Tuesday, December 26, 2017

Does Parenting Style Matter?

A recent study found that toddlers with permissive parents had more than double the risk of internalizing behaviors (having anxiety or somatic complaints) and triple the risk of externalizing behaviors (bullying or being destructive) compared to peers whose parents used an authoritative or authoritarian parenting styles.  The fact parenting styles could influence the long term behavior and development of children was first hypothesized by Dr. Baumrind in 1967.  She described three styles of parenting:  authoritative, authoritarian, and permissive. 

Authoritative parents, also known as democratic, are those with high demands and high levels of responsiveness to their children.  Their children tend to be happy, confident, independent and have better mental health overall.  Authoritarian parents are those with high expectations yet low responsiveness to their children. This style produces children who are unhappy, insecure, and have more behavior problems. 

Permissive parents, also known as indulgent, place few demands on their child, yet are highly responsive to every whim.  These children have difficulty following rules, poor self-control, and struggle with emotional self-regulation.  As a group, they tend to withdraw socially, have the highest risk of developing mental health disorders, and are more likely to become addicted to drugs or alcohol. 

Parenting is never easy.  It is like navigating one thousand miles through a tunnel with uneven terrain while blindfolded.  Sometimes, using our “gut instinct” to wing it is all we can do; the story below is one example which comes to mind.

A little over a year ago, my strong-willed daughter needed a slight adjustment in attitude.  We were driving home from the dance studio close to our home.  “I don’t like my dance bag and I want a new one.”  I was quiet.  “You are going to buy me a new one because I said so.”  I was pondering a suitable response.  “I don’t like you and I don’t like my dance bag. I want a new mom and a new bag.”  My reaction to her outburst needed to leave a lasting impression.

There is a park and ride between the dance studio and our home.  After turning into the parking lot and swinging a U-turn, I pulled up next to the covered bus stop.  Putting the car in park, I opened the minivan side door and tossed the dance bag outside onto the ground.  “What are you doing?” she demanded.   “You said you did not like your bag, we should leave it here for another little girl who would love a bag like this, so she can take it home.”

Eyeing me suspiciously, she gently unclipped her car seat straps, and got out of the minivan to retrieve her dance bag.  I continued, “While we are at it, I think you would be happier if a different mother was raising you.  Why don’t you get out and wait here (at the covered stop) until you find another mother you like better who wants to take you home?”

Reaching down to pick up her dance bag off the ground, I began to close the van door, knowing the child safety feature would not allow complete closure.  This really got her attention.  She grabbed the bag, used her body to block the door, and hopped back into the van.  “Wait! I want you as my mother.”  She even wanted to go home with me.  Skeptical, I clarified, “Are you sure?  It means you must commit to being my daughter from now on?”  She nodded. 

We drove home in silence.  I was wondering if my approach had been over the top; she was reflecting on the event also.  As we pulled into the garage, she said “Mom, I am sorry for what I said to you. I do want you to be my mother.  Can you promise never to drop me off at the park and ride again?” I smiled before responding, “Ok. I promise never to leave you at the park and ride again, but the next time you tell me you want a new mother, I might try the mall instead.” Having an incredible sense of humor, my daughter giggled and gave me a hug. I returned her affection heartily.    

While an unconventional example of the authoritativeness, high demands were made; after all, she had to pick out a mother (symbolically, at least) for herself.  This was balanced by a high degree of responsiveness on my part in supporting her choice.   Be authoritative whenever possible, remember to “mix it up” sporadically to avoid being predictable, and be open to learning a great deal from mistakes along the way.  Raising a child who is independent, determined, and clever has many challenges, but I would not have it any other way.  Apparently, neither would she.     

Tuesday, December 19, 2017

Could Dignity Health + Catholic Health Initiatives = Micro Hospital?

Bremerton has a large population of elderly, disabled, economically disadvantaged and medically fragile individuals. A targeted, viable solution to meet their healthcare needs is absolutely imperative; strategies must expand access to inpatient, outpatient, and emergency services for everyone. 

My “field of dreams” would be the development of a Harrison Community Campus, bringing together a micro-hospital, a small emergency department, a primary care clinic, and an assembly of satellite offices from multiple social service agencies. And there’s reason to believe it could happen here.

This week Dignity Health officially announced a merger with Catholic Health Initiatives (CHI), the entity that Harrison Medical Center is part of. Their new organization will be the largest non-profit hospital system in the nation, employing roughly 159,000 employees at hospitals and clinics in 20 states. Dignity Health already supports construction of micro-hospitals as a cost-effective solution for healthcare delivery in urban, suburban and rural areas. Peggy Sanborn, Vice President of strategic growth for Dignity Health, said “micro-hospitals have a shorter build time, allowing the health system to bring healthcare services to patients in the community faster.”

Micro-hospitals are independently licensed facilities with approximately 8 to 25 inpatient beds, fully-equipped emergency departments and ample ancillary services, such as pharmacy, laboratory and imaging. Micro-hospitals already exist in 19 states, including Arizona and California, and have the capability to handle acuity levels equivalent to those of any standard community hospital. The micro-hospital concept is gaining traction across the nation because construction costs are considerably lower — between $7 million and $30 million — than traditional hospital facilities, according to Advisory Board statistics. 

Micro-hospitals are best suited to handle short-stay admissions anticipated to be less than 48 hours. Costs are slightly higher than for an urgent care center, yet lower when compared to traditional hospital settings. Micro-hospitals can meet 90 percent of patients’ basic healthcare needs and tend to flourish most in markets with critical service gaps by preventing at-risk populations from falling through the cracks. Ideally, micro-hospitals should be located within 20 miles of a full-service hospital, to facilitate transfer of patients to larger institutions should higher acuity healthcare needs arise.     

An organization called Emerus is the nation’s largest proponent of micro-hospitals, with 22 fully operational and almost two dozen projects currently in development. Structures range in size from 15,000 to 50,000 square feet and function as “healthplexes,” with primary care and specialty clinics. According to Vic Schmerbeck, executive VP of business development at Emerus, the objective is to provide services “in a place where people work, live and play.” 

A community facility, including a micro-hospital, would not only benefit patients, but also providers and insurers, who are crumbling under the weight of increasing costs.  Bringing together primary care, specialty care, and social services in one place would facilitate enhanced care coordination and follow-up. A single, convenient location would lead to healthier outcomes for patients and lower hospital readmission rates, especially for “high utilizers” of emergency services.

Involvement from organizations like Kitsap Connect, the pilot program focused on uniting the “social service silos” under one umbrella, would be crucial to the success of a community campus. Currently, they are compiling data to evaluate whether this innovative, connected approach provides tangible economic savings. If statistics support their assertion, this social service infrastructure must be incorporated into the community health improvement strategy to ensure long-term gains.

Some experts are concerned smaller hospitals may hinder access for larger, underserved populations; however, being slight in scale allows for considerable flexibility, an essential attribute when serving the unique needs of diverse communities. The only drawback to this plan is that right now micro-hospitals exist only in states without certificate of need (CON) laws, and Washington State has strict CON regulations. Building a micro-hospital in Bremerton will require CON approval, an obstacle that may be challenging, yet not entirely insurmountable. 

Population health strategies, focusing on value over volume, are being touted by industry experts as the next frontier toward achieving improved health outcomes. A Harrison Community Campus is an innovative answer for delivering high quality services in cost-effective manner. Micro-hospitals are a highly successful model, delivering convenient care, closer to home, while being suitably-sized to meet the fluctuating needs of evolving communities. 

Primary care, specialty care, inpatient, and emergency services must be affordable and accessible to everyone.  With careful planning and conservative execution, construction of a community “field of dreams” is feasible and would be a worthwhile investment in our children, our neighbors, and ourselves. If we build it, they will come. 

This article was originally published by the Kitsap Sun Newspaper and can be found here:  http://www.kitsapsun.com/story/opinion/columnists/2017/12/17/could-micro-hospital-work-here/956420001/

Tuesday, December 12, 2017

Does the CVS-Aetna Merger Condone Segregation in Healthcare?

photo credit: the Economist

Last week, pharmacy giant CVS has agreed to purchase Aetna for an astounding $69 billion dollar sum.  The company allegedly plans to reduce health spending by developing an integrated system touted as “a new front door for health care in America.” This merger is actually an acquisition, entailing transfer of ownership.  The central aim of an acquisition is to increase market share, expand the scope of services provided, and improve financial stability.  CVS hit the jackpot on all three objectives.  While Wall Street investors celebrate, many of us knowledgeable in the delivery of healthcare services are wondering who will bear the responsibility for the patients harmed by this experiment?

Aetna has compiled vast amounts of data from 22 million health plan members.  CVS provides pharmacy benefits management to nearly 90 million consumers.  Together, with 10,000 stores and 1,100-minute clinics already in the CVS network, this acquisition will create a ‘Walmart for Healthcare.’  Applying bulk-purchase business strategies to the sale of merchandise is one thing, while providing healthcare services by ‘trial and error’ to human beings is another matter entirely.  Bypassing physicians to deliver healthcare by protocol categorically jeopardizes patient safety. 

Executives at Aetna-CVS plan to utilize pharmacists and nurses in the evaluation of acute illness and management of chronic disease.  If an insurer, drugstore, and pharmacy benefit manager unite as one, it will usher in an era of medical “segregation,” defined as the isolation or separation of a race, class, or group by enforced or voluntary restriction, by barriers to social intercourse, by separate educational facilities, or by other discriminatory means. 

CVS-Aetna executives are hypothesizing these clinicians working independently can provide “separate but equal” healthcare services at a lower cost than physicians.  There is no scientific evidence their assertion is true or even possible.  Their innovative business model will be, in a word, an experiment on citizens of this nation.  In Brown v. The Board of Education in 1954, the Supreme Court unanimously agreed “separate educational facilities are inherently unequal” and are in violation of the Fourteenth Amendment equal protection clause (“no state… shall deny to any person…the equal protection of the laws.”)   Why is “separate but equal” suddenly acceptable for healthcare?  It is absolutely not.

For example, recently, a mother brought in her 18-month-old with a fever, runny nose, and ear pain.  On examination, he had an ear infection and was prescribed Amoxicillin.  The next evening, he refused oral intake, and developed a rash in his mouth, hands and feet.  The mother took him to a retail clinic after work that evening. “Minute Clinics” are convenient because they accept walk-ins, charge by the visit, and order tests by protocol, as if ordering dessert, a la carte in a restaurant.   

At the retail clinic, a rapid flu test was negative and a rapid streptococcal test was positive.  Using this “information” to guide diagnosis and treatment by protocol, his “Strep Throat infection” in conjunction with a rash was assumed to be Scarlet Fever, which was theorized to be “resistant to Amoxicillin.” The clinician prescribed Omnicef, believing something “stronger” was required for Streptococcal bacteria.

Having regular commercial insurance, the mother returned to my office for medical care when her son continued complaining of ear pain despite the “stronger” antibiotic two days later and his oral lesions continued to multiply.  His exam revealed Herpangina (a variation of the hand, foot, and mouth virus) and his eardrum was now bulging with pus.  I recommended restarting the amoxicillin and for her son drink cool liquids until the oral lesions resolved; the child recovered uneventfully.

Pharmacists and nurses will be thrust into independent roles for which they are ill-equipped to handle; if using this shotgun approach, costs will continue their upward climb.  First, children under two rarely get streptococcal throat infections, so strep tests should not be routinely administered in this age group.  Secondly, symptoms of streptococcal infection are well-defined:  sore throat, fever, swollen lymph nodes, and abdominal pain in the absence of a runny nose and cough.  A positive test in this child indicated they were a carrier which needs no intervention.  Third, scarlet fever looks nothing like herpangina, which is a virus and resolves on its own.  Fourth, Omnicef, at a cost of $150 per course, is not a first, second, or even third-line treatment for Group A Streptococcal infection; the first line choice is amoxicillin, costing less than $5.

If this ill-advised merger between Aetna and CVS proceeds, millions of lives will hang in the balance. This new business model reminds me of the scene from Dickens’ A Christmas Carol, when Ebenezer Scrooge sees the Cratchit family mourning the loss of Tiny Tim.  Research has shown life expectancy is directly proportional to the ratio of primary care physicians available per 100,000 population.  How many children, like Tiny Tim, will be harmed before lawmakers and the public refuse to accept a future devoid of primary care physicians? 

Thankfully, time has a way of revealing truth.  CVS considers having a medical degree to be an “obstacle” to affordable medical care, which they plan to eliminate with “one-stop shopping,” having pharmacists and nurses practicing medicine by protocol.  A segregated, two-tiered healthcare system will ultimately emerge as Aetna members are directed to “Minute Clinics” without access to physicians while those on other commercial insurance plans will see the physician, nurse practitioner, or physician assistant of their choice.  Changing the delivery of healthcare services by circumventing physicians to save money is equivalent to gambling with patients’ lives.  This vertical business model should induce fear and panic in all of us – we should run for our lives, and never look back. 

Tuesday, December 5, 2017

Honesty, Trust, and Transparency: PA-C and MD

Honesty, Trust, and Transparency

Recently, the New York Times published an article on excessive costs incurred by mid-level providers over-treating benign skin lesions.  According to the piece, more than 15% of biopsies billed to Medicare in 2015 were done by unsupervised PA’s or Nurse Practitioners.  Physicians across the country are becoming concerned mid-levels working independently without proper specialty training.  Dr. Coldiron, a dermatologist, was interviewed by the Times and said, “What’s really going on is these practices…hire a bunch of P.A.’s and nurses and stick them out in clinics on their own. And they’re acting like doctors.”

They are working “like” doctors, yet do not have training equivalent to physicians.  As a pediatrician, I have written about a missed diagnosis of an infant by an unscrupulous midlevel provider who embellished his pediatric expertise.  This past summer, astute physician colleagues came across an independent physician assistant, Christie Kidd, PA-C, boldly referring to herself as a “dermatologist.”  Her receptionist answers the phone by saying “Kidd Dermatology.”

The Doctors, a daytime talk show, accurately referred to Ms. Kidd on a May 7, 2015 segment as a “skin care specialist.”  However, beauty magazines are not held to the same high standard; the dailymail.com, a publication in the UK, captioned a picture of “Dr. Christie Kidd”, as the “go-to MD practicing in Beverly Hills.”  The article shared how Ms. Kidd treats the Kardashian-Jenner family, “helping them to look luminous in their no-make-up selfies.”  While most of us cannot grasp the distress caused by not appearing luminous in no-makeup-selfies, this is significantly concerning for Kendall Jenner.  At the tender age of 21, she inaccurately referred to Ms. Kidd as her “life-changing dermatologist.”  Cosmopolitan continues the charade, publishing an article on the Jenner family “dermatologist.” 

It astounds me how some medical professionals can contentedly live in the gray, south of brutal honesty, yet somewhere north of deceit.  Until a few months ago, the Kidd Dermatology website erroneously listed her educational background as having graduated from the USC School of Medicine with honors and made no mention of her supervising physician.  It was later modified to reflect she graduated from the Physician Assistant program at USC. 

There are laws mandating physicians display diplomas and certifications prominently in the interest of transparency.  According to Title 16, California Code of Regulations sections 1399.540 through 1399.546, a PA in “independent” practice is limited to the scope of his/her supervising physician by law.  A board-certified plastic surgeon is supervising “skin specialist” Christie Kidd, PA-C, not a dermatologist.  The website of the plastic surgeon states, “Trust only a Board-Certified Plastic Surgeon;” which in my opinion, seems astonishingly tongue-in-cheek.   He may believe treating bullous pemphigoid disease is just another day in the life of plastic surgeons everywhere, but plastic surgery is a far cry from practicing dermatology and vice versa.  

credit: dailymail.co.uk 
When asked about this, the Public Affairs Manager, Cassandra Hockenson, at the Medical Board of California responded“there is not a huge difference between plastic surgery and dermatology.”  She suggested contacting the Physicians’ Assistant Board for the State of California instead.  She kept repeating that the supervising plastic surgeon had no complaints against him.  I learned two important lessons from contacting the Medical Board of California:  1) Without complaints, a physician can supervise midlevel providers in any specialty they choose, and 2) while required by law to supervise mid-level providers, the safety of patients is not a high priority for the Medical Board of California. 

At a minimum, physicians complete four years of college, four of medical school, and between 3-7 years in residency.  The years of education required for obtaining a PA degree are considerably fewer than that of an MD.  For all intents and purposes, Christie Kidd, PA-C is running an independent dermatology practice directly under the nose of an apathetic California State Medical Board indifferent to regulations.  PA’s can be fined and disciplined by their own board for misrepresentation, however, her “supervising” physician is, in fact, also out of compliance with the law.

While not all celebrities understand the difference in education between an MD or PA, mid-level providers and their supervising physicians should not be immune to the rules and regulations.  Honesty, trust, and transparency are ideals essential to the medical profession.  Physicians are held accountable for the health and safety of the patients we serve.  Google Business modified the Kidd Dermatology listing from “Dermatologist” to “Medical Spa.”  The unsinkable Christie Kidd struck a compromise, settling on the designation as a “skin care clinic.”  Carpe Diem, Ms. Kidd, Carpe Diem.