rate.  The wheel is turning, but the hamster is dead, literally. 

If a physician is suffering from burnout, let us walk through the conversation Dr. Noseworthy is so naively proposing. 

Patient:  “Doc, You are not as empathetic as you used to be.  I am thinking about changing physicians?” 

Physician:  “Well, what exactly is the problem?” 

Patient:  “Well you used to spend more time with me at appointments and seemed to care.”

Physician:  “I wish there was more time to talk. I sure loved my job back then...”  (Sigh.  Continual tapping of computer keys heard in the background while trying to seem empathetic.)  

Valuing the physician-patient relationship allows it to be a central transformative therapeutic force.  Obamacare expanded coverage for almost 20 million Americans seemingly overnight.  Patient volumes doubled due to the unprecedented surge in insurance coverage?  There were not enough physicians in reserve to care for the overwhelming onslaught especially in underserved rural areas; most of us on the front lines are drowning in paperwork, administrative and regulatory burdens.  Being a physician under current circumstances is like trying to get a sip of water out of a fire hose.  Every physician in this country is on the train barreling toward burnout.    

Last week, I referred four different patients to four different local pediatric specialists.  Three of those four physicians called to let me know they are retiring at the end of the year.  With all due respect to Dr. Noseworthy, at the rate things are going, firing your physician will land a patient in medical limbo until they can find a physician desperate enough to accept them.  This man is so out of touch with reality outside the ivory tower, he is completely oblivious to the larger implications of the looming physician shortage. 

According to the Association of American Medical Colleges report, the projected shortage will reach 85,000 physicians by 2020.  In Will the Last Physician in America Please Turn Off the Lights, three co-authors from Merritt, Hawkins & Associates say the wait to see a physician will jump to three to four months for a non-emergent visits, and it will cost two to three times what it does now–whether you are insured or not. Guess what? I am already at the three month mark for non-emergent appointments and struggling to keep up with the growing patient demand. 

Physicians are resilient to a fault, coupled with stoic demeanors, inquisitive minds, and strongly empathetic natures, but we all have our limits.  Reducing burnout will only be feasible when we have more independence over the particulars of our self-sacrificing occupation.  If every physician in this country insisted on caring for patients as we saw fit and refused to click even one more box, a revolution would ensue.  We must stop “rolling over” when asked to do more with fewer resources, reduced pay, and even less time.  Physicians must put on their own oxygen masks before helping others with theirs.  

Despite his insulting recommendation, Dr. Noseworthy might actually be on our side.   “Physicians are highly dedicated professionals, who are good people, but have been crushed [by the system.]”  Do not allow yourself to be destroyed by a system we cannot control.  Take back medicine for yourself and your patients.  Know your value.  Do not bend to the demands of managers and administrators; refuse to accept a workload that prohibits attaining occupational jubilation and enlightenment. 

There is an impending crisis no one has foreseen; the winds are about to shift in our direction. Rules of supply and demand are universal. Soon, it will be a “physicians market”; we will cherry pick patients based on their having good insurance, a healthy medical profile, and a pleasant demeanor. 

Let us circle back to Dr. Noseworthy, “Change physicians.  It is too risky to be cared for by someone who is impaired.”  You know what is more risky than that?  It is having no physician at all when you desperately need one.  My advice is to build a relationship with a physician while you still can.  If your physician is not empathetic or appears to be suffering from burnout, my cautionary recommendation is to be careful what you wish for, because you just might get it.