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Law 13: THE DELIVERY OF GOOD MEDICAL CARE IS TO DO AS MUCH NOTHING AS POSSIBLE

Samuel Shem, House of God (Quoting the Fat Man’s Laws)

On rounds a while back in the hospital, we had a patient who had come from ICU and was being cared for by our team. He was a little older than our average patient (he was in his mid 80s), a little sicker (his kidneys and liver were failing), and a lot scared (I don’t want to die, doc. I want to feel better. I want to go back to how I was. Don’t let me die). He was getting a lot of blood draws, had a catheter in, and was getting IV fluids and a strong diuretic. Thanks to “big data” we now have calculators that we can plug in certain data and determine the likelihood of the patient being alive at 3 months, 6 months, and a year. In this patients case, there was a 50% chance that he would be alive in 3 months. As much as I wanted to, I was not ever going to be able to put him back together. I was also sure that he would have at least one or maybe two more trips to the ICU before he died. The sad thing is, those trips to the ICU might just cause him to die sooner.

Americans have believed that the US Healthcare system is the best in the world despite the fact that we consistently rank last among wealthy countries in almost every category measured. We are the most expensive in the world, spending twice what the next highest country spends.. It appears, that we have mistaken excess for quality. It also appears that we physicians are complicit in selling this belief to the public.

I often have patients say to me “do everything.” Often, they make that statement as the end of life is rapidly approaching. In this country, everything comes with a steep price-tag. Part of that price is monetary, For example we spend $1.25 billion in Medicare recipients for cancer care with 25% of that occurring in the last month of life. Part of that price is in shorter life-spans (from the Dartmouth Atlas):

Ironically, research has found that in patients with chronic illnesses, more aggressive interventions result in shorter life expectancy, probably because of the risks associated with hospitalization. This indicates that the best strategy for extending the life of people with chronic illness is to focus on those activities that provide a survival benefit – better control of blood pressure for people with diabetes, for example – rather than on “heroic” end-of-life care.

It turns out that the Fat Man was right. For a lot of people, symptom management (What would you like to be able to do?) with the reduction of aggressive care actually leads to a longer, better life.

What can you do? Take advantage of being well and determine what you would like others to do for you when you are sick. The CDC has some good information on advanced care planning. Only 20% of Americans have done so. If you suffer from chronic illness, have a conversation with your physician about what your expectations are regarding your last year. Only 25% of physicians report having such a conversation. Limit your care seeking behavior to what really is necessary. One in three Americans who die have seen over 10 physicians in the last 6 months and yet they still died (and perhaps sooner than they might have). When it is clear that a cure is not possible, seek symptom relief. Programs providing palliative care improve length and quality of life. In Alabama, only 20% of hospitals have such programs. Makes it hard to follow the Fat Man’s advice.

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Dr Perkins, can you come see this baby? Something about it just makes me feel uncomfortable.

I walk into the exam room to evaluate the week-and-a-half-old baby that was being seen by our new nurse practitioner. The child had a late morning appointment, the mother having called at 8 because the baby “wasn’t feeding.” No fevers, nothing else out of the ordinary per mom (although the baby did up having a fast heart rate). But as soon as I walked into the room, I quickly agreed with the nurse practitioner. The child was sent to the hospital for a “septic work-up” and was indeed septic.

Dr Perkins, I just don’t feel good. I have this chest pain when I go to sleep at night. Not during the day, mind you, only at night. That’s right, it hurts right there when you mash down.Why, yes, I have been getting a little short winded when I walk the golf course but isn’t that just weight gain?

Despite the reassurance that reproducible chest wall pain brings, based on reduced exercise tolerance we went ahead and obtained an EKG. To make a long story short, 3 vessel disease.

It was quite the Monday.

Despite running a busy department, I do a lot of clinical medicine. Trained in the underserved environment where I continue to practice today, I care for all ages, do some minor procedures, deliver babies (and now the babies of the babies I delivered). As my practice has aged with me, I see a lot more older than younger folks and find myself diagnosing more dementia and less strep throat the older I and my patients get.

Being comprehensive defines my specialty along with continuity, coordination, and first contact care. We preach to our learners the importance of these attributes, we test our graduates on the comprehensiveness of their knowledge, and we criticize ourselves for allowing our scope of practice to shrink. Now there is one more piece of evidence that should make us think twice about that cushy outpatient job ($50,000 signing bonus, no call, no hospital, 15 minutes to the beach). The Graham Center has authored a very elegant study that links scope of practice with actual practice. They found that doctors who were able to do more (were more comprehensive in their approach) had Medicare patients who were less likely to be hospitalized and who had better care-seeking behavior. By better, I mean that they cost the system about 15% less.

Not measured in this study were quality and patient satisfaction. This is important. As one of the commenters points out, sometimes comprehensiveness can be misused.

[F]or some populations with higher disease burden, high comprehensiveness (or scope, as we say) may be counterproductive. PCPs that maintain “too much” comprehensiveness for patients who need more contributions by other providers may be doing so because of lack of coordination with specialists, inadequate supply of alternative providers, an inability to recognize limitations, or resistance to “letting go”. Whatever the reason, the decreasing value of expanded scope in high risk individuals is a phenomena we have seen in numerous populations.

Despite these limitations, this is important.  In the words of Kevin Grumbach (one of the smartest people I know) on NPR (one of the best sources for information I know)

the new study confirms a belief that had long been suspected, but has rarely been proven: Coordinated care, led by a family doctor who is judicious about referring patients to specialists, leads to cost savings.

“It goes from a matter of philosophical preference to actually showing that this saves money,” Grumbach says.

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When I was growing up my sisters and I would play the “Are we there yet” game. For those of you who do not indulge, this game is played by getting in the car, allowing the adults to begin the journey, then about 5 minutes into the ride begin asking “are we there yet?” in a rapid fire fashion using the most annoying voice one can muster. The adult’s role is to sit and ignore the game as long as possible and, when the time is right (generally about 5 minutes in) turn to the back and say “WE ARE HALFWAY, NOW SHUT UP.” At that point, the game is over and, in my family car, generally transitioned to the pinching game (“Allen is pinching me”).

Our Governor’s journey through the changing healthcare landscape has been evolving. In 2010, while campaigning for Governor, he had some deeply held beliefs regarding the newly passed Obamacare:

I started laying the groundwork for Alabama’s rejection of Obamacare by pre-filing a Constitutional Amendment to prohibit any person, employer, or health care provider from being compelled to participate in any health care system. It also codifies Alabama’s 10th Amendment rights over this issue. I have real-world solutions that will result in affordable and accessible health care for all without bankrupting our nation or pushing us closer toward a government-controlled, single-payer system.

The Supreme Court decreed the Medicaid expansion part of ObamaCare to be coercive in 2013 (As an aside, for it not to have been coercive it would have had to meet the following criteria (1) related to the general welfare, (2) stated unambiguously, (3) clearly related to the program’s purpose, and (4) not otherwise unconstitutional.) 26 states elected not to take the expansion, preferring to stick with the (poorly funded, focused on wasteful inefficient care delivery) old program. Our Governor announced that we would be one of the states refusing the Medicaid expansion:

The Affordable Care Act–or ObamaCare–and Medicaid expansion is taking our nation deeper into the abyss of debt, and threatens to dismantle what I believe is one of the most trusted relationships, that of doctors and their patients. Essential to ObamaCare is Medicaid expansion–a federal government dependency program for the uninsured. …

Now they are telling us we’ll get free money to expand Medicaid. Those are your hard-earned tax dollars. Our great nation is $17.2 trillion in debt and it increases by $2 billion every single day. That is why I cannot expand Medicaid in Alabama. We will not bring hundreds of thousands into a system that is broken and buckling.

The good news is that his view continues to evolve. Over the objection of our state senators, he is now ready to accept Medicaid expansion IF there is a work requirement, along with a few other conditions:

“It would have to be in the private sector and there would have to be some requirements on it,” Bentley told reporters in December. One specific requirement he mentioned was that he’d like to see the system tied to employment. “(Recipients) need to be working on getting a job, or having a job.”

A couple of things, Governor, to consider before you start playing the pinching game with Senator Pittman. 72 percent of uninsured adults who are eligible for Medicaid coverage live in a family with at least one full-time or part-time worker. More than half (57 percent) of these adults are working full- or part-time themselves. The overwhelming majority of workers earning less than 138 percent of poverty—81 percent—don’t have coverage through their employer because their employer either doesn’t offer it or it is unaffordable to them.The Kaiser Family Foundation recently looked at the main reasons for not working among unemployed, uninsured adults likely to gain Medicaid coverage if their state adopted the Medicaid expansion. It found that 29 percent were taking care of a family member, 20 percent were looking for work, 18 percent were in school, 17 percent were ill or disabled, and 10 percent were retired.

Maybe we really are halfway there.

“…the moral test of government is how that government treats those who are in the dawn of life, the children; those who are in the twilight of life, the elderly; those who are in the shadows of life; the sick, the needy and the handicapped. “ ~ Last Speech of Hubert H. Humphrey

When people think of Qbamacare, they think of the insurance aspect. A lot of the law, however, was  designed to deal with a health care system in crisis. No aspect of our healthcare system was more in crisis than the care of our seriously mentally ill. One reason is a lack of private insurance (many folks with serious mental illness can’t hold down steady jobs, which is how America distributes its private health care dollars). Secondly, if these folks had coverage it tended to be Medicaid, and Medicaid is known to be a poor payer, so poor that many general med-surg hospitals closed their in-patient psychiatric units in an effort to limit their “exposure.” Thirdly, through a quirk in the Medicaid enabling legislation, freestanding psychiatric hospitals were not allowed to bill Medicaid for services even if the folks were admitted to their hospital. (50 years ago, state and local hospitals provided such care, and Congress did not want to shift that expense to a federal program.)

The Obamacare act was designed to right many wrongs, and included was a effort to fix this problem. In a section called the Medicaid Emergence Funding Demonstration Act, it provided funding to freestanding psychiatric hospitals to:

provide $75 million to the new demonstration to determine whether it will improve access to psychiatric treatment, lower costs, and reduce crowding in general hospital emergency departments (EDs). At the end of the 3-year trial period, the CMS will make recommendations to the US Congress about the feasibility of offering the program nationwide.

Alabama applied for and received funding to do just this and the community mental health center in Mobile (Alta Pointe) took the money and opened many more beds to help relieve the congestion. The next thing that happened following the demonstration in Alabama? The slicing of the state mental health budget by 25% and the closing of acute crisis beds at several state hospitals. Thanks Obama!

The difference between Obamacare and other programs was the inclusion of evaluation and outcome measures in these pilots. This particular program is being looked at and so far has been found wanting.

So what’s the status? CMS reported on MEPD progress at the end of one year in a mandated report to Congress (see CMS Report To Congress On The Evaluation Of The Medicaid Emergency Psychiatric Demonstration). CMS’ endorsement was tepid – it stated it did not have enough data to recommend expanding the demonstration, but that it supported allowing the demonstration to continue through the end of its authorization in 2015.

At a year, though overall hospital costs were down, length of stay was the same, as was the rate of discharge to the home environment. In other words, the care by the measures agreed upon was the same. Anecdotally, though many benefited, in Alabama care delivery was not improved. In the words of a spokesperson from the Alabama Hospital Association:

“Most of the hospitals feel that the number of patients in departments continues to increase and the length of time it takes to get people into beds is increasing,” Blackmon said.

The national evaluators apparently felt that there were more comprehensive ways to provide care, so this program will likely not be reported favorably to congress and will end.

Which brings us to yesterday’s news story. Alta Pointe, which opened a hospital in response and is now the effective state facility of the seriously mental ill in Alabama (though with little state money), has been using this “demonstration” funding to provide services previously paid for by the state. Now that the demonstration is going away, they will likely close their 100 beds, leaving only 34 crisis beds for approximately 2,000,000 people. Congress has an opportunity to pass a stand alone to continue the program but, given the outcome and the mood in congress, this is unlikely. Alabama has the opportunity to replace the money with state dollars. Given that they are looking to cut half a billion from existing programs and didn’t budget for this expense, not likely either. Don’t think the citizens of lower Alabama are in the mood to pony up an extra $2,000,000 annually in donations, either.

In the words of one al.com commenter:

Let’s look for Al.com’s isolated sob stories to make our hearts heavy and give in to another tax hike. Nonsense. Cut the programs. Cut the departments. Cut the government in half.

So what will happen? Fortunately, space under the bridges is available and serves the dual purpose of allowing the non-afflicted to get to where they want to go. If it gets too cold, those with serious mental illness can commit crimes. Alabamians are always willing to pay for jail cells..

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One of the advantages of living in Alabama (state motto: “We dare to defend our rights” which sounds much less like an angry, red faced person yelling when translated into Latin: Audemus jura nostra defendere) is that others are always more than happy to come here and help us defend our rights. The most recent came in the form of a “essay” from a rights defender in the Arkansas legislature (%uninsured before Obamacare 22%, % after 12%). Senator Bryan King (with help form the Alabama Policy Institute) examined Arkansas’ efforts and has issued a strong warning to us Alabamians. He dared us, at least as much as he could on al.com, to defend our rights. In his assessment, Arkansas did not do so with the following consequences:

1) Arkansas’ leadership was misled into thinking that they were being allowed through waivers to do something state-based, flexible, or innovative, which was, in Senator King’s eyes, untrue. He provides some examples of innovative things Arkansas was not allowed to do. They were not able to make healthcare access a privilege that came only through hard work, for example. They were unable to place burdensome restrictions on Medicaid recipients to force them to chose between medication and food. They were not allowed to arbitrarily identify certain segments of the population as unworthy of health care and deny it to them. This alone—not being able to deny the unworthy access to healthcare—is reason enough to defend our rights.

2) Arkansans are now dis-incented to work. Senator King points out that many Arkansans are sitting around sucking up free health care because if they make over 133 of poverty they will have to pay “thousands” for healthcare (Senator King must not have read the guidelines for premium assistance and cost sharing under ACA, which provides health care very inexpensively to the working poor). Better to spend time in the doctor’s office, I suppose. Keeping those deadbeats out of my office and into a low-paying job with no health coverage is something we should certainly want to continue as a state.

3) We are threatening Arkansas’ safety net for the truly needy. This argument goes something like the way lifeboats are filled on a sinking ship: the Medicaid net is mighty frail, and if more childless adults are added, it will break and all the women and children will fall into the ocean, um, that is, the uninsured void. As Arkansas now manages to get only half of her children vaccinated, the safety net their may actually already be a little frayed. But, none the less, we should aspire to be better (worse?) than Arkansas and decline the expansion. No sense in keeping folks HPV-negative for free, is there?

4) Arkansas opted to not go with the traditional expansion, which cost them more money. This is, per Senator King, is a reason not to expand at all. If we can’t go in a Cadillac, let’s not go at all.

5) Provision of healthcare to the poor already costs states a lot of money (the Senator points out that it is 35% of Alabama’s general fund, not pointing out that the bulk of that money is a provider’s tax that would not be collected if not for Medicaid). Per the Senator, this is a deal breaker.

Governor Bentley has recently appointed a “task force” to identify ways “real ways to make health care accessible and affordable to everyone while also combating the shortage of primary care physicians in 65 or the state’s 67 counties.” I suspect this article was targeted at the members of the task force. Expanding Medicaid would be an important tool to accomplish the governor’s charge. In addition, it would bring 30,700 jobs into the state, shore up the rural (and urban) hospitals, and provide currently uninsured citizens citizens access via the same provider network current Medicaid recipients receive care. Our 15% uninsurance rate post-Obamacare would be reduced to about 7% if we were to accept the expansion. Yeah, but you say, where does that money come from? Obamacare, as expertly explained by Dr David Bronner, takes the money states were already getting to take care of their poor (disproportionate share funds) and moves it into the Medicaid expansion program. If you don’t take the expansion, you no longer get those funds. In our case, the $14 million/year that used to come to us is going somewhere else.

Fittingly, the state motto was taken from  the poem “What constitutes a State?” written about the Gordon Riots in England. Adopted by Alabama in 1939, the rest of the line is as follows:

Men, who their duties know,

But know their rights, and, knowing, dare maintain,

Prevent the long-aimed blow,

And crush the tyrant while they rend the chain:

Wonder in this case, if our elected officials choose to deny Alabamians access to healthcare, who the tyrant is?

 

 

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Obamacare is 5 years old this past week. There have been many articles (such as this one on the economics of the lack of death panels and this one on how Obamacare zombie day never arrived). There are two very interesting articles that offer a fuller accounting of what Obamacare has accomplished.

The first was published in Medscape, an industry publication that goes mainly to physicians (thanks to our librarian Jie Li for calling it to my attention). Using a “by the numbers” approach, it shows how much has changed in 5 years. Some of the more interesting numbers:

37.2 million: Number of Americans who were uninsured in the first 9 months of 2014, a decrease of 23% from 2010, when the ACA was passed.

2.3 million: Number of young adults who gained coverage from 2010 through September 2013 by staying on their parents’ health insurance plan up to age 26 years

30,700: Jobs that Alabama would have gained each year through 2020 if it had expanded its Medicaid program.

900,000: Number of Americans whose individual or employer-sponsored health policies were cancelled for 2015 because they did not comply with the ACA.

$7.4 billion: Drop in uncompensated care for hospitals nationwide in 2014 resulting from ACA exchange coverage and Medicaid expansion.

87%: Percentage of 2015 enrollees in ACA exchange plans in the 37 states using healthcare.gov who receive a premium subsidy in the form of a tax credit.

$3960: Average premium subsidy (annual) in 2015.

$15 billion: Amount saved so far by 9 million Medicare beneficiaries receiving prescription drugs as a result of the law’s shrinkage of the infamous Part D “doughnut hole.”

Yeah, you say, but at what cost? Turns out, less than government was paying before:

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The second article of interest is a “fact check” on a statement President Obama made while celebrating the anniversary of the signing of the bill:

The Affordable Care Act is “a major reason why we’ve seen 50,000 fewer preventable patient deaths in hospitals.”

To make a long story short, the answer is that this statement is correct and is the consequence of the improvements in quality dictated by the ACA.

The question has to be why only a 41% approval after 5 years when it is reducing costs and improving quality? Maybe people are disappointed that the death panels are working in reverse?

26%/12%: Percentages of Republicans and Democrats, respectively, who said in March 2015 that an ACA government panel helps make decisions about patients’ end-of-life care. As in a “death panel.”

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“As you may know, a health reform bill was signed into law in 2010. Given what you know about the health reform law, do you have a generally favorable or generally unfavorable opinion of it?” (Kaiser Family Foundation tracking poll question)

The Affordable Care Act was signed into law in 2010. Most of its controversial provisions were delayed for 2-4 years, partly to allow the taxes to pay for the subsidies to ramp up and partly, I suspect, to put some distance between the passage of the law and the reelection of the lawmakers. The distance aspect was not nearly as successful as it could have been, as many folks developed a deep and persistent hatred for the law. Kaiser Family Foundation, a non-partisan group focused on health care access, has tracked public opinion since the law was signed. In April 2010, 46% of Americans viewed the law favorably, 42% unfavorably and 14% had no opinion. In March 2015, favorables have gone down to 41% and unfavorables have stayed roughly the same. In other words, opinion has not changed much in the past 5 years.

Part of the reason that people are ambivalent is that until they approach mid-life, their interactions with the health care system are limited. Half of all Americans spend less than $300 annually on health care. Basically, some folks may have noticed that their contraceptive method was a little cheaper (thanks, Obama) and some may have noticed a higher co-pay for their once a year visit for allergy symptoms (thanks A LOT, Obama). Once people hit 65, they are in the Medicare system. This system is being affected by changes in care delivery but not in a way noticeable to the average consumer. Even so, 46% of those over 65 view the law in an unfavorable light. (What, Medicare doesn’t pay for Viagra? THANKS FOR NOTHING, Obama).

Many changes in health care were put into motion prior to the passage of the ACA. These include efforts to improve Medicare quality (Bush), improved access through better funded community health centers (Clinton, Bush) and money for better health care information technology (Obama). With the ramp up to ObamaCare being several years, almost anything that folks notice that is different from when they previously sought care (What, no cough syrup for babies anymore? Damn you Obama!!!) is blamed on Obama.

This brings me to the story of my friend, John Waits. He is a rural family physician who lives in Centreville, Alabama. He has a wife, several (I believe 5) children, and a passion for rural medicine and for his adopted home town. I have known John for about 10 years, and he has consistently wanted to bring training to rural Alabama. Through a combination of a Bush administration program designed to improve access for the poor (expansion of community health centers) and a program included in the ACA designed to take money away from large hospitals and move it into communities where it can do the most good (Teaching Health Centers) he was able to do just that. Although the funding was through the ACA, the idea, like many included in the law, was much older and was a bipartisan idea.

The funding for the teaching health center side needs to be renewed, and so John has been speaking out a bit. Not calling attention to our lack of Medicaid expansion. Not calling attention to the fact that we only have one statewide insurer so no real competition. Simply asking our delegation to pull the Teaching Health Center idea from the ACA and make it a separate idea to allow him to continue to train doctors for rural Alabama, in rural Alabama. Al.com posted a nice story about it.

Someone forwarded me the story, so I sent John a congratulatory email: subject line, IGNORE THE COMMENTS. There are now 230 comments on the article at al.com. The commenters are projecting what they believe about the ACA onto poor John’s program, including at least one former patient who will not see him OR ANY DOCTOR whose boss is the “gummint.”

The lesson for all of us, I suppose, is to be like John and keep on trying to do the right thing. Read more about Teaching Health Centers (here is a place to start). Call your representative and ask for the Teaching Health Center program to be continued (it is currenty in the SGR repeal bill stalled in the Senate). Mostly, be like John and do the right thing even at some personal cost. And always: ignore the comments.

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Remember back in the 1990s? Clintons were in the White House. Bushes wanted to be in the White House. Health care reform was fresh on everyone’s mind. As the French say, plus ça change, plus c’est la même chose, I guess.

The care delivery reform vehicle of the 1990s was to be Health Maintenance Organizations. Not particularly liked by physicians, these were groups of physicians and non-physician providers (hospitals and other health care entities)  who were tied by a common goal of delivering quality care at low cost. The problem is the definition of quality on the part of the HMO (low use of services that were not proven to be effective) was not the same as that of the patient (immediate access to services felt to be necessary by a prudent lay person).

In 1998, 3200 graduates of US medical schools went into Family Medicine.

The HMO movement eventually receded, as a consequence of consumer and physician revolt, although some remained (Kaiser and Group Health Puget Sound are the most well known from that era). For most Americans in the ensuing years, health care consumption was considered a matter of personal choice and, as Americans, we opted for convenience and technology. Insurance companies obliged us by limiting out-of-pocket cost. One could eat at the health care buffet and it only cost a couple of dollars.

As  physicians, we opted to provide these services in as efficient a manner as possible, with this efficiency being manifest as immediate access for folks with insurance. What happened was fairly predictable. Physician salaries skyrocketed. Health care inflation soared. Consumption was increased in areas of surgical procedures and high cost medications. Use of opiates such as Lortab dramatically increased.  If the analogy was one of restaurant dining, it is as if everyone with insurance in America got a free dining card with unlimited dessert.

For those without insurance (about 15% of adults under 65), care was not readily accessible unless they had significant cash to spend. Their dining card allowed them to stand by the dumpsters and wait for table scraps.

In 2004, only 1100 US grads went into Family Medicine.

Medical students in this country started talking about the ROAD to success, getting a position in a Radiology, Ophthalmology, Anesthesia, or Dermatology residency. Relatively easy work, really high pay. The pastry chefs of medicine.

American medical school in 2006 stood ready to respond to this new market reality, as encapsulated in this report from the era. They recommended a strategy of increasing enrollment in medical schools by 30%, supporting it with evidence of an aging workforce and the fact that physicians were not located where they needed to be (areas of shortage). In addition, they pointed to increased demand for more convenient access by an aging population.

If you fill the bucket to overflowing, they figured, student physicians could not help but go to places of need and select specialties of need. The market would sort things out. The aging population would get the doctors they needed, more Americans could catch the brass ring of “my son/daughter the doctor,” and we could continue to allow the market to set the tone. Or, to use the restaurant analogy, everyone who wants to be a pastry chef can be, and certainly someone will want to clean the dishes.

Did it work? We have increased the number of medical students from 14,000 in 2006 (the year the AAMC decided that the answer was to increase the number of doctors) to 22,500, an increase of 66%. The number of positions offered for training after medical school has increased from 24,000 to 27,000. Of those new US grads, the number electing to do radiology is up 200% and anesthesia is up 300%, Physical medicine and rehabilitation (one of the “new road” specialties) is up 300%. Family medicine, the specialty that goes to rural areas, the most rapidly aging specialty—how are we doing? Up 20%. The rest of the Family Medicine training slots? Filled by folks who went to medical school  in other countries

American students, it seems, are betting that we as a country are going to continue to allow people to eat unlimited dessert and they all want to be the pastry chef. So much for allowing our country’s workforce policy to be set by 25 year-olds. Heck of a way to run a restaurant.

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Resident: Hey, I diagnosed a black child with thalassemia today

Attending: Oh, really

Resident: Yeah, the funny thing is it was picked up on the newborn screen. Child and parents are obviously of African-American decent. They are not aware of any Mediterranean ancestry.

Attending: And that’s why we shouldn’t take race too seriously when screening folks for disease.

Medical learners are taught from an early age to speak clinically in a very distinct language. We call the method of communication regarding patients a “presentation” and typically the pattern is age, race, sex presented with symptom constellation. The story then goes on to recount pertinent positive and negative information, past medical history, family history, social history, physical findings, and ends with the clinician identifying the diagnosis and plan. A lot of information is distilled to keep these presentations concise. The shorthand starts with the age (if the complaint is chest pain, heart attacks don’t occur in 14 year olds, for example) and sex is an important component (a man with “blood on underwear” has fewer moving parts “down there”). Race has always been included in the construct. What goes with race?

Unlike veterinarians, we physicians only have to deal with one species. I have to admit, I almost always assume the entitiy being presented by the learner is human. Having said that, within the homo sapien species there is a lot of genetic variation. If I know something about their family (the patient’s mother and father both have sickle cell trait) then I can draw a conclusion about the patient (this person has a 1 in 4 chance of having sickle cell disease). Otherwise, unrelated people have 3,000,000 distinct variations and people of the same “race” differ by as much as 85% from each other. What of the other 15%? Turns out less than half of it can be traced to similarities in skin color, hair form, and nose shape. In other words, what we see as commonalities that track together (skin, hair, and nose) are for the most part the only things that track together. Diseases tend not to cluster based on these, even less so given our current patterns of population movement. Biologists abandoned the construct of “race” for plants and animals a long time ago, because of a lack of utility. The concept of different races, itself, dates from the fifteenth century when, in response to the Catholic church‘s new “anti-enslavement of humans position,” King Alphonse of Portugal sent ships into Africa and found folks who spoke no European or Arabic tongue and had different skin, hair, and noses, so were obviously NOT human and therefore enslaveable in the eyes of the church.

The  problem with using (skin, hair, nose) to categorize people medically is that it misleads. A tragic example of this occurred in the south. Several physicians, including John Searcy of Mount Vernon Hospital in Alabama, noticed a cluster of folks with a distinctive skin rash beginning in 1906. Now known as pellagra and due to a deficiency of nicotinic acid in the corn-based diets of poor people (a byproduct of the introduction of modern agricultural methods to corn harvest), it was proven to be a consequence of poverty and inadequate nutrition by 1912. However, despite the elegant proof, the deaths continued because of the insistence of leaders in the field that it was clearly an inherited condition because it tended to run in poor black families. Coincidentally, so did poverty.

By continuing to include race on the front end we perpetuate the myth of causation instead of using it to identify groups that need special attention. Per the new England Journal:

It is indisputable that social perceptions of what a person is or is not influence the availability, delivery, and outcome of medical care. It is incontrovertible that these perceptions apply with dismaying regularity to black people and other minorities in the United States. And it is undeniable that lifestyle, socioeconomic status, and personal beliefs are powerful influences on health. But these are matters of morality and culture, and we must clearly distinguish them from the biologic aspects of race-based medicine — from the danger of attributing a therapeutic failure to the patient’s “race” instead of looking for the real reason.

When this article was written in 2001, there were 1300 articles published containing the search terms “Negroid race” in the previous two years. In what is clearly an improvement, there have only been 700 articles in the last two years,

What we know is that (skin, hair, and nose) is at best an incomplete marker for geographic genetic origin, which might be a useful clue for certain diseases. In this country, we know that it is a marker for poverty and oppression, which does seem to be correlated with disease. Instead of Black, White, Hispanic, maybe I’ll make the learner say something to the effect of “This 52 year old ‘manual laborer who lives in a bad neighborhood among drug dealers and has to sleep in his bath tub for fear of being shot accidentally’ female comes in for high blood pressure and headaches.” Too long?

S73

Childhood vaccines are one of the great triumphs of modern medicine. Indeed, parents  whose children are vaccinated no longer have to worry about their child’s death or disability from whooping cough, polio, diphtheria, hepatitis, or a host of other infections.
Ezekiel Emmanuel

If you give us a safe vaccine, we’ll use it. It shouldn’t be polio versus autism. Jenny McCarthy

One of the earliest choices parents have a chance to make is one of whether or not to have their child “get shots.” On day one of life, the medical system is mobilized to prevent Vitamin K deficiency bleeding and liver cancer in the child. For 90% of parents, the response is “Thank you.” For 10% (but a very vocal and increasingly evangelistic 10%) the answer is “could we wait a little while?

Why do they want the delay? Most blame it on a general distrust of the “medical-industrial” complex and a lot of conflicting (and overwhelmingly incorrect) data on the internet regarding vaccine safety. I suspect a large part of the problem is our inherent inability to work with probabilities to understand health risks.

First is our conviction that because we can see a relationship we can extrapolate a cause. Take polio and ice cream. Setting aside the crazies who deny that polio ever existed, there was a time (1952, to be specific) when 50,000 American children came down with paralytic polio. Several folks quickly identifies a striking relationship between ice cream sales and the peak of the polio epidemic. Ice cream was banned in several states before it was determined that summer was the common factor. It is flawed observations like this (leukemia and Vitamin K, autism and MMR vaccine) that have led to some of our problem. Oprah, in a nod to allowing personal observations to be treated as fact, brought on Jenny McCarthy and treated her as an expert on autism because she had “mommy instinct…. She knows what she’s talking about.”

Second, and perhaps more problematic, is our inability as physicians (and a society) to communicate the consequences of a delay. Vitamin K deficiency bleeding, for example, is only a problem very early in the infant’s life. Delaying the shot (only the shot is effective) beyond 2 months of age renders it worthless. You have already placed a bet on your child’s life (or at least risked his or her future ability to function), reducing his or her ability to pass kindergarten by 1:10,000. So what, you say? By making children get out of the pool when there is lightning over a lifetime, the risk of dying of a lightning strike is reduced by approximately the same amount (1:12,000). Why is this? I suspect the difference is folks see the damage lightning causes to trees and fuse boxes so the risk to them is much more real. Who knows, though, maybe there are anti-lightningers as well.

According to the article on vaccine delay, approximately 50% (9 minutes of the 18 minute visit) of the face-to-face time is spent discussing vaccination instead of other, more pressing issues of development and parenting. Brochures alone are not helpful in speeding up the discussion. What we as health professionals need to do is change the discussion. First, we need to be frank and truthful with the parent provide factual data and address the parent’s fears. Parents need to catalog their fears going in but need to be open minded to evidence that these fears are unfounded. Secondly, we need to address risk. Third, the use of motivational interview techniques might help clinicians to get patients to better verbalize their concern.

So, parents, you need to learn to be just as skeptical of the “interwebs” as you are of “big medicine.” Doctors, you need to understand that parents will do the right thing (witness the lack of anti-lightningers) but they gotta believe.

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