A Potentially Critical Hole

From the Los Angeles Times: Hospitals swamped amid flu fears

At Loma Linda University Medical Center near San Bernardino, emergency room workers have set up a tent in the parking lot to handle a crush of similar patients. In Chicago, ER visits at the city's biggest children's hospital are double normal levels, setting records at the 121-year-old institution.

So far, few of the anxious patients have had more than runny noses. But the widening outbreak of swine flu, also known as H1N1 flu, is exposing a potentially critical hole in the nation's defenses.

Across the country, emergency care facilities are straining at the seams even though the outbreak is relatively small and the federal government has launched a mammoth disease-control effort -- dispatching antiviral drugs to states, attempting to contain the limited number of cases and beginning to develop a vaccine against it.

"It is a major Achilles' heel in our state of readiness," said Dr. Irwin Redlener, director of the National Center for Disaster Preparedness at Columbia University. "If we get a situation that is really out of hand with large numbers of people affected, I fear that our hospital and healthcare facilities simply won't have the materials or even the staffing to respond," he said.

I can't help but wonder what this situation would look like if patients had a personal primary care doctor they could go to or call or e-mail, instead of going to the ER.

Hey, you know that impending health care collapse that they've been talking about for years? Maybe there's some connection with that and the shortage of primary care doctors. Ya think?

A Little Help Please?

Vaccinations are an important tool for keeping people healthy. Like many family physicians, I give vaccines to my patients. Unfortunately, also like many other family physicians, giving vaccines is often not cost-effective and in some cases, a money-losing endeavor.

Part of the problem is that some vaccines cannot be purchased as a single dose. That leads physicians to decide if they should buy 10 doses of one vaccine just to immunize one child, and hope that they can use up the rest before they expire. This becomes a problem when a vaccine's wholesale costs run over $80 per dose, such as for Prevnar.

This is an e-mail I got from Dr. Jean Antonucci to her physician friends asking for some help. She has been trying to buy a single dose of Prevnar to finish immunizing one of her patients. But Wyeth, the manufacturer, only sells Prevnar in boxes of 10 doses:

So help me out here. I got a call from Wyeth — from a David Ross. Wyeth sells single dose Prevnar in other countries where "there is low demand". They are not very open to doing that here.

I told this man, "Look, this is a win-win. You want to sell Prevnar, I want to buy it." He goes on and on about how he cannot believe practices would need so few doses over a few years. So I say, OK, look, help me out here! I tell him about primary care. I point out that I ANSWERED the phone!! He repeatedly tries to deflect me — "This is about reimbursement". Well, no it isn't. Blue Cross pays for the vaccine just fine. It does not pay for 9 doses sitting in the fridge rotting.

SO anyway I say, here is an alternative. Sell it to Cardinal Health. THEY supply my drugstore. The drugstore will buy 10 doses from you and lots of us can use them.

He then says, well, he would have to know that there was more than one doctor in the USA who had need for small amounts of Prevnar. So aha! I say, oh really?? How many do you need to hear from? I have 700 friends.

"Uh uh, I dunno."

So PLEASE call up David Ross (484-865-6057) and plead the case to sell Prevnar EITHER to drugstores OR in single dose units to physicians. PLEASE?

Love, Jean

I called Mr. Ross and left a voice message saying I am a family doctor who would also like to be able to buy Prevnar in a single dose. If anyone else out there is in a similar situation, you might want to give him a call, too.

If nothing else, it may help one child get their Prevnar. And if he gets a lot of calls, maybe a lot of children across America will finally be able to get their vaccines from their local primary care doctor.

Grateful

I met Beatrice (not her real name) a little more than 2 years ago. She had just turned 90, and her daughter brought her in because she had been feeling a little more tired and short of breath lately. As she put it, she was having problems "getting going" in the morning. She had rarely been to a regular medical doctor, preferring homeopaths, in line with her beliefs as a Christian Scientist.

Up until a year before, she had been living for 19 years in Ojai, CA, 9 of them with her husband who passed away 10 years earlier of lung cancer. She had been active and doing yoga up until 1 year earlier when she fell and broke her arm. Ever since then, she had been living in an assisted living facility closer to her daughter. She had also been developing signs of Alzheimer's dementia over the past 4 years.

Beatrice was a pleasant and cheerful woman who acknowledged having some memory problems but kept repeating over and over again how “grateful” she was for her life so far. She proudly told how she was one of the first female bank tellers before she became a permanent homemaker. She also mentioned how throughout her life she never liked to take medicine or see doctors.

After examining her, I discovered that she had atrial fibrillation causing mild congestive heart failure, which was also the cause of her shortness of breath and fatigue. She also scored 13 out of 30 on her Mini-Mental State Exam, consistent with moderate dementia. Beatrice went home without any medications because her daughter wanted more time to think about what to do next. This first visit took 90 minutes.

After a series of e-mail communications and a follow up visit, we agreed to start Beatrice on some medication to help her breathe better. Over the next few months, she gradually improved with medication to the point where she was breathing comfortably again. Her daughter told me that while Beatrice couldn’t remember anything about what we had talked about, she did remember me and liked me.

I would see Beatrice several times for follow up over the next 12 months, and even though she couldn’t remember what she had for breakfast, each time she would smile and say how “grateful” she was for everything. That seemed to be the one thing she would never forget. She remained stable as far as her breathing but her dementia continued to worsen ever so slowly, and eventually she started having trouble with agitation and even remembering who her daughters were sometimes.

Unfortunately, this happens all too often with many elderly patients in this day and age. Even as you wonder if this is the kind of life they, or anyone, would want to have, it is often too hard to stop giving medications that you know are helping to keep someone alive.

In a typical busy doctor’s office, there just isn’t enough time to talk about what is really important to her or her family. It would just be assumed that we should just do our best to keep her heart from going into rapid A-fib and developing congestive heart failure, and to do otherwise would be unmerciful. And so, Beatrice would continue to take her Digoxin and Lasix, and her mind would continue to gradually wither away, losing bits and pieces of herself as time went on.

And eventually she would get a stroke and lose her ability to walk, speak or feed herself. Or she would fall trying to get out of bed in the middle of the night and break her hip. And she would end up bedridden and develop pressure ulcers on her fragile skin. And finally, if she didn't die of something else first, she would end up in a “persistent vegetative state”, her self-awareness gone, left with only a thin, frail body curled up in a nursing home bed, kept from malfunctioning further with well-intentioned medications, waiting to die.

That is, she would have if she had received care as usual.

Instead, I had long discussions with Beatrice’s two daughters that started 9 months ago, in person, by phone and by e-mail. We discussed the likely outcomes of continued treatment along with that of stopping treatment. We discussed adding medications to treat her agitation and anxiety and their potential side effects. We discussed what Beatrice valued in life, what her preferences would have been and what she would have chosen for herself, if she were able. We discussed their concerns that their mother not suffer.

After 4 months of discussion and reflection, her daughters decided that a palliative approach was what their mother would have wanted and started inquiries into hospice programs. A month later, she had enrolled with a hospice program, and I stopped directing her medical care, since the hospice program already had a physician.

Yesterday, I received an e-mail from Beatrice’s daughter saying that, after a few weeks of terminal agitation, her mother had passed away peacefully.

I’d like to think that Beatrice was grateful to go this way.

I'd be grateful if every primary care physician could be given the time and paid for the time to do the right thing for their elderly patients, rather than give "care as usual".

Pre-existing condition of being human

This article by syndicated columnist Ellen Goodman from yesterday's Washington Post gives a nice summary of what ails our current US healthcare non-system: "The Care in Health Care":

I was tickled to hear that the insurance industry is beginning to commence to start to think about lifting bans on the pre-existing conditions that keep a slew of Americans from getting health coverage. This has always been on the deep end of a pretty wacky system.

But there is a pre-existing condition that hasn't garnered nearly as much attention in the health care debate. It's the condition we all share: being a human being. As opposed to, say, being an organism subdivided into parts and scattered over the medical landscape from neurology to podiatry.

The current system makes it hard for people to get care for their whole body, much less their whole self (mind and body). The balance between splitters and lumpers has been tipped to the splitters by a wide margin for some time now.

Consider one of the least secret medical records in the country: the erosion of primary care doctors. A half-century ago, we had an equal number of generalists and specialists. Today there are two specialists for every generalist.

In clear view and with all undeliberate speed, we developed a system that rewards procedures over primary care. As analyst Robert Blendon puts it bluntly, "It's absolutely clear that payment systems have been negotiated that reward specialty time and use of equipment." The incentives tip toward the kind of medicine that is performed with hands, tools and technology over the medicine that is practiced with eyes, ears, and mind.

The average generalist now earns 55 percent less than the average specialist. Many students apply to medical school to connect with and take care of sick people. They graduate to become what one doctor slyly calls "proceduralists." They enter with a strong desire to look after families and exit with a ticket to X-ray femurs.

Read the entire article here.

She gets it. More and more people are finally getting the message that no meaningful healthcare reform will take place without fixing primary care first. And to fix primary care, you need to fix the system so that it will encourage, and not discourage, doctors from going into primary care. Otherwise we will continue to have too many doctors who look at you primarily as a body part rather than a human being.

This is also the diagnosis

Keep The Faith

When I arrived this morning in Sacramento, I wasn't sure why I was here. I am attending the California Academy of Family Physicians 2009 Congress of Delegates. I am one of many family physicians who have come from all over the state. They are leaders in their community, faculty in academic medicine and residency programs, department chairs, chapter presidents.

I am here because I happen to show up at most of the meetings. If you go often enough, you get nominated to be a delegate. This year especially there weren't enough of us coming from the Los Angeles Chapter so they asked for volunteers. At the registration table, my name was not listed as one of the delegates. Maybe I don't belong here.

The guest speaker is Dr. Ted Epperly, the current president of the American Academy of Family Physicians (AAFP). He notes the current national crises (crisises? crisii?) and says that he believes that, after many years of failed attempts, healthcare reform is finally going to take place in 2009 because of a miracle. According to Epperly, that miracle was the election of Barack Obama.

He said that he was at the White House 2 days ago, invited along with representatives from the 3 other primary care specialties (American College of Physicians, American Academy of Pediatricians, American Osteopathic Association) and a host of legislators, insurance representatives and stakeholders. They were part of a White House Health Care Summit there to discuss how to fix what ails our nation's medical non-system.

During the summit, Obama asked for the cooperation and participation from all the interested parties. And when he came to physician participation, he called on Epperly (who was taken by surprise and only had about 20 seconds to speak).

What he said was:

"Speaking on behalf of over 100,000 doctors, we're ready to do our part. We very much believe that we need to expand coverage in this country to everyone, and we need to fix the work force, sir, so that all those patients have a place to go.

We'll roll up our shirtsleeves and do everything possible to make this work. Because it is the right thing to do, and I applaud you and this body for doing this today, to do it this year. And we must do it. Thank you."

Epperly said he feels it was not by accident that Obama chose a family physician to speak for American physicians. It’s because he understands that primary care is broken.

He also said the president made it clear that everyone must be at the table, everyone must listen and everyone must give up a little something. Epperly quoted Victor Fuchs, a noted Stanford economist, as saying US healthcare reform would only come about if there was a war, an economic depression or major civil unrest. (We got 2 out of 3 so far.)

The Patient Centered Medical Home (PCMH) has become more than a model of healthcare, Epperly said. It has become a symbol of a movement to restore healthcare to this country.

Epperly observed that the current healthcare system is totally unsustainable, especially in this recession. Healthcare spending rose to $2.4 trillion in 2008 and is projected to rise to $2.5 trillion in 2009. But Epperly is hopeful that reform will finally take place under the Obama administration. "More has been done in one month than has been done in the past decade as far as healthcare reform," he said. "We can't afford to keep putting it off. President Obama recognizes that if there isn't enough investment in our domestic policy, this country will fall apart."

Epperly also called on family physicians to take a more active role in advocating healthcare reform. "If you're not at the table, you're on the menu," he said. "We family physicians are in the position we are in, not because the work we do is not worth it, but because we didn't step forward when we needed to."

Even though family physicians may feel like they're not getting the respect or the payment that they deserve for their work, Epperly feels Obama recognizes the value of family physicians to care for patients and their community. "Don't lose faith," Epperly said. "It won't be easy, but a better day is coming."

At the end of Epperly's talk, I felt re-energized and motivated, hopeful that our healthcare system can and will change for the better, sooner rather than later. I will continue to try to improve my solo practice using the principles of the PCMH. And while I don't have the charisma, eloquence or leadership of Obama or Epperly, I can blog.

I guess I figured out why I am here in Sacramento after all:

To keep the faith. And to help Save Primary Care.

But Is It Covered By My Insurance?

An ad for a longevity-enhancing product in today's Washington Post:

INDICATIONS AND USAGE: Marriage is the therapy of choice for treatment of the condition of being unmarried. Marriage is approved to manage the dread of growing old alone and missing the opportunity to have dinner every night with a special someone, but without talking. Clinical trials indicate that marriage is recommended if you have found either a true soul mate or someone who has an excellent 401(k).

"It may also cause children."!!! Well, that explains how the kids got here.

At least it's probably more effective than multivitamins at extending lifespan.