The emphasis in the movie was placed on the construction of the new “Wing of Zock.” In the movie, the Wing denoted progress. It was going to be a modern setting to provide access to technological advances in health care, financed by grateful and wealthy benefactors.However, in the movie as well as in medicine today, there is a tension. The adminstration realized that having such a Wing meant paying for the care delivered in the Wing. The Interns in the movie were encouraged to “Putzelize” patients. This was a term for admitting a patients with no known medical illness to the hospital solely for attention and their ability to pay for the care rendered. Although it was unnecessary and expensive, it was clear that these patients were an important part of the business plan to pay for the new wing.

The other overarching theme was the replacement of a caring doctor with technological intervention. The Fat Man, kind of a Zen Master for the Interns, instructs the Interns on the importance of doing less rather than more at the beginning of their training. So important is this, in fact, that the last of the Fat Man’s Rules is “THE DELIVERY OF GOOD MEDICAL CARE IS TO DO AS MUCH NOTHING AS POSSIBLE.” Unfortunately, as in medicine today, the Fat Man loses to the sterile, technologically driven world of modern health care. To bring home the point, Wayne Potts who is an Intern from Charleston South Carolina does not perform the technologically correct (at the time) therapy of giving steroids to a patient dying of fulminate hepatitis and the patient eventually does dies. Wayne has a very touching scene where he and Roy (the main character and also an Intern) discuss why they went into medicine. Wayne poignantly discusses how “All I wanted to be was a country doctor.” Ultimately, the hierarchy at the House of God are unable to forgive him for making their numbers look bad, he is unable to forgive himself for the patients death, and he commits suicide by jumping off the Wing of Zock.

In a new blog named “Wing of Zock” the LCME, the organization of medical schools, identifies the needs for medical education in the new era:

Academic medical centers and teaching hospitals are at a crossroads in redesigning our health care system and examining how they educate medical professionals. They are experiencing tremendous discontinuity: Current payments, incentives, and value systems don’t reward excellence in care delivery and medical education. They are constantly engaged in building the next Wing of Zock as they seek to define a future that signifies hope.

In creating the next Wing of Zock, I hope we can avoid “putzelizing” America in hopes that it will pay for the education of medical students and residents. In addition, we in medical education need to support the Wayne Potts’ of this world. We need to nurture those who want to be “someones doctor” Turns out that steroids in the case of the “yellow man” would really not have made a difference in his survival. Putting a Wayne Potts in a country town for 40 years makes a huge difference. Now more than ever we need to figure out how to teach the right people to deliver exceptional care and hopefully the money will follow.

We were looking for potential investment property and this would certainly allow us to invest quite a bit of money (sort of like a sailboat). The truth is that with enough money, the building could be made into a showplace. An article in the New England Journal reminds us that the body does not work that way. In this article people’s blood pressure, cholesterol level, smoking status, and diabetes status looked at in various ways. The investigators found that of the people who were 55 and had everything well controlled, 85% were very likely to live beyond 80 years of age regardless of race or sex. Of people who had two or more of their risk factors uncontrolled or who smoked, 50% were likely to be dead of heart disease or a stroke before age 80.

To fix this building, we would likely have to tear out the entire interior and retrofit it with a modern building. We would end up with a 1920s facade in a 1920s neighborhood but would functionally have a 2010s building. Many of my patients would like to believe that if they let their insides go, I can retrofit them as well. A better approach for the building would have been ongoing maintenance over the past 90 years. It turns out that it is the only approach for the human body.

In your training, what 3 things (maximum) were stressed/emphasized to you regarding how to take good care of people?

In your experience, what 3 (maximum) lessons have you learned about taking good care of people? (if you had just three suggestions to pass on to students and residents regarding how to take good care of people, what would you say?)

My medical school training was at Tulane and my clinical training was mostly at Charity Hospital (also known as “The Big Free”) in the mid 1980s. It was a different time and a different place. There were no work hour restrictions, there was very little contact with attending physicians in conjunction with patient care, and as a student you had the distinct impression that you were an important part of the health care team (and occasionally the only thing standing between your patient and death).Everyone, from the dean down to the intern on the serviced stressed one thing:

“Know Your Patient!”

In a place like Charity, this could not be overemphasized as to call the “health care team” stressed would be a generous understatement. Although the health care environment our resident learn in today is quite different, I still cannot overemphasize the importance of this.

The hospital had open bay wards where everyone could see everything. I still have a distinct memory of me as a 3rd year medical student watching a gangly white medicine resident trying to describe in very technical terms (using the barium enema image as a teaching tool) what Crohn’s Disease was to an impoverished African-American patient who clearly did not believe that the image was of his insides, much less that his insides were defective in some way. It was clear to me from that day forward that I had to:

“Speak the patient’s language.”

It may be through a translator or to the patient and a parent, or to the child of an elderly patient, but it is less important for me to be accurate than it is for me to be understood.

I did my first year of residency at Portsmouth Naval Hospital in Internal Medicine and stayed on working the Emergency Department for a year waiting to become a Diving Medical Officer. As a ED doc walking in with one year of post-graduate experience, I could not be accused of being over-confident in my abilities. Many of the residents who had been with me throughout my PGY1 year were still in training and I interacted with them on a regular basis. I was functionally the “admit resident” and they were my consultants. The ED staff and my colleagues  hammered home to me the lesson that:

“Medicine is a team sport.”

Never be afraid to ask for help. Always accept criticism and try to improve. Know what your role is in the health care team and hope that everyone else does as well. Put a good team in place and good care follows.

After I finished dive school, I was stationed in the clinic in Kaneohe, Hawaii. I got the job because no one else wanted it, based on rumors of what the job might entail.  At the end of three years I had made a bit of money on a condo, seen almost everything to see in Hawaii, made friends for lifetime, learned I wanted to do Family Medicine, and had a wealth of experience in leadership positions. In other words:

“Make the best of the hand you are dealt.”

Admittedly, raising your hand to volunteer to go to Hawaii isn’t like agreeing to fight “a land war in Asia” but it might have turned out badly.

I did my residency in Family Medicine at South Alabama. Ellen Sakornbut knew that I wanted to do Academics and challenged me to acquire and maintain OB skills (I still take OB call 20 years later). In her words:

“OB keeps your practice young.”

As I find myself caring for an increasingly aging patient base (despite miraculously not aging myself!), I am grateful for that piece of advice  when I see a pregnant patient in my practice (often, these days, the child of one of my older patients).

The last lesson that I learned in medical school and had emphasized in my internship, Navy career, and residency is this one:

“Always do the right thing.”

Of course, trying to figuring out what that is can be tricky!

With this information, [Watson, the IBM supercomputer] can suggest options targeted to a patient’s circumstances. This is an example of technology that can help physicians and nurses identify the most effective courses of treatment for their patients. And fast: in less than 3 seconds Watson can sift through the equivalent of about 200 million pages, evaluate the information, and provide precise responses. With medical information doubling every 5 years, advanced health analytic systems technologies can help improve patient care through the delivery of up- to-date, evidence-based health care.

The point he makes following this, though, is not that the computer will lead to a reduction in health costs by decreasing the need for human interaction. This data needs to be converted to actionable information. That is where IBM, the company that purchases health care, has taken the lead:

So, how to make sure this actionable information flows and is held accountable at the level of a healing relationship?With this question in mind, in 2006, IBM – as a buyer of care- hosted a meeting for 47 of the Fortune 100 buyers, TRICARE, the federal Office of Personnel Management (OPM), buyers and the whole house of primary care. They agreed to guidelines now known as the Joint Principles of the Patient Centered Medical Home (PCMH).

This is how the Patient Centered Primary Care Collaborative got its start.From this group came many of the elements of care transformation included in the Affordable Care Act.

As you can see, Paul and IBM have influenced healthcare for the better and will continue to do so. If you have an interest in policy, specifically where its going as opposed to where it has been, I would advise you to pay attention to his thoughts.

When asked how Americans will respond to health reform -

Two-thirds of the American people say they favor universal coverage, but the minute you start to spell out what that means — subsidization for the people who are poor and who are sick, and that the plan has to be compulsory — they are less supportive

When asked what is driving up the cost of health care -

The principle factor by far is medical innovations like new drugs, new surgical procedures and new diagnostic techniques. This is [confirmed by other] health economists in the country.

When asked if more medical care would make us more healthy -

I’m saying that almost everyone is getting the medical care that matters to health. Adding more care does not make much difference. The stuff that’s really effective, the antibiotics, the appendectomies and so forth — people get them. Health depends much more on the things we do to and for ourselves or that we don’t do. It depends on cigarette smoking, it depends on obesity, it depends on certain environmental conditions.

When asked what should we do to improve our health -

Improved health will come about through changes in the physical and psychosocial environments and in individual behavior and in medical advances, not in increasing the quantity of medical care at a given point in time.

In the recent New England Journal essay, Dr Fuchs identifies the payment structure as a significant barrier to reducing health care costs

The context… will affect the physician’s choice. If the physician is paid on a fee-for-service basis and the patient has open-ended insurance, the scales are tipped in favor of doing as much as possible and against limiting interventions to those that are cost-effective. In that setting, who would benefit from the resources that are saved by practicing cost-effective medicine is not obvious to the physician.

He believes that changing the payment structure to create an environment where the physician is responsible for the totality of care of a defined population will cause the physician to make better decisions based on a different frame of reference. He also believes that the patient will more readily accept physicians decisions not to recommend marginally effective care based on a “group good” in this context. Being in it together will help us to reduce both supply (from the doctors side) and demand (from the patients). There are several components of the Affordable Care Act including the Accountable Care Organization vehicle that use this strategy to reduce health care costs.

There is one other problem…who picks which group of people are in the health care lifeboat together? In doing some research on another topic, I came across this quote taken from a 1968 interview with a Mobile landlord regarding his plan to move his rental housing to an unincorporated area rather than offer city services (garbage pick up, sewerage and running water) to his (African-American) tenants:

“These people don’t mind,” he said. “You know, that’s the way with niggers. They’ll be happy in a community–everybody together. They try and go back to African tribal life. He don’t need garbage service–a darkie will feed it to his pigs. He don’t need a bathtub–he’d probably store food in it. Wouldn’t know how to use it.”

Granted, it was a different time. In conversations I have had with people both in and out of healthcare, though, I am concerned that we are still not certain that our neighbors are all striving for the same healthcare goals that we are. In the last 60 years we have come to realize that everyone likes to feel clean, regardless of skin color. How long will it take for us to believe that everyone wants to be healthy.

The Medical Expenditure Panel Survey (MEPS) is a set of large-scale surveys of families and individuals, their medical providers, and employers across the United States. MEPS is the most complete source of data on the cost and use of health care and health insurance coverage.

Spending includes all spending (health insurance, out of pocket, etc). The most recent numbers available are from 2008, prior to the passage of the Affordable Care Act and following are some of the more interesting ones

• $90,061 – amount spent per person in 2008 by the people in the top 1% of health care consumers
• 20.2% -Percent of health care dollars used by the top 1%
• $35,829- amount spent per person in 2008 by the people in the top 5% of health care consumers
• 50% -Percent of health care dollars used by the top 5%
• 5%  – Percent of Americans who spent more than $24,000 a year on health care  for two years in a row
• $232  – Amount spent annually by 50% of Americans on health care
• 13.2% – Percent of people over 65 in general population
• 43%  – Percent of those over 65 who spent over $24,000 in 2008 on health care.
• 11% – Percent of Americans who reported being in poor (2%) or fair (9%) health in 2008
• 64%  - Percent of people who spent over $24,000 on health care and still reported feeling in poor or fair health
• 95% – Percent of people who spent under $300 on health care and reported being in excellent or good health

To set a race up takes a lot of effort and infrastructure. This particular race benefited the L’Arche community.  People volunteered willingly to help control traffic, hand out water, offer band aids and fruit to the runners, and in general make the runners feel welcome and supported. Turns out that racing itself is not nearly as important as training for a race. The act of training provides an opportunity to participate in “vigorous intensity aerobic activity.” For adults, in addition to strength training the CDC recommends:

2 hours and 30 minutes (150 minutes) of moderate-intensity aerobic activity (i.e., brisk walking) every week or 1 hour and 15 minutes (75 minutes) of vigorous-intensity aerobic activity (i.e., jogging or running) every week or an equivalent mix of moderate- and vigorous-intensity aerobic activity.

In addition the CDC points out the the more time you spend exercising, the greater the benefits are.

Human beings are designed to be physically active. People who are physically active get fewer heart attacks,have less hypertension, less diabetes, less colon cancer, less depression, and less anxiety. At these races, there are very few people who do not routinely participate in physical activity and they look healthy for the most part. In my clinical practice, on the other hand, I see a lot of folks who have led sedentary lives and are often afraid to begin exercising. The CDC recommends that those starting a program do so in doable chunks, 10 minutes or so at a time. In additions, they recommend a gradual increase over time:

If you want to do more vigorous-level activities, slowly replace those that take moderate effort like brisk walking, with more vigorous activities like jogging

For those of you who are physicians seeing patients with chronic illnesses, instead of adding another pill try an exercise prescription. Exercise prescription involves a planned or structured physical activity regimen given to an individual or group that includes specific recommendations for the frequency, intensity, and type of exercise. Write it out as you would a pill to lower cholesterol (it is almost as effective).

I often offer may patients the opportunity to begin a trial of exercise rather than adding another pill or potion and write them a prescription. Sometimes, it even works.

• Support obesity- and disease-prevention programs through the new health reform law’s Prevention and Public Health Fund
• Align federal policies and legislation with the goals of the forthcoming National Prevention and Health Promotion Strategy.
• Expand the commitment to community-based prevention programs
• Continue to invest in research and evaluation on nutrition, physical activity, obesity and obesity-related health outcomes and associated interventions.

I was reminded of the ranking of our state by a future medical student who is very interested in healthy eating and obesity prevention, and he met with me to call my attention to Wholesome Wave, a program designed to inexpensively deliver fruits and vegetables to low-income patients.

Obesity is a huge (no pun intended) problem without an easy fix. In my conversation with Will, we talked at length about how the problem is a mixture of diminished opportunity to purchase and eat healthful  foods combined with limited opportunities to participate in physical activities.Programs such as this are a start but need to be combined with biking, walking, and other means of burning calories.

US News and World Reports offers another opinion. They found 22 experts

including nutritionists and specialists in diabetes, heart health, human behavior, and weight loss

who reviewed and rated 25 diets in seven categories, including short- and long-term weight loss, ease of compliance, safety, and nutrition.

The winner, as identified by the experts, was the DASH diet, rated 4.1 out of 5 (lots of vegetables, fruits, low in fat). The loser, the Paleo diet (eat only what cave men eat) was only rated 2.0 out of 5. The website offers a feature where readers can identify with a YES or  NO whether or not the diet worked for them. Although liked by the experts, the DASH diet has only been tried by 1600 readers and only 24% found it effective. By contrast, the Paleo diet had been tried by 30,000 folks with roughly the same amount of weight loss. The winners, based on readers clicking YES were the Vegetarian, the Vegan, and the Eco-Atkins (#10, #14, and #17) which had 93% self reported success by over 40,000 readers.

Fad diets tend to work in the short run by limiting food choices and forcing participants to select lower calorie options. This is reflected in the number of people who reported losing weight with the “bad diets.” This weight tends to come back as people revert to old habits hence the ongoing problem of obesity. On the other hand, losing weight is more than choosing healthy foods. Losing weight is always ultimately about burning more calories than you take in. The DASH diet is a healthy long term diet and, for example, would work even better if it included actual dashes. The Paleo diet to be effective would have to include participation in activities only a cave man might do. As to what that might be, you’ll have to use your imagination.

If [ObamaCare] survives the multistate challenge it will face this spring in the U.S. Supreme Court, Alabama will be well on its way to securing an expanded and fairer health insurance market for everyone, and a stronger safety net for low-income workers and their families.

That outcome will be thanks to the work of a commission Gov. Robert Bentley appointed to study the ins and outs of implementing a key aspect of the reform, despite his strong opposition to the law.

Mr Carnes points out that the combination of expanded Medicaid and these exchanges  will be a boon to the 15% of Alabamians who currently lack access to anything but emergency care and care provided by the charity of others. Once the law is fully enacted, people will qualify for subsidies to purchase insurance:

One crucial step for expanding coverage in Alabama will be the creation of what the law calls a state health insurance “exchange.” This will be a user-friendly marketplace where people who need insurance can compare and choose plans and get assistance for paying their premiums, on a sliding scale determined by income.

The full report of the Commission is found here. In addition,

The Affordable Care Act requires all states to offer Medicaid coverage to people earning up to 133 percent of the poverty line, or just under $30,000 for a family of four. That’s more than 12 times Alabama’s current Medicaid income limit. Alabama Medicaid estimates the change will bring coverage to around 500,000 more Alabamians.

Thank you, Governor Bentley, for setting aside your personal feelings and putting the groundwork for implementing the Affordable Care Act in Alabama into place.

Why are they closing? Per their web site, they are going to a strategy of “factory stores, doughnut and coffee shops and satellite units.” I suspect they were unable to convert this to a coffee shop in a cost-effective manner, and with the construction of a new factory store in town the location is unneeded.The company has a growth strategy to bring doughnuts to multiple sites to an area through new technology that can create HOT DOUGHNUTS with minimal infrastructure and the company has an app to make consumption of HOT DOUGHNUTS even easier. From the web-site:

With Hot Light Online you can map your nearest Krispy Kreme location from your phone and get alerts when the neon glow of “Hot Now” is activated in your area. So look up, download or tweet your way to find a hot Krispy Kreme doughnut near you with any of the following free options.

Now the downside. Each of the tasty glazed morsels has 200 calories, 110 from fat (per the company’s nutritional info). Although the company reports a serving size of 1 (one) doughnut, they are most commonly purchased by the dozen meaning that the average consumer purchases between 24 and 36 hours worth of calories if you get the simple glazed. In addition to the 2400 calories you’ve consumed (after eating  “just one more” times 12), you will also get 72% of the day’s requirement of calcium and 48% of the iron.

Krispy Kreme expanded too rapidly in the early 2000s but has recently righted themselves financially and has turned a profit for 12 straight quarters. They have selected a new CEO, Kenneth May, who

…is a highly respected business leader with more than 25 years of operational, retail, supply chain and brand experience.  As part of a successful career with FedEx Corporation, he served as President and Chief Executive Officer of FedEx Kinko’s Office and Print Centers, and led the integration of Kinko’s into FedEx.

I should wish them the best, but won’t. It concerns me that to increase profit, they are looking to increase sales of these little fat bullets through innovative marketing techniques. For me, these were an annual treat and now they will be less so but then again, I am not in their target demographic. To be honest I would rather hang at a locally owned shop such as Serda’s, Cream and Sugar, or even a Starbucks and spend my money on good coffee and skim milk. I encourage you to do the same.