2018 Midterm Election: The Year of the Female Physician

While women make up more than half of the U.S. population, an imbalance remains between who we are as a nation and who represents us in Congress. The gender disparity is no different for physicians; more than a third of doctors in the U.S. are women, yet 100 percent of physicians in Congress are men. To date, there have only been two female physicians elected to Congress.

But in the coming midterm election there are six races with a chance at making history. It's these battles which could make 2018 "The Year of the Female Physician."

I remember being a first-time voter in 1992, labeled at the time "The Year of the Woman." I was a sophomore at Michigan State University and turned 18 just three days before the election. Following the contentious Supreme Court hearings involving Clarence Thomas and Anita Hill, an unprecedented number of female candidates were vying for office that election year.

President George H.W. Bush was vilified for an appalling answer to the question of when his party might nominate a woman for President. “This is supposed to be the year of the women in the Senate," he quipped. "Let's see how they do. I hope a lot of them lose." Frustrated about the state of gender inequality in politics, a little known “mom in tennis shoes,” Patty Murray, decided to run for the U.S. Senate to represent Washington. She won, paving the way for an unprecedented number of women to enter national politics over the next 30 years. Yet very few of them have come with a background in medicine.

Since 1960, just 49 physicians have been elected to the U.S. House or Senate.  Currently there are 15 physicians serving in Congress, 13 of whom are Republican and all of whom are men. Technically, the first female physician to win a congressional election was a non-voting delegate from the Virgin Islands, Rep. Donna Christian-Christensen. The only two voting members were former Reps. Nan Hayworth of New York and Shelley Sekula-Gibbs of Texas, both Republicans.

In 2018, eight Democratic female physicians ran for Congress: Dawn Barlow (TN-6), Kyle Horton (NC-7), Danielle Mitchell (TN-3), Hiral Tipirnini (AZ-8), Jennifer Zimmerman (FL-1), Shannon Hader (WA-8), Kim Schrier (WA-8), and Nadia Hashimi (MD-6). After state primaries, six remain in contention for Congressional seats. Here's who they are, and what their election could portend.

Dr. Dawn Barlow is an internal medicine physician running in Tennessee’s 6th Congressional District. She is married to an Iraq War veteran and hopes to improve the health of veterans. She supports preserving the 10 essential benefits of the ACA, Medicaid expansion and a single-payer system.

Dr. Kyle Horton is an internal medicine physician running for the seat in North Carolina’s 7th District. She wants to lower the Medicare age to 50 and provide universal health coverage though public option coverage that can be purchased. Her focus is to reduce pharmaceutical costs, expand Medicaid and Medicare, and fund the Children's Health Insurance Plan (CHIP.)

Dr. Danielle Mitchell is a family physician running in Tennessee’s 3rd. Raised in poverty, she lost her 12-year-old brother to a life-threatening, though treatable, medical condition due to inability to afford health coverage. She supports universal health care, the preservation of Medicare and Medicaid, and making pharmaceuticals more affordable.

Hiral Tipirnini, MD a candidate in Arizona's 8th District, is an emergency physician who supports repairing the ACA, rather than repealing it. She wants those under 65 to “buy-in” to Medicare and feels free market competition the best way to reign in healthcare costs.

Jennifer Zimmerman, MD, is a pediatrician and Filipino immigrant who is running in Florida’s 1st District. Her campaign slogan is apropos: “This woman can.” Having faced adversity in her formative years, she believes in Medicare and Medicaid expansion and universal healthcare.  

One of this years’ most watched races is in Washington State’s 8th District, where Dr. Kim Schrier is vying for the open seat vacated by Rep. Dave Reichert. Dr. Schrier is a physician, wife, and mother, with a broad view of the world; but, she is also a patient who was diagnosed with Type I Diabetes as a teenager.

Her academic resume is impressive. Despite having chronic disease, she earned an Astrophysics degree from UC Berkeley, finished medical school at UC Davis, and did residency at Lucile Packard Children’s Hospital at Stanford, one of the top pediatric programs in the country. She lacks deep political ties, not unlike Sen. Murray did once upon a time. Practicing as a pediatrician in Issaquah for the past 16 years lends a unique perspective — one currently missing — when Congress debates issues of women’s healthcare, reproductive rights, and children’s health. Her steely resolve to strengthen our healthcare system so every person has access to affordable, high-quality care is one ideal the nation should endorse.

Physicians are experts on the implementation of policies which facilitate an effective healthcare system. These six female physicians have the knowledge, intelligence, and determination that Congress and the nation need. I, for one, plan to keep my fingers crossed that these female physicians make history on election night.     

The Reasons Childbirth is safer in Libya than the United States.

Maternal mortality can seem like a throwback to the Victorian era, a bygone relic of a time before modern medical technology turned childbirth from a dicey, high-stakes gamble into an anodyne rite of passage. I must admit that until recently, I, a practicing pediatrician, agreed with this view – despite the fact that my great-grandmother died in childbirth and my grandmother nearly suffered the same fate. But statistics on childbirth and the local case of a 2014 death at Naval Hospital Bremerton, back in the news just this week, remind us of the risks that still exist to a high degree in our developed world.

According to the World Health Organization, the global maternal mortality rate has fallen by 44 percent in since 1990, with 157 of 183 countries tracked by the organization experiencing a decrease between 2000 and 2015. The United States, however, was not among those 157 countries.

During the same period, the U.S. maternal mortality more than doubled, skyrocketing from 9.8 to 21.5 maternal deaths per 100,000 live births. That’s six times higher than most Scandinavian countries and three times higher than Canada and the United Kingdom. In the U.S., around 700-900 women die and another 65,000 experience life-threatening complications during or after childbirth. By any standard, the U.S. has the worst performance on this crucial measure of any country in the developed world. 

And while complications from pregnancy and childbirth can, of course, strike women of all backgrounds, maternal mortality in the U.S. afflicts certain demographics --African Americans, low-income women and those living in rural areas-- much more than others. According to the Centers for Disease Control, the maternal mortality rate is three times higher for African American women than white women. (40.0 vs. 12.4 deaths per 100,000 live births in 2011-2014.) 

To make matters worse, research done by the CDC Foundation determined up to 60% of these maternal deaths were preventable.

These stats got me thinking: Seeing that maternal mortality clearly remains a serious problem, why are we taking a head-buried-in-the-sand approach? (The most recent nationwide maternal mortality statistics date from 2007.) And how can childbirth in the U.S. become equally as safe as it is in Libya or Vietnam? 

Since 2006, the state of California has been working with Stanford University School of Medicine to buck the status quo, by starting the California Maternal Quality Care Collaborative (CMQCC), aimed at developing best practices to reduce maternal mortality.  The medical director at CMQCC, Elliott Main, formed a review board made up of concerned doctors, nurses, midwives, and hospital administrators to analyze root causes of mortality and propose solutions. Through their work, it quickly became apparent that hemorrhage and preeclampsia were the most common preventable causes of maternal death.

While hemorrhaging is associated with such risk factors as delivering twins or having multiple pregnancies, as many as one-third of mothers don’t fit into a risk profile. This means that a life-threatening hemorrhage – which can be lethal in under five minutes-- often comes on suddenly making time, of the essence. The maternal mortality review board found that obstetric teams were often unprepared to deal with unexpected hemorrhaging and wasted precious time searching for the drugs and supplies needed to staunch bleeding. 

Hopsitals have had “code carts” for decades - wheeled contraptions stocked with basic equipment necessary to resuscitate patients - so why, the mortality review team reasoned, don’t obstetric units have “hemorrhage carts” to keep all the emergency supplies in one easy-to-reach place?

The CMQCC team also took umbrage with the tried and true practice of eyeballing maternal blood loss. There are better, more objective ways of measuring real blood loss. They recommended that obstetric teams weigh the pads and sponges they use to collect blood before and after they are soaked to quantify the exact volume of blood loss and therefore replace losses when necessary.

Another top maternal killer, a condition called preeclampsia, is highly treatable, if caught early and treated aggressively. However, it’s been shown that in fatal cases, healthcare providers fail to do either. In 2014, CMQCC developed a “preeclampsia toolkit” calling for more careful monitoring of blood pressure and swift administration of magnesium sulfate and anti-hypertensive medications when vital signs indicate abnormal blood pressure readings.

While data evaluating effectiveness of CMQCC’s approach has yet to be published, among the 126 hospitals taking part in the group’s maternal hemorrhage and preeclampsia projects, maternal morbidity fell by 20.8 percent between 2014 – 2016. And overall, their efforts are credited with helping the state of California reduce its maternal mortality rate by 55 percent from 2006-2013. The state’s rate dropped from 16.9 to 7.3 per 100,000, even as the U.S. maternal mortality rose from 13.3 to 22.0 per 100,000 during the same period.

Though, in Washington State, our maternal mortality ratio has held steady at 9.0 per 100,000 births for years, we too stand to learn from California’s example.  Childbirth is no party.  It can be one of the riskiest endeavors women face in their lifetime.  We must mobilize our health providers, policy-makers, and communities to do better. With increased awareness of maternal mortality– and tangible, targeted actions to ensure pregnant women receive the highest quality care– many fatal and near-fatal outcomes can be avoided.

Can Physicians Push Back Against Big Pharma?

A few weeks ago, I saw a young patient who was suffering from an ear infection. It was his fourth visit in eight weeks, as the infection had proven resistant to an escalating series of antibiotics prescribed so far. It was time to bring out a heavier hitter. I prescribed Ciprofloxacin, an antibiotic rarely used in pediatrics, yet effective for some drug-resistant pediatric infections.

The patient was on the state Medicaid insurance and required a so-called prior authorization, or PA, for Ciprofloxacin. Consisting of additional paperwork that physicians are required to fill out before pharmacists can fill prescriptions for certain drugs, PAs boil down to yet another cost-cutting measure implemented by insurers to stand between patients and certain costly drugs.

The PA process usually takes from 48-72 hours, and it’s not infrequent for requests to be denied, even when the physician has demonstrated an undeniable medical need for the drug in question.

I saw my patient with the persistent ear infection on a Thursday afternoon. It would be Monday, at the very earliest, that his Ciprofloxacin prescription could be filled – provided the insurance company granted my PA request.  Because he needed the drug as soon as possible, the patient’s mother and I called the pharmacy to see how much a 100ml bottle of Ciprofloxacin would cost if she were to pay out of pocket. The answer was $135 – an almost unthinkable sum for a single mother of three who was working two jobs to make ends meet.

That’s when my frustration led to a breakthrough.

My grandfather was a general practitioner who prepared medications from the “virtual pharmacy” that lined his office walls in order to send patients home with medically-necessary medications.  Washington State allows physicians to dispense medications directly to patients, just as most general practitioners did well into the 1960s.

As my patient and his mother waited, I contacted Andameds, one of the country’s largest distributor of wholesale generic drugs.  I was told that the same 100 ml bottle of Ciprofloxacin that would have cost $135 at the pharmacy could be purchased directly by me for under $20. It arrived at my office the next day, and I sold it to my patient’s mom at cost, thus bypassing the insurer and the pharmacy benefit manager (PBM) entirely. 

Bypassing both the insurer and PBM entirely will soon take on a great deal of significance to physicians and their patients. 

The PBMs are essentially middlemen, who go between pharmaceutical companies and insurers, negotiating lower prices for drugs bought in bulk and passing much of those savings on to the insurance company. (They make their money on the margin between what the pharmaceutical companies charge for the drugs and the slightly up-charged price PBM’s charge the insurance companies.)  According to recent disclosures, CVS and Express Scripts—two of the largest PBM’s in the nation – are passing 95-98% of the rebates they receive from the drug manufacturers on to the insurers. 

While it is not clear exactly what insurers are doing with the revenue generated through drug rebates, it is obvious why a merger between CVS and insurance giant, Aetna, might be so lucrative.  If the Department of Justice approves this merger of titans, it will surely pave the way for another, between insurance behemoth Cigna and Express Scripts - which is, along with CVS and OptumRx, one of the Big Three in pharmacy benefit management entities.  After merging into one entity, it is conceivable that Aetna-CVS and Cigna-Express Scripts will control price, access, and distribution of drugs for the majority of the U.S. population. 

Purchasing generic medications through Andameds allows me to bypass the insurer and the PBM, and purchase Epi-Pens for $300, compared to the $600 retail price; Amoxicillin suspension for $2 per bottle, compared with $15; and just about any other generic medication for pennies on the dollar. 

Darwin said, “It is not the strongest of the species that survive, nor the most intelligent, but the one most responsive to change.”  At the rate we are going, a bottle of Amoxicillin suspension will soon cost more than $1000.  With the pharmaceutical industry poised to become increasingly vertically integrated, this sort of direct distribution of medications by independent physicians, like me, can be an efficient and effective way to get necessary drugs into the hands of patients who need them at prices they can afford.