The Understated Impact of a Public Health Officer

The announcement that Dr. Susan Turner, the Kitsap Public Health District Health Officer, plans to retire next July was met with little fanfare.  It occurred to me that Kitsap County residents may be unaware of how much Dr. Turner has touched their lives.  In reality, we are losing a passionate health advocate who has worked tirelessly to improve the health and wellness of this community for more than five years.

 

Over the last 100 years, life expectancy at birth has increased from 45 to 75 years, in large part due to our public health services, such as improvements in sanitation, the provision of clean drinking water and safe food, and the elimination of occupational and worksite hazards.  Policy-guided public health interventions continue to address major health issues:  new environmental hazards, tobacco and opioid addiction, infectious disease, racial health disparities, injuries, gun violence, and worsening maternal mortality.

The potential impact on countless lives makes the medical health officer position the single most important physician in a community, yet, at the same time, the fruits of their labor are often largely unseen. Public health is an essential part of the healthcare system.  In fact, I believe the goal of universal healthcare cannot be achieved in the United States without incorporation of the already-existing public health infrastructure and collaboration with innovators like Dr. Turner. 

Having more than 25 years of experience in the public health sector, Dr. Turner dove right in when she first joined the Public Health District in 2014.  We collaborated serving patients at the Juvenile Detention Center where I learned firsthand, she was also a tremendous and compassionate clinician.  

Throughout her tenure, Dr. Turner championed many public health initiatives, including restricting smoking and vaping in public places, modernization of the Health District’s syringe exchange program, and narrowing the focus offered by the district to prioritize funding programs which encompassed “the greatest good for the greatest number.” Dr. Turner accomplished all of this while weathering significant challenges during a time when public health services were devalued and grossly underfunded.

My own professional career began at the Kitsap County Public Health District in 1995, when I accepted a job as the Assistant Health Educator after graduating from college.  I first learned that my childhood dream of becoming a doctor would come true while standing in the hallway of the old building on Austin Drive, when my acceptance to the University of Washington School of Medicine was announced by overhead page. 

Since that time, I have had the honor and privilege of collaborating with three Kitsap Health Officers, including Dr. Willa Fisher, Dr. Scott Lindquist, and Dr. Susan Turner.  After becoming a practicing physician, my reverence for the public health system has continually grown.  I literally cannot do my job without the support of the dedicated employees working there. 

My last call to Dr. Turner—which required about a half dozen conversations—was about measles.  A patient too young to be immunized had been inadvertently exposed to a case of measles at a hospital outside of Kitsap county and had been seen in my clinic before being informed they had been exposed to someone with the disease.

   

Measles is highly contagious; up to 9 out of 10 people with close contact to a measles patient will develop measles. A child can contract measles by being in a room where an infected person has been, even up to two hours after they leave.  Even worse, an infected person can spread measles to others before knowing they are infected themselves. 

After realizing more than a dozen children in my practice could be at-risk, I called Dr. Turner in a state of panic.  In usual fashion, Dr. Turner calmly talked me off the ledge, providing reassurance she would obtain more information before deciding our next steps.  Thankfully, proper precautions had been taken to prevent spread of infection for all involved.  The buck stops with Dr. Turner and for that, I am truly grateful.

I am going to miss Dr. Turner as my colleague, friend, and mentor.  The Health Board has started nationwide recruitment efforts for a new health officer to serve the Kitsap community and if the Health Board finds someone even half as good as Dr. Turner, then Kitsap County should consider themselves lucky.  I wish her many wonderful and quiet years in retirement, but hope she plans to keep her phone on just in case I need her calming presence and expert advice.

Consenting to Learn Publicly

No one wants to make mistakes.  It is a humbling experience.  It is healing to admit it. 

It was brought to my attention by a patient of mine that I have hurt the Native American community.  It wasn’t my intent to hurt anyone, but that is what happened and that is what matters. I would like to address that previous column, “The trouble with tying all police shootings to racism.”

First, I acknowledge the harms caused by racist power structures in medicine, our justice system, and daily life.  On this, my second attempt, I want to be crystal clear.  I believe systemic racism was at play in Stonechild Chiefsticks’ death.  And, when I said, “Is such a significant racial discrepancy due entirely to police officers being racist?  In a word. No,” I wanted to express that this problem is much larger than one officer-involved shooting.

Battling organized racism has never been about a single person or one moment in time—it is about exploring deeply ingrained beliefs each of us hold about those individuals who we see as different from ourselves. Outcome disparities due to race are not limited to the healthcare arena; they affect our education system, justice system, law enforcement, social media and everyday life.  While this death, and countless others, was extrajudicial and tragic, focusing solely on the officer who pulled the trigger does not solve the larger, widespread problem at hand. 

In fact, Reverend Jessica Star Rockers said it perfectly in the Kitsap Sun on November 18 when she wrote, “Chiefsticks’ death is the result of a much deeper issue than the skin color of the officer who killed him. It is the result of a justice system that values white bodies over bodies of color.” I wholeheartedly agree with her sentiment. Unfortunately, I failed to convey this important message.

 

My purpose in writing op-ed columns for the Kitsap Sun has been to stimulate meaningful conversation viewed through the lens of healthcare on the front lines, where I spend most of my days.  Writing has partly been about finding my voice, as a mother to four children, as the daughter of an Iraqi-immigrant father and an Irish Catholic mother, and as a pediatrician practicing in the town where I was born and raised.  Tackling controversial subjects in this column has also been about consenting to learn in front of all of you who read it, and apologizing publicly for missteps along the way.

 

Until a few years ago, I incorrectly believed racism was not as prevalent in Kitsap County as it was everywhere else.  Over that time, I have witnessed racial discrimination firsthand, professionally and personally.  And recent news reports have continued to prove how wrong I was.  Numerous patients of color have shared alarming stories of facing blatant racial and gender-biased treatment right here in our community.

 

Elie Wiesel, an author I greatly admire, wrote “Wherever men and women are persecuted because of their race, religion, or political views, that place must—at that moment—become the center of the universe.”  While many see this topic as unrelated to my scope of practice as a physician and healthcare columnist, to me, racial bias and discrimination transcends the boundaries of healthcare because it harms people irrespective to race, ethnicity, socioeconomic background, gender, or sexual orientation.

 

I do not regret tackling the subject of racism—we need to be talking about it, and I wanted to use my voice and my platform to do so.  For me, this place where our community is right now should become the center of the universe. 

And to that end, I acknowledge my failed attempt to spark a critical discussion about race. I realize my intended message was muddy and read as an anti-Native dog whistle by implying that I was choosing to ignore the effect of racism in Kitsap County. I would like our community to talk about racism and its negative effects—ad nauseum—so we can do better. I would like to see Stonechild Chiefsticks’ death bring about meaningful systematic change in how our community addresses cultural and racial differences.  I would like to see local organizations build bridges of understanding between one another.

 

In closing, I acknowledge that the impact of my column was harmful to the Native American community.  For that, I am deeply sorry.  I can do better in the future when writing about controversial subjects—for the purpose of sparking meaningful community debate--by bringing more clarity to both sides.  

Finally, I am grateful to my patient, Elizabeth Montez-Giras, who held me accountable, as my patients often do.  It is with her encouragement that I have returned to this divisive topic one more time. 

A Second Opinion When Doctors Accuse Parents of Child Abuse

Last spring, 2-year-old girl ran into a sliding glass door at daycare and sliced her forehead. The cut was deep, nearly reaching the skull. Her parents, brought her to me, their pediatrician, and her father held her arms as I stitched her up.

The day I removed the stitches, the child’s mother showed me a row of thin bruises on her daughters right buttock, explaining that her accident-prone toddler had fallen when climbing over a baby gate and landed on a heating grate.  The bruising—3 straight, parallel lines about the length and width of matchsticks—appeared to match the explanation. Having no concerns about child abuse, I told the mother that the bruising pattern was normal and the marks would soon fade.  

A few days later, the girl’s father was stunned to receive a call from Child Protective Services. His daughters’ daycare had reported that Sammy had concerning bruises on her arm and right buttock. On the phone with CPS, the father explained the incident with the baby gate, and also that he’d had to restrain his daughter as she got stitches.

Still, the process moved forward, and the case was assigned to Robin Duer, a CPS caseworker. The family found themselves plunged into a nightmare that is becoming all too common.  The legal system—bolstered by the opinion of a “child abuse expert”—turned their lives upside down, despite the fact that the bruises were so inconsistent with the markings of adult hands that the police detective assigned to the case concluded it was almost impossible they were finger marks.  

The family lives in Washington State, and gave me permission to share their story anonymously.  But a recent investigation conducted by the Houston Chronicle and NBC News revealed an alarming trend—children are being taken from their parents based on disputed medical opinions from physicians trained to spot abuse.  After speaking with more than 100 attorneys, doctors, and state employees, the investigation uncovered over 40 cases in Texas alone where families were torn apart after “child abuse physicians”—on contract with states’ child protective agencies to assist in borderline cases—overcalled child abuse.

As a result of the investigation, Texas lawmakers have called for stronger safeguards in the state’s child welfare system and to create an avenue for accused families to seek a second opinion before the state removes children from their homes. Washington State lawmakers should consider doing the same. 

This is of course not to downplay the vital role that child abuse pediatricians play in protecting society’s most vulnerable members: Their expert reports and court testimony shield countless children from harm. However, definitively determining whether or not injuries resulted from abuse can prove extremely difficult, which means that even these experts are bound to make mistakes—erroneously implicating innocent parents, with terrible ramifications for the entire family.

 

Given the inherent trickiness of diagnosing abuse, specialized child abuse training programs have been established, which incorporate elements of forensics, law, and puzzle-solving. Since 2010, in order to be certified, child abuse specialists must complete three years of additional training, known as fellowship. Only half of the 375 child abuse pediatricians currently in practice nationwide are fellowship-trained. The rest have completed only a three-year pediatric residency in general pediatrics, as I did. 

In this case, CPS called upon child abuse pediatrician Dr. Elizabeth Woods, a new director at the Child Abuse Intervention program at Mary Bridge Children’s Hospital in Tacoma. Although she told me on the phone she had “14 years of child abuse experience,” in actual fact, Dr. Woods resume tells a different story.  She completed only a residency in general pediatrics in 2010 and has not completed a child abuse fellowship. And recently, NBC news reported on a family wrongly accused of medical child abuse by Dr. Woods. It took the Carter family 14 months to get their children returned by the courts.

After reviewing photos of the child’s bruises taken by Ms. Duer of CPS, Dr. Woods determined they were “consistent with a hand mark.” Dr. Woods ignored the fact that this child had been restrained for stitches, and also that the pattern of bruising could be consistent with lines on a baby gate or a heating grate.

Contrary to Dr. Woods, after reviewing the same photos, a police detective assigned to the case concluded that “the bruising appears to be very inconsistent, almost impossible to be hand, finger, fingertip marks.” The officer added, “it is a little difficult for me to understand what the medical professionals are talking about.”

The CPS caseworker would ultimately disregard the opinion of the veteran police detective, as well as my own findings, as the pediatrician, instead favoring the objectively illogical conclusions of Dr. Woods.  On the basis of a single piece of evidence, Dr. Wood’s opinion, Ms. Duer decided the allegations of abuse were “founded”—meaning the state believed it was more likely than not that the family had intentionally inflicted harm on their 2-year-old.

The battle to keep their child cost this family more than $10,000 in legal fees.  Unfortunately, when compared with stories like the Walkers, who were sentenced to 25 years in prison when wrongly convicted of intentionally burning their granddaughters feet in the bathtub, the cost to my patient’s family means they emerged relatively unscathed.  Both involved overzealous child abuse pediatricians who made mistakes.  Those with fewer financial resources have had their children mistakenly torn from their homes while battling against an agency that considers parents guilty until proven innocent. 

What other choice do good parents have?  Seemingly none.  What happened to this family could happen to any of us. 

Washington State lawmakers should implement stronger safeguards to protect families when Child Protective Services defer to contracted “child abuse experts” whose opinions are in dispute by primary care physicians.  Keeping families intact should always be a top priority.  

*Details and identifying information has been altered to protect identity

Is the Patient-Doctor Relationship Still Alive? Yes.

Norman Rockwell vs. Walgreens Definition of the Physician-Patient Relationship

When I describe it, many of you will instantly recall the Norman Rockwell painting of a doctor holding a stethoscope to the chest of a little girl’s doll.

 

Historian Neil Harris described that iconic image, published in a 1929 edition of the Saturday Evening Post, beautifully: “Such a willingness to place professional expertise at the feet of childhood magic serves to remind us, again, of things we have forgotten: secret kingdoms inhabited by imaginary beings whose needs seemed as real as those of the people around us. Rockwell's physician may appear to take the doll's health seriously as an effort to gain the child's confidence and trust, but his act of sympathy is also one of grace, accepting his patient's needs with serenity."

It’s a classic American image, and meaningful in my profession.  Rockwell knew the importance of rapport between doctors and patients.

This week, Walgreens announced they will shutter 160 of their “in-store” health clinics to focus on other ways to bring consumers through their door, like partnering with Jenny Craig weight loss centers.

Retail clinics like those targeted by Walgreens are mostly located in drugstores, supermarkets, “big box” retail settings. Touted as a cheaper alternative to urgent cares and emergency rooms—early studies showed costs were 30% lower compared to care provided in more traditional settings—it turns out 58 percent of retail clinic visits represent a new use of medical services.  The study, published in Health Affairs, revealed the increased use of medical services obliterates any cost savings of utilizing retail clinics.

 

Retail clinics are accessible and convenient.  They are open from 7 a.m. to 7 p.m., seven days a week, and staffed by a nurse practitioner or physician assistant. They treat a variety of minor illnesses such as colds, pinkeye, and urinary tract infections, and provide an array of preventive services, like vaccinations.

However, retail clinics do not offer big profits for corporations or big savings for consumers.  But then again, is the practice of medicine a profit-generating machine or an art and science?

It depends on who you ask.

In one of the last conversations with my grandfather—a solo physician in Tacoma for four decades—he shared his dismay that home visits were no longer a routine part of medical care.  He admonished, “You will never be a good doctor if you don’t know the environment in which your patients live.”   He was probably right.

On the other hand, if you ask Walgreens, profit margins are prioritized over the art and science of healthcare.  And they are going all-in on comprehensive care for senior citizens. Jim O’Conor, senior vice president of Walgreens Neighborhood Health Destinations, said, “We are finding that seniors appreciate not just the high quality of clinical care, but also the social interactions, the personal attention, the convenience and the enhanced coordination between their pharmacist, physician and the health guides we have on site.” Walgreens and Microsoft are developing a “seamless ecosystem” to connect consumers to providers, payers and others. Approximately 200 retail clinics will operate through new arrangements with large health systems, to focus on complex issues and chronic conditions to make more money.

Such grand plans disregard the physician-patient relationship, which is a big mistake.  Rockwell’s painting still has relevance as today’s healthcare market is redefined.

Walgreens “seamless ecosystem” offers full-service primary care, pharmacy, nutrition, and wellness support.  Clinics will be staffed by physician-led teams, registered nurse ‘care coaches,’ behavioral health specialists and social workers.  The retail giants believe seniors will flock to “convenient neighborhood health destinations” where they can get healthcare services where they buy their salad dressing.  Target is teaming up with Kaiser Permanente, CVS—of Minute Clinic fame—is partnering with Aetna, and Rite Aid is working with a telehealth service provider to expand “virtual care” services. 

  

Is a Minute Clinic on every street corner really a panacea for the over-60 crowd?

One of the wisest women I have ever known was Millie, a neighbor and friend who lived well into her 90’s.  After her primary care physician retired, she asked for help to find a new doctor.  She was emphatic about having a physician who knew her name and cared to ask her opinion.   

Millie was not willing to get a flu shot at a retail clinic, so there is no doubt she would not seek care at one when she was ill.  In fact, I visited her home to give her the influenza vaccine myself over the years.  She would often speak fondly about the doctor she had as a child.  It is during one of those home visits when I first learned Millie had lost her father to influenza during the epidemic of 1918. 

It seems perverse to deliver healthcare services at a place called the Minute Clinic. The kind of physician-patient relationship that can be cultivated in a minute is not one to write home about. 

While CVS and Walgreens see geriatric primary care as yet another untapped gold mine, for me, the relationship memorialized in Norman Rockwell’s “Physician” resonates as much today as it did 90 years ago.  Seamless ecosystems are no match for a “willingness to place professional expertise at the feet of childhood magic.”

 

The bond Millie and I shared was magical.  And every patient deserves a physician who knows their name.      

When the Excuses for Assault Blame the Victim

Last week, investigative journalist Ronan Farrow, one of a group of reporters awarded the Pulitzer Prize for prompting a cultural reckoning of workplace behavior through the Me Too movement, released “Catch and Kill,” an in-depth exploration of workplace abuses committed by men in positions of power.
  

“Catch and Kill” contains previously unreleased details from Today Show veteran Matt Lauer’s primary accuser, Brooke Nevils, including an account of rape which allegedly took place in Sochi, Russia, when he was covering the 2014 Winter Olympics for the NBC network.  Mr. Lauer denies the allegations and released a letter through his lawyer that acknowledges engaging in a consensual sexual encounter, stating: “I had an extramarital affair with Brooke Nevils in 2014.  It began when she came to my hotel room very late one night in Sochi, Russia.”


Ms. Nevils describes Mr. Lauer’s letter as “a case study in victim blaming.” 

By focusing on the fact Nevils came to his hotel room late at night, Lauer was, in fact, “victim blaming.” While it has taken decades to pull back the curtain on gender-based discrimination in the workplace, society still excuses the sexual assault of women who placed themselves in “compromising” situations. In reality, whether or not a woman is alone with a man in a hotel room is immaterial to whether or not she was sexual assaulted. If a woman said “No”, then those words should be respected. 
  

Society must endorse the idea that a woman must consent prior to being touched.  And when there is a power differential, consent may not meet the necessary criteria to avoid allegations of sexual assault.  In fact, it might be equally plausible that Mr. Lauer “lured” Nevils to his hotel room as it is that she showed up of her own volition.


I ask this question because of my own experience of having been lured by a physician colleague to his home in the evening under false pretenses.  It is a mistake I have never made again.


At the time, I was heading to a medical meeting and a colleague phoned to ask for a ride because his car was in the shop.  When I arrived, he asked me to come in for a few minutes while he gathered his things.  Feeling fatigued after 24 hours of hospital call, in hindsight, my guard was down.
  

I was leaning up against a wall in the entry hall when this man suddenly pushed me up against a wall, used his body weight to confine me, restrained my arms, and began kissing me.  Exhaustion mixed with shock dulled my response.  I struggled to break free yet was not able to push his body off of my small frame.  Fear quickly gave way to panic and the skills acquired while growing up with three brothers came in handy.  Somehow, I landed a solid blow to his groin and used my elbow to jab at his throat.  Caught off guard, he stumbled back and allowed my escape.  I ran out of the house with tears streaming down my face. 


For years afterward, I wondered what I had done wrong. Even now, I kick myself for not turning around and walking out the door as soon as I realized his wife and children were not home that night.  But those are the musings of an experienced woman in her mid-forties rather than the thoughts of the trusting and naive woman I once was at 27, having recently returned to my hometown. 



 I do remember feeling ashamed and wanting to pretend the assault never happened.  After sharing my story with two trusted confidants, they informed me that being alone in a married man’s house “didn’t look good.”  I chose to remain silent.  The day that man left our community remains one of the happiest of my life.  I could finally breathe again.
  

Lauers’ response triggered me.  His statement that Nevils came to his hotel room “very late” is being used to support the notion that any sexual interaction was consensual or implying that she should have known his intentions. The only way to communicate consent is by being asked and then saying “yes”. Not having the opportunity to say “No” is not the same thing.


Writing about his very personal experience still rattles me today.  Even worse, this physician systematically spread salacious rumors about me amongst hospital administration and staff.  I will never know if it was in retaliation for rejecting his advances or an attempt to assuage his guilt by telling himself I “deserved” it.  And while most of the nursery staff who were convinced by his lies have long since retired or passed away, the fact remains many inadvertently supported a physician assailant over a physician victim.
   

Today, stories about women being harassed or assaulted in work-related settings have finally become part of our national narrative.  Maybe it is time to acknowledge that when a woman goes up to a man’s hotel room, she is not “asking for it” and does not “deserve” to be assaulted or raped.  In fact, there is no reason ever to excuse the sexual assault of a woman.   Period.    

Tijuana's Perilous "Waiting Room"

This past summer, I volunteered in Tijuana, Mexico at a clinic serving patients in the Migrant Protection Protocol program, or MPP.  Also known as “Remain in Mexico,” MPP sends migrants who appear at official places of entry along the U.S. border seeking asylum, back to Mexico to await future immigration hearing dates. 

Introduced in January 2019 to slow the flood of immigrants across the U.S. border, the program has returned 38,000 migrants to wait in dangerous cities like Tijuana and Ciudad Juarez.  The MPP program has been lauded as a “success,” though in my opinion, it is quite the opposite. 

The majority of patients were from Guatemala, Honduras, and El Salvador, however, I encountered many from Haiti, Cuba, and many other countries throughout the world.   MPP policy essentially forces desperate migrants —comprised of single parent families with small children— to wait months in Mexico, where they are often unable to find work, housing, legal support, or proper medical care.

For immigrants awaiting their U.S. immigration hearings and seeking asylum, conditions for those seeking asylum are tenuous at best. If they are lucky enough, migrants reside in local shelters, which are jam packed with others “returned to Mexico.”  The physician in me saw many medical problems, and as an individual and a parent I observed even deeper issues.

One young mother was in desperate need of medical services when I met her.  She lost her husband and teenage son to gang violence in Honduras before making her way north to Mexico with her young daughter in tow.  A petite brunette, wise beyond her years, she was nursing her toddler when I entered the room.  While living at a shelter in Mexico, she had contracted some sort of infection on the back of her leg.

By the time I saw her, the infection had eaten through layers of her skin, soft tissue and even into the muscles of her leg.  It is one of the worst skin infections I have ever seen and was excruciatingly painful.  In reality, she needed hospitalization for more extensive wound cleaning (known as debridement) and intravenous antibiotics, however no Mexican hospital would provide care due to her immigrant status. 

If they can find adequate food and shelter and survive daily setbacks, there are logistical obstacles to attending immigration hearings when they do get on the docket.   Some migrants miss their court dates because they are refused entry when trying to return to the U.S. for their hearing.

Legal representation in the U.S. is hard to come by.  Only 1% of migrants in the MPP program are able to retain an attorney, according to the Transactional Records Access Clearinghouse at Syracuse University.  Often working pro bono, lawyers are reticent to assist migrants at shelters run by the Mexican government because they aren’t licensed to practice across the border or have security concerns. 

What legal advocates fear are the same safety concerns migrants in the MPP program face.  Tijuana is somewhat safe during daylight hours, but a couple had been shot and killed directly in front of the clinic where I treated patients scarcely a month before I walked up its steps. 

But more than anything, it was the arbitrary nature of the immigration process that struck a chord with me while working south of the border. 

Another mother I met, this one with an asthmatic son, Jesus, were an example of the impact chance alone can have on a family’s future. The son was sitting on the exam table struggling to breathe as I examined him.  The worry etched on his mother’s face was palpable.  She began to cry, recounting the journey her family had made together from El Salvador. Her spouse and her older son had made it safely across the border into the United States.  But she and her youngest child were separated from the other two, and returned to Mexico through the MPP.  It had been three months since she had last seen her son or husband.  Every night when I fall asleep, my thoughts return to the mother and her young son and I hope they are both still safe as they await their day in court. 

And finally, there are the already-known casualties of the MPP program, like Vilma Mendoza, a 20-year old Guatemalan woman who entered the U.S. on July 4^th seeking asylum, who was “returned to Mexico.” Though her asylum hearing was scheduled for August 18^th, Mendoza drowned July 29^th while attempting to re-enter the U.S. through an irrigation canal.   Some may wonder why she took matters into her own hands.  I know why.  I saw the reasons first-hand.    

I left Tijuana with more questions than when I arrived, which is difficult to reconcile working in a profession which focuses on easing the suffering of human beings.  I don’t know the answer for our country, and I don’t know that there is a simple solution. 

When I became a physician, I swore to uphold the Hippocratic Oath, an ethical guideline that includes the phrase, “I remain a member of society with special obligations to all my fellow human beings…”

While it’s doctors who are most often associated with that covenant, each one of us is a member of this society, which doesn’t always end at a national boundary or physical border.  So maybe we all need to share that oath’s burden.  Leaving young mothers with untreated infections, leaving sons separated from their fathers, and seeing so many people with a desperation that drives them to decisions you and I never have to make isn’t anywhere close to what I consider progress. 
Tig

The Orphans of Hahnemann University Hospital

This past week CHI Franciscan broke ground on what will be a 26,000 square foot outpatient clinic at 4207 Kitsap Way in West Bremerton.  The grand opening is slated for May 2020.  At the ceremony this week, Harrison President David Schultz noted that the community’s “single greatest [healthcare] need” is access to primary care.  He is right. 


While Mr. Schultz and I have not always seen eye to eye on healthcare issues, we are in lock-step on the importance of training more primary care physicians to improve access to the services they provide.  This clinic will house the Northwest Family Medicine Residency Program, currently composed of 16 family medicine resident doctors—which will ultimately grow to 24—and 10 faculty instructors.
  

In my opinion, supporting the NFMR program should be a top priority in order to ensure enough primary care physicians are available on the Olympic Peninsula over the next 50 years.  When corporations and communities do not lend support to their physicians-in-training, that failure can be catastrophic.


This past summer, Hahnemann University Hospital—a teaching site for Drexel University College of Medicine in Philadelphia—closed their doors.  When Hahnemann closed, its’ residents were essentially “orphaned,” losing their jobs overnight.  Residency refers to the post-graduate training period following medical school graduation compulsory for a physician to be licensed to practice medicine.  After “matching” to an open residency position at a given teaching hospital, resident training begins across the entire nation on July 1^st every year once a contract is signed with the employing organization. 


When I applied to residency 20 years ago, there were more spots available than applicants to fill the positions, however in 1997, the federal funding allocated to residency positions was capped.  Despite the fact there have been more physicians churned out by more medical schools in an attempt to meet the increasing demand for physicians, the number of residency positions has not changed, which has created an alarming bottleneck.
  

Today, as a consequence of capped funding, only 79 percent of the 38,000 applicants successfully matched to a first-year residency position in 2019, leaving nearly one in five medical school graduates jobless.  Hahnemann added 570 residents and fellows to an already-growing unemployment list.
   

The Hahnemann orphans have nowhere to go.  And even if they could secure training positions elsewhere, Hahnemann inexplicably refused to release the contracts, leaving countless physicians—55 of whom hold J-1 visas and face deportation if unable to secure new jobs within 30 days of the hospital closure—on uncertain ground. 


Hahnemann was once a venerable safety-net for poor and disenfranchised patients in the inner-city for more than 170 years, yet having a proportionally larger Medicare and Medicaid patient population made them vulnerable to closure. And they are not alone.  More than a dozen U.S. hospitals have filed for bankruptcy since January 1^st of this year, according to Becker’s Hospital Review, most likely due to declining Medicaid and Medicare reimbursements. 


As a part of bankruptcy proceedings, Hahnemann decided to sell off 570 residency “positions” at auction instead of releasing the contracts, making residents akin to financial assets.  The Centers for Medicare and Medicaid Services (CMS) deemed the sale illegal, yet the positions garnered an astounding $55 million at auction, making each physician worth approximately $100,000.  And on September 5, despite CMS objections, U.S. Bankruptcy Judge Kevin Gross approved the sale of Hahnemann University Hospital’s medical residency programs to Thomas Jefferson University Hospitals Inc. for $55 million, acknowledging his ruling could “cause a judge to lie awake at night.”


This ruling should keep us all awake at night as this decision sets a dangerous legal precedent.  One we must hope is not repeated anytime soon. Hospitals and medical clinics are struggling to stay afloat on the amount that the Centers for Medicare and Medicaid (CMS) pay for healthcare services.  And while the “Orphans at Hahnemann”—570 physician residents and fellows—are the first to be auctioned off, they will certainly not be the last.


Kitsap County is extremely blessed to have the Northwest Family Medicine Residency Program and our community already benefits greatly from their presence.  There are 8 new resident physicians who began training on July 1^st.  

If you have not yet met them or had the pleasure of working with them, I encourage you to stop by their current clinic over on Wheaton Way with a basket of goodies or a warm home-cooked meal to welcome them to Kitsap County.  And if you get the chance, share some words of encouragement for the work they are already doing to make Kitsap County a better place.  Remember, we want every one of these family physicians to call this community home very soon. 

Universal Care for Children: Are School-Based health centers the answer?

Last week, Peninsula Community Health Clinic announced an agreement with the Central Kitsap and Bremerton School Districts to open school-based clinics at Esquire Hills Elementary, Fairview Middle School and Mountain View Middle School this fall.  The clinics will be funded and staffed by the PCHC organization and the schools are sponsoring the clinic space. 

School based health centers (SBHC’s) are an integral part of healthcare delivery for children and adolescents in this country.    SBHCs deliver a variety of services, to include medical, oral, nutritional, case management for chronic conditions, and mental health services.  Because these clinics are located where children spend a significant portion of their day, obstacles to accessing healthcare, like transportation and scheduling issues, are minimized.

Studies demonstrate that students with asthma who have access to SBHCs had fewer emergency room visits and lower hospitalization rates.  Mental health services decrease school absences by as much as 50% among those with 3 or more absences in a six-week time period and an 85% decrease in school discipline referrals. 

SBHC’s generally use one of three staffing models.  The primary care model involves a nurse practitioner or physician assistant who provides basic health services.  The second model is geared toward the mental health needs of students and consists of a mental health professional such as a social worker or psychologist. Finally, there is a hybrid primary care-mental health model staffed with both types of health professionals plus a case manager or nutritionist.   

The most common conditions being managed at school are acute illness, comprehensive health assessments, prescriptions for medications, vision and hearing screens, sports physicals and reproductive health services.  In Washington State, a single, unemancipated minor may receive medical treatment without parental consent in the following areas: birth control services and prenatal care at any age, mental health disorder or substance abuse treatment at age 13 or older, and testing or treatment for sexually transmitted diseases at age 14 or older. 

This decision to open school-based clinics is a step in the right direction to improve access to healthcare for staff, students and families.  However, as a local pediatrician and more importantly, a parent to four children in one of the affected school districts, I would like more information.  

1)     Communication is essential for continuity between students, families and community health professionals.  Will parents always be informed when their children seek care at one of the school-based clinics or only in certain circumstances? Will PCHC collaborate with community clinicians directly for shared patients? 

2)     What should a parent do if they already have an established relationship with a primary care physician?

3)     Will those students who establish medical homes at school-based clinics be connected with available health care resources in the community during weekends or extended school breaks? 

4)     CEO Jennifer Kreidler-Moss commented that one “purpose of the clinics is to put more trusted adults in kids’ lives.”  Who are these trusted adults?  Is there are policy about chaperoning children when they are evaluated and examined by health professionals? Where can parents get more information about those clinicians who will have access to our children?

5)     And finally, what is the scope of available reproductive health services that will be offered to middle-school aged children in the school-based clinics?  

School based clinics will accept all insurances.  Parents with children in the Central Kitsap and Bremerton Schools will be provided consent forms at the beginning of the school year, in order to have their children seen at the school clinic.   In addition, parents need to provide their insurance information, so children will not have to pay for their care prior to being seen. 

Again, I support any endeavor, including school-based clinics, that brings us one step closer to universal care in Kitsap County.  School-based clinics can address the needs of underinsured or uninsured children by reducing obstacles families face accessing healthcare services.  Peninsula Community Health Services is the right organization to provide this outreach in the schools, employing 62 health professionals and already serving 29,000 patients across the region.  I applaud their efforts to bring care to patients who need it most. 

Accad and Koka Episode 74: Can We Have a Reasonable Discussion About Vaccines?

Does the vaccine debate have to be polarized according to “Pro-Vaxx” or “Anti-Vaxx” camps?  Is it possible to have a reasonable discussion about harms and benefits of vaccines?  Are public health concerns about unvaccinated children sufficient to trump individual liberty?

Exploring the question with us is Dr. Niran Al-Aqba, a board-certified pediatrician in private practice in Washington State, an area hit by the recent outbreak of measles.  Dr. Al-Aqba is a prolific writer who speaks widely and openly on a variety of issues, including policy, ethics, and medical practice.  She is a regular contributor to the Kitsap Sun, to The Deductible blog, and to a variety of other outlets, including her own blog, MommyDoc.  She is a mother of four children who’s been voted best doctor in Kitsap County on multiple occasions.  She also serves on the clinical staff and admission committee at the University of Washington School of Medicine.

https://accadandkoka.com/episode74/

Are Mass Shootings Caused by Firearm Access or Economic Inequality?

Gun violence has become a public health epidemic.  Despite countless deaths in mass shootings over the last 2 decades, the Dickey Amendment—a provision inserted into the 1996 spending bill which blocked federal funding for research on gun violence—remains on the books.  While every politician, media pundit, and policy expert “know” the solution, the answers are not that simple. 

In reality, the factors which have fueled the rise in gun violence across America are largely unknown. And if the deep-pocketed gun lobby continues pouring millions into politicians’ war chests to stifle critical gun research, we may never know.  Science must be part of the mass shooting debate.  Congress must “stop dicking around and repeal the Dickey Amendment,” to fund federal research. 

What if the premise that more guns cause more mass shootings—a contentious debate that has the left and the right locked in battle—is entirely wrong? 

A 2018 study published in Frontiers in Public Health shows that income inequality in communities with higher than average household incomes have a statistically significant relationship with the incidence of mass shootings. 

This association is far stronger than the now-debunked theory that untreated mental health disorders are responsible for mass shooting events.  And while more research like the aforementioned study is necessary, it is highly likely that economic inequality increases the risk of mass shooting to a greater extent than even firearm access. 

For instance, the community of Littleton, CO—where Columbine High School is located—is among the 15% highest income neighborhoods in America. Newtown, Connecticut—a once-idyllic community where a 20-year old murdered twenty children and six adults at Sandy Hook Elementary School—is located in Fairfield County, the wealthiest metropolitan area in the country, according to the Labor Department's Bureau of Economic Analysis, yet it is also among the most unequal in terms in income distribution. 

Gun violence is not a new phenomenon, the number of deaths in children ages 12-17 by shooting increased 95% between 1980 and 1994.  Once considered a problem exclusive to poverty-stricken inner cities, today, gun violence has become pervasive in middle to upper class neighborhoods, which are no longer exempt from the unjustified carnage. 

According to the Economic Policy Institute, the three states with the highest income inequality are New York, Connecticut, and Florida.  Ironically, those same states have seen some of the deadliest mass shootings in U.S. history.  Thirteen people were killed at an immigration center in Binghamton, New York in 2009.  On June 12, 2016, In Orlando, Florida, 49 people were killed and 53 were wounded in a shooting at Pulse, a gay nightclub. Then, on Valentine’s Day 2018, a former student at Marjory Stoneman Douglas High School—in Parkland, Florida—killed 17 and wounded 17 more. 

While it is not well understood how economic disparity is related to the incidence of mass shootings, research indicates a perspective of ‘relative depravation,’ fuels anger, frustration, and resentment especially in young men between the ages of 15-34. Those young men living in highly income variable areas tend to view themselves as “superior,” feel more entitled, and are less willing to share resources they perceive as scarce.

The touchstone of social mobility, income opportunity, and social justice have given way to a harsh new reality in America where radically different trajectories are determined by the circumstances into which one is born. The opportunity gap, known as the “Great Gatsby Curve”, has widened dramatically over the last 40 years.  While household income for the lower half of Americans has barely grown, those in the top 20% of earners has soared, increasing by 75%.  Those earning in the top 5 percent of Americans have seen earning growth of 95 percent. An increasing proportion of society is watching the American dream slip away. 

The deadliest mass shooting in U.S. history took place in Las Vegas, Nevada on October 1, 2017. A man on a high floor of a hotel opened fire on a country music festival crowd, killing 58 and wounding 422 others.  Does the fact Nevada is ranked 4^th highest in income inequality in the U.S. have any bearing?  Don’t you want to know if it does?  I certainly do.  

Economic inequality may have an even greater impact on the incidence of mass shootings than firearm access.  While the rampages in Gilroy, California, El Paso, Texas and Dayton, Ohio dominate the national narrative, with all due respect, America is having the wrong conversation.  Congress has a golden opportunity to right this wrong: Repealing the Dickey Amendment would - finally - fund critical research on gun violence and foster healthy conversations between policymakers, physicians, and patients. 

The Need to Protect Teenagers from Predators Too

A man convicted of procuring a girl under the age of 18 for prostitution should not get away with serving only 13 months in prison.  A level 3 registered sex offender shouldn’t hobnob with Harvard’s finest or be able to fraternize with prominent New Yorkers, such as President Trump and President Clinton, while repairing his tarnished reputation. 

But, in the United States, registered sex offender Jeffrey Epstein, managed to do both. 

Is the notion of adult males having sex with tweens considered quasi-acceptable by society at-large?  After all, Epstein told the New York Post in 2011, “I’m not a sexual predator, I’m an ‘offender,’…It’s the difference between a murderer and a person who steals a bagel.”

The pediatrician in me finds this notion reprehensible. The mother in me is scared beyond belief.  Teenage girls are still children. It is high-time our society started seeing them that way. Bagels, however, will never quite be the same for me, again.

Jeffrey Epstein is accused of running a pyramid-like sex trafficking scheme involving dozens of underage girls between 2002-2005.  In early July, he was arrested on charges that he "sexually exploited and abused dozens of minor girls at his homes" in Manhattan and Palm Beach, Florida. Evidence in the recently unsealed federal indictment indicates Epstein may have a sexual preference disorder, most likely, hebephilia, meaning he is sexually attracted to pubertal children.  Scientifically, hebephiles are not that different from pedophiles, who target younger children who have not yet entered puberty.

 

If convicted of the charges, Epstein could be sentenced to 45 years in prison.  Knowing the average child molester offends 200–400 times before being caught makes four and half decades seem like a slap on the wrist.  Hebephiles are predators.  They tend to engage in frequent, indiscriminate, and compulsive sexual encounters with young victims. They also target at-risk children:  those who live with a single parent that has a live-in partner are 20 times more likely to be sexually abused and those in foster care are 10 times more likely to be victims of sexual abuse than children who live with both parents.

 

Perpetrators take pleasure in abusing children sexually.  They believe their needs are more important than those of the children they harm.  But there is something even more sinister at play: underneath their often-charming facade lurks a sense of pathologic entitlement to take what one wants regardless of consequences, coupled with a lack of empathy for the children they abuse.      

         

Abusers often rationalize their actions by telling themselves what they are doing isn’t harmful or the child ‘consented’ to the sexual contact.  For instance, in a recent conversation with publicist R. Couri Hay, Epstein claimed that his conviction did not constitute pedophilia.  Epstein reportedly told Hay that the girls he had sex with were “teens and tweens,” as if that fact makes his actions less objectionable. 

  

Like pedophiles, hebephiles were often molested as children and had no control over the situation.  By sexually assaulting children, molesters gain the upper hand through a reversal of roles.  Unfortunately, their sexual attraction to children is highly resistant to change. Yet, Epstein’s defense team argued he has lived a law-abiding life for the past decade and should be permitted to await trial in his $77 million Manhattan mansion. Ironically, it is inside this very same mansion where authorities found hundreds of nude and seminude photographs of underage females on the night of his arrest. 

U.S District Court Judge Richard M. Berman denied bail, citing concerns that Epstein posed a danger to underage girls and his extraordinary wealth and overseas connections made him a flight risk.  Berman said, "it seems fair to say that Mr. Epstein's future behavior will be consistent with past behavior." Judge Berman is unequivocally right.

 

This week, Epstein “appears to have made a suicide attempt” resulting in non-life-threatening injuries.  If accurate, Epstein engaged in non-suicidal self-injury (NSSI,) an action intended to quickly alleviate intense negative emotions.  While one hopes he is experiencing tremendous guilt for those he allegedly harmed, it is far more likely that his mounting frustration after being denied bail, finally got the best of him.

 

The bottom line is that there are no effective treatments for hebephilia or pedophilia, so our society should focus on protecting innocent children, including vulnerable “teens and tweens.” Epstein has appealed the bail decision to the 2^nd U.S. Circuit Court.  While Epstein seems to be capable of convincing almost anyone of anything—just look at U.S. attorney Alexander Acosta—let’s hope the buck stops with the U.S Circuit Court of Appeals.