Innovations In Primary Care, Part 1

As part of my family medicine residency training, I’m taking a month-long elective called Innovations in Primary Care. This month is an opportunity for primary care doctors from family medicine and internal medicine residency programs in Seattle to explore some of the different primary care models being trialed in the Seattle area and to use those experiences to fuel discussion about how primary care (and really, all medical care) can be improved in the United States.

Today was our first meeting, during which we gathered to collectively write an H&P for our current medical system. For those reading this who are not in medicine, the History and Physical or H&P is a semi-standardized note-writing structure that doctors use to describe the subjective and objective information about a patient’s health, assess why  the patient is experiencing illness, and describe the next steps we need to take (diagnostic tests and/or treatments) going forward. It’s a structured way of thinking about a patient that helps us be rigorous and methodical.

It was a gratifying process because each of the doctors at the table shared a passion for making our health care system better, but brought a different set of experiences and priorities to the conversation.

Some of the take-aways I had from this conversation are as follows (in no particular order):

  1. The insurance framework for paying for health care, while originally conceived to improve access to surgical services which would otherwise be prohibitively expensive to most people, was quickly recognized by doctors as a way to extract larger fees for patient care. After all, when a third party (the insurance company) pays the bills, people tolerate much higher fees even if the end result is steady rise in out-of-pocket costs for everyone. Doctors, hospitals, and pharmaceutical companies have abused this system so greedily under the previous usual-and-customary payment system that increasingly rigid cost-containment measures have had to be implemented to control costs. We now live in a society where the average doctor makes $294,000 per year–more than 98.9% of Americans–while medical bills bankrupt patients and health insurance cost suppresses wage growth. Recognizing and holding ourselves accountable to how capitalism in medicine has brought out the worst in us is necessary before we can even begin to conceptualize a new system.
  2. The costs of most important and effective interventions to improve health, including primary care, are recurring and predictable costs that are best paid for through public health funding, NOT through health insurance. Access to clean water, nutritious food, safe housing, and preventive medical care is necessary for All People at All Times.
  3. America fails to invest in public welfare programs because of racism. The idea of the racialized-and-thus-undeserving Other benefiting from public welfare programs (e.g. the racist specter of the Welfare Queen that Reagan so infamously promoted) is fundamentally intolerable to White America. We are comfortable with 1 in 7 people in the United States facing food insecurity if it means we can prevent one person from buying steak with food stamps. There is no justice without racial justice.
  4. Many participants are needed to transform our medical care system into a true health care system. While there are only physicians in this particular group, the real work requires public health professionals, community health workers, housing experts, policy wonks, political activists, artists, chefs, personal trainers, behavioralists, and many others to both design an implement a better system.

I’m looking forward to the experiences and conversations this month will bring, and I hope to walk away with greater insight into how I can be a better advocate for effective and equitable health care in this country.

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Why I wear a Black Lives Matter pin

 

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This is the badge where I choose to display a Black Lives Matter pin. I wear this pin to work each day because I believe that Black Lives Matter is a message that is essential for all Americans to see and hear on a daily basis. I’ve distributed almost a hundred of these pins to my co-workers and every month I order more. It was brought to my attention that my employer has received anonymous complaints about seeing medical staff wearing these pins, so I wanted to clarify why I as a doctor make the choice to wear this pin.

Black Lives Matter became a prominent slogan during nationwide protests against police violence.  According to the federal Bureau of Justice Statistics, between 2003 and 2009 4,813 Americans died at the hands of police. Black people are disproportionately the victims of these police homicides, accounting for 32% of these deaths despite constituting only 12.6% of the population.

In this context, #BlackLivesMatter was used to remind the White American public that Tamir Rice, Sandra Bland, Freddie Gray, and Walter Scott are precious souls to be grieved, not mere statistics. However, the slogan gained a life of its own as a push back against the myriad ways in which Black life is denigrated in our country. It is a pinprick to the conscience meant to call attention to the cynicism with which too many of us receive news of the deaths of our Black neighbors.

This is a message that we healthcare professionals need to hear as we are all too often oblivious or callous to the enormous health disparities that exist between Black and White people in this country. A 2013 CDC report showed that rate of deaths from heart disease and stroke is 20% greater for Black people than White. That’s 6,942 deaths every year that could be prevented if racial inequality was addressed. The same report showed that the infant death rate is 130% greater for Black children than White. That’s 4,576 Black babies that don’t live to see their first birthdays because of racial disparity.

When I say that racism kills, I am speaking to these thousands of deaths that occur every year because of the racial injustice that permeates our nation. When I wear that pin, it’s because the deaths of four thousand Black babies every year is a tragedy and an injustice and it matters.

As a profession that is committed to preserving health and prolonging life, we have a duty to push back against all things that threaten the well-being of our patients. That is why I wear this pin and will continue to do so.

If you wish to take a stand in your workplace as well, I encourage you to order your own Black Lives Matter pin here: http://www.radicaldreams.net/product/black-lives-matter-lapel-pin

 

EDIT 5/16/17: An earlier version of this post stated that “4,813 Americans died at the hands of police every year.” This has been corrected to state “between 2003 and 2009 4,813 Americans died at the hands of police.”

Physicians in Solidarity

Since Donald Trump’s election on Tuesday, I have seen a renewed call to solidarity and resistance amongst my friends and colleagues in medicine. As I did with racial justice activism, I wanted to put together a post to consolidate the opportunities for action. This is both to help me clarify my own thoughts on action in the coming years, but also to help anyone else in medical professions who are trying to figure out how they can best work for a healthier and more just America in the coming years. This list is geared toward the particular expertise of medical professionals and is not meant to exclude work that the more general population needs to fight for such as the incredibly important work of dismantling White supremacy.

The Affordable Care Act

One of the more obvious threats of a Republican-dominated legislature is to Obama’s signature piece of legislation. Although it was developed as a near-duplicate of Republican Mitt Romney’s healthcare access effort in Massachusetts, Congressional Republicans decided that repeal of the ACA was the hill they wanted to die on and now that they actually have control of the legislature and the executive branches, they now have the power to follow through on their threat. There’s a lot of great writing on why complete Repeal and Replace would be incredibly difficult and likely extremely politically damaging, but if we’ve learned nothing from this election its that the predictions of experts should not let us become complacent. Here are something things you can do:

  1. Call (not write, not email…call) your congress people at their local offices and talk to their staff member in charge of health policy about what the coverage expansions under the ACA have meant for you and your patients. I’ve been in residency for 6 months and I already have about a half dozen powerful stories of people who only have access to life-saving care because of either Medicaid expansion or subsidized marketplace insurance. Use these anecdotes, This is doubly important if you are represented by Republicans who need to understand just how many people ACA repeal would hurt.
  2. Write op-eds the same and then shop them around and get them published in local or national newspapers. When they publish these letters, work your social media networks and make it go viral.
  3. Call up your professional organizations (AAFP, AMA, ACP, AAP, etc.) and make sure they are going to DC to keep pressure on the legislature to maintain the core benefits of the ACA. If you have time, travel with them to DC to speak to congress in person.

Women’s Health

Another prominent goal of the Republican party is to make it more difficult for women, especially poor women, to have access to birth control and abortion. As physicians, we bear witness to the impact of unintended pregnancy and cannot stay silent on this issue.

  1. As above, call your congress people, write op-eds, and work with your professional organizations to keep pressure on the legislature to protect access to affordable birth control. A great talking point here is emphasizing that access to affordable birth control is the most effective way we know of to decrease the rate of abortion.
  2. Set up a recurring donation to Planned Parenthood. With public funding under threat, private financial support of Planned Parenthood is more important now than ever. This is a vital organization which provides

Social Determinants of Health

As much pride as we take in our work in the diagnosis and treatment of disease, when it comes to improving the quality and quantity of our patients’ lives, healthcare is a drop in the bucket. Directly addressing many of these social determinants of health may feel like it is outside your purview as a medical professional. However, we also have an obligation to Do No Harm and without an understanding of social determinants of health we can inadvertently counteract the health gains we make through our clinical work. Hopefully I can do more to flesh out this list over the next few weeks. Please send me items you think I should include here!

  • Anti-Racism
    • As a society founded on the mythology of White supremacy, every one of us is socialized into White supremacist beliefs. This is not a question of being a Good or Bad person, but rather about the cognitive biases we can’t help but internalize. The first step in any anti-racist work is introspection into the ways in which we’ve been socialized into White supremacy and act on that socialization without realizing it.
    • White Coats For Black Lives has put out a call for medical professionals to commit their time and energy to anti-racism. Answer that call here.
    • Learn more about anti-racism efforts by following these people on Twitter.
    • Wear a Black Lives Matter lapel pin. However, make sure that it’s not performative allyship but rather a constant reminder to demonstrate that Blacks Lives Matter through your clinical and public works.
  • Immigrant Health and Rights
  • Anti-Poverty
    • Welfare programs and their beneficiaries are easy political targets. Using the above methods, speak up for high quality programs to promote economic safety net programs, especially cash assistance. A promising advocacy target here is cash assistance for all children which you can read about here.
  • Housing
    • Housing is very much a hyper-local issue. Seek out housing-first programs in your city and advocate for them.

Get on Twitter

I know it’s fun to dismiss social media, but there are some amazing physician activists on there whose writing has been incredibly helpful in broadening my thinking about where healthcare fits into the larger goals of a just society. Here’s a follow list of medical activists to start with. While you’re at it, check out this list of great anti-racist writers.

Welfare and Wellbeing

I’ve been listening to The Uncertain Hour by Marketplace’s Wealth and Poverty Desk. This season, they’ve taken a deep dive into the United States’ welfare system and the consequences of welfare reform in the 90s.

The podcast provides a great introductory education about American poverty, a topic where opinions are strong and facts are frequently scarce. Interviews with families receiving cash welfare benefits reveal the daily compromises and anxieties which are the lived reality of America’s poor.

Equally disturbing, however, are the interviews with the middle and upper class people who maintain political control of America’s welfare system and the profound contempt for the poor which suffuses their conversations about poverty and welfare.

It’s easy to understand why we have failed to develop a coherent, evidence-based system for addressing poverty in America when you listen to these people and realize that their primary goals are to shame and punish the poor for daring to seek joy or create life, actions that lie at the core of our common humanity.

Two thousand years ago, Jesus of Nazareth pushed back on the prevailing idea that poverty was God’s punishment for sinfulness. Today, in a country where nearly half of the population claims loyalty to his Good News, we remain in this punitive mindset.

I am biased in this conversation because my daily work brings me face-to-face with the suffering that poverty creates, the shorter and sicker lives the poor live out in the midst of abundance. But I truly believe that if our anti-poverty initiatives were crafted by people with direct experience with poverty and designed specifically to promote joy and reduce suffering in our fellow human beings lives that they would be radically different than the systems we have today.

I, Physician. I, Witness.

Richard* comes into my office with low back pain.

He was 27 when he first tweaked his back while loading some tools into his work truck. It had been sore for a week, but nothing a little ibuprofen couldn’t help. Certainly he was glad that he didn’t have to take time off of work. A couple years later, he slipped on some spilled lubricant. Fortunately, he didn’t crack his head, but this time his back hurt so bad that it was three days before he could get out of bed and get back to work.

Even when he was able to pick up a shift again, there was a dull, throbbing pain that stayed with him for weeks. He thought he had healed, but then a couple months later the pain came back after driving four hours out to a work site. He could hardly get out of the truck because of the pain, but he took a couple more ibuprofen and pushed through. At first it flared once a month, then once a week. He started moving slower, avoiding work that would requiring lifting because that would make the pain worse.

Soon enough he was taking ibuprofen every day just to get by. Then, one morning he noticed his urine was bloody. He went to the emergency room and found out that the ibuprofen had been damaging his kidneys. “Acute interstitial nephritis” is what they wrote on the paperwork, though he had no idea what that meant. All he knew was that he couldn’t take the ibuprofen anymore without risking kidney failure.

Without these medications, he couldn’t get through a day of work. He applied for disability, but the application was denied. The letter explaining the denial was incomprehensible to him, but he was sufficiently demoralized to not apply again. His wife had a job as a teacher, so his unemployment wasn’t an immediate disaster, but he felt worthless sending his kids to school and his wife to work while he sat around the house all day in pain.

And so he comes into my office and says, “Doc, I’m in pain.”

This scenario, all too common in my medical practice, is the focus of “Work, worklessness and the political economy of health inequalities” by Clare Bambra. People of low socioeconomic status have fewer job opportunities available to them, and the jobs that they can get have a higher risk of causing workplace injury. To add insult to injury, because these jobs generally require more physical labor, workplace injury is much more likely to disable these workers and expel them from the labor force. Unemployment and underemployment themselves have severe psychosocial and financial consequences and without strong social safety nets, the bottom quickly falls out.

Medical professionals are increasingly coming to grips with the fact that healthcare-based interventions have at best a marginal impact on our communities’ health and quality of life. In the case of Richard, by the time he arrives to my office, pain relievers and physical therapy have very little power to restore his quality of life.

This is the tortured position of the modern physician. Every day we face the consequences of socioeconomic deprivation as borne by the bodies of our patients, and yet the pharmacological and surgical therapies we have at our disposal offer meager relief.

However, this does not mean we are powerless in the face of suffering, because we have two compelling tools at our disposal. The first is social status in a society obsessed with respectability politics. The second is our witness to the true ugliness of socioeconomic inequality.

To proclaim this witness is a political act, one that many physicians are deeply uncomfortable with. However, to deny the witness and stay silent is also a political act. In truth, as soon as we are witnesses to injustice, we lose the option of true neutrality.

It is for this reason that I believe that for every physician-scientist we need a physician-witness. We need a workforce of doctors who can correctly diagnose both the pathophysiology and pathosociology (just making words up now) of a patient’s ill health and intervene on both.

As Bambra’s work argues, we need to target our socioeconomic interventions not just on individuals but on the socioeconomic systems in which those individuals operate. For Richard, this means not only referring him to a medical-legal partner so that he can get access to the disability payments that he’s entitled to (individual intervention), but also political action for safer working environments and more equitable economic opportunity (systems intervention).

This is not a trivial task, which is why I believe that we need training in the correct diagnosis of pathosociology as part of our medical training. We need to create training opportunities for physician-witnesses that begin during pre-medical education. We need to recruit students with a talent for witness into medicine, recognizing that these talents are more often found in students who themselves were raised in the midst of social and economic inequality. We need to ally ourselves with non-medical folk with talent for witness and use our voices to amplify theirs. We need to use our social privilege as doctors to speak truth to those in power who are slaves to respectability politics and would not get the message otherwise.

There is work here for all of us, and its a labor that is necessary if we are to truly work for the health and well-being of our patients.

*To protect patient privacy, this narrative is an amalgamation of several different patients’ stories.

Why do we pay more to treat illness than prevent it?

(The following has been cross-posted to the Leonard Davis Institute’s Health PolicySense blog)

David Asch, Mark Pauly, and Ralph Muller have a great piece in this month’s New England Journal of Medicine on how we as a society think about preventive versus cancer care. They observe that whenever preventive care strategies are studied, there is an obsessive concern with the return on investment of these strategies and that this same scrutiny is not applied to cancer care.

The entire article is well worth reading, but in summary their argument is that this difference occurs because:

  1. Cancer care is more profitable for healthcare providers than preventive care.
  2. There are more well-defined and evidence-based strategies for cancer treatment than for preventive care.
  3. Seeking reward for treating illness is a much stronger motivator than avoiding penalty for failing to prevent illness.

Continue reading “Why do we pay more to treat illness than prevent it?”