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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?

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.

toon840For those who watch professional football, there is nothing worse than seeing your team’s quarterback blindsided. A quarterback, for those who do not watch football, is the guy who takes the ball from the center and either hands it off to someone else, runs it himself, or passes it to a person down the field. He does this with about 1500 pounds of collective humanity chasing him. Quarterbacks tend to be runty by comparison (Johnny “Mr Football” Manziel, it turns out, is under 6 feet tall and weighs 207 in gym shorts) and when turned to their dominant side cannot see people coming from their other (blind) side. If two 300-pounders meet at the quarterback they can turn a hundred million dollar investment into just another confused short person, especially if the quarterback isn’t expecting it.

Football teams learned that having a good quarterback was good, and good protection was better. Left tackles, the 300-pound dudes who keep the other guys’ 300 pound dudes off the quarterback, have quietly become among the highest paid ball players in the NFL, second only to the quarterbacks. Part of the reason is that the number of 300-pound men who can run fast, have tremendous peripheral vision, are smart enough to understand an NFL playbook,  and can fight off other 300-pound men are few . The other part of the reason is that without one of those dudes, you are paying a confused short person a lot of money to run for his life in front of a lot of empty seats. It wasn’t until players renegotiated the collective bargaining contract and lineman were able to become free agents that the true value of a great left tackle (for a right handed quarterback) was realized.

As Uwe Rheinhart discussed several years back, we have yet to learn the value of left tackles in American medicine. Every medical student wants to be the star who gets to brag about the robotic surgery success in the doctor’s locker room after the game and collect the star’s paycheck (an consequence of our current payment system). Fewer want to be the primary care doctor, who facilitates collaboration, engages in  probing conversations with patients, and takes the myriad of small steps that avoid medical errors. The primary care doctors, the left tackles of medicine, were left behind by the payment structure.

What free agency did for fast, smart, 300-pound guys, health reform might do for primary care. By paying less for bad care (readmissions, excess test utilization) and more for good care (satisfied patients, meeting benchmarks for chronic illness care) Medicare might add value to the primary care visit. While primary care docs will likely never generate over $200 an hour in a fee-for-service world like our surgical and radiologist colleagues do, in the future we will add value to their care by reducing bad care and improving care within the system. By holding the system accountable, everyone working as a team will allow effective care delivery to happen. For some now, for others of us in the near future, more money will flow into systems that deliver better care.

Of course, as a healthcare left tackle, this may just be my fantasy. Some think that left tackles are over-rated. Perhaps we can have the line count 1001, 1002, 1003, 1004, 1005 before they run in. Then everyone could be a quarterback.

william-haefeli-if-you-bring-joy-and-enthusiasm-to-everything-you-do-people-will-think-y-new-yorker-cartoonI received the following comment to my previous post (which I have paraphrased some) and feel compelled to respond in depth:

I am a new 4th year medical student who entered medical school to become a Family Physician. However, the challenges facing family medicine give me great concern and I was wondering if I could get feedback on a few of these concerns.

(1) The Turf War between Nurse Practitioners and Family Physicians.

It seems to me that Family Physicians are treating only a fraction of disease entities that comprise the requirement for licensure and graduation from medical school. From what I have seen Family Physicians are not even reading EKGs and require a cardiologist.

To me, this creates a opportunity for the nurse practitioner to boldly say they can function as family physicians – by addressing that small fraction of entities which makes up the current repertoire of FPs. 

Family physicians need to be vocal about what their training and expertise bring to the table. Most of the noise regarding nurse practitioners and physicians assistants becoming the primary care provider of choice is just that, noise (go to this link for more details). First, as Bob Bowman I’m sure will elaborate, the workforce and work product from these types of providers has not been shown to provide for the needs of our country.  Every other country uses generalist physicians to lead the primary care team. The move to exclusive use of these providers for primary care would be yet another natural experiment in health policy for our country should we chose to go in that direction. The ones to date have not been shown to lead to better quality, less cost, or better health for Americans. We are now in the process of transitioning to the Patient Centered Medical Home team based approach to care in this country. The team will almost certainly include other providers and I would argue we need to be more expansive and include pharmacists and care managers as part of the team. Yes, Family Physicians need to maintain core skills but in our 11 years of training (as compared to 5-7 for PAs and NPs) and 21,700 hours of clinical training (as compared to 5350) we learn how to provide the first contact care that Americans need. As we transition it will be important for physicians to reacquire skills that may have atrophied as they focused on acute, self-limited illness care (which is likely more suited to care in a collaborative fashion by a PA or NP).

(2) The huge number of referrals from a family physician also results in disrespect from the medical and patient community.

– Examples include dermatology, minor procedures, ophthalmology referral for a retina screening 

Family physicians have been trapped in a world where they were seeing patients every 7 minutes, which is untenable. This was an artifact of our payment structure which valued volume over value and encouraged physicians in some settings to refer rather than perform many services they were trained to do. As payment methods change, chronic illness care is valued, and patient satisfaction is measured to reflect the skill and care of the physician, this will change. You need to learn how to perform procedures skillfully while being cognizant of your limits. Realize also that in academic settings referrals are made often for political reasons and do not reflect the scope of practice that physicians can enjoy away from the academic health center. The following is from an open letter to new graduates after the question was raised in one of our journals several years back

Avoid the temptation to limit voluntarily the things you do simply because the subspecialist does it better or more frequently. Your patients want and need you to do all that you can for them, not for you to be a speed bump on their road to care. If your consultants do not respect you enough to return your patients after answering the question you asked, find other consultants. Their role is to answer a question or perform a procedure you choose not to perform, not to expound on their superiority in some field or another. Your job is to take care of your patients, not to make the limited practitioners feel better about themselves.

(3) The future of Family Medicine :
I believe, that if Family Physicians continue to practice in this manner of treating only a fraction of what they know how to treat, within the next 10 years no one will go into family medicine…. Right now the numbers going into family medicine ranges below 10% at the “top schools”.

I believe that medicine is changing. Our specialty went through a thought exercise about 10 years ago now and put out a series of articles regarding where the specialty needed to go called, ironically, “The Future of Family Medicine.” Our Academy has taken up the mantle and provides information for students such as yourself here. The future of all health care in this country is a team approach to care with a focus on improving the health of the population at a high quality and lower cost. Family physicians have been shown to do just that. We have taken the principals developed in the Future of Family Medicine project and, working with the American Academy of Pediatrics, American College of Physicians, and the American Osteopathic Association among others, embraced the Joint Principals which led to the Patient Centered Medical Home (more information found here)

(4) Also can Family Medicine training agree to evolve the services of a Family Physician? Or is the plan to stay the same?

If only a minority of Family Physicians take the lead in providing full-spectrum services while the vast majority treat a fraction of what they were taught to treat – there will be nothing to distinguish their service from the one provided by the nurse practitioner.

Family medicine (and all residency training) programs are dynamic processes. About 70% of the curriculum is proscribed by the governing body, the Residency Review Committee. This curriculum is reviewed about every 5 years and another review is due out any day now. It is anticipated that there will be major changes in training requirements to reflect the changing needs of our health care system. We are already training our physicians to be leaders of the care team, knowledgeable about chronic illness care, and able to care for all patients as a physician of first contact. I anticipate that this is the direction training will take. In addition, 30% of the curriculum can be set by the program to reflect local strengths and all of the curriculum acquires a local flavor. Our program, for example, has a strong underserved component. Our patients cannot get in to see a dermatologist closer than 4 hours away (an insurmountable barrier to those with poor transportation). As a consequence we are very good at managing diseases of the skin without a dermatologist. Programs in the west offer a lot of OB. I would encourage you to look at the 400 family medicine programs in the country and find one that offers training you find appealing. My experience in training residents who have taken positions everywhere from rural Alabama to Alaska tells me you will find a practice that will value your skill set.

Good luck with your decision. I hope that others will pitch in their two cents about “Why Family Medicine” as well because people like you are our future.

11046819There was another article on NPR this morning about Brad Duke. For those of you whose memory of current events is slipping (I didn’t remember him either) he was the Powerball gazillionaire from 2005. Well, not a gazillionaire but a $225 millionaire. In this follow-up he seemed like a very nice young man, the kind I would want my daughter to marry (well, the cash WOULD be a plus). He lives modestly, manages his money well, and in general he is doing quite well. He told interesting stories of all of the people who tried to separate him from his money. In the story, an interesting fact came out. It seems that 70% of Lotto winners who win over $10,000,000 will be broke in a couple of years. Advice to lottery winners from financial planners: Don’t forget who you are.

Lottery winners and students who have made it into medical school have a lot in common. Many really good students are strongly encouraged to buy a ticket in the pre-medical school lottery. I suspect the enticement of money doesn’t hurt. Preparation for the required entrance testing begins before high school. Failure to perform well on one of the pre-admission tests results in disqualification. Once accepted into a pre-professional college curriculum, a single bad semester will result in disqualification. Though not as bad as the odds of winning the lottery, not great odds.

The acceptance to medical school is the winning ticket. Those who are successful in obtaining entrance into medical school have a 98% chance of becoming a physician. They are exposed to multiple strong role models throughout their medical training. Though they will likely say in the admissions interview “I like science and I want to help people” the evidence shows that are they will pick a career based on projected income, and perceived specialty status (the higher the better) when making their final career selection.

While our students may have won the lottery, Alabama has not.  Of our 67 counties, 60 of them have insufficient primary care. An additional 128 primary care physicians are needed now to relieve the existing shortage and over 400 are needed now just to provide optimal care. Given that the average age of the primary care physicians in Alabama is 50, we need our own lottery ticket and creating medical schools is not it. 86% of the students in our medical schools are Alabama residents but only 14% of these students come from rural Alabama. The results of the most recent “match” provide evidence that the existence of these medical schools is insufficient to respond to this crisis. UAB, the largest of the allopathic medical schools in Alabama,  put 12 students from a class of 200 (7%) into family medicine. Although 35 students were placed into Internal Medicine, the literature suggests that at most 8 of those will specialize in primary care. South Alabama, with a class size of 77, put 7 (10%) into family medicine and 21 into internal medicine. Based on projections, 4 of these IM residents will go into primary care. Given these numbers, best case scenario is that 28 graduates of the allopathic medical schools in Alabama will provide primary care. This is well under half of the projected need. In addition, 50% of these  medical students will leave the state upon graduation, presumably including at least some of students choosing primary care.

So what do we do? First, we need to stop treating medical school admission like winning the lottery. As my friend  Josh Freeman points out, we are lottery winners because we physicians have rigged the game. This needs to change. Secondly we need to rig the game to make sure the right people get a winning ticket. We know that it is possible to select students who are much more likely to seek out primary care and rural practice. Students are more likely to return to a community of the size they were reared in. Students who attend osteopathic schools are more likely to practice primary care upon completion of their studies. Students who attend a small college are more likely to practice primary care. Students with a spouse from a rural area are more likely to return to a rural area. These folks, if qualified, deserve a ticket. Lastly, a grown-up somewhere needs to take control of how many and what kind of doctors come out of the residency end of the pipeline?

As it stands now, the lowest paid physician is in the top 3% of all wage earners. Can’t we find people who consider this a winning ticket?

colonoscopy5Student (to friend while walking to hotel): All of these programs compete on the number of procedures they claim to teach. I don’t see how you have time to learn all of that in a three year residency. They are going to have to go to four years, like Med-Peds.

I spent a couple of days with our team in Kansas City at the National Conference of Family Medicine Residents and Medical Students this past week, as I do every year. We sat in a booth and interacted with young physicians-to-be who were looking for residency training information as well as information regarding Mobile (our fair city) Alabama. We did not discuss the upcoming mayor’s race  but instead talked about what we thought would attract young people (mostly the beach). All residency programs in Family Medicine are required to have about 27 of the 36 months in common. The 300 or so programs that also had booths at this conference  were also trying to show their programs’ differences in the best light possible. Thus, the emphasis on teaching procedures such as colonoscopy.

Medical students apply to medical school with surprisingly little knowledge of what the future will hold in the way of medical practice. They enter medical school, for the most part, secure that they are very smart, enjoy science, and (as they invariably will tell me when asked) “want to help people.” The initial medical school experience is rather generic and very few students enter into it knowing what kind of a doctor they want to be when they grow up. My experience, back up with some data, is that potential income plays a large role in student career choice when they start paying attention to the residency selection selection process. Thus the emphasis on teaching procedures.

Forever, doctors and medical students have liked performing procedures. Partly, this the nature of the job. Allopathy (also known as heroic medicine), the lineage from which the M. D. degree was derived in the early 1800s, emphasized purging, blood letting, and other very aggressive manners of curing illness. Partly this is the nature of students. Liking science and wanting to help people goes hand in hand with “doing stuff to people.” We on admissions committees don’t look for shrinking violets. Partly, as was recently pointed out in the Washington Post, doing stuff to people pays more per hour than not doing stuff. A LOT more. The American Medical Association has been entrusted since 1965 to give Medicare time estimates on how long a procedure should take. Medicare uses that information to set the reimbursement rates which end up being the standard by which every insurance company sets rates.  The Post’s investigation revealed that the time component was overestimated by 100% in some cases. Meaning that physicians who do a lot of procedures are packing into 8 hours what Medicare considers to be 26 hours worth of work. The payment follows. Thus the emphasis on teaching procedures.

We spend twice as much on healthcare in this country than the average industrialized country and though we get more stuff done to us we do not live as long nor find ourselves healthier (in fact we find ourselves less healthy) than our peer countries. Our program is teaching the tenets of the Patient Centered Medical Home, emphasizing care that is of high quality, evidence based, and focused on the patient needs as opposed to income generating. These concepts and skills we can teach in 3 years. Although, I will admit, we do teach our share of procedures.

I am hopeful that the price we pay as a country for “procedures” will become less over time. I am also hopeful we will select students who really want to improve people’s lives. It turns out that high quality primary care often improves health much more than a procedure does.

al-ross-is-there-a-doctor-in-the-house-that-s-the-call-harold-s-been-waiting-new-yorker-cartoonMedical students no longer dissect a cadaver in most medical schools. After hours call, or working outside of regular work hours to provide care to hospitalized patients needing assistance, is rapidly becoming an anachronism as well. Teaching hospitals used to use residents and students in lieu of hiring physicians to work at night. The learners would take care of sick people at night and in exchange teaching would occur during the day. One attending I had fond memories of his call days as an intern, sitting at the nurses station playing the guitar.

When I was in medical school, call was busy. The medical student would be expected (at least at Tulane in the 1980s) to come into work at Zero dark thirty and work all day taking care of the daytime patients. When the day’s clinical duties were winding down, the student who was on call would find the resident that was on call (protocol varied from service to service) and get “sign-out,”  or in other words find out what tasks needed to be done between now and 0 dark thirty tomorrow. The time that sign-out occurred varied depending on the speed of the clinical team you were on as well as the willingness of the other team to accept sign-out. You might be finished by four but if the on-call team wasn’t ready for you, tough. The feeling was that you were responsible for your patients 24/7/365 and the privilege of sign-out could only be enjoyed if both parties were ready. I remember several nights when I was not on call but was not afforded the luxury of sign-out until 8 pm or later.

The job of the person on call was to work-up all of the new admissions as well as take care of the work that was left over from the folks who signed out. Oh yeah, there was nobody to draw blood, transport the patients to x-ray, or any other menial tasks. Oh yeah, and no radiologists, either.

Resident: Take the new admission up to CT, he’s still not right and I don’t think we can wait until morning. After you drop him off go run this blood to the lab and tell them we need it STAT! Then go find an endotracheal tube. We’re going to have to intubate.

Me: On my way

Me, to CT tech: I’m leaving this guy here and going get some stuff. He needs a CT without contrast. Yes I paged my attending (a white lie) and he says we need it. Page me if he stops breathing.

Me, to lab clerk: We need this STAT

Lab clerk: The tech is on break, feel free to run it yourself (which we actually did at Charity)

Me to central supply clerk: I need a number 7.5 ET tube

Bored clerk: It’s in the back somewhere, knock yourself out.

After a night of admitting sick people, running labs, gathering equipment, and in general feeling useful, we (after, as Doctor Eaton points out in the comments, “morning report” where the attending would grill us for not knowing what we were doing) then had to work the next day until “sign-out.” The difference being that as the off-coming team we got to sign-out first.

This was the job of residents and students because, as we used to say at Tulane, calling an attending after hours was a “sign of weakness.”

At least that is the way it seems in my 30 year old memories. In actuality, what I remember is being bone tired, being scared to death that I wasn’t doing the right thing by the patient, but living with the certainty that late in the night New Orleans in the 1980s I was the best shot for these folks to get better because the alternative was death on the streets.

Today, the trends that led to my bad call nights have accelerated. Hospitalizations are much shorter (Average length of stay 11 days for hospitalized Medicare patients in 1980, 5.7 days today) and patients are much sicker (50% of hospitalized Medicare patients are obese up from 25% in 1980, over half have over 2 chronic conditions, and almost 1 in 5 are on dialysis).  Consequently, the world of hospital call (and medicine) has changed. Medical students and residents are only allowed to work 80 hours in a week, and if they are working a 24 hour shift they must be allowed to “strategically nap.” Sign-out is now termed Check-Out and is much more formalized. The expectation is that, though the patient has a primary physician, a team will see the patient through the hospitalization. That team includes physicians, nurses, techs, and others whose job it is to get the person healthy enough to leave the hospital as soon as possible. Many times check-out is to a night float resident (and a night float attending) who only work from 7pm to 7am.

We are still working through some kinks such as how best to handle the hand-offs. Despite these challenges, I believe that teaching hospitals are almost certainly much safer today as a result of the changes.

images (1)Last night I was at a local pub listening to a band when suddenly everyone’s eyes were drawn to the television over my head. Straining to look around and see what had happened (another airplane crash, Lance Armstrong caught doping as a spectator in the Tour de France?) I read that a verdict was in regarding the death of Trayvon Martin. As the “Not Guilty” verdict was read, the crowd seemed relieved that the shooter would walk away (though civil proceedings will almost certainly follow). I must admit, I have not been following the trial. To me the entire episode was a tragedy.

As we were walking home, we ran into a neighbor and fell into conversation about the events. My wife, who followed the story, pointed out that the shooter was not participating in a neighborhood watch event but was going to the local “big box” to purchase groceries with HIS GUN IN HIS POCKET when he stopped to follow a “suspicious character.” Made me wonder how many of my neighbors are packing heat and why would they feel compelled to do so.

In my home town of Baton Rouge, Louisiana in 1992, Japanese exchange student Yoshihiro Hattori was going to a party and knocked on the wrong door. Mistaken for a burglar intent on home invasion (he was dressed in a tuxedo recreating John Travolta’s look in Saturday Night Fever) and not understanding the meaning of the word “Freeze” in the context of potential victim-of-gun-violence lingo he was shot and killed by the home owner. The home owner was charged with manslaughter and later acquitted with the court identifying that the shooter had a right to use lethal force to “protect himself.”.  In 2005 there were 30694 people who died of gun violence. When a gun is pointed at a person and the trigger is pulled, about 1 in 3 people with die prior to reaching  the hospital. Since the death of Yoshihiro, laws have been changed. in 35 states anyone requesting a concealed carry permit must be given a permit. In 2 states, no permit is needed. In my home state of Louisiana, where the gun laws were “liberalized” after this shooting, about one in every 10000 people can expect to die from a gun shot. Half of these from their own hand.

So, what should my response as a medical educator be? Gun violence is a serious public health issue. It costs about $2 billion in direct costs, and because it overwhelmingly affects young people, there are about $100 billion in indirect costs (loss of future productivity, health care costs for the rest of their lives, etc.). How should we as physicians and educators be involved in the prevention of this often needless tragedy?

First, as with any complex illness we need to be aware who is really at risk and target those people. The belief in our society is that personal risk of violence at the hands of a stranger is great and mitigated by the presence of a gun. Unfortunately, research on gun violence is sketchy at best. Recently, the Robert Wood Johnson foundation published the findings of Andrew Papachristos on their website. He found that a lot of the potential victims (41%) come from a very small circle of people at risk (about 4% ) in a given community. Many of our Academic Health Centers sit in these at risk neighborhoods (and have benefited from caring for trauma victims). Based on this, those of us interested in teaching prevention should be promoting our Academic Health Center’s involvement in these high risk communities through partnering with community organizations.

Second, we need to teach our learners how to preach gun safety. A gun in the home is associated with violence to the people living in the home. About 25% of households report having a handgun (and there are guns enough for almost every citizen already in circulation in this country). These guns should be locked up, especially when there are children in the house. In one of the few studies done of trauma center workers (in Birmingham in 1994) 33% of those with children (who presumably knew better) did not keep the weapons properly stored.

Third, we need to understand and teach risk assessment. Our well child form has a question regarding guns in the home which we ask all parents. If the answer is “yes, there are guns in the home” there is then a prompt that directs us to ask about storage and safety methods. This is because, though patients perceive the societal risk to be great, we need to understand and preach that societal risk is small and localized. The greater risk when a gun is present is to a family member or a stranger that happens to get in the way. For us to convince our patients of that we need to understand and believe it ourselves.

Fourth, we need to fight against willful ignorance. In Florida, where the Trayvon Martin was shot, a law was passed (later blocked) barring physicians from asking about weapons in the home. It is important for health care professionals to be clear and of one voice, the opportunity for gun violence is lessened greatly when there are NO guns in the home and lessened when the guns that are there are stored safely.

imagesMy training was interrupted by my military service. As the saying goes, don’t cry for me. I knew I would have to leave my training program in Internal Medicine after the first year  because the Navy pretty much insisted that all of us “go to the fleet” before beginning our second year. A buddy of mine and I, after looking into where the jobs might be, elected to enter into the Submarine Navy and became Diving Medical Officers and eventually Qualified in Submarines. I ended up completing my military career (the last 3 years of my 5 year commitment) in a half time clinical-half time diving billet (military for a job) in Kaneohe, Hawaii. This happened to occur during Desert Storm so I proudly tell people who don’t know me very well that 40 years after my dad’s generation I successfully helped  keep Pearl Harbor from falling to the Iraqis.

When I arrived in Kaneohe, I found out that half of my time was to be spent providing primary care, mostly to the wives and children of the Marines. I was given two exam rooms, an office, and a prescription pad. I quickly found I was suited for the job, able to see the relatively healthy patients in the 20 minutes allocated efficiently and provide care that was appreciated (based on the satisfaction surveys, at least). I also learned a lot about myself.

I knew I was only there for 3 years and would have to find residency to complete if I wanted to move from the Navy into the “real world.” I had completed a year of Internal Medicine, so strongly considered completing the final two years of this residency. The nurses I worked with urged me to consider Family Medicine (my ultimate specialty choice) because of my winning personality. On a busy day I would end up seeing about 24 patients. At the end of those days, my feet hurt. Moving from room to room in regulation Navy shoes was hard on the arches. In our clinic we had an x-ray machine that we could use every day but only had a radiologist once a week. This was before electrons could be sent all over the world so we had to read out own x-rays 4 out of 5 days. On the day the radiologist was there, he would “over-read” the films and if I missed something I would have to call the patient and explain that I needed the patient to return for another film, go to the Army Hospital for ongoing care, or find out if they had died from my miss. I became quite good at reading films and on those days my feet hurt would think to myself, “If I were a radiologist, I would get $75 a film for showing up once a week, sitting down in a chair in a dark room, and second guessing the primary care doc.”

I thought about those days this past week-end as I was speaking about a career in Family Medicine to 33 medical students at the Alabama Academy of Family Medicine. These were medical students who want to be someone’s doctor. They asked me very good questions and indulged me by listening to my Kaneohe stories. Though my feet sometimes still hurt at the end of a full day of patient care (I wear much more comfortable shoes now) I was able to recommend the specialty without reservation. Not only are they going to be much more in demand than their radiology colleagues (see this New York Times article for details) but their care will result in a measurable improvement in the health of Alabamians. My advice to them was to wear comfortable shoes.

imagesThe physicians had a special relationship back in the pre-forties. They were respected by the entire community; the were looked upon as gods in their own rank.

Chandler Bramlett at age 74, as quoted in Health Care in Mobile: An Oral History of the 1940s

The Alabama Academy of Family Physicians flew me to Washington DC last week to represent the interests of family docs to our congressional delegation. I have been up to the Hill several times representing the interests of my rural colleagues, but this was the first time I was exclusively representing physicians. When you are representing all of rural Alabama’s health care needs, people tend to give you a lot of respect. When you are representing the economic interests of a group of people who, although relatively underpaid, still make in the top 3% of Americans and the top 1% of Alabamians, respect is not nearly as forthcoming.

I had the privilege of having John Waits as the other half of the small Alabama delegation. John is a family physician in Centreville, Alabama, who has established an FQHC and is in the process of using the Teaching Health Center mechanism to bring family medicine training to his small town with the first class starting this year.

The five-year, $230 million Teaching Health Center Graduate Medical Education (THCGME) program is designed to boost the number of primary care residents trained in teaching health centers (THCs), which are community-based ambulatory care centers that operate a primary care residency program.

Unlike Medicare GME funding, which goes mostly to hospitals, THCGME funding goes directly to community-based sites. The funding is tied to specific health care workforce goals, and THCs must report annually on the types of primary care training programs offered, the number of resident positions, and the number of residency graduates who care for vulnerable populations in underserved areas.

That’s the good news. The bad news:

One area of concern, however, is the funding uncertainty for the future of the program…. The THCGME program is funded only through 2015, which creates a challenge for the THCs…. Unless Congress provides additional funding for 2016 and beyond, THCs may have residents in the middle of their training without THCGME payments to support them.

It was this message we chose to bring to our delegation, asking them to help us make a difference.

We were doing OK with our message except for two little roadblocks. The first, especially problematic for our deeply Red delegation, is how the program got its start. It was included in the Affordable Care Act. Given that we were there on a Wednesday and the vote scheduled for Thursday was REPEAL OBAMACARE (which won 229-195 on a partisan vote), no one in our delegation could see a way to supporting a part of a law which was described this way by one physician congressman:  “Obamacare is terminally sick and we need to call the time of death.”

The second obstacle was, well, the physician congressmen. While Alabama has no physician members, our delegation tended to defer health issue specifics to a group referred to as the “Doc Caucus.” Formally known as the Republican Doctors Caucus, it was formed by Republican House physician members and includes all 15 GOP physician members as well as a psychologist, two dentists, and three nurses. Their issues (from their website) include: Repeal ObamaCare and end federal government’s involvement in healthcare; Encourage (but not mandate) state based high risk pools; Encourage (but not mandate) adoption of Electronic Health Records; Tort reform; Medicare and Medicaid reform (through competition and the repeal of the IPAB); Allow health insurance to be purchased across state lines (not through the exchanges in ObamaCare); Transparency of quality data (different than what was in ObamaCare or outlined by Dr Berwick while he was at CMS); Fix the sustainable growth rate.

Rather than move backwards, I would encourage them to listen to one of their former colleagues, Bill Frist, and consider using the Affordable Care Act to effect change by fixing the payment system:

“We are convinced that reforming our nation’s health care system to prioritize quality and value over volume will not only improve health outcomes and the patient experience, but also constrain costs and produce systemwide savings.”

“Care is organized around what the patient needs, not around what is expedient for an individual provider,” says the report. “Information, such as lab tests, referrals, notes and updated medication lists, is shared seamlessly among health care professionals without the need for patients to intervene.”

Maybe the American public should get to be the gods for a change.






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