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.