'Not cremated exactly, but barbecued would be okay.'The critical question is how soon that sort of quality and cost control will be available to patients everywhere across the country. We’ve let health-care systems provide us with the equivalent of greasy-spoon fare at four-star prices, and the results have been ruinous. The Cheesecake Factory model represents our best prospect for change. Some will see danger in this. Many will see hope. And that’s probably the way it should be.

Atul Gawande “Big Med”

There is an article from the New Yorker that made the rounds a couple of years ago about the coming revolution in medical care. The author, Atul Gawande, uses the Cheesecake Factory restaurants as an example of a business that delivers a high quality product in every location in a predictable fashion. He then identifies several examples in medicine where these sorts of things are beginning to happen, one around orthopedic procedures and one involving care of the intensive care patient. The orthopedic procedure is much more personalized, in part because Gawande’s mother is the “case” with her knee replacement being the example. As a wise health care consumer, he identifies the surgeon with the best outcomes for his mother’s  particular need. What he finds is that standardization, team-based care, and attention to consistency trump individual skills in healthcare. The article was not without its critics. Mostly, not about how dare Dr Gawande criticize the-best-healthcare-system-in-the-world but more about how taking bad systems and superimposing incremental change was a recipe for disaster. Might make for a delicious sandwich brought out quickly but not great hip replacements and diabetes care. Instead, it was suggested, medicine as an organization should look at “new methods of managing [that] have been developed that build on self-organizing teams working in an iterative fashion and closely linked to what customers might want.” Less putting a delicious sandwich on the table, more giving people the equivalent of an  “Angry Birds” app when they need it. People do love Angry Birds… In the last 2 years we at South Alabama have been struggling how we are going to practice and teach in our Academic Health Center. We need to train the next generation of physicians. The next generation of family doctors will need to be able to move quickly from caring for people who have a minor complaint to working with non-physicians doing the same to helping folks manage their own chronic illness to helping those whose illness has progressed manage their symptoms. We have decided, as a system, to get good by focusing on the following:

  • Create and sustain culture of constant improvement throughout care delivery cycle
  • Create and sustain highly accessible primary care medical homes
  • Coordination of services between primary and specialty care
  • Coordination of services across hospital, ambulatory, and rehabilitative settings
  • Reward interdisciplinary team-care approaches as defined by coordination, communication, and shared responsibility
  • Create and sustain infrastructure to provide real-time data to inform care decisions
  • Partner with sister institutions and community agencies who share common patients/clients to facilitate care across continuum

South Alabama is about to begin redesigning our care delivery and, presumably, educational offerings to meet these goals. I suspect we will need more and better recipes. I also think some Angry Birds might help as well.

how-about-never-cartoon-credit-mankoffI

Is it society’s duty to ensure equitable access in healthcare?

Question posed to my students in a health policy course

In his book “The Healing of America,” T.R. Reid identifies four distinct methods of (paying people who are) providing healthcare to the citizens of a country. Some countries follow the model of England and collect money form all citizens, mostly via taxes, and use that money to pay for needed care. It is also referred to as  the Beveridge model, after Lord Beveridge, who wrote a report in the war years identifying disease as one of the five “Giant Evils” and recommended state action to combat this and other evils. In this model everyone is entitled. The second was the German model which mandates participation in private insurance. This is also referred to as the Bismark model, after Otto von Bismark, the Prussian chancellor who determined that universal healthcare could be a force in the fight for a unified Germany.  In this model, everyone is mandated to participate. The third is the Canadian model, which taxes citizens to pay for care but allows health care entities to be private contractors. In this model, budgets are set at a regional level and as a consequence some artificial shortages are created. In this model, everyone is treated equitably within the system.  Lastly is the “out-of-pocket” model. In this model, prevalent in developing countries, care is rationed based on ability to pay. In this model, no money=no access.

As T.R. Reid explained in his book and my class identified as America’s unifying model, we use an “all of the above” approach. For those over 65, active duty military, eligible veterans, and native Americans we apply the Beveridge model. Once Americans are in one of these groups, it IS society’s responsibility to provide equitable access in healthcare (well, sort of. Physicians can “opt-out” but for the most part, this is true). For those who work at jobs in larger businesses, we tend to apply the Bismark model (and Obamacare reinforces this). The employers are given a significant subsidy to provide health insurance and most Americans (before 2010, 66%) pay through healthcare via this mechanism. For some of the poor (mostly children and pregnant women but some with chronic illness) and military dependents we apply the Canadian model (how Medicaid and Tricare work, for the most part). For everyone else, we apply the pay- out-of-pocket-or-die-or-go-to-jail model. Obamacare attempted to move the last three groups into an amalgam of Beveridge (poor) and Bismark (everyone else) model.

Turns out the sticking point is the question I asked my students. Unlike my students, who had about a 70-30 split that it was a society and thus government problem, the American public thinks differently. Only 42% of Americans feel a responsibility for their fellow American’s access to healthcare. This increases as people get older peaking with of those who are 65 and older. 53% of these  believe that government should not be providing their health care. The majority of folks opposing the law, in all fairness, despite this believe it is the responsibility of our elected officials to make the existing law (be it via Bismark, Beveridge, Canada, or other) work.

The New England Journal of Medicine has published two essays on this topic this week. The first, out of Kentucky, discusses the benefits to patients living in a poor state that has elected to avail itself of the improvements in access offered by the Affordable Care Act. The author, who had previously written of access problems, says it this way:

But during the past year, many of my lowest-income patients have, for the first time as adults, been able to seek nonurgent medical attention. I recently evaluated a 54-year-old man with hyperlipidemia and a systolic blood pressure of 190 mm Hg whose last physician visit had been with a pediatrician. Before he enrolled in Medicaid, he would have been unable to pay for his appointment and laboratory work, and I wouldn’t have considered offering him a screening colonoscopy since he would surely have been billed for it. Newly insured, however, he was able to afford the tests and medications that most Americans would expect to receive, and he told me he felt proud to have witnessed a sea change in health care delivery in Kentucky and that recent reforms seemed “just.”

On the other side of the discussion is South Carolina, an equally poor state that has elected not to avail itself of the benefits afforded via implementation of  Obama-care. The author speaks of the many attempts to influence policy makers into accepting access for South Carolina’s poorest citizens. This culminated in a series of arrests following peaceful protests on the capitol steps. In his words, he had to act because

When I graduated from medical school in 1979, we did not take an oath, but I have since striven to adopt the words of Moses Maimonides as my guiding philosophy: “The eternal providence has appointed me to watch over the life and health of Thy creatures” and “Preserve the strength of my body and of my soul that they ever be ready to cheerfully help and support rich and poor, good and bad, enemy as well as friend.” My interpretation of this prayer is that I need not only be a good clinician in the hospital or clinic but also attend to the effects on my patients’ lives of the wider world, whether my own hospital or the state government. [W]e must pay attention to the whole patient. Similarly, I now believe that our concern for our patients should encompass the effects of public policies that result in direct harm.

I do believe it is society’s responsibility to provide equitable access and believe Obamacare is the mechanism through which to accomplish this. Living in Alabama, a state that has not accepted the Medicaid expansion, how do we as educators look those we teach in the eye and say “We did all we could” to ensure access for those who are poor, who have mental illness, who are unable to speak for themselves? Anyone else ready to march on Montgomery?

'I know I failed all the tests and never handed in any finished assignments. So what's your point?'Resident – You know that girl who just found out that she was pregnant and came to us around 26 weeks

Me: Yeah

Resident: Well she has a Hemoglobin A1C (measure of long term blood sugar control) of 11. Turns out she has undiagnosed diabetes.

Me: (Sigh) Go ahead and call high risk OB

The March of Dimes gave Alabama an F in the prevention of pre-term birth. That is not surprising in and if itself. We always get an F. In 2006, when 1 in 5 infants in Alabama were born before 37 weeks, we got a “low F.” At least this year, it was only 1 in 7. I guess that is an F+. In the United States as a whole, the number is a little over 1 in 10, putting us up there with Sierra Leone and Ghana and well below that of Cuba. Best state is California with a preterm birth occurring every 1 in 15 times. “Best practice” countries (the Scandinavian countries are the ones that do it best) have a preterm birth rate of about 1 in 20. The Alabama county with the highest (Bullock, 1 in 4, as a country would be worst in the world), through no coincidence, only has 4 primary care doctors, 2 dentists, and no obstetricians or hospitals that provide care for pregnant women.

Why does preterm birth matter? The vast majority of infants that die are delivered before 37 weeks; some die for no apparent reason. The more births beyond 37 weeks gestation, the lower the infant mortality. In addition, these infants are more likely to be admitted to a neonatal intensive care unit. March of Dimes anticipates that if Alabama were good at preventing preterm birth, we could save almost $500 million, most of it Medicaid.

You ask, why not just do what it takes? Saving half a billion dollars, improving the lives of almost 10,000 children in Alabama. Who could be against it?

Funny story, that. It was during the 1980s in the Bush 41 administration when we as a country identified infant mortality as a problem. Nationally, about 4 in every 1000 newborns were dying in the period of time between birth and 1 month of age. Some great thinkers and law makers got together and suggested that a lack of access to healthcare was a reason that these women were having early and unhealthy babies. In 1986, Congress passed, George HW Bush signed and Alabama Republican Governor Guy Hunt accepted a Medicaid expansion to provide care to pregnant mother because, well, “Won’t somebody please think of the children?” Today, almost 80% of pregnant Alabamians get prenatal care in the first trimester and 49 in 50 receive some type of prenatal care.

Fast forward 30 years later. We now know that, as I told my resident who presented this patient, by the time the woman presents for prenatal care, the horse is out of the barn. About half of all pregnancies are unplanned. Many women suffer from poorly controlled chronic illness that, should they become pregnant, can worsen pregnancy outcomes. Many woman are making lifestyle choices that can cause unintentional harm to their yet-to-be conceived infant but can be changed in a positive manner. To reduce preterm births we need to focus on pregnancy spacing, pre-conception counseling, addressing lifestyle choices that lead to poor outcomes, and planning pregnancy for those with chronic illnesses such as diabetes. There is a term “strong for surgery” that is gaining traction. Women also need to be “strong for pregnancy.”

This is a problem of primary care. We should provide preconception counseling to all women of child bearing age when given the opportunity. We as a society should provide access to primary care for all women of reproductive age (especially those with chronic conditions), and provide outreach to those with conditions related to poor behaviors to correct the behaviors before pregnancy. Our current President, a Democrat, gave us one of the tools (Medicaid expansion to women prior to conception) that is necessary if we want an A. It would still take a lot of work to get that A, as it almost always does. Just by accepting the expansion, we could easily get a gentleperson’s “C.” I suspect instead we’ll take the “F” in hopes that the next test will be on something easier, like football.

fantasyfootballPeople in the south have always had a love-hate relationship with crazy people. On the one hand, we tend to believe that a little crazy is a good thing. “You know how crazy Uncle Joe is” people would say when telling the story of how after an LSU loss Uncle Joe unplugged his television and threw it into the swimming pool. Uncle Joe, though, did not suffer from a diagnosible mental illness and so likely went to work on Monday with no one knowing his secret shame. His family, though they ran through televisions like it was going out of style this season, I don’t believe ever thought about having it any other way.

Maybe it was crazy Uncle Joe types that Governor Bentley was thinking about when he closed the psychiatric hospitals in Alabama. This wasn’t the first time that they had been closed. We were also on the cutting edge in the 1960s when de-institutionalization was all the fad. See, in Alabama, we’ll tolerate Uncle Joe throwing a television in a swimming pool as long as he spends his own money to replace it. We don’t believe that government should by him a new TV, though. I bet Governor Bentley just thought that if the mental hospitals were closed, Uncle Joe might just stop throwing TVs in the pool.

Government is still paying for the TV, only they are doing it by putting folks with severe mental illness in jails where they can watch for free. It is estimated that as many as half of all incarcerated individuals have significant mental illness. In Alabama we save money through under-diagnosis (we only a have mental health diagnosis on 12% of our prisoners), under treatment (only 4 psychiatrists for a 29 facility system) and overcrowding (the prisons are running at 189% of capacity). As outlined by the Southern Poverty Law Center here is how crazy Uncle Joe is faring in Alabama custody:

One prisoner reported hearing voices and engaging in self-harm thousands of times over a period of about eight years before finally being identified as needing mental health care. Another prisoner was placed on suicide watch three times within four months and asked for mental health treatment, but has not been given any treatment. A prisoner who repeatedly mutilated himself was threatened with forced medication by staff. Just two weeks later, he asked to be placed on the mental health caseload only to have the request refused.

They report misdiagnosis (mostly underdiagnosis), undermedication, overmedication, forced medication, and significant guard on patient violence. However, since they are prisoners instead of patients, it is OK.

There are now more than ten times more people with mental illness in prisons nation wide than in mental health facilities. This compares favorably with the 19th century, but for most of the 20th century America sought to be better and in the 1960s in the golden age after de-institutionalization but before budget cuts less than 10% of the prison population had a serious mental illness.

Most people with mental illness have some type of health insurance (usually Medicare or Medicaid) and they cost both the prison system and the healthcare system a lot of money. In Alabama, thanks to Medicaid reform, we might have an opportunity to move back to the the 10% days of the 1960s (mental health wise, that is). The new Regional Care Organizations have a significant emphasis on improving medication compliance and outreach to those with major mental illness. We are discussing creative solutions such as assistance with housing and other programs to prevent incarceration rather than encourage it. Turns out, Bryce Hospital in Tuscaloosa, built in in the 1830s, was a trend setter in a good way. Maybe we can be once again. Warning, though, it might involve purchasing televisions.

154919_600Me, interviewing applicant for medical school: So, have you been following the Ebola outbreak? What do you think?

Student, very sincerely: I have been and I guess I would go. Isn’t taking care of the sick what we sign up for when we get into medical school? I do spend a lot of my time trying to talk sense into my friends who are caught up in the hysteria so maybe that should count for something.

Fear has often been used by people in power to exert control. Fear of disease is powerful, especially when that disease has elements of the unknown. The latest Ebola hysteria seems by many to be whipped up, in part, to “demonstrate” the powerlessness of people, the monolithic failure of government, and the need for us all to purchase guns, vote for individual responsibility (mostly Republican, it seems), and build individual border fences around our homes to keep out the eye bleeding zombies.

The counter-argument is not being made very well. Partly is is because we have “A PERSON WITH EBOLA” in this country and everyone is yelling about it, drowning out civil discourse. Partly it is because America seems to go on despite the presence of Ebola, much to the chagrin of the yelling class. Why is that?

1) The food supply in this country is safe – Much has been written and said about the number and amount of calories available and the subsidization (through what used to be called food stamps before that term was demonized). Many west Africans live on a subsistence diet. This diet relies on “bush meat” as a protein source. Bats, monkeys and other primates, pangolins, and other assorted animals found in the wild constitute bush meat. How does this spread Ebola? These animals are a natural reservoir. They bite, kick, and scratch while being captured and killed. Unscrupulous hunters are likely to bring in an animal found dead to market (less biting) and the consumer is none the wiser. So, every day you wake up without Ebola (or dysentery,  ptomaine, botulism, etc) thank the feds.

2) We have safe water and sanitary sewers – although the direct link is difficult to prove, it is very likely that poor sanitation has contributed to the spread of the disease. Though many people think of Ebola as the “bloody eyed ISIS monsters coming from Mexico” disease, it is actually more akin to cholera. The death is not caused by zombification but actually by profound diarrhea (as much as 5 and 1/2 liters per day). It is spread through contact with body fluids and if there is that much vomiting and diarrhea, chances of exposure are high. Most west Africans in villages have no sanitary water. In Liberia, only 17% of the population has access to toilets. If there is NO TOILET and 5 and 1/2 liters of diarrhea, the chances of exposure are very high. The Environmental Protection Agency plays a large role in making communities comply with laws regarding clean drinking water and those  requiring sewage treatment prior to emptying the raw sewage into the nearest body of water. Next time you don’t wake up with cholera, typhoid, polio, or Ebola, thank the feds.

3) We have access to medical care – Although not perfect, the experience with Ebola in this country shows that western medicine does help. With cholera, there is not much vomiting so oral rehydration is sufficient. With Ebola, the patient vomits it back up so early and massive amounts of IV fluids are proving essential. If Thomas Eric Duncan had been admitted at the earliest sign of the disease, we now think he would be alive. IV fluids are not available in many areas of western Africa. Early access to care is now guaranteed to most Americans through the Affordable Care Act. Next time you have a fever, vomiting, and contact with a friend with Ebola and want to seek care, thank the feds.

A lot of work is left. This disease has been around a while. If this were a disease of the west, it is likely there would already be a vaccine developed. Let us hope that happens next. If it does, the development likely will be funded through the National Institutes of Health. And if it is, you can thank the feds…

med27I write this blog for 3 audiences. Many of these posts are written for the lay audience. Someone will ask me while mowing the grass about ebola or chikungunya fever and I will provide my (not so) learned opinion in blog form. My friends then access my deep thoughts through Facebook so that at the next cocktail party the conversation goes like this:

Friend: I read your post about chikungunya fever

Me: Chick-a-what?

It seems I have a short memory.

Another audience I write for is folks who make policy. I have a small following of people who actually have some influence. When I write about access to care for Medicaid-gap Alabamians (my favorite subject), insurance monopolies, or the fact that a certain legislator is both against Medicaid expansion and for trying to insert a phrase into a law that takes money away from Medicaid and puts it into a client’s pocket that is the audience that I’m writing for. So, after writing a blog like that, a conversation might go:

Person in position of authority: Who is this Perkins character?

Person who actually knows me: Some commie, I suppose.

Lastly, I write for students of family medicine. In my day job, I run a department of family medicine. This means that I am involved with teaching medical students (most of whom will not go into family medicine) and resident physicians (almost all of whom will go into family medicine), seeing underserved patients (who likely do not know they are seeing a family physician), and supervising faculty physicians (ALL of whom know what they do and let me know about it ALL the time). This blog post is for this audience (but all of you others feel free to read as well).

This past week, the president of the American Academy of Family Medicine, Dr Robert Wergin, announced that Family Medicine 2.0 has arrived. Why the reset? As Don Berwick and T.R. Reid point out at the accompanying press conference, we in family medicine have been working on changing the way we do business since 2000. Meanwhile, the rest of the the medical-industrial complex, not so much. In the words of Dr Berwick, the time to change healthcare is NOW.

What we as a specialty have committed to  is this:

  • Give patients the care they need when they are most vulnerable
  • Care for patients regardless of age and health conditions, and work to sustain an enduring and trusting relationship with them
  • Be each patient’s first contact for health concerns. Address all their health concerns, and resolve most of them
  • Help patients with preventing, understanding, and managing illness
  • Navigate the health system with patients, including coordinating with specialists and staying connected with patients before, during, and after time spent in a hospital
  • Set health goals that adapt to each patient’s needs as defined by them
  • With the care team, use data and best science to prioritize and coordinate services most likely to benefit patients’ health
  • Use technology to maintain and enhance access, continuity, and relationships, and to optimize patients’ care and outcomes
So, medical students, you are on notice that you need to leave our rotation knowing that this is who we are. Residents and prospective residents, you will be held to this standard. Patients, this is our promise to you. Faculty, we have some work to do.

63514_cartoon_mainNews item: An airplane in Birmingham is detained because a passenger threw up (into a vomit bag, I hope) and, not being clearly Caucasian, concern was raised among the crew about EEEEE BBBBB OOOO LLLL AAAA. Two hours later, the fellow passengers were allowed to deplane and the poor, sick Jordanian (home to no Ebola) who had a layover in Turkey (also straddling two continents without Ebola) was allowed to go to his destination. I hope to take his Zofran and suffer in peace.

News item: A woman in Mobile, Alabama who has lived in this country for seven years BUT who had visitors from the Congo ( in east Africa, where no Ebola is but sure sounds like Ebola should be there) was transported via ambulance (with roads blocked off in case the Ebola jumped out, I suppose) to a local hospital where, upon taking an effective history, the patient’s lack of Ebola was confirmed. Who paid for the ambulance ride was not discussed.

It has been a long time since we have had a good pandemic scare in this country. A pandemic, typically caused by an infectious agent, is notable for  its ability to cross over country boundaries and in general wreak havoc.America tends to be protected because of our size, limited number of international boundaries, and  public health infrastructure. The last really good pandemic we had was the “Spanish” flu which was blamed for almost 700,000 deaths in the US. The stories from that era consistently identify the randomness of being stricken as a dominant feature (person gets on the streetcar healthy and at the end of the line is found dead). It is the randomness of being afflicted that seems to create havoc as much as anything else. When a pandemic comes, there are often voices prematurely calling for closing the borders and the schools. Way back in 2009-2010, the public health officials were able to resist such calls when swine flu came. They were able to vaccinate the population and keep public concern to a minimum through creative use of media. They were also fortunate in that the case mortality rate was 1:2000 (as compared to 1:40 for the Spanish Flu and an apparent 1:2 for Ebola).

American reaction to pandemic risk can be constructive. For example, it was a measles epidemic in 1989 to 1991 that led Congress to change the way vaccines were distributed, creating the Vaccines for Children program. Maybe some day we’ll look back and see improved infection control in our hospitals in response. For now, my current hope is that the media, medical establishment, and all branches of government will act responsibly.

Some facts about Ebola:

  • As of today, there are 0 deaths of American citizens from this virus.
  • It is only transmitted through blood and body fluids of a person with a significant infection. People who are contagious are REALLY SICK. Don’t be afraid of the not so sick ones. Casual contact with a person will not infect you if there is no blood or body fluid transmission. If someone looks sick and you happen to touch their skin, hand sanitizer is likely sufficient protection
  • It is found in the semen of people who have recovered for 3 months. It is wise to avoid sexual contact with men who have a questionable illness history (likely always wise).
  • Avoid eating bats and monkeys (especially ones found already dead)
  • Avoid hospitals in West Africa. They don’t have enough gloves. In fact, get a flu shot so you can potentially avoid health care workers completely

Interestingly, Shep Smith on Fox News makes the same points…go figure.

'When did you first notice your timbers were shivering?'I get the New England Journal of Medicine (NEJM) delivered to my home. I know, I know, it is so 1980s to read a journal in paper form (ok, even to read a journal) but I enjoy browsing the most current science and sometimes retain a factoid that later might be useful. I still remember the time I read the Clinical Pathological Conference about a person with confusion and thrombocytopenia (low platelets) where the diagnosis turned out to be thrombotic thrombocytopenic purpura (very rare) and darn if a person with that exact same presentation didn’t call me about a month later. I, the junior resident,  called the hematologist who was at a party and he said something to the effect of “Yeah, right, what do you know…” I elected not to say “I read the New England Journal of Medicine, sir.” Instead I cited all the evidence without mentioning the NEJM article and he agreed with my diagnosis and came in. The patient survived without knowing that her life was saved (or at least the diagnosis was made in a timely fashion) because I got a journal and actually read it.

Many of the diagnoses for those complex cases in the NEJM hinge on an unusual piece of history. Typically, that history is not in the story of the illness (in doctor lingo, the HPI). A fever that starts a week ago is pretty much the same whether it is the flu or malaria. Instead, the clue is in the family or social history. “The patient reports swimming in a waterfall pool in Hawaii” would make me think “leptospirosis” (an infection carried by rats and spread through their urine, typically in large concentrations in the stream above the waterfall…kind of makes you think twice about those movie love scenes, doesn’t it). Part of the job of the health care team is to gather the correct information and synthesize it, keeping the valuable information (swimming in a waterfall pool) and discarding the red herrings (wearing a blue bathing suit). Part of the fun of medicine is to put things together and make a diagnosis so as not to miss a NEJM moment.

Although the details are sketchy, apparently someone in Dallas missed their NEJM moment and is blaming the computer. If you have not heard, Thomas Eric Duncan, a Liberian national, got on an airplane feeling well in Monrovia. He then flew to Brussels, Washington DC, and ended up with family in Dallas. When he started to feel ill, he want to the Emergency Room. At the time (5 days before he got really sick) he had some fever, body aches, and in general wasn’t feeling well. This is where the facts become murky but clearly the moment was missed. Even a doctor, half paying attention (“Ok, so any travel? New pets?”) should raised an eyebrow when a person with an accent says “Well, I did just get in from Liberia.” Reading between the lines of the Slate article, the hospital apparently assigned someone to take a history and enter it into the electronic medical record (perhaps to save the clinician time). Thus, “travel to Liberia” was buried in the record.

Doctoring is very expensive and interpreting symptoms is often unrewarding. Of 1000 people with fever, 999 will have something self-limited. This is especially true in America, where many infectious diseases have been eliminated. There is something, however, to be said for inefficiency. Every now and again, what one person thinks is a red herring (just where is Liberia, anyway) another puts into a pattern and prevents an epidemic. Doctors have got to want a NEJM moment enough, though, to pay attention.

1_123125_123050_2279896_2300573_2302170_3_lineup.jpg.CROP.original-originalDoes the money to pay for this come from taxpayers held at gunpoint?

Comment on a forum about an upcoming meeting on the need for Medicaid expansion

Long answer: I am serving on a panel in Fairhope, Alabama to discuss the need for Alabama to accept the Medicaid expansion. Fairhope is a Victorian resort town on the bluff overlooking the Eastern Shore of Mobile Bay, about 30 miles from where I live. The town itself was first known as Alabama City but a group pf 28 folks from Des Moines, Iowa, purchased land in the area in 1894 and created a single tax colony:

The people who established Fairhope wanted to create a community that would, as best they could, implement the theories of economist and social activist Henry George. George wanted government to tax the full rental value of land, the value of which is created by community improvements and not by labor or invested capital. He felt that if the full rental value of land were taxed (including minerals under the land) that all other taxes could be abolished, thus becoming the single tax. Others termed his theories the Single Tax, and the name stuck.

The single tax corporation collects all taxes associated with property due to state and local governments and distributes them as well as administration and demonstration fees. These fees go to things that raise the value of the property for all. These projects include bayfront parks, a pier that goes a quarter mile out into the bay, the library, and many others. The Fairhopeans do indeed get value for their housing dollar. They also get waterfront parks.

The state share of Medicaid in Alabama is not paid for by a tax on property. In fact, very little of the tax dollars the state actually collects are used to pay for healthcare for the poor, as I have previously outlined. Though the people of Fairhope may want further the common good, averages Alabamian seems much more concerned about keeping their hard-earned in their own pocket. As such, they are seemingly willing to forgo 30,000 jobs and hundreds of millions of dollars of federal money to keep their own, personal, income taxes from going to someone who is undeserving. In the words of one commenter “Why should I work anymore if the government will give me everything I need?”

So, I will go and spread the word to the gentle socialists of Fairhope of the reality that corporations look for good community health when they relocate, along with the concern that, since the mechanism to fund poor people who become sick has changed, we are getting LESS federal dollars as a consequence. I feel certain that those in the room who are true Fairhopeans will see the need for them to look after their brother and, given that the federal dollars going into Medicaid ARE OURS ANYWAY, will nod their heads in agreement. I despair of convincing the people of the rest of Alabama that poor people are folks who get sick anyway, need care to prevent illness, and Medicaid is the only mechanism to provide that care. I can only hope they remember the wisdom of the Fram oil filter man, “You can pay me now, or, you can pay me later.”

cartoon9I have to remember that I’m an officer and when I give a Marine an order they will obey no matter what. When I use the tonometer and say “don’t blink” I had better remember to follow up with “blink” before they get dry eyes.

Conversation with a Navy Optometrist

I remember fondly my time being a doctor to the Marines. Wet behind the ears, eager to hone my craft, suddenly given superhuman abilities such that with only an internship I could function independently in a remote setting…oh, wait, that last part didn’t happen. Fortunately there was, on the base with me, a wizened old doc (I think his name was Wenzel) who had practiced in rural Kentucky prior to going back and studying pediatrics. His counsel was always wise and when distilled down often ended up being “When in doubt, turf it out.”

We were at a fairly busy ambulatory clinic and urgent care center in Kaneohe, Hawaii. All of us took call. I remember making multiple trips to the civilian hospitals to transport patients. The active duty dependent and military retiree patients had to pay quite a bit out-of-pocket if they used the civilian facilities without consulting us first. We used to get folks driving PAST the civilian hospital to come to our ambulatory dispensary having heart attacks (I can remember one dying on the H-3 while in the car, wife driving 80 miles an hour) and  respiratory arrests (one of the most harrowing ambulance rides of my life, ever) in addition to the assorted 21-year-old Marines who never failed to learn the lesson that alcohol renders no one invincible. The lessons I learned there about the limits of an ambulatory practice setting, the triage and transport of sick people, as well as the health risks folks will take as they try to save a buck,  have stayed with me for 25 years.

I also learned some very concrete lessons on practice organization and care delivery. First, we had a very robust quality assurance program and worked hard to create a culture of quality and safety before it was fashionable. Second, against the wishes of the base commanding officer who wanted to have “his own hospital,” any attempt to be who we were not (a small ambulatory presence designed to get folks the care they need when they need it) was resisted by folks above my pay grade. Third, the Navy was experimenting with nurses in charge of practices such as this and I was extremely fortunate to work with several very good Nurse Corps OICs and learned to work as a member of a care team.

The military is a unique practice environment. The emphasis on readiness as well as wellness provides lessons for all of us in healthcare. Unfortunately, military medicine may be in trouble. The remote locations, providers who may not be invested with tours of only 3 to 5 years, and inexperienced physicians who are moved rapidly up in rank based on medical training apparently has led to problems.  The New York Times has recently published a story highlighting the downside that is worth a read. I was most struck by the quality and safety problems highlighted in the article. Physicians are apparently being placed in small hospitals with skills ill-suited for the location and/or patient population and attempting to provide care comparable to what they learned in their training. In addition, data aggregation techniques now used in the civilian world to assess quality and improve care are not in common use in the military hospitals. Leadership positions are being given to physicians who have a high rank by virtue of their residency training but limited real world or even military experience. The military is not entirely to blame. When they try to consolidate hospitals or provide care in a different fashion they are obstructed by the community, who uses their congressperson to keep the jobs local.

Our troops and their families as well as those who have retired from active duty have the expectation of high quality and safe healthcare, as does the general public. We need to equip all physicians with the skills necessary to practice in the environment in which they find themselves. Surgeons in isolated areas need to focus on doing small procedures well and leave the complex cases for hospitals with teams to provide care, whether on a military base or in rural Alabama. We need to teach how to assess and incorporate meaningful quality and safety practices starting at day one of medical school and not assume competency by virtue of a residency training certificate. The Milestone project seems to be a good start at making sure this happens at the residency level. Lastly, we need to teach leadership. Physicians are expected to be leaders. It’s time we give them the tools to do it.

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