Tuesday, July 18, 2017

An Open Letter to the Future Mayor of Bremerton:

The single most critical issue facing your tenure will be improving access to healthcare for the population of Bremerton.  On May 1, 2017, the state Department of Health granted Catholic Health Initiatives (CHI) a long awaited Certificate of Need to transfer all of the available hospital beds outside of the city and complete a $600 million dollar hospital expansion project in Silverdale, at the expense of healthcare access. 

Recently, I attended a town hall meeting where neighbors came to brainstorm how to best advocate for themselves and hospital staff, who are struggling under the cost-cutting measures being implemented to prop up revenue.  We learned  a great deal about the experience of Piece County residents after CHI merged with Franciscan three years ago. 

St. Joseph Hospital in Tacoma sent $21 million in profit to headquarters in Denver rather than reinvesting it locally, quality ratings have fallen to an F grade, and the population lives 7 years less than the state average while paying $1000 more to reach that substandard milestone. 

On February 13, 1965, Harrison Hospital opened a new facility, the one in which I was born almost 10 years later.  At its inception, Harrison was a source of pride for our community.  Originally, the ER was staffed by community physicians of all specialties, including my father, who volunteered for monthly 12-hour shifts.  As a non-profit organization, Harrison was exempted from paying property taxes in exchange for providing charity care to citizens when necessary.  For decades, Harrison Memorial remained true to its mission, contributing a great deal to the health and wellness of our residents. 

Much has changed since Harrison Hospital was acquired by CHI in 2013. Over the last that time, spending on charity care has decreased from $27 million to $5 million annually, a reduction of 81%.  The number of patients receiving financial assistance for medical bills has been cut in half, from 10,685 to 5,040 individuals.  Some decrease is in part due to Medicaid expansion under the ACA; however, 11% of the population remains uninsured. 

CHI is in significant debt.  Our local hospital, one of many owned and operated by CHI across the country, is one of the few profitable locations.  As a result, revenue is sent elsewhere to prop up ailing locations.  This revenue should be reinvested in OUR community, not sent out-of-state to support others.  Over the last three years, there have been significant cuts to staffing and availability of necessary medical supplies resulting in a detriment to the health and safety of patients and a decline in quality ratings. 

CHI is a non-profit organization and as a result, currently enjoys a property tax exemption in the City of Bremerton of almost $950,000 annually.  This number does not include exemptions such as federal taxes, payroll taxes, and sales tax to which they are additionally authorized.  Over the next five years, CHI will leave an aging Bremerton facility with no plans for repair.  Re-evaluating the property tax exemption in the City of Bremerton is an issue worth some of your time and energy. 

CHI proposes building a brand new facility offering primary care and urgent care.  This structure will house the Family Practice residency program, training physicians who will hopefully join our community once completing their education.  As part of a non-profit organization, this “new” clinic will reap the benefits from requisite property tax exemptions; money the City of Bremerton will absorb in exchange for having access to charity care for those in the community in need. 

Instead of accepting leftover crumbs from CHI because we are starving for access to care, the City of Bremerton needs a comprehensive plan of their own. Please go back to the drawing board and find suitable alternatives rather than kowtowing to a corporation which is destroying the morale of staff, physicians, and our community.  Do not let CHI do to Kitsap County what it has already done to the Louisville, Kentucky community. 

CHI has demonstrated in the past how they cut costs:  by laying off employees, pruning supply budgets and shrinking employee benefits.  Through social media, countless CHI employees throughout the country have contacted me, including those in Kentucky, Nebraska, and Tennessee.  “Employee morale and retention are at an all-time low.”  The have shared difficulties faced working in an environment which is constantly in upheaval.  In a typical day, senior management changes tactics, outsources more services (like telemetry), and eliminates resources necessary to do our job.” 

They share their experience being pushed to the limits by administrative requirements.  “Profit drives decision making now, patients are no longer the top priority.” High acuity areas are reportedly short-staffed requiring employees to do overtime.  High standards of care are difficult to maintain as staff are being asked to do “training” on downtime during shifts.

In closing, the best predictor of future behavior is past behavior.  Once elected, please consider innovative solutions for solving the issue of reduced healthcare access in the City of Bremerton.  The lives and livelihoods of your constituents depend on it. 

Thursday, July 6, 2017

Welcome to the Kitsap Independent Physicians Group!

Happy Fourth of July!

In the Kitsap Sun, today, is this

example of the solidarity amongst medical professionals in ONE small community. Please share far and wide. I am so very proud to be amongst this group of diverse medical professionals, who collectively are fighting for a future which values the physician-patient relationship above all else.


On this Fourth of July 2017, we, the undersigned independen...t physicians in Kitsap County, solemnly pledge that we will continue to provide the highest quality medical care to our patients through its purest, most original form -- the small private medical office. We hold sacred the one to one relationships we have with our patients. Our allegiance is to you, the individual patient, is unwavering. We commit ourselves to continuing to strive to place you, our patients, at the heart of all that we do. 


Silverdale Pediatrics, LLP
Niran S. Al-Agba, MD,
Saad K. Al-Agba, MD

Achieve Eye and Laser Specialists
Dana Jungschaffer, MD,
Martha Motuz Leen, MD
Deanne Nakamoto, MD,
Todd Zwickey, MD

Bainbridge Anesthesia Associates
Blake E. Reiter, MD,
Carol Wiley, MD

Bainbridge Skin Surgery and Consultative Dermatology
Dr. Whitaker

Cole Aesthetic Center
Eric Cole, MD

Dr. Gillian G Esser
Gillian Esser, MD,

InHealth Imaging
Manfred Henne, MD

Kitsap General Surgery
Kristen Guenterberg, MD,
Tom Wixted, MD

Kitsap Podiatry
Paul Aufderheide, DPM,

Paul Kremer, MD

Member Plus Family Health
Blain Crandell, MD,
Viola Medina, ARNP

Michael Metzman, MD,

Pacifica Medicine & Wellness
Andrea Chymiy, MD
Marie Matty, MD,

Peninsula Cancer Center
Heath Foxlee, MD
R. Alex Hsi, MD,
Berit Madsen, MD
Aaorn Sabolch, MD,

Retina Center Nw David Spinak, MD

Sheila C Lally,DO Sheila Lally, DO

Silverdale Eye MDs
Glen Rico, MD

Sound Family Health
Charles Power, MD,
Brad Andersen, MD
Teresa Andersen, MD,
Mark Hoffman, MD

The Manette Clinic
Alisa Blitz-Siebert, MD,
Bill Minteer, DO
Tanya Spoon, DNP,
Kristen Childress, DNP
Teri Scott, ARNP,

Vintage Direct Primary Care Peter Lehmann, MD

Bronx-Lebanon Hospital: Believe Them the First Time

I remember the first time someone threatened my life as a physician.  It was my day off, so I was not in the clinic that day; a Children’s Hospital specialty group was working there instead, and after a staff member called the police, she notified me.  A father had walked in saying he wanted to kill me for “taking his children away from him.”  Wracking my brain as to this man’s identity, I drew a blank. 

The police found him in a local park a short time later and judged him to be “harmless.”  Somehow, I did not share their reassuring sentiment.  I figured out who the individual was, tracked down his mother, and promptly explained the situation.  She provided a recent photograph so my staff could be trained to recognize him and contact the authorities the moment he entered our building.  That photograph still hangs in our “Most Wanted” section of my front office, amongst other pictures which have been added.  Occasionally, I request an updated picture to make sure we are keeping our office environment safe. 

The second time a parent threatened my life was over the phone.  I was taking call on the weekend for a group of pediatricians.  One of them had evaluated a child for a finger injury and had not quite done their due diligence.  It sounded infected and in need of repair as the father described its appearance over the phone.  I recommended he take his daughter to the local Emergency Room.  He threatened to stab me instead.  I called to warn the ER staff and then notified the other practice.  The response was less than vigorous from my call partners, “you must have done something to upset him.” Their reaction astonished me; “blame the victim” is an unacceptable response to a colleague in this situation.    

When a patient or disgruntled coworker threatens to kill us, that threat should be taken very seriously.  Physicians must become less tolerant. Tolerance is defined as an objective or permissive attitude toward opinions, beliefs, and practices that differ from our own.  In my opinion, the administration of hospitals and some large clinics are far too permissive of violent threats against their staff.  I have heard numerous stories from across the country of physicians being told the “patient is always right” as patient satisfaction scores reign supreme. 

We have been taught when a patient threatens to commit suicide, we take them at their word.  Why is it any different when our very own lives are at stake?  The idea that physicians, nurses, pharmacists, and ancillary medical staff are expendable is ridiculous and policies must be enacted to protect the lives of medical personnel.

As I reflect on the tragic events that unfolded inside the Bronx-Lebanon Hospital last weekend, it is difficult to comprehend. My first thoughts are for the victims and their families, in particular those who knew Dr. Tracy Sin-Yee Tam.  She was a family practice physician in the hospital that day by chance, filling in for a colleague.  My second thought is to recall a quote from Maya Angelou, “When people show you who they are, believe them the first time.” 

According to the New York Times, Dr. Henry Bello had a background which spelled trouble right from the start.  His life story reveals a chaotic trajectory of bankruptcy, alleged addiction, workplace difficulties, homelessness, and brushes with the law.  He declared bankruptcy in 2000.  In 2004, Dr. Bello was charged with unlawful imprisonment and sex abuse involving a 23 year old woman in Manhattan.  In 2009, there were allegations of unlawful surveillance when he was caught using a mirror to look up the skirts of two women. 

In 2014, he was hired by Bronx-Lebanon Hospital as a family practice physician with a limited medical license and in February 2015 was forced to resign in lieu of termination after an allegation of sexual harassment.  After his resignation, Dr. Bello warned former colleagues he would return someday to kill them.  On Friday, June 30, he exacted his revenge, entering the Bronx-Lebanon Hospital carrying an AR-15 rifle and opening fire — fatally shooting a physician and wounding six others before killing himself.  Something more should have been done about this man to protect the hospital staff and patients. 

This post was not penned to “Monday-morning-quarterback” the events of last Friday.   I want to emphasize in the future, these threats should be taken seriously and closely monitored to keep those inside the hospital, medical facility, or clinic walls safe.  Two hours before the shooting, Dr. Bello emailed the New York Daily News to say the allegations that ended his medical career were “bogus.”  He stated, “This hospital terminated my road to a licensure to practice medicine.”  In addition, a week prior to the rampage, he was reportedly fired from his job assisting AIDS and HIV patients by the city.  This was a clear sentinel event and foreshadowed the possibility of something ominous. 

Physicians on the “front-lines” are facing a battle for their survival, literally and figuratively.  Friday, June 30, I lost a physician colleague in a senseless tragedy.  We do not handle threats haphazardly when they occur in airports, schools, or police stations.  We cannot properly care for a patient when we are in fear for our lives.  It should not be tolerated any longer.  There are many valuable lessons to be learned from the events of June 30th. We need to sit up, pay attention, and make changes.  The loss of Dr. Tracy Sin-Yee Tam and injuries to the other victims should not be in vain; physicians and other medical staff deserve to feel safe in their work environment while trying to save the lives of others.  

My sincere condolences go out to the friends and family of everyone inside the Bronx-Lebanon Hospital that day.  May you find peace, hope, and healing and may we, as collective communities of healers, refuse to tolerate serious threats to our lives, those of our colleagues, and those of the patients we serve. 

Tuesday, June 27, 2017

One Difficult Day

As a pediatrician, I work to keep children healthy so they can grow up and achieve their dreams.  Occasionally, my na├»ve optimism has gotten the better of me.  I especially have a soft spot for angry, defiant children.  These children are given my undivided attention and respect and I expect the same in return. I never call them names, insult them, or label them.  On the contrary, I have high expectations and am always encouraging them to be their best selves.  I often hug them tight as their anger gives way to tears, reassuring them as much as possible. 

A decade ago, I took care of a blended family with three children by three different fathers.  The oldest boy, Bobby, was an “angry” seven year old with wide eyes and an endearing, crooked smile.  His mother was exasperated and demanded tranquilizers be prescribed to him or she would switch physicians.  I asked Bobby what was going on.  He talked about conflicts with his mothers’ new boyfriend and how he resented this man calling him lazy and stupid. He had tears in his eyes, which broke my heart. 

I talked to him about ways to deal with his anger and recommended a nearby family counselor.  I hugged him, acknowledged his frustration, and told him he was neither lazy nor stupid.  I reminded him to never give up on himself and no matter what happened, I would always believe in him.  Needless to say, his mom changed physicians and I did not see Bobby again. 

When children enter the Juvenile Detention system, they lose Medicaid insurance coverage.  As a result, I was the consulting physician at our local juvenile facility.  I cared for children who were addicts, thieves, vandals, and committed a variety of other crimes.  I reviewed their health history, updated immunizations, and prescribed medications when necessary.  It was difficult to reconcile my job as a physician looking into their eyes and seeing their fear, yet knowing I could do nothing to alleviate the obstacles they faced. 

My toughest day was the one when I unexpectedly ran into Bobby.  I had been consulting over the phone with the RN at Juvenile Hall on a teenager who sustained injuries during arrest by coordinating care with a local specialist.  Over the five day time period, I never asked his name. 

Each week, I drove to Juvenile Hall to sign orders and examine children when necessary.  That day, I came upon Bobbys’ chart.  “This is my injured boy? I know him.” I declared.  She smiled and replied, “He said you were his doctor when he was little, and he is excited to see you.” 

As the guard left to get Bobby, I told him, “Be prepared.  I am going to hug this next one like he is my own son.  I do not care what he did.”  The guard gave me a funny look as he sauntered away.   I had thought of Bobby so often over the years, yet had the sinking feeling things had been far from rosy.  As Bobby walked through the metal double doors, I was struck by how much he had changed in both size and stature (now well over 6 feet tall.)  We hugged as if no time had passed, “Bobby, you are so much more grown up than I remember.”  He smiled with that same crooked grin I found so endearing a decade before.  “You are so much tinier than I remember,” he replied looking down at me.

Over the last decade, his mother and her children moved multiple times, had done their fair share of couch surfing, and Bobby had been suspended for misbehavior and truancy.  A few months before his arrest, his mother kicked him out, he moved back to the area, was stealing, using drugs, and suspected his 17 year old girlfriend was newly pregnant. 

Crestfallen, I almost started crying, then and there.  My dreams for this young boy from ten years ago were shattered into tiny little pieces.  In my mind, at the tender age of seven, he had been a ball of clay ready to be molded into something beautiful.  Instead, all hope had been extinguished from the young man who stood before me now.  There was no sparkle in his eye; the devilish grin was all that remained of that innocent child I once knew.    

Honest to a fault, we talked about lost opportunities and lasting consequences of his poor decisions.  I encouraged him to dream of a future outside of prison walls.  I reminded him of how kind, warm, and genuine he was with a great deal to offer the world. 

Unprepared for my own feelings of sadness and disappointment, this experience hit me unexpectedly like a ton of bricks.  I have yet to recover the abiding faith that all children can achieve their dreams.  It has been an extremely tough lesson to accept; yet it reaffirmed my commitment to continue encouraging, loving, and supporting each and every child who walks through my doors and into my heart.   

While I do not know where Bobby is today, I hope our brief encounter had as profound an impact on him and he did on me.  Kiddo, I think of you every day and hope you are safe, know you are loved, and remember you have much to offer the world.     

Tuesday, June 20, 2017

1,000 Miles with My Daughter

As we move into the longer and lazier days of summer, I thought taking on a lighter subject this week seemed appropriate for the season.  I have tried to take my children walking from time and time and it just has not worked out quite like I hoped.  There were lots of complaints about feet hurting and such after the first mile and tackling steep hills nearby was unpleasant at best.  However, this summer, my only daughter is finally old enough to not only engage in pretty deep and meaningful conversations but is enthusiastically joining me on long walks. 

A few nights ago, I found myself itching to get outside before the sun went down and my daughter insisted on joining me.  Sometimes I get impatient because her little legs cannot match my grown up stride, yet the last few walks have allowed us to settle into our own comfortable rhythm.  My time with her is so emotionally fulfilling that the physical differences have melted away. 

We took off together and she filled me in on her week at school (as I was out of town with one of my sons on a special vacation) and everything else I missed while I was away.  She covered the pretend games she played and the good, bad and ugly of living with her three brothers.  We were so intent in our conversation that we actually missed the fact my parents drove right past us.  The only reason we became aware of this fact is they turned around and came back to check on us. 

We talked about our plans for the summer, which season is the slowest at my office, and the difference between maiden names and married names.  It is really interesting what things a five year old can come up with to discuss.  Then she said something that piqued my interest more than the anything else.  “After we finish tonight, we have walked 7 and one half miles,” she stated with a proud smile on her face.  Having only gone about a mile and a half, I balked. 

She expanded on her thought process a bit more.  This was our third walk for the summer. The others were three miles each (we started out on those a bit earlier than this one.)  Adding them all together she was spot on with her calculation.  I realized she was, in fact, keeping track of our lifetime miles, though she called them “forever miles.”  I kind of like that phrase.  I let her know of my loving approval on her approach. 

Then the real calculating began, literally and figuratively.  As we continued, she began asking what her reward should be when we reach 100 miles.  At first, I tried to pass off the reward as being the time spent with her mom, but that went over like a pregnant pole-vaulter.  I suggested some things, a few of which met with her approval.  After mulling this over a bit more, she wondered what we should do when we reach 1,000 miles together?  My answer was something to the effect that my reward would be “the book I get to write after 1,000 conversations.”  She laughed and suggested a vacation was a far better idea.

Regardless, it got me thinking about the fact that whether or not we reach 100, 1,000, or even 10,000 miles together in our lifetime, we will have time spent enjoying one another.  Time is a gift we should all appreciate.  I am well aware of the fact in 10 years, she could recoil at the thought of taking a walk with dear old mom, but what if she doesn’t? 

I can only hope this is the beginning of something beautiful.   At the very least, when she is fifteen, I can remind her of the awesome idea that formed in her impressionable 5 year old mind.  Imagine the conversations we will have had after 1,000 miles with one another?  It is going to be a great summer. 

Tuesday, June 13, 2017

Is the KentuckyOne Health Experience a Road Map for Kitsap County?

In Louisville, Kentucky, Jewish Hospital is a 342-bed facility similar in size and scope to Harrison Memorial Hospital.  It had knowledgeable physicians, engaged staff, a bustling emergency room, and solid patient care ratings.  Due to health care reforms, Jewish Hospital, St. Mary’s Healthcare, and St. Josephs Healthcare (JHSMH) merged into one organization, KentuckyOne Health (KOH).  To expand services further, a joint operating agreement between the University of Louisville Hospital, a private Cancer Center, and KOH was inked in 2013.   University leaders supported this arrangement because the parent company of KOH agreed to invest over $500 million in the U of L facility. 

Unfortunately, due to unpredicted financial woes in 2014, KOH laid off 500 employees and left 200 open positions unfilled to yield $218 million in savings.  Many physicians were concerned that “virtually all of the experienced nurses” were preferentially terminated.  KOH contemplated closing one of their hospitals, ultimately shuttering an emergency room instead.  Despite these measures, KOH registered an operating loss of $69 million. 

An executive team was assembled to focus on revenue growth and expense reduction.  Vacant land was purchased nearby for “a new facility to meet the evolving needs of the community.”  Does this story sound familiar? It should.  The parent company of KOH is Catholic Health Initiatives (CHI), the same organization that entered our community a few years ago. 

Greg Postel, MD, U of L’s Vice President, warned KOH CEO Ruth Brinkley by letter “the number and quality of nursing staff has severely declined” since affiliation.  He alleged these deficiencies damaged the U of L Hospital reputation and physicians were leaving due to “unsafe working conditions” for staff.  He accused CHI of breaching the fiduciary obligations in the operating agreement, being $46 million in arrears. 

A complaint filed by the Vice-chair of Surgery, Dr. J. David Richardson asserted a decline in morale and inadequate staffing was compromising patient safety.  “Patients are being held in the ER until enough nurses are available,” he wrote. In an interview with the Courier-Journal, Dr. Richardson thought the best resolution would be to “unwind” the joint operating agreement.  “They [KOH] are destroying the hospital,” Richardson said.  The following month, a state inspection confirmed nursing deficiencies had undeniably endangered patients. 

In December 2016, KOH and U of L Hospital terminated their agreement, releasing management of the U of L Hospital and the cancer center effective July 1.  CHI anticipates $272 million in losses from this dissolution.  

Last fall, CHI began merger talks with Dignity Health, a company facing financial difficulties of its own with an operating loss in 2016 of $63 million across 39 hospitals.   The same year, CHI operating losses were almost $500 million amongst 103 hospitals.  Both organizations already carry higher than average debt loads, though with complementary markets, merging might be advantageous.

Interested in affiliation, CHI implemented a “turnaround plan,” to bolster their negotiating position.  However, 2 of CHI’s 11 “multi-hospital hubs,” the Louisville and Houston markets, are failing, necessitating relief from profitable markets like Ohio and the Pacific Northwest group.  KOH eliminated 250 non-clinical positions in the interest of fiscal health last month. 

The most alarming actions by KentuckyOne Health is the termination of 25 professional service agreements of their employed physicians without justification.  These are the very same physicians who sold their private practices to KOH just 5 years ago.  Dr. Richard Holt, a spine surgeon, was affiliated with Jewish Hospital while practicing independently.  He sold his practice to relieve the overwhelming administrative burden and was satisfied working at the hospital-based clinic, meeting productivity goals.   Surprised by sudden dismissal, his last day is July 31.  Sadly, he will retire because at 69, he is no longer willing or able to launch a private practice from scratch.

After five years under the management of CHI, Jewish Hospital is being placed on the auction block, to “slim down” operations.  After divesting of almost every hospital acquired over the last 5 years, they will concentrate on “opportunities for growth” elsewhere.  KentuckyOne Health may be the red-headed stepchild, though we should not forget Jewish Hospital was a thriving community hospital before their ill-fated merger. 

The Pacific Northwest hospital group may be considered the “golden child” for now, but what happens if profit margins decline and further cutting costs is not feasible? The Jewish Hospital merger experience should serve as a cautionary tale for Kitsap County.   Will our beloved community hospital be sold off five years from now or can we escape the same fate by devising a viable alternative for healthcare in our community?    

Tuesday, June 6, 2017

The Small Giants of Healthcare

A recent Medical Economics article asked “Is the DPC model at risk of failing?”  The piece focuses on two large DPC-like organizations, Qliance Medical Management of Seattle, Washington and Turntable Health of Las Vegas, NV, working in partnership with Iora Health, which recently closed their doors.  Qliance and Turntable were not actually DPC practices by strict definition; they were innovative large business operations providing healthcare services to patients and excluding third party payers.  Their idea was commendable, but their closure indicates little cause for concern in regard to the growing Direct Primary Care movement.

Robert Berenson, MD, who admits to not being a fan of the DPC model, said “Qliance has been the poster child for DPC… If that one can’t make it… it suggests the business model (of DPC) is flawed.”    He is correct about one thing; the “business” model of medicine is certainly flawed.  What he does not realize is DPC is not a “business” model; it is a “care” model.   Whether accepting insurance or DPC in structure, we already know solo and two-physician practices deliver the best care and have been doing so for the past 100 years.  These intimate clinics know their customers better than anyone else in the industry, and can devote the time necessary to their clientele; these micro-practices should be known as the small giants of healthcare.

Strictly defined, Direct Primary Care is where a patient and physician enter into a contract to provide unlimited primary care services for an affordable monthly fee (less than $100/month.)  80% of healthcare needs can be met in a DPC practice. The typical DPC practice has 1 or 2 physicians, 600 patients maximum per physician, and on average each physician sees 10 patients per day.  Employees are minimal, usually including a receptionist and/or medical assistant.  Only minimal office space is required to run such a lean operation, so overhead remains low.  Supplies, medication, and equipment are purchased on an as needed basis and used only when necessary. 

Qliance, founded in 2007 by Dr. Garrison Bliss and Dr. Erika Bliss, charged $64/month for adult members and $44/month for children.  They had 13,000 patients in total including primary care and emergency care services, more than 20 times the number of patients compared to a traditional DPC clinic.  They were trying to use a model embraced by the small giants yet contort it into something entirely different simultaneously.  After 10 years, the experiment failed. 

Iora Health, vying to become the “Starbucks” of healthcare, was in partnership with Turntable Health utilizing a “team based” concept.  Each “team” included a physician, nurse, and a health coach.  This model contracted with individuals, but also employers and unions already paying for healthcare by offering improved access to primary care services and pocketing a portion of the savings that materialized.  In this model, physicians usually had 1000 patients and each health coach with a few hundred.  Turntable charged $80/month for adults and $60/month for children to have access to their vision of a “wellness ecosystem”, which included yoga, meditation, and cooking classes. 

An article in the New York Times quoted Duncan Reece, the VP of Business at Iora Health, “We wanted to do something radically different and show this isn’t your grandfathers’ doctor’s office.”  Can someone please tell me what was wrong with that model?  It was a quintessential small giant of the business world.  My grandfather was an outstanding general practice physician with a small office and one nurse on staff.  He made house calls.  He did appendectomies, tonsillectomies, C-sections, vasectomies, and met most of his patients’ basic primary health care needs for 40 years.  Why do we need something radically different? 

The bottom line is healthcare requires two people – one physician and one patient.  While it is a nice idea, we do not need yoga, massage, or smoothie bars in our clinics to improve patient outcomes.  Adequate medical knowledge and time for meaningful conversations is essential; something the small giants of healthcare are experienced in providing.  The vision of a “wellness ecosystem” should probably go the way of the “patient-centered medical home,” as there is little cost savings or difference in outcomes compared to the traditional fee-for-service system.    

So what qualities make the best practices? According to a study conducted by The Peterson Center on Healthcare at Stanford, the very best  primary care practices have either one location or a small handful of them.  Stanford compiled a list of 10 distinguishing features of these top practices and many are commensurate with being a “small giant” of the business world.  My favorite characteristic on the list is to invest in people, not space or equipment.  By lowering overhead, physicians are not relying on patient volume to generate adequate income.  These practices are consciously choosing to stay small by renting minimal space and investing in added services only when believing them to be more cost-effective.

The government and insurance companies cannot fix healthcare.  It is up to physicians and patients– one micro-practice or DPC clinic at a time.  Dr. Kimberly Legg Corba, owner of Green Hills Direct Family Care, said “The DPC model is growing and practices are converting all the time.  Some are opening by transitioning an established practice, some are physicians starting clinics fresh out of residency from scratch, and others are leaving employed positions to return to practicing medicine in a way they love.” 

While my practice is not DPC, it is a small, old-fashioned clinic serving families for as long as three generations.  Our records are still on paper, a real human being answers the phone when it rings, and for occasional emergencies, patients stop by my house for a “reverse house call.”  My belief in the DPC model is steadfast because any “care” model placing control directly into the hands of physicians and their patients is worth fighting to preserve and protect.  The more small giants able to thrive in the constantly evolving healthcare landscape, the greater chance physicians have of inciting a large scale revolution to benefit patients everywhere.

Since the Affordable Care Act legislation went into effect, mergers and consolidations have increased by 70%, at the expense of care becoming less personalized and increasingly fragmented.   These large institutions are profit centers for CEO’s and business executives who have very little knowledge of what goes on between a physician and a patient.  They need the independent practice model to fail so patient choice is no longer an option. 

The small giants, micro-practices and DPC clinics, will continue to prosper and grow because a “care” model devoted to preservation of the physician-patient relationship cannot be defeated.  Physicians must stop being afraid to take that leap of faith, leave employment, and go back to doing what we love most, caring for our patients and improving their lives.   Physicians should be standing at the bedside, not in front of computer workstations.  Direct Primary Care is a model for which we should all be rooting; it is transforming the physician-patient relationship and restoring the practice of medicine to its noble roots, allowing for the art, the science, and the wholly fulfilled physician.     

My advice for patients everywhere:  Whenever possible, find an independent practice, whether a solo doctor or direct primary care clinic, and patronize that physician.  Your care will be more personalized, cost less in the long run, and your health will be better for the investment you made in yourself. 

Tuesday, May 30, 2017

MD and DNP: WHy 20,000 Hours of Difference in Training and Experience Matters

As southern states entertain legislation granting nurse practitioners independent practice rights, there are some finer details which deserve careful deliberation.  While nurse practitioners are intelligent, capable, and contribute much to our healthcare system, they are not physicians and lack the same training and knowledge base.  They should not identify themselves as “doctors” despite having a Doctor of Nursing Practice (DNP) degree.  It is misleading to patients, as most do not realize the difference in education necessary for an MD or DO compared to a DNP.  Furthermore, until they are required to pass the same rigorous board certification exams as physicians, they should refrain from asserting they are “doctors” in a society which equates that title with being a physician.
After residency, a physician has accrued a minimum of 20,000 or more hours of clinical experience, while a DNP only needs 1,000 patient contact hours to graduate.  As healthcare reform focuses on cost containment, the notion of independent nurse practitioners resulting in lower healthcare spending overall should be revisited.  While mid-level providers cost less on the front end; the care they deliver may ultimately cost more when all is said and done.
Nurse Practitioners already have independent practice rights in Washington State.  In my community, one independent NP has had 20 years of clinical experience working with a physician prior to going out on her own.  Her knowledge is broad and she knows her limits (as should we all); she prominently displays her name and degree clearly on her website. This level of transparency, honesty, and integrity are essential requirements for working in healthcare.  Below is a cautionary tale of an independent DNP elsewhere whose education, experience, and care leave much to be desired.  I thank this courageous mother for coming forward with her story.
After a healthy pregnancy, a first-time mother delivered a beautiful baby girl.  She was referred to “Dr. Jones,” who had owned and operated a pediatric practice focused on the “whole child” for about a year.    This infant had difficulty feeding right from the start.  She had not regained her birthweight by the standard 2 weeks of age and mom observed sweating, increased respiratory rate, and fatigue with feedings.  Mom instinctively felt something was wrong, and sought advice from her pediatric provider, but he was not helpful.  This mother said “basically I was playing doctor,” as she searched in vain for ways to help her child gain weight and grow.
By 2 months of age, the baby was admitted to the hospital for failure to thrive. A feeding tube was placed to increase caloric intake and improve growth.  I have spent many hours talking with parents of children with special needs who struggle with this agonizing decision.  It is never easy.  A nurse from the insurance company called to collect information about the supplies, such as formula, required for supplemental nutrition.  Mom was so distressed about her daughters’ condition, she could not coherently answer her questions.  As a result, the nurse mistakenly reported her to CPS for neglect and a caseworker was assigned to the family. 
Once the tube was in place, the baby grew and gained weight over the next three months.  At 5 months of age, mom wanted to collaborate with a tube weaning program to assist her daughter with eating normally again.  A 10% weight loss was considered acceptable because oral re-training can often be quite challenging.  As this infant weaned off the tube, no weight loss occurred over the next two months, though little was gained.  She continued to have sweating with feeds and associated fatigue.  On three separate occasions mom specifically inquired if something might be wrong with her daughters’ heart and all three times “Dr. Jones” reassured her “nothing was wrong with her heart.” 
However, “Dr. Jones” grew concerned about the slowed pace of weight gain while weaning off the feeding tube.  Not possessing the adequate knowledge to recognize the signs and symptoms of congestive heart failure in infants, he mistakenly contacted CPS instead.  After being reported for neglect a second time, this mother felt as if she “was doing something wrong because her child could not gain weight.”  This ended up being a blessing in disguise, however, because the same CPS worker was assigned and recommended seeking a second opinion from a local pediatrician. 
On the first visit to the pediatrician, mom felt she was “more knowledgeable, reassuring, and did not ignore my concerns.”  The physician listened to the medical history and upon examination, heard a heart murmur.  A chest x-ray was ordered revealing a right-shifted cardiac silhouette, a rather unusual finding.  An echocardiogram discovered two septal defects and a condition known as Total Anomalous Pulmonary Venous Return (TAPVR), where the blood vessels from the lungs are bringing oxygenated blood back to the wrong side of the heart, an abnormality in need of operative repair. 
During surgery, the path of the abnormal vessels led to a definitive diagnosis of Scimitar Syndrome, which explains the abnormal growth, feeding difficulties, and failure to thrive. This particular diagnosis was a memorable test question from my rigorous 16-hour board certification exam, administered by the American Board of Pediatrics.  If one is going to identify themselves as a specialist in pediatrics, they should be required to pass the same arduous test and have spent an equivalent time treating sick children as I did (15,000 hours, to be exact.)
A second take away point is to emphasize the importance of transparency.  This mother was referred to a pediatric “doctor” for her newborn.  His website identifies him as a “doctor” and his staff refers to him as “the doctor.”  His DNP degree required three years of post-graduate education and 1,000 patient contact hours, all of which were not entirely pediatric in focus.  His claim to have expertise in the treatment of ill children is disingenuous; it is absolutely dishonest to identify as a pediatrician without actually having obtained a Medical Degree. 
The practice of pediatrics can be deceptive as the majority of children are healthy, yet this field is far from easy.  Pediatricians are responsible for the care of not only the child we see before us, but also the adult they endeavor to become.  Our clinical decision making affects our young patients for a lifetime; therefore it is our responsibility to have the best possible clinical training and knowledge base.  Acquiring the aptitude to identify congenital cardiac abnormalities is essential for pediatricians, as delays in diagnosis may result in long-term sequelae such as pulmonary hypertension which carry with it a shortened life expectancy. 
Nurse practitioners have definite value in many clinical settings. However, they should be required to demonstrate clinical proficiency in their field of choice before being granted independent practice rights, whether through years of experience or formal testing.  In addition, the educational background of the individual treating your sick child should be more transparent.  When it comes to the practice of medicine, the knowledge and experience required are so vast that even the very best in their field continue learning for a lifetime.

Raising our children is the most extraordinary undertaking of our entire lives.  Parting advice from this resolute mother is to “trust your gut instinct, and no matter what, keep fighting for your child.” Choosing a pediatrician is one of the most significant decisions a parent will make.  This child faced more obstacles than necessary as a result of the limited knowledge base of her mid-level provider.  A newly practicing pediatrician has 15 times more hours of clinical experience treating children than a newly minted DNP.   When something goes wrong, that stark contrast in knowledge, experience, and training really matters.  There should be no ambiguity when identifying oneself as a “doctor” in a clinical setting; it could be the difference between life or death.