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My, how time flies when you are having fun. As president of our national organization of Family Medicine Department chairs, I had the opportunity to lead our group in a discussion regarding the response to Covid-19. As a work product (a great meeting BINGO word) we created a to do list for America (found here). We are now 3 weeks, 500,000 cases, and 20,000 additional deaths from the publication of this work product. How did we do?

  1. 4 week shelter in place order for all jurisdictions – as of April 7th, at least 316 million people in at least 42 statesthree countiesnine citiesthe District of Columbia and Puerto Rico are being urged to stay home. This is up from 9 states on March 23. While correlation does not prove causality, at least we were on the leading edge of recommendations. It is believed that this action saved (or will save) over a million lives in this country.
  2. Training and deploying a cadre of individuals capable of contact tracing and dramatically increasing access to testing – This will be vital to the SUCCESSFUL reopening of the country. As of today we have tested 3,000,000 Americans over the course of the outbreak. While a big number, in a country of 325 million people, not so many. We need to test close to 2,000,000 folks PER WEEK. We need to test people who have fevers. We need to test people who have been with someone with a fever. We need to test people who work in nursing homes. We also need to, once we find a positive, go and make sure that they are quarantined AND THEN TEST THEIR CONTACTS. This is a skill set that many in public health have allowed to atrophy since infectious disease became unsexy. If we were good at this, syphilis would not be a problem. For Covid control if we were to open the country, everybody would need to be tested approximately every 2 weeks with adequate investigators for the positives.
  3. Adequate personal protective equipment. – As someone who trains medical learners, this is near and dear to my heart. It is unclear how many health care workers, first responders, even grocery workers have been infected in their line of work. This is due to a broken supply chain, inadequate planning, and an inability to plan for the “unthinkable.” The CDC, on April 3rd, issued guidance on reusing “single use” equipment, One can only hope that we are working to adequately protect our health care workers. While there are many feel good stories about folks repurposing their plants to make eye protectors, there are many more about the lack of PPE and the fear that care delivery workers carry home with them.

So, now what? Hopefully we will continue to shelter in place, obtain testing and case finding to allow us to open the country, and obtain adequate PPE to protect vital workers. Fact is, Covid-19 is a disease that has no effective treatment and when fully manifested does not respond well to supportive care. It kills very few people in their 30s, more in their 40s, and so on until the population gets to be around 80, where 20% of those who develop an infection will die. For most of these older folks, besides protecting them from the virus we cannot alter the course of the disease

What can we do? To quote one of America’s great physicians, Sir William quote Osler, “Ask not what disease the person has, but rather what person the disease has”. The reality is we as caregivers are back in the era of “The Doctor.” I took some time today to read the bio’s of the Covid victims and I recommend you all do the same. Honor the victims. Let’s take some time to remember the people we care for, despite the isolation.

This is not about an invisible enemy except in that if you remain isolated you will not encounter it. This is about an insidious disease that is brought to our patients because of the efficient way we care for them (nursing homes, group homes), the way we ask them to work (low wages, no health insurance, limited childcare, no sick leave), and the limited information we give them (let’s reopen the economy). We need to fight THOSE enemies.

 

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The group of academic family physicians that I have the honor of leading this year have found themselves in the midst of a Covid 19 outbreak. Representing all 50 states, these academic leaders are working in some of the largest, most modern academic health centers in the world. Academic health centers that, unfortunately, are not prepared for the challenge that is just now hitting the coasts but will soon spread across the country.

The preamble to this crisis goes back 30 years. As hospitals have tried to maximize their profits, they began using “just-in-time” inventory. Toyota, it turns out, does not have a warehouse for parts. Instead it gets the carburetor (or whatever parts cars have in them now) delivered at the exact moment the car rolls to that point on the assembly line. Hospitals began using the same, getting only the masks or other equipment they need for the next week from the plant (in China) rather that maintain a warehouse. Well, also only having enough hospital beds for people who need them. Toyota never needed to plan on all of America needing a car within the same 2 month period. Hospitals, turns out, also never planned for Americans to get sick all at once. Guess now we know.

We might have overcome the lack of protective gear except for one problem. If you are treating all of America for a virus that acts like 5 other viruses except it kills you, the only way to “not going to die” people from “just might die” people is by testing for the bad virus. If you know the patient has the bad virus, you can isolate him or her and protect the health care workers more accurately. America, with the best funded health systems in the world, botched the test.

If the country could have accurately tracked the spread of the virus, hospitals could have executed their pandemic plans, girding themselves by allocating treatment rooms, ordering extra supplies, tagging in personnel, or assigning specific facilities to deal with COVID-19 cases.

We have less protective equipment, fewer hospital beds, and more chronically ill people than Italy (7503 deaths to date, 743 last night) and Spain (3434 deaths to date, 514 last night). We did not spend the last year preparing for this surge and, by screwing up the testing, we probably have 200,000 infected people going around infecting others. If you look at the cities where things are bad, they are also cities where either lots of people live (New York, Los Angeles) or cities that had a lot of recent visitors from all over (Mardi Gras in New Orleans). It takes about 4 days to know if you are infected (with something….is it the flu? I just feel a little achy) and if you are going to get really sick it happens on about day 8. So now what?

  1. Sheltering in place. What we know is that if people who are infected limit themselves to limited contact with a small group people, the virus “dies out.” It takes enough time for the virus to finish with patient 0 (the first sick person) and the 2 other people who will likely get sick from that person as well. This virus is spread through coughing, sneezing, and otherwise having fluid spewed. 15 days is not nearly enough time to reduce the number of infected people. Even of only 5% of Americans get this virus (17,000,000) and 10% need intensive care we would need almost 1,000,000 ventilators. This is about 700,000 less than we have now. Without these ventilators people die, with them they live.
  2. Testing and contact tracing. Once we stop sheltering in place, the virus will still be with us. The countries that have successfully reopened have continued to test their populations and, once a positive is found, identified all of the folks they have come in contact with and placed them in “shelter in place” for 2 weeks as well. We not only have not invested in protective gear, we have not invested in this very basic public health workforce.
  3. Adequate personal protective equipment. 40% of those who became ill in China were associated with health care delivery, either as care providers or the families of care providers. Protecting health care workers is vital. Sending health care workers out to potentially die is unconscionable.

So, here we are. One choice is to shelter in place for the next month or three, put up with occasional outbreak which gets tamped down, and delay until a vaccine is developed. Another choice is to throw our hands in the air, declare this too hard, and sit back while 4,000,000 die a potentially preventable death. My colleagues and I believe the first choice is the only choice. Please discuss with the policymakers in your states.

edu93Charity Hospital in New Orleans was an incredible place for learning clinical medicine in the 1980s, a veritable clinical playground.  As a third year medical student I was required to do difficult blood draws, put in central lines, and other tasks after seeing someone else do one (the phrase is  “see one, do one, teach one”). In addition, I was called upon to write orders for antibiotics and do other “doctor” things which taught me responsibility, with my role increasing as I become more experienced. It was, however, a playground that was largely unsupervised.To say that supervision was limited was, well, charitable. We saw the attendings maybe once a week in the clinical wards. The residents were overwhelmed, leaving much of the work and the decision making to the medical students. As a student I grew up fast but often acted with little clinical seasoning and limited information.

Mostly what I remember is being scared that I would miss something. We had lectures in every clinical specialty but I remember them as being esoteric. at best. The Starling curve, while unquestionably amazing and unfailingly covered once a week, had little to do with what the Lasix dose should be in heart failure (for this particular drug the “Fat Man’s law” was much more useful). When I discovered the lectures were less useful than a work of fiction, I really panicked.

What did I use? For Internal Medicine, there were two great books. Harrison’s was written by a gentleman named Tinsley Harrison who had by that time made his way to UAB. Cecil’s was written by another guy (named Cecil, I believe). They covered the same material and were each over 1000 pages in length. I had classmates that read them both, in case there were discrepancies. The Washington Manual  was written by some residents at Washington University (St Louis). My attendings looked down on it because it was lacking the academic rigor of Harrison’s or Cecil’s. I found it very useful at 0:darkthirty with a sick patient and not much time. If we had time, we went to the library. There was a multi-volume set,  the Index Medicus, where one could look up a factoid using key words and track it to the source.

In addition, we used each other. We would ask each other  “Hey, what do you think about…” and reassure ourselves that whatever course we decided on was the best one. We would then get the opportunity to defend ourselves in the cold light of day, always being asked for our source of information. We never claimed our colleagues as the source.

Which brings us to yesterday. I was the attending (Attendings now round every day) and their was a question about optimum antibiotic selection for a neonate with a fever. No textbooks. No manuals. Cellphones and tablets came out, databases were consulted (along with Up To Date) and within 3 minutes an evidence based answer was obtained (in fact, I won the mad google prize by getting to it in 3 clicks). Patient received optimum treatment less than 3 minutes after the treatment course was decided.

From the literature, it was clear that the Cecil’s/Harrison’s/Index Medicus skills used in residency did not move with the physician to private practice but asking a colleagues (or drug reps) opinion did. I am hopeful that mad googling skills will.

 

 

 

'Ms. Smith, I have a meeting in ten minutes and I can't find my hidden agenda.'

Discussion in medical school admissions committee:

Colleague: So I asked him “just why do you think you want to be a doctor” and he said, “Oh, you know, I like science, want to help people , like to problem solve.”

Me: I just learned about a new term called “the consent agenda.” In a meeting, if there is stuff everyone agrees on, you put it on the agenda as “consent items.” Then, with no discussion it can pass and you can move on to discussing something germane. I propose we notify all students that love of science, helping people, and problem solving are consent items. Then, we need to find out, how does this person know they REALLY want to be a doctor?

I just learned about this web site called DOC. DOC stands for “Drop Out Club” and it exists to help people transition from clinical medicine into a non-clinical arena such as management or sales. On their web site they say that the “name reflects the sentiment at our original gathering that no clear support systems existed for the paths we were pursuing.”

The site has about 10,000 members, although some may be lurkers like me. The forum at the site is full of folks who feel like they have made a terrible mistake with their lives and are looking for a way out. Many are in residency with statements like “I look around and can’t see myself doing this for the rest of my life” predominating.

Physician career dissatisfaction is a real problem. About 400 physicians commit suicide each year. Suicide is the number 2 cause of death in medical students (following accidents, some of which are also likely suicide). This is thought to be a consequence of underdiagnosed depression, almost certainly made worse by a rapid and monumental debt accumulation. In addition, I will concede that a love of science, a desire to help people, and a joy of problem solving are all good attributes. Unfortunately, they are not sufficient to combat an inchoate  fear that you are 5 years and $300,000 into a terrible, terrible mistake.  And it starts early, also:

A study of all medical students in the United States found that about 49.6% of medical students met the criteria for burn out and 51.3% for depression. Trust me—it’s not all from studying, but from being treated like crap, feeling like we can never make a mistake or ask for help and wondering if anything we do will help to change the status quo or are we just cogs in a wheel trying to crush us.

Approximately 15 years ago, Don Berwick outlined the triple aim for improving healthcare in this country – enhancing patient experience, improving population health, and reducing costs. Tom Bodenheimer recently outlined a fourth aim – improving the work life of health care providers, including clinicians and staff. He identifies the following as some of six things we can do in primary care to keep our colleagues engaged and off the DOC website:

  • Reduce the burden on the physician through team documentation: An encouraging trend I have seen among pre-med students is their being engaged as scribes. This way they get to learn what it is really like to be a physician by being a part of the team and the physician gets to go home without having to do two hours worth of charting after dinner.

  • Expand roles allowing nurses and medical assistants to assume responsibility for preventive care and chronic care health coaching under physician-written standing orders. Things that are automated should happen automatically with the physician not being a barrier to good preventive care. We need to model this for students

  • Co-locate teams so that physicians work in the same space as their team members; this has been shown to increase efficiency and save 30 minutes of physician time per day. We have gotten rid of the office in our practice. The physician work space is a shared space where interaction can occur. It is really important to level the field.

  • To avoid shifting burnout from physicians to practice staff, ensure that staff who assume new responsibilities are well-trained and understand that they are contributing to the health of their patients and that unnecessary work is reengineered out of the practice. This holds true for student members of the team as well. They need to understand their role in care delivery as part of the stress of being a student is constantly being thrown into a new environment.

In short, what we as educators need to do is make sure students understand what they are getting themselves into and make sure they have the tools necessary to do the tasks they are assigned. What students need to do is look away from the books and understand that this is not about science or helping people but is about acquiring the skills to enter into a very difficult profession. While interviewing a residency candidate  for our residency it came out that she had been to cosmetology school and had cut hair at Walmart for 2 years. I asked her what the best thing she had learned from that experience was, and she said “When people sit down in that chair and say ‘do whatever you want,’ they don’t mean it.” I suspect she won’t burn out.

 

'Let's make a quick stop in Vegas and blame it on an unruly passenger.'

Last night we were at a dinner party where I met an honest to goodness professional poker player. I have to admit that I have never met someone who makes money off poker. Living close to Biloxi (home of several casinos) and knowing a lot of smart people I do know folks who count cards in blackjack. These people tend to be regular folks who can keep a running dialogue in their heads that goes something like +1, +1, -1, -1, +1, hit at 18. Folks who like to go to the casinos for entertainment and can count cards tend not to because it take all of the fun out of it. Folks who try to make a living by counting cards get found out and put on a “No Fly” list for gamblers mostly because the house resents them.

This professional gambler didn’t wear fancy clothes or a lot of jewelry. Turns out she could count cards and win at blackjack, but prefers poker because poker is a game of skill and the house tales a cut then lets players play (to coin a phrase). She is even better at online poker which is where my interest was piqued.

Me: So, I would think that on-line poker would be dominated by computers masquerading as real people

Poker-lady: Not so. Computers are actually not very good at poker.

Me: Really. But they are really good at chess

Poker-lady: Chess is a game where all of the elements are known. When a computer loses at chess it can go back and analyze every move, learning from its mistake and not making the same one again. In poker, there is too much uncertainty. The computer doesn’t know the opponents hole card or betting strategy. Computers don’t do well with uncertainty.

Turns out there is one bot (Cepheas) that is now able to hold its own in a type of poker (head-up limit Texas hold-em). This computer will play a single person (head up) and win money over time if the bet size is prescribed (limit). The computer is the work of AI investigators at the University of Alberta who, aside from trying to build their school’s endowment, are interested in solving the “imperfect information” game. Chess is an example of a perfect information game where all players have all information. In poker, everyone has limited information regarding their situation as well as their opponents’ situation. You know what your hole cards are but not your opponents’.

Doctoring, it turns out, is a game of imperfect information. I know what I have prescribed (medications, exercise, less calories) but have to ferret out what my opponent (patient) is holding (But doctor, when I said I only drink water, I meant to say a liter of soda pop. Does that make my sugars higher?). For years, programmers have tried to write code to do what I do and have been unsuccessful. The folks in Alberta are now working with diabetologists to create a program to help with diabetes:

“It turns out that one of the things a doctor does so well is come up with robust [recommendations] … And that’s what our poker programs have to do, they have to be robust to ‘what are the cards my opponent has, and how does my opponent play?’ ”

So, one day I might be able to use the wily computer to help me with my patient who “just can’t get controlled.” For most of my patients now, the flop is hypertension, diabetes, and hyperlipidemia, Until I get a bot, I’m assuming they have non-compliance and a lack of physical activity as their hole card. Does that make me a cardsharp?

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?

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.

'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.

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.

barbara-smaller-it-s-fine-to-discover-cures-but-remember-chronic-conditions-are-our-br-new-yorker-cartoon (1)Forever there has been a power struggle between the medical school faculty and physicians in the community. For those of you who are versed in House of God, the book about medical care in the early 1970s, attendings and residents at the House as well as the students who went to BMS (Best Medical School) would reference care delivered by LMDs. This term referred to “Local Medical Doctors,” known uniformly for taking crappy care of patients who were then transferred to the “House”  where life-saving intervention would occur. The protagonist soon realized that there was more to medical care then doing stuff to people, culminating in realizing the truth in Fat Man’s Rule 13 (THE DELIVERY OF GOOD MEDICAL CARE IS TO DO AS MUCH NOTHING AS POSSIBLE). In the 1970s, the reality is that physicians on medical school faculty tended to earn less, a LOT less, that the LMDs, may have adding to the tension.

Somewhere about 20 years ago, LMDs traded their label for another that was even more pejorative – PCP. The Primary Care Provider concept was created in part to reduce the confusion around training requirements of physicians (Family Medicine, Internal Medicine, Pediatrics) and non-physicians (Physicians Assistant, Advanced Practice Nurse) who might provide primary care to a given patient. Patients don’t use the term, PCPs find the term demeaning, and the term doesn’t really reflect the complexity of care delivery that happens in the primary care office. Teaching hospitals, though, became Academic Health Centers and were distinguished in part by their lack of PCPs as well as their lack of desire to train them. The Academic Health Center was home to Specialists.

It is now almost 40 years since House of God was published. Obamacare is the law of the land and  the law encourages the use of primary care. This is in part because the work of Barbara Starfield demonstrated that health care is just better when people have access to primary care, and in part because a lot of work was done to demonstrate that specific models which incorporate primary care lead to better health outcomes. Programs like the Massachusetts Blue Cross Alternative Quality Contract and truly integrated systems like Kaiser and Health Partners  led to better outcomes. The work on Patient Centered Medical Home initiatives led to this specific type of primary care being incorporated in the law as well. Good primary care, so the saying goes, will keep you healthy. If you happen to get sick, it will help keep your costs down by keeping you out of the hospital. If you happen to go to the hospital, it’ll keep you from being harmed and help maintain quality care.

This week, the Houses of God are fighting back against the LMDs. The University Healthsystem Consortium (the trade organization for Academic Health Centers) put out a video entitled Through the looking glass: a new perspective on population management. Their video tells us the following in convenient cartoon form: 1) Most people just randomly become ill so don’t need a specific LMDs but instead need access to a CVS with a nameless Pee Cee Peee (their pronunciation) sitting and waiting for you to show up (and perhaps willing to give you a Z-pak “to prevent pneumonia”).  Oh, yeah, and prevention is too expensive so let’s blow off trying to get people Pap smears and mammograms and focus on treatment. 2) If you are chronically ill or sick with a serious illness, you don’t need a Pee Cee Pee at all but a House of God led team of folks. According to the video, they are sitting on the steps of the House just waiting for you to show up. 3) If you suffer from an early chronic illness you might want a Pee Cee Pee, but only get one who has the number to a specialty hotline, just in case you need one of the specialists at the House. You know how those Pee Cee Pees are.

The UHC’s vision is a dystopian one where patients are taking ambulances to the Academic Health Center for their not-well-controlled diabetes because the local House of God is 2 hours away and the Pee Cee Pee is unqualified to administer insulin. The evidence they cite for the effectiveness of this model is dated and incorrect. I can only hope that the Academic Medical Centers and their research arm, UHC Research Institute (TM), have a better plan for survival before the next “House of God” is written without them.

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