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Two weeks ago today I lost my lovely wife.  Coronary atherosclerosis. That is what the death certificate says. My family and I have received an outpouring of love and heartfelt sympathy from our community of twenty-five years. We will never be able to repay their kindness.

Danielle was a craftsperson when it came to her writing. She would work for hours (or days) to express a thought or concept in just the right way. Medical writing was a mystery to her with its passive voice and weasel words. Early in my career I tried to enlist her help with one of my “scholarly” articles. We soon reached an agreement that I would write what I needed and she would pretend to read it once published and say “that’s nice dear.”

This blog was a collaboration and was different. Our attempt was to write it for a layperson with an interest in health care, a passion for doing the right thing, and a desire to connect the dots regarding the flaws in our care delivery system. If we succeeded it was because of her. If we failed, I take the blame. I only hope I can continue and not embarrass myself too much without her contributions.

Danielle was a healthy, fit, active women who unfortunately had a terrible predisposition to cardiac disease and no sensation of cardiac pain. In other words, no “warning signs.” She did not smoke, was not overweight, and ate mostly vegan. Her “coronary atherosclerosis” would have been as much of a surprise to her as it was to the rest of us. Here are my thoughts, at two weeks out:

  • Disease occurs randomly. Being adopted, she had limited knowledge of her family history.Had she known that that was a possibility, there are only a couple of things she could have done to change the outcome.This is true for many people who suffer from illness and disability. Victim blaming serves no purpose and is an incorrect response. This we all need to stop.
  • That being said, risk factor mitigation only makes good sense. Eat right (a diet low in fats and animal protein, high in fiber, and minimize processed components), exercise daily, avoid cigarette  smoke and alcohol in excess. While it didn’t save her life (nor any of us eventually) this type of living likely gave her 10-15 years she would not have had. And gave us that time as well. We all need to try and live in harmony with our bodies.  As a community we need to provide these opportunities.  Farmers’ markets, community gardens, and bike paths all contribute and should be supported.
  • Human connections are very important. What I learned of Danielle after her death was how important her friendship was to many people. I cannot count the number of people who have come up to me to say that at a vulnerable time she reached out and help him or her through the rough patches. As a primary care physician I am brought in at times of crisis. We need people like Danielle who will take an interest and have a serious discussion about concerns with folks who are vulnerable. Things like this prevent crisis. Please reach out to someone who seems distress and ask them what can be done to help them. While churches can serve that purpose, activities involving the arts, informal interactions within the community at open air markets and dog parks, for example, are where such interactions take place. As a community we need to build in these opportunities for casual interaction.
  • Illness, random or otherwise, in America is expensive with insurance and cost-prohibitive without it. We are very fortunate that we had health insurance through my employer and enough money to cover incidental costs.  Without insurance, the hospital would be able to put a lien on my house if I didn’t have the money. While the ACA is not perfect, it is what we have at this time. President Obama has made it so that, at least in those states that have expanded Medicaid, bankruptcy for medical bills is much less common. Please support the Medicaid expansion.

Enough rationality. For those who know us, I miss her every day in ways both big and small and I know you do as well. For those who did not have the opportunity, hug someone and go back to helping us continue the fight.

Aloha, Danielle.

 

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From the US Congress, 1837

Mr. L. insisted that the same reasons which had been urged by the gentleman from Louisiana (Mr. Johnson), in support of his amendment, applied with equal force to Mobile. That city was known to be increasing in population, wealth and business, with great rapidity. It was situated in a climate regarded as somewhat unhealthy at certain seasons, but its immense trade required the employment of seamen and boatmen at all seasons of the year, and if hospitals were to be provided for sick seamen and boatmen at the expense of the Government at any points, he regarded the southern cities as the places most entitled to notice. The amount he had proposed was small, and he hoped his amendment would not be rejected. The amendment prevailed without a division.

The last sentence seems sort of quaint today, doesn’t it. This was the discussion that ensued when the Marine Hospital in Mobile Alabama was funded in 1837. This bill funded hospitals in New Orleans, Mobile, Portland, Newport, and Wilmington, North Carolina, at a cost of $115,000 each.

Why were these hospitals needed? Most illness and death at the time was due to infectious disease. Most sick folks were treated in their homes;  physicians (or other healers) were in attendance, but the nursing was done by family members. In port cities, merchant seamen were necessary to transport goods  from America to Europe (here in Mobile, it was transporting cotton to Liverpool, England). To quote from the National Library of Medicine:

These seamen traveled widely, often became sick at sea, and then, away from their homes and families, could not find adequate health care in the port cities they visited or would overburden the meager public hospitals then in existence. Since they came from all the new states and former colonies, and could get sick anywhere, their health care became a national or Federal problem.

What began as a loose network of hospitals eventually became the US Public Health Service.

In the 1870s, when the Marine Hospital Service was federalized, the city of Mobile saw the need to provide these types of services for her citizens, and the Board of Health was created (by Alabama constitutional mandate). The duties included:

  • Examine all cases of malignant, pestilential, infectious, or epidemic disease
  • Exercise general supervision over sanitary regulation
  • Supervise all matters pertaining to quarantine
  • Supervise all measures of detention, disinfection, and purification of vessels from ports against which quarantine is proclaimed

The county health officer was employed by the Board to oversee the above. In addition, he was required to maintain vaccine and vaccinate all indigent people free of charge (that would be smallpox and rabies in 1873). He was also directed to maintain a dispensary where poor, sick people could receive care.

Fast forward to today. The traditional “health department” is performing roughly the same tasks as outlined in the 1870s, immunizations, control of infectious illnesses (in Mobile, mosquito control is a big part of this), and care of the  sick who happen to be poor. They are, it seems, victims of their own success. Malaria is unheard of in Mobile except when it arrives in a person who has traveled here with the parasite already incubating in his or her bloodstream. Vaccination has moved to the physician’s office with the Vaccines for Children program. Community Health Centers have taken over care of the poor sick. The public health focus needs to be on prevention and early detection of chronic illnesses. These account for 70% of American deaths and most of our disability. Many chronic illnesses are a consequence of tobacco use, poor diet, sedentary lifestyle, and risky behavior.

In Louisville, Kentucky, the “Board of Health” is now the Louisville Metro Department of Public Health and Wellness. Not only do they do they perform the traditional health department role but they

  • provide education regarding health behaviors that affect health, such as tobacco use
  • distribute condoms to prevent STIs
  • work to combat childhood obesity through physical activity
  • work to eliminate food deserts through food justice
  • sponsor a health equity speaker series

They do this in a belief that they can address the root causes of health disparities by supporting projects, policies and research working to change the correlation between health and longevity and socioeconomic status.

A far cry from running the quarantine station, is it not?

In this country we have had difficulty delivering basic health care to our citizens. We have had a larger problem delivering basic dental care to our citizens. We are almost unable to deliver mental health care given the constraints of the current system. Health insurance reform at this time will not provide the delivery system reform necessary to fix the oral health problem. It may provide resources that will help people get needed mental health care.

The Milbank Fund has published a report on mental health care delivery system transformation. In it they point out that the method of care delivery is important:

A comprehensive health care system must support mental health integration that treats the patient at the point of care where the patient is most comfortable and applies a patient-centered approach to treatment. Integration is also important for positively impacting disparities in health care in minority populations.

A 2008 report by Funk and Ivbijaro cited seven reasons for integrating mental health into primary care. Each must be considered in any effort to design or implement a collaborative approach, partial integration, or a fully integrated model.

  1. The burden of mental disorders is great. Mental disorders are prevalent in all societies and create a substantial personal burden for affected individuals and their families. They produce significant economic and social hardships that affect society as a whole.
  2. Mental and physical health problems are interwoven. Many people suffer from both physical and mental health problems. Integrated primary care helps to ensure that people are treated in a holistic manner, meeting the mental health needs of people with physical disorders, as well as the physical health needs of people with mental disorders.
  3. The treatment gap for mental disorders is enormous. In all countries, there is a significant gap between the prevalence of mental disorders and the number of people receiving treatment and care. Coordinating primary care and mental health helps close this divide.
  4. Primary care settings for mental health services enhance access. When mental health is integrated into primary care, people can access mental health services closer to their homes, thus keeping families together and allowing them to maintain daily activities. Integration also facilitates community outreach and mental health promotion, as well as long-term monitoring and management of affected individuals.
  5. Delivering mental health services in primary care settings reduces stigma and discrimination.
  6. The majority of people with mental disorders treated in collaborative primary care have good outcomes, particularly when linked to a network of services at a specialty care level and in the community.
  7. Treating common mental disorders in primary care settings is cost-effective.

The writers acknowledge barriers, including the traditional mind-body dualism which has led to silo thinking, the problems inherent in attempting information sharing with sensitive information,  and the fact that payment for mental health care is not assured even with the new law. helping is the fact that organizations such as the Carter Center are working to de-stigmatize mental illness

The report points out that vital to improving this care is the Patient Centered Medical Home, the team approach to care (incorporating mental health professionals and primary care practices), and stepped care. In addition, they propose the use of a (proven) model where patients with low health and high needs and low behavioral health needs are cared for in the primary care medical home, and those with high behavioral needs and low and high health needs are cared for in the primary care and specialty mental health setting, all in a coordinated fashion.

The report makes for an interesting read and offers concrete solutions to some vexing problems.

My friends Lloyd Michener at Duke, Janice Benson in Chicago, Josh Freeman in Kansas, and I have a running conversation that is about 15 years old and only occurs when we get together at national meetings. The conversation runs something as follows: Janice will argue that the role of the physician is to be immersed in the community and the role of the medical education infrastructure is to develop instructional modalities which, although limited in scope, will lead to physicians doing great things in the community in which they eventually find themselves. Josh will argue that all physicians ought to be governed by a higher purpose and we should develop our community outreach to allow learners to develop that sense of purpose while in the educational environment. Lloyd will argue (or at least as best I can explain Lloyd’s very complex arguments) that physician need to partner with agencies doing activities which benefit the broader public and our educational efforts should be in making learners see the value of this truth. For the most part I entered the discussion about 5 years into it so I mostly sit and watch.

I find that each of these arguments have merit. It is clear that the current effective primary care delivery system is built on the backs of primary care “providers” who are pillars of their communities and at great personal expense deliver patient centered care (to a greater or lesser extent) to a pool of patients who choose to use these practices as an entryway into a very complex care system. These physicians (and others) are the ones described in the FOFM literature.  They believed so much in what they were doing and wanted so much to do it better that they volunteered for the National Demonstration Project. Their patients enjoy better outcomes than those who access the system through the ‘ologist route, get less stuff done to them, and result in less cost to whomever pays the bills. It is important to acknowledge that they are underpaid, are spending personal money on personnel to facilitate unreimbursable activities, and in general it turns out are the glue that holds the current system together. As much as some in Academic medicine would like to believe, this service will not be replaced by non-physician providers any time soon if ever. The services will be augmented by non-physicians and we in the Academic medicine need to determine the educational needs of those folks. Community Medicine curricula at the residency training level (as championed by Janice) clearly informs these physicians’ practices in a good way. Unfortunately,  if additional money doesn’t follow as a consequence of the reform effort it may be a moot point.

On the other hand, Lloyd often speaks of a different reality. He speaks of ” patients who are not well-connected to a practice.” He points out that much of the avoidable cost is with these patients, the ones who are not plugged into the health system, and that caring for them often takes a different skill set and as well as a different tool box. The primary care system, with its office based emphasis, can only go so far, as Lloyd says, “especially for folks who are struggling with chaotic lives, difficult behavioral change, and psychiatric comorbidity.” For these folks, traditional community medicine interventions associated with Family Medicine (and other clinical specialty training curricula) have been ineffective. Duke has shown that linked office and community programs seem to have better outcomes. Partnering with community agencies, focusing on community outcomes, outreaching to those folks using disease specific information will almost certainly improve these patient’s (and the communities) health outcomes. As I described before, Duke is doing some incredible things as they train learners in the community.

The Academic Heath Centers have proposed the Healthcare Innovation Zone  as the fundable and scalable fix for how learners and academic physicians should fit into the community. Unfortunately, we in Academic Health Centers have accrued a lot of healthcare dollars and yet have been incredibly ineffective at population definition, needs assessment, and assessment of intervention effectiveness (the skill set associated with Community Medicine). We have tried Academic-o-centric interventions (look at the GCRC /CTU model) to little improvement in the health of the population. NIH tried to impose some higher level thinking through the Roadmap process but it is unclear how many of the AHCs have fully embraced it. Large care delivery groups who have no vested interest in population clearly do not value this type of care. The exceptional groups, Kaiser, Group Health, and some other groups, are showing that this system is cost-effective but on a “shared savings” measure to which I’m afraid the average Academic Health Centers will be a cost to be jettisoned. Academic Health Centers with rare exception have not proposed improving community health markers as an outcome for which they should be held accountable.

Those of us in Academic Departments of Family Medicine like to believe that we can offer different perspective to Academic Health Centers. We bridge both of these worlds and we are more successful than other academic departments at training learners for (little c) community practice. The problem is that no one has yet asked us to do so and so the question continues to be can an ant move a rubber tree plant?

Coming back from the Society for Teachers of Family Medicine meeting in Vancouver, BC. Lots of buzz, excitement, fear, concern about the “new law” and the implications for healthcare. I always find this a very energizing meeting and this time was no different. I had the opportunity to share a project that our residency program is doing with the Mobile Housing Board around chronic disease self-care in elderly residents of an independent living facility near our office. My co-presenters were Brian Halstater of Duke and Lisa Weiss of Youngstown Ohio who shared what their residents are doing in the community as well. The Duke program I have been following with interest for a while and I remain impressed (funny what tobacco money and guilt will make you do). I was blown away by what Lisa is doing in Youngstown. Her program is in a town with 20% unemployment, the hospital is in a poor financial situation, many of her residents are not from the area (or even the country) but they are out in the community providing care, educating the healthcare TEAM about their own community, and working with the hospital to obtain needed care for folks who have no coverage.

Teaching community medicine in a family medicine residency program requires a certain mindset. One mindset is to shoot to be above the floor. Another mindset is to shoot for the ceiling. STFM is a bunch of people describing their efforts to reach that ceiling. Lisa Weiss of Forum Health/Western Reserve Care System Family Medicine Residency Program is awfully close.

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