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. 





Tuesday, November 28, 2017

CHI Franciscan Harrison to Close, So Where Do We Go From Here?






Last week, the final decision was handed down by the State Department of Health on the CHI Harrison Certificate of Need application.  Closure of the CHI Harrison Bremerton facility and relocation to Silverdale will be proceeding as planned.  Some Kitsap residents are discouraged at the thought of losing our beloved hospital in the City of Bremerton while others are thrilled at the prospect of having access to advanced technologies at the new, state-of-the-art facility in Silverdale.  

So where do we go from here?  First, we need to put our differences aside and reflect upon the core values which ignited the spirited CHI hospital debate in the first place.  Everyone in Kitsap County needs access to affordable, high quality healthcare because we will all be patients eventually.  We need a representative voice on health care matters to speak for the community.  The mission of this formalized group, known as a Community Oversight Board (COB), would be to work in collaboration with CHI Harrison leadership to draft a community benefits agreement (CBA.) 

Having a COB is critical for Kitsap County to improve the health of our community.  Non-profit hospitals are required to provide tangible community benefits to in order to qualify for tax-exempt status.  Lack of transparency on behalf of non-profits and subjective calculation methods regarding “uncompensated care” led to increased oversight by the IRS and Congress.  Out of 2900 hospitals nationwide, 60% are tax-exempt; these exemptions are worth $12.6 billion annually. Including the Bremerton and Silverdale locations, CHI Harrison received a combined property tax exemption totaling $1.63 million dollars in 2016.    

In 2010, the Patient Protection and Accountable Care Act (ACA) amended the IRS code to regulate tax-exempt hospitals more closely.  They are required to conduct community health needs assessments every three years (here is the CHI Harrison survey), develop improvement strategies, and implement consumer protections on financial assistance, billing, and collections practices.  Additionally, Section 9007 of the ACA requires annual reports by the Secretary of the Treasury to Congress on four categories of community benefit involving tax-exempt hospitals:  charity care, bad debt, unreimbursed costs for services of government programs, and the costs of community benefit activities. 

This concept of community benefit is vital, going beyond improvements in health – ensuring effective use of scarce resources, enhanced accountability of hospital leadership, and building the capacity to address health care issues. Increasing community engagement does not appear to be a high priority for all non-profit hospitals.  One study examined governance structure at 14 of the 15 largest non-profit hospital systems in the nation, 8 of which are controlled by Roman Catholic organizations. 100% of those hospitals had oversight for financial compliance measures, while only three of eight Catholic hospital systems had established a committee to oversee community benefit policies and programs.

In Kitsap, a COB would serve as an established platform for collaborating with CHI Harrison leadership while holding the parent corporation accountable for meeting the healthcare needs of our community by improving our health, quality of life, and even community vitality.  This entity could include hospital administrators, elected officials, health care workers, and interested community members.  Ideally, representatives from CHI leadership and the Harrison Hospital Board would be at the table, as should elected officials including City Council members and possibly, a Kitsap County Commissioner.   Involvement on behalf of police, fire, and EMS personnel would be critical, as would utilizing the expertise of healthcare workers from a variety of disciplines and backgrounds.  Finally, interested community members who see access, affordability, and choice as high priorities are vital to the long-term success of this endeavor.

While improving the health of our community can sometimes feel like trying to move mountains, Kitsap County residents undeniably need a representative voice on health care matters.  Confucius said, “the man who moves a mountain begins by carrying away small stones.”  It is time to lay the groundwork for Kitsap residents to formally engage in meaningful dialogue with leaders of our local hospital corporation, whether operated by CHI Franciscan, Dignity Health, or a still-to-be-named corporate entity. 

Please fill out the CHI Harrison community benefits survey linked above and do not miss this novel opportunity to influence health care in our community.  Together, we can have a representative voice and we should use it to hold the non-profit corporation operating our community hospital accountable for making decisions that are unquestionably in the best interest of our people in this constantly evolving healthcare landscape.  


Tuesday, November 21, 2017

A Thanksgiving To Remember








As we come upon the holiday season, it seemed appropriate to tell a Thanksgiving story from a few years ago.   Our family spent the day playing board games, watching a little football and taking a long walk.  After an early supper at my parents’ house, we returned home and started our typical evening routine -- baths, bedtime stories, and snuggles; the night was mundane until well, it wasn’t.  



Having four young children within a four-year span meant chaos had become ever-present in our lives and yet, this evening was almost serene by comparison.  The children were not screaming and yelling, jumping off the furniture, or tackling each other.  There were no unforeseen accidents or injuries, like a child falling and cracking their head open on the toilet after getting out of the bathtub.  While our house never seems ready for entertaining surprise visitors, this night was as good as any for unanticipated events.  



The older two were already dressed for bed, my husband was bathing the baby, and I was putting away clean laundry when there was a knock at the door.  After descending the stairs, I opened the door to face two police officers.  My surprise was likely evident.  “Happy Thanksgiving officers.  What brings you to my front door on Thanksgiving?”  I secretly hoped their visit was part of a new outreach program, but it was not.  They informed me there had been a 9-1-1 call from our house fifteen minutes ago followed by a hang up and they were obligated to respond because someone might be in trouble.



Someone was DEFINITELY in trouble, I thought to myself.  When a parent is uncertain, my advice is to simply pause and take a few deep breaths.  This not only gives us a moment to think before we act, but it also allows the perpetrator to give themselves away unintentionally, which may guide our next move.  The boys were old enough to know better and our youngest child was 2, which left my three-year-old daughter as the most likely culprit.  Getting undressed for a bath, she poked her little head out the door of her bedroom to say “hello” with a big grin and a wave. She looked pleased with herself, but maybe a little too pleased. 



There needed to be a lesson in all this, so I asked the officers into our foyer to have a few words with my children.  I threw a bathrobe on my daughter and the three boys came to sit on the stairs for this brief educational opportunity.  The officers reviewed the when and why for calling the emergency number.  My children nodded in understanding, though my daughter still had a sheepish grin. 



As the officers turned to leave, they reminded us they always check homes when hang-ups occur and if it happens frequently, there will be fines attached to not controlling our little ones better.  My husband and I are still unsure of where she learned about dialing 9-1-1 for emergencies.  It could have been at pre-school, a family movie, or even overheard in public. As she has gotten older, I have realized she rarely misses the details of anything.  It is a valued quality except when in combination with the impulsivity of a three-year-old. 



While there have been no more 9-1-1 calls and unexpected visits from police officers, this experience is another one of those parenting life lessons. Most of all, I am thankful the deputies “dropped by” when the scene was calm.  If they were on my doorstep on any other regular evening, things might have turned out differently.  I wish all of you a Happy Thanksgiving, and may you enjoy a day free of a surprise visit from your local Sheriffs’ deputies. 


Tuesday, November 14, 2017

A Tear and A Smile: A Eulogy for My Father




My father was my mentor, friend, business partner, and stalwart supporter throughout my life.  He was a phenomenal physician who will be dearly missed by all who knew him.

Below is the eulogy given at his Celebration of Life on November 11, 2017.  

My father was not religious in the traditional sense, so rather than quoting from scripture, it seemed best to look for a passage which epitomized the man he was.  If you knew him well, you will understand why I chose the poem, “A Tear and a Smile,” by Khalil Gibran, an Arabic Christian poet. 



I would not exchange the sorrows of my heart, for the joys of the multitude.
And I would not have the tears that sadness makes to flow from my every part turn into laughter.

I would that my life remain a tear and a smile.

A tear to purify my heart and give me understanding

A smile to draw me nigh to the sons of my kind.

A tear to unite me with those of broken heart;
A smile to be a sign of my joy in existence.





It is difficult to imagine anyone touching more lives than my father.  Over the past few weeks, many of you have shared his huge smile as the thing you will miss most.  What I find so remarkable is that, that smile was the result of many tears shed in sorrow for losses in his life outside of his control. 



I have learned one cannot have a truly unforgettable smile without shedding ample enough tears.



Dr. Saad Al-Agba was born in Baghdad, Iraq in 1936, and raised by a Turkish mother and Iraqi father.  His life was marked by tragedy almost from the start; he lost his father in battle at the tender age of five.  His mother was unable to speak Arabic, leaving him and his five siblings struggling to find their way.  His uncle, a teacher, became a stand-in “father.” Saad had to take over managing the family finances at nine, when his mother would give him the monthly pension check to divvy up for the food, shelter, and clothing needs for the seven in his family. 



There were days at school where clothes would be given out to the children who lost their fathers in war.  He had a great deal of pride and would stay home from school to avoid taking charity in front of others, even though his family desperately needed it. 



Full of entrepreneurial spirit, he started a number of small businesses selling toys and other handmade goods while in elementary school.  He took his family responsibility very seriously, and found himself apologizing to the principal at 11, on behalf of his 10 year old brother, who was in trouble.  The fact he was always cleaning up the messes of his carefree younger sibling was a bit of a thorn in his side. 



He worked hard and became a physician.  His first order of business after going into practice was to buy his mother a home of her own.  Shortly thereafter, his older sister was tragically widowed leaving her with five young children to raise alone.  My father helped her raise his nieces and nephews, just as his uncle had done for him so many years before. 



After journeying to England and then to the United States, he settled in Bremerton, with my mother, Barbara in January 1971.  There were abundant smiles during those early years for my mother and father after the arrival of two daughters, Laila in 1973 and me, 18 months later.  Tear returned when his beloved oldest daughter, Laila, drown in the shallow waters of Brownsville in 1975.  He never quite recovered, carrying the scar of this painful loss deep in his soul for the rest of his life.



As time passed, and other parents lost children, his tears and empathetic nature served to unite him with them.  He shared the same broken heart in a way few physicians or parents could even fathom. His ability to comfort a distraught parent through his tears and theirs was his gift to the world.  



He and my mother raised four children to adulthood, me and my three younger brothers.  He always made time for us despite running a bustling medical practice.  He could always be counted on for good advice hidden in esoteric philosophical statements, the message from which could take a few days for me to fully comprehend.



Joining his practice and being able to work side-by-side with him for 16 years was an extraordinary experience.  He had a wonderful way of sharing knowledge and we were always learning from one another.  Many patients benefitted from the “two-for-one deal,” basically the opinion of two physicians for the price of seeing one.  Sometimes, he would have me look at a patient and ask me to guess who they reminded him of, which had nothing to do with the practice of medicine;  though his grin would be a mile wide if I could read his mind accurately. 

 

Heartbreak found our family again when my little brother, Laith, died in an accident.  My father was out of town at a medical school reunion; we waited until he returned home to tell him so he was surrounded by his family.  Watching my father accept his son was no longer with us on earth will remain one of the most challenging moments of my life.  After that, his smile was never the same, yet continued to face the world with an admirable grace and endearing, yet subdued grin.

  

It was during that summer while filled with grief, my father said if he ever meets God, he would have one stone in each hand to throw at Him, one for his daughter and one for his son.  I told him God would understand, because he knows our hearts, He has a sense of humor, and most important, He lost his own son as well. 



Four grandchildren came along pretty quickly after that terrible summer and my father relished in his time with them.  When they were small and I was constantly pregnant and exhausted, he would come by every weeknight to help me bathe them.  I would not have made it through that challenging time without his loving assistance. 



As the grandchildren grew older, my father could be seen around town with them at Goodwill, Chuck E. Cheese, the bowling alley, Kohls, and McDonalds. He insisted the plain cheeseburger and milk was the healthiest meal on the menu and he was usually right when it came to such things.  We did tangle about whether chocolate milk should count as part of this nutritious meal, and with a twinkle in his eye, he reminded me to “let them live a little.” 



My father fought with death until the very end.  In reality, God likely waited until my father no longer had the strength to carry those two stones with him on the journey home.  That October day was probably memorable for God and my father as they went head to head.  I have no doubt he and God talked about many things as my father made peace.



“The deeper that sorrow carves into your being, the more joy you can contain.”



Over the last few weeks, I have realized while death played a larger role in his life than my father wished; his sorrow connected him to people in a way that was unparalleled.  His agonizing wounds allowed him to know unadulterated joy deep in his soul. It was his many tears and his big smile together, which made him so endearing, beloved, and revered.



In closing, I will share my favorite Kahlil Gibran poem, On Children:



Your children are not your children.

They are the sons and daughters of Life's longing for itself.

They come through you but not from you,

And though they are with you yet they belong not to you.

You may give them your love but not your thoughts,

For they have their own thoughts.

You may house their bodies but not their souls,

For their souls dwell in the house of tomorrow,

which you cannot visit, not even in your dreams.

You may strive to be like them,

but seek not to make them like you.

For life goes not backward nor tarries with yesterday.

You are the bows from which your children

as living arrows are sent forth.

The archer sees the mark upon the path of the infinite,

and He bends you with His might

that His arrows may go swift and far.

Let your bending in the archer's hand be for gladness;

For even as He loves the arrow that flies,

so He loves also the bow that is stable.



Reflecting on my father’s life and legacy, I will remember him as the bow that was stable.  There are countless stories of lives he saved and hearts he touched.  Just as God loves each arrow that flies, He loves the bow sending the arrows forth.  His last day in our office was Friday September 15; he saw 17 patients including one child with an allergic reaction to medication.  This heartbroken mother shared that my father saved her daughters’ life, providing care for which she will always be grateful. 



He spent a lifetime sending forth those he loved; including his nieces and nephews, me and my siblings, my four children, and many of you sitting here today, so each of us could go as swift and as far as possible. 



It is in heartfelt gladness we should celebrate and remember my father, Dr. Saad Al-Agba.  He knew the souls of the children for whom he cared would dwell in a future he would never see; yet, he accepted while he could not visit that tomorrow, even in his dreams, he could touch it in a small way through his connection with each and every one of us.  He freely shared his tears and his smiles with so many and for that; I thank God from the bottom of my grieving heart. 






Wednesday, November 8, 2017

Talking with a Four-Year-Old About Death and the Silver Can.






The past six weeks has been a challenging time for my family, my medical practice, my young patients, and my community.  My father, a pediatrician for more than a half century and my business partner for 16 years, lost his battle with heart failure, after a five-week hospital stay. 



While tackling difficult subjects with children is supposed to be within my expertise as a pediatrician, in reality, there is no “right” way to discuss the end-of-life with them.  It never hurts to lead with the truth.  My children, ranging in age from 4-9, visited my father in the ICU and each one asked if their grandfather might die.  Knowing his chances were less than optimal, I answered their questions as honestly as possible.



One child went every day with me to the hospital, one only wanted to see him twice, and the other two were somewhere in between.  The three oldest children cried, openly sharing their feelings during this journey; yet, my four year old was not as demonstrative, which is to be expected based on his developmental age.  



After my father passed away, each child has grieved in their own way, sharing things about him they will miss most, while my four year old has only said “I am sad papa died, mommy.” Knowledgeable on the developmental capacity at the tender age of 4, I considered excluding my youngest from the graveside service last week on the presumption he didn’t “need’ to see a process which he could not place in a larger context. That decision would have been short sighted. Instead, I asked my youngest child if he wanted to attend the service.  He chose to go with all of us to the cemetery.  It was a solemn affair and the children understood the significance of the occasion.  



At the conclusion of the service, my brother placed the metal urn into the grave and attendees dropped rose petals on top as they left.  Ten years ago, my father, brother, and I stayed after the service for my younger brother in order to shovel dirt ourselves.   As a matter of principle, I felt burying my father was a loving way to “take care” of him and show my respect.  Each of my children chose to be involved as well, something in which my father would have been proud.  



As we worked together, there was a quiet, contemplative energy to the endeavor.  The children took turns by handing off the shovel to one another while my husband and I helped guide their movements.  My oldest used the tamper and as the process reached completion and oddly, my heart felt calm for the first time that day.  “Helping” to bury my father appears to have given my children some much-needed closure as well.



They have returned to their regular activities with a comfort in knowing where my father is and accepting this life transition.  In the back of my mind, though, I still wondered about the perspective of my youngest son regarding the service. Then, a few nights ago, we had a notable bedtime conversation.   



He asked, “Why did they put papa in a silver can?” 



I answered, “They put his ashes in a metal container so they can rest in one place.”    



“Did they burn him?”  He asked.  Explaining cremation to a young year child was not necessarily something for which I had a prepared response, but I led with honesty.



 “Why can’t they put his whole self in the grave?” He astutely inquired.



The answer concentrated on the limitation of cemetery plots. 



“Why can’t we just dig a bigger hole?” To his credit, these questions were fitting ones.



“We could do that, but we wanted to honor papa’s wishes.”  I answered.



His next words reassured me his attendance at the service had been the right decision for him.  “Mom, I am glad we helped bury papa.  It was nice to take care of him and make sure he is cozy and warm.  I miss him and that makes me sad, but I know he is happy in the silver can.”      



“Sweetheart, I miss him too.  You are right, he is probably happy in the silver can.”  



While a four-year-old child has a different understanding of death than most of us, it is our job to help even the youngest among us process their experiences in their own time.  They will always land on their feet if we give them the space they need in which to do it in their own way.  




Tuesday, October 31, 2017

How Important is A Mother's Intuition?






A career in medicine wears down the hearts and souls of many physicians.  My pediatric journey has been filled with countless rewarding moments, but also haunting ones as well. By the third and final year of residency arrived, I was unclear as to whether medicine had been the right choice for me at all.  After 11 years of hard work, dedication, and the burden of heavy debt, the destination looked different than I had imagined.  While filled with doubt, one of the most important lessons of my career reeled me back for more:  the necessity of trusting a mother’s intuition. 

When I entered room number 10 in the emergency room, a 6 year old girl was sitting on the bed and her mother was sitting next to the bedside.  When I inquired as to her chief complaint, she answered “something is not right about my daughter and I would like you to do a blood test.”  It was the final day of 10 12-hour shifts in a row and I could not seem to muster even one more ounce of compassion.  “Ok” I replied without giving it much thought.  I sighed, completed a cursory history and physical, and though many years have passed since this night, nothing seemed clinically worrisome at the time.  In all fairness, my closed minded perspective likely got in the way. 

While checking the computer for prior visits, I saw her daughter had a blood count done the previous day.  Yesterday, the result had been normal.  I was incredulous. The pediatric emergency room was very busy that night.   Relaying the story to my attending, he told me to “do another CBC and release her once the result came back normal.”  Returning to the room, I let her know a complete blood count (CBC) had been ordered.  Relief washed over her face.

Reflecting back years later, I would characterize myself as being abrupt, condescending, and dismissive of this mother and her concerns.  I felt justified thinking she could not possibly “know” what I knew as a physician and she was being overprotective.  Let me be very clear, this story is absolutely about a night this physician-in-training learned a hard lesson, one which changed the course of my practice of medicine for the better.

Approximately one hour later, the lab called up to the emergency room with results.  “It’s leukemia”, said the lab technician.  My jaw, and my heart, hit the floor.  “Excuse me, will you say that again please?” I asked, still unable to believe this healthy child was sick.  “Leukemia”, she repeated.  “There must be some mistake. The result of the smear was normal yesterday.”  She replied, “No, we missed it yesterday.”  Apparently, the laboratory director pulled the smear evaluated the previous day, reviewed it, and found immature cells which are characteristic of early leukemia. 

I slowly walked to the exam room wracked with guilt while tears welled up in my eyes and sat down to tell this mother that her beautiful little girl indeed had leukemia. The oncology team planned to admit her that evening and begin the oncologic evaluation and treatment process according to protocol.  I felt terrible; not only for the diagnosis, but also for my glib demeanor while interacting with this mother and her child.  She sighed and said she was relieved to finally know what was wrong with her daughter.  “I am so sorry,” I said.  I was sorry for many more things than I could say. 

This is one moment I wish could be erased from my memory and done again, though differently.   Ideally, I would greet the mother and child with a warm smile, take an extensive history, perform a thorough physical exam, discuss a list of possible diagnoses with mom, and send blood tests accordingly.  I would reassure this mother we would properly evaluate her concerns.

The wisdom imparted to me by this mother has been absolutely priceless.  She taught me the most vital thing physicians do is to take time and listen to the patient or the person who knows their child best.  This unforgettable lesson has stayed with me for the past 18 years.  This “little” girl would be 24 years old today and may already have children of her own; she owes a debt of gratitude to her mother for having the tenacity to push a doubting physician to do her job.    Thank you.     

Tuesday, October 17, 2017

Do Physicians Deserve Our Mercy? #silentnomore





This past week a video went viral when a woman complained about the lengthy wait time at a clinic.  On video, we see the physician asks if the patient still wants to be seen.  The patient declines to be seen, yet complains patients should be informed they will not be seen in a timely manner.  The frustrated physician replies, “Then fine…Get the hell out. Get your money and get the hell out."  While we do not witness events leading up to the argument between doctor and patient, we do know staff at the front desk called the police due to threats made by the patient to others. 
Based on the statement released by Peter Gallogly, MD, he is a humble, thoughtful, and compassionate physician who was very concerned for the safety of his staff, which he considers “family.”  Physicians like Dr. Gallogly do their best to serve patients, ease their suffering, and avoid losing ourselves to burnout at the same time. Every human being deserves our compassion, kindness, and clemency.  Patients and physicians must accommodate each other when possible.
Do physicians actually deserve our mercy when necessary?  Yes, they do.  I should know.  The kindness shown to me by my patients over the past month has been unparalleled, leaving this physician thankful beyond words. 
My father has been a practicing pediatrician in our community for 47 years.  As I type these words, he is dying in a hospital bed.  We have worked side by side for the last 16 years.  It is difficult to make it through the day, desperately hoping to hear his voice one last time in the clinic hallway.  He was carrying a full patient load before an unexpected cardiac arrest ended his career.  The patient load doubled overnight; it is a burden I am carrying alone.
Many families have brought their children, grandchildren, and great-grandchildren to us for more than 40 years.   We have seen them through the darkest moments of their lives, at their most vulnerable, and brought them into the light.  Now, our patients must guide me through unimaginable heartache and grief. 
Long wait times can be terribly frustrating.  Punctuality has long been a personal obsession. Lately, I have been unable to keep up; patients with appointments are waiting more than two hours to be seen.  Every new encounter begins with an apology for tardiness followed by an update on the condition of my father.  Most families are aware of my overwhelming task -- running a practice built for two when I am but one physician.  Not a single parent or child has complained, yelled, accosted, or threatened.  Each family has shown me desperately needed mercy.
 
Over the last twenty-one days, patients have provided 15 home-cooked meals.  Some have assisted by car-pooling my children or taking care of them when my presence at a last minute hospital care coordination meeting was required.  Others have simply offered a helping hand, by filing charts, running errands, or landscaping the grounds.  This is the physician-patient relationship as it was meant to be, simple, beautiful, and perfect. 
Yesterday, after apologizing yet again, a mother reassured me she would wait as long as it took to have her child seen, hugged me tightly, told me to take a deep breath, and offered me her chair to rest.  She reminded me to take care of myself.  In the next room was a grandmother who has been patronizing our practice since 1977, when I was barely three years old.  She offered billing services free of charge and emphasized how grateful she was for the loving care provided for two generations to her family.  
The clinic my father established is a place where mutual admiration between physician and patient has existed seamlessly for a half century.  Magic happens when patients walk through our doors.  The next time your physician is running late, consider the challenges they might have faced that day.  Accommodating their delay will be treasured more than you can possibly imagine.
Medicine is not a hospitality industry.  Patients are not customers and physicians are not restaurant wait staff.  We gave up our youth to become educated, skilled, and compassionate.  Saving the life of human beings is not equivalent to ordering a hamburger and having it served your way.  Physicians genuinely work hard to serve patients at their most desperate hour.  Remember, we are also human beings, who unequivocally need and deserve your mercy.      
     

Tuesday, October 10, 2017

Building Better Metrics: Immunizations and Asking the Right Question?






As policy experts cling to pay-for-performance (P4P) as an indicator of healthcare “quality” and shy away from fee-for-service, childhood immunization rates are being utilized as a benchmark.  At first glance, vaccinating children on time seems like a reasonable method to gauge how well a primary care physician does their job.  Unfortunately, the parental vaccine hesitancy trend is gaining in popularity.  Studies have shown when pediatricians are specifically trained to counsel parents on the value of immunizations, hesitancy does not change statistically. 

Washington State Law allows vaccine exemptions on the basis of religious, philosophical, or personal reasons; therefore, immunizations rates are considerably lower (85%) compared to states where exemptions rules are tighter.  Immunization rates are directly proportional to the narrow scope of state vaccine exemptions laws.  Immunization rates are used to “rate” the primary care physician despite the fact we have little influence on the outcome according to scientific studies.  Physicians practicing in states with a broad vaccine exemption laws is left with two choices:  refuse to see children who are not immunized in accordance with the CDC recommendations or accept “low” quality ratings when caring for children whose parents with beliefs that may differ from our own.   

The more willing a physician is to care for those with differing philosophical, religious, and cultural beliefs, the more CMS metrics will discriminate against our open-hearted approach.  Reflecting upon my medical school admissions interview, my open heart and mind are some of the reasons for entering medicine in the first place.  As I contemplated my tumbling quality indicators by continuing to see children regardless of immunization status, I stumbled upon some ICD-10 code gems: 

  • Z28.0 -   Immunization not carried out because of contraindication
  • Z28.01 - Immunization not carried out because of acute illness of patient
  • Z28.02 - Immunization not carried out because of chronic illness or condition of patient
  • Z28.03 - Immunization not carried out because of immune compromised state of patient
  • Z28.04 - Immunization not carried out because of patient allergy to vaccine or component
  • Z28.09 - Immunization not carried out because of other contraindication
  • Z28.1   -   Immunization not carried out because of patient decision for reasons of belief or group pressure
  • Z28.2  - Immunization not carried out because of patient decision for other and unspecified reason
  • Z28.20 - Immunization not carried out because of patient decision for unspecified reason
  • Z28.21 Immunization not carried out because of patient refusal
  • Z28.29 - Immunization not carried out because of patient decision for other reason
  • Z28.8  - Immunization not carried out for other reason
  • Z28.81 - Immunization not carried out due to patient having had the disease
  • Z28.82 - Immunization not carried out because of caregiver refusal
  • Z28.89 - Immunization not carried out for other reason
  • Z28.9 - Immunization not carried out for unspecified reason

Surprisingly, ICD-10 and the advanced coding technology might have had some unanticipated benefits.    If a physician uses vaccine refusal codes appropriately, the patient in question should be removed from the denominator being used to calculate immunization rate for a given clinic or physician. 

This allows immunization rates to reflect “quality” while accounting for factors outside the control of the primary care physician.  Vaccine exemption laws must be considered confounding variables when using immunization rates as a quality metric; eliminating confounding variables purifies the data set.   This is a simple concept, so why are metrics being collected by CMS not controlling for caregiver refusal when it is mandated by law?  Accuracy is the point of collecting data in the first place, right?  If you believe CMS is interested in accuracy, then I have a bridge somewhere to sell you on the Olympic Peninsula.

ICD-10 codes already allow for regional specificity; a physician in Washington State has codes when a patient is pecked by a chicken (W61.33) or bitten by a cow (W55.21); there is even a code when a one is struck by an Orca Whale (W56.11), an event more likely to occur in Washington than Idaho.  If we can code for injuries sustained when our water skis catch on fire (W91.07) after a civilian boat collided with a military watercraft (V94.810) while waterskiing on the Puget Sound near the Naval Undersea Warfare Center Keyport, then we certainly should be capable of controlling for confounders which do not reflect the “quality” of care a physician provides.  

Claude Levi-Strauss, once said, “The scientific mind does not so much provide the right answers as ask the right questions.”  Immunization rates are clearly NOT an accurate quality indicator.  Maybe it is time for policy experts and physicians to question what constitutes the provision of high-quality health care in the first place.  Only then, can this country move in the right direction.