Tag: Healthcare

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Clinical General Healthcare Costs Healthcare Disparities Law Public Health Quality Improvement

On Public Charge

A step forward or a step back from self-sufficiency?

By: Souma Kundu

At the start of 2020, I remember the Trump administration celebrating what it saw as a victory for “self-sufficiency,” and “protecting law-abiding legal citizens from undue tax burdens”. Following a battle in the lower court, in a much-anticipated Supreme Court ruling, the court sided 5-4 with the administration, allowing enforcement of the 2019 expansion of the Public Charge rules.

This court ruling on Public Charge marks only the latest iteration of a policy dating back to the 1882 Immigration Act. While the definition and enforcement has varied over time, the essence of the law remains true to its origins: immigrants who are deemed unable to take care of themselves without becoming dependent on public assistance are unsuitable for American citizenship and therefore denied entry. Historically, public charge was determined by a holistic review of an applicant’s circumstances including age, health, financial status, education and skills. The use of public benefits for cash assistance and long-term institutionalization could be considered in this review, but other programs such as nutritional/housing assistance or public insurance were not included. In 2019, the United States Citizenship and Immigration Services (USCIS) expanded on the existing criteria to consider public benefits such as supplemental nutrition assistance, Medicaid or public housing. Additionally, it stipulated that the use of any of these public benefits for more than twelve months within any 36 month period may classify an applicant as a “public charge” effectively making them ineligible for permanent residency.

At the heart of this policy’s long-standing history is a deep-rooted belief that self-reliance is inextricably linked to the worth of an individual. It also posits that requiring public assistance is not only a burden to society, but one that is unlikely to be paid off or utilized for eventual gain.

But is this policy, and its predecessors really helping us increase self-sufficiency? Or is it robbing the US of its vast current and future population of contributing citizens? Even more pressing in 2020, is the impact of enforcing public charge during a pandemic leading to an underutilization of health care and resources only to increase morbidity and mortality across the nation?

From the lens of a healthcare worker, the general concern that efforts to rehabilitate lead to dependence baffles me. In medicine, from a sprained ankle to a surgery, achieving ultimate goals of “returning maximum function” all depend on how we can aid the healing process along the way. Generally, the use of a brace to offload the weight of a broken foot is not contested. Neither is the need for physical therapy to retrain our muscles after injury. But when it comes to rehabilitation of a person, our nation is much more skeptical of the process.

The abundance of research in the US and other countries on long-term effects of various welfare programs such as cash assistance, nutrition, and housing, point to the overwhelming benefits to the health of the recipients. Interestingly, benefits can also be seen towards community, by way of increased rates of labor participation, education attainment, employment status and productivity (Banerjee, Blattman, et. al). In a 2019 study on long-term economic impacts of childhood Medicaid, researchers found Medicaid-eligible children had higher wages starting in their twenties with wages increasing as they age. By the time these children reach age 28, their expected annual tax on earnings will return 58 cents for each Medicaid dollar spent to the government (Brown 2020). Providing basic human needs can be life changing – and it seems not just an ethical imperative, but a sound investment.

As many physicians, policy makers, immigration lawyers and researchers have feared, the changes to public charge determination is adding fear and confusion, resulting in underutilization of services available to immigrant families. Even programs such as the Children’s Health Insurance Program (CHIP), which is exempt from public charge review, have experienced a decrease in utilization.  An early impact study of public charge since enforcement began in February 2020, showed a 1% increase in the US’ noncitizen population that was associated with a 0.1% drop in child Medicaid use, estimated as a decline in coverage of 260,000 children. Researchers attribute this drop in enrollment to the fear and misinformation spreading amongst immigrants around public charge (Barofsky 2020).

As a medical student in San Diego where roughly two-thirds of our county’s population is Spanish-speaking, the impact of fear-mongering could not be more clear. Since the start of the pandemic, our once overflowing children’s hospital emergency department has been eerily quiet. Parents are worried for the safety of their families at the cost of health consequences from delays in care. At a time when access to medical care is imperative, our patients without documentation fear being turned away, or worse, turned in.

Meanwhile, disenrollment affects more than just immigrant families foregoing public assistance. Safety-net hospitals which rely heavily on Medicaid and CHIP payment are estimated to be at risk for a loss of $68 billion in health care services for Medicaid and CHIP enrollees (Raphael 2020). A drop in Medicaid enrollees will lead to increases in uncompensated care, lower Medicaid and CHIP revenue, alongside the cost of complications and emergencies secondary to foregoing early/preventive care. The fear and reluctance that public charge has created is not a simple reduction in federal spending, but rather a shifting of the burden with downstream financial havoc.

With the ample evidence that negates the assertion that the use of public assistance dooms one to a lifetime of dependency, and evidence to the contrary, that foregoing use has downstream effects on society, I urge us to rethink the dominant narrative around welfare and its implications for our nation. If we reject the belief that we must limit the use of public resources in favor of nurturing our communities most in need, we are much more likely to manifest our nation’s values of self-sufficiency and unlocking its potential. I’m not asking you to give up on self-reliance, I’m asking you to invest in it.

References:

  1. Blattman C, Jamison J, Green E, Annan J. The returns to cash and microenterprise support among the ultra-poor: a field experiment. SSRN Journal. Published online 2014.
  2.  Banerjee AV, Hanna R, Kreindler G, Olken BA. Debunking the stereotype of the lazy welfare recipient: evidence from cash transfer programs worldwide. SSRN Journal. Published online 2015.
  3. Brown DW, Kowalski AE, Lurie IZ. Long-term impacts of childhood medicaid expansions on outcomes in adulthood. Review of Economic Studies. 2020;87(2):792-821.
  4. Barofsky J, Vargas A, Rodriguez D, Barrows A. Spreading fear: the announcement of the public charge rule reduced enrollment in child safety-net programs: study examines whether the announced change to the federal public charge rule affected the share of children enrolled in medicaid, snap, and wic. Health Affairs. 2020;39(10):1752-1761.
  5. Raphael JL, Beers LS, Perrin JM, Garg A. Public charge: an expanding challenge to child health care policy. Academic Pediatrics. 2020;20(1):6-8.
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Clinical Emotion General Humour Lifestyle Literature Medical Humanities Narrative Reflection

On Playing Doctor

An excerpt from “Playing Doctor: Part Two: Residency”

By: John Lawrence, MD

As was her habit, she [the surgical chief resident] had called to check in with a surgical nurse to see how each of her patients was doing. They were discussing each patient when the nurse stopped to mention that there was a code team outside a room on the sixth floor with a collapsed patient.

My girlfriend quickly realized that it was one of her patient’s rooms, then raced back to the hospital, sprinted up six flights of stairs, and dashed onto the sixth floor, where she encountered a chaotic group of people surrounding one of her patients lying unconscious in the hallway.

The internal medicine residents and attending physician running the code were about to shock the unconscious patient because he had no pulse. As we’ve discussed previously, no pulse is bad.

Suddenly, in the middle of their efforts, and much to everybody’s surprise, the 5’1” surgery chief ran up, injected herself into their midst, ordered them to stop, and demanded a pair of scissors.

Nobody moved. The internal medicine attending exploded, wondering who the hell she was and what she was doing. It was his medicine team in charge of the code, and this patient had no pulse. Protocol was shouting for an immediate electric shock to the stalled heart.

Paying little or no attention to his barrage of questions, she grabbed a pair of scissors and now, to everyone’s complete and utter shock, cut open the patient right through the surgery wound on his abdomen.

Let me recap in case you don’t quite appreciate what’s going on: she cut open a person’s abdomen in the middle of the hospital hallway—and then stuck her hand inside the patient!

When the chairman of surgery came racing down the hall, he found his chief resident on the floor wearing a full-length skirt, with her arm deep inside an unconscious patient, asking, “Is there a pulse yet?”

The furious medical attending was shouting, “What are you doing? Are you crazy? What are you doing?”

And she kept calmly asking the nurse, over the barrage of shouts and chaos, “Do you have a pulse yet?”

Suddenly the nurse announced, “We’re getting a pulse!”

Which immediately quieted everyone.

Being an astute surgeon, she remembered thinking that the patient’s splenic artery had appeared weak when they operated on him. She correctly guessed that the weakened artery had started bleeding, and that his collapsing in the hallway was due to his rapidly losing blood internally. She had clamped the patient’s aorta against his spine with her hand to stop any further blood loss.

From the sixth-floor hallway the patient was rushed to the O.R. with my girlfriend riding on top of the gurney, pressing her hand against his aorta, keeping the guy from bleeding to death.

She then performed the surgery to complete saving his life.

The guy took a while to recover. Being deprived of blood to the brain had its detriments; when he awoke, he was convinced the 5’1” blond surgeon in the room was his daughter. When he was informed that no, she wasn’t his daughter, he apologized, “Sorry, you must be my nurse.” That comment, one she heard all too frequently, did not go over well.

To put this somewhat crazy event into perspective, within a day or two, the story became the stuff of legends told throughout surgical residencies across the country—and this was before social media sites existed to virally immortalize kitten videos.

Opening a patient in the hallway and using her hands inside the guy to save his life? This feat, treated by her as nothing more than a routine surgical moment, was akin to knocking a grand slam homerun in the ninth inning of the World Series in game seven to win the game—well, something like that. It’s what little kid wannabe surgeons would dream of if they cultivated a sense of creativity.

And to be fair, I thought it was an exciting episode, but she was always running off to save lives as a surgeon. The moment however, that finally put this accomplishment into perspective for me occurred when I was having dinner with her brother, the ace of aces surgeon, along with several other all-star surgical resident friends. This was a few weeks later, and without her present.

Eventually their surgery discussions (because that is pretty much all that this group of surgeons discuss when stuck together: surgery, ultra-marathon running, and more surgery) turned to loudly bantering back and forth about the whole event.

They boisterously argued about how much better they would have handled the whole situation, and wished they had been there to save the day instead of her:

“You dream of something like that going down.”

“Can you imagine being that lucky?”

“Should have been me.”

“Oh man, I would pay to have something like that happen.”

All the young surgeons agreed that this was their medical wet dream, being the rebellious action hero, on center stage, in such a grand case, in the middle of the hospital, no less, calmly saving a life in front of everyone with attending physicians yelling at you.

Then there was a moment of silence, total quiet as everyone reflected on the event…

“But you know what?” her brother finally said, looking around at everyone, then shaking his head and chuckling, “I never would have had the balls to do it.”

And every single surgeon around the table slowly nodded their head in agreement—they wouldn’t have either.

True hero.

Playing Doctor: Part Two: Residency is a medical memoir full of laugh-out-loud tales, born from chaotic, disjointed, and frightening nights on hospital wards during John Lawrence’s medical training and time as a junior doctor. Equal parts heartfelt, self-deprecating humor, and irreverent storytelling, John takes us along for the ride as he tracks his transformation from uncertain, head injured, liberal-arts student to intern, resident and then medical doctor.

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Clinical General Healthcare Costs Innovation Quality Improvement Technology

Let Me Be Brief: Principles of Value-Based Health Care

A series of briefs by Texas Medical Students

By: Sanjana Reddy, Tsola Efejuku, and Courtney Holbrook

In the seminal 2006 text, Redefining Health Care, Harvard Business School professors Michael Porter and Elizabeth Teisberg describe a healthcare market with a “positive sum” game; a market where all professional and economic incentives are aligned towards the maximization of “value,” defined as the “the quality of patient outcomes relative to the dollars expended.”1 Value in health care is the measured improvement in a patient’s health outcomes for the cost of achieving that improvement.1 Value-based care transformation is often conflated with cost reduction methods, quality improvement, or even evidence-based care guidelines. Rather, the goal of value-based care is to enable healthcare systems to improve health outcomes for patients over the full cycle of care. Tiesberg further elucidates three key dimensions (the Triple C’s) for measuring patient outcomes: capability (the ability for patients to do what is important to them), comfort (relief from emotional and physical suffering), and calm (reducing the chaos of navigating the healthcare ecosystem).2

In the U.S., improving patient-centered outcomes has become a highly discussed topic with ABIM’s Choosing Wisely program3, American College of Physicians’ High Value Care initiative4, and even major publications like the American Journal of Medicine’s recurring column on high-value care practice.5 In response to escalating healthcare costs, the Centers for Medicare & Medicaid Services (CMS) and other payers have shifted from traditional fee-for-service payments to value-based reimbursements such as the CMS Merit-Based Incentive Payment System (MIPS).6 Value-based health care empowers the clinician-patient relationship, places care delivery decisions at the expertise of a coordinated clinical team, and focuses on outcomes that matter most to patients.

The leadership of professional organizations, such as the Texas Medical Association (TMA), is invaluable to the process of defining and upholding the principles of value-based health care for systems and individual practitioners. Current TMA policy recognizes the need to advocate for high-value care principles in undergraduate and graduate medical education (Res. 201-A-18)7 and the adoption of the Choosing Wisely campaign (265.023).8 Although the evidence-based model (265.018.)9 previously adopted by the TMA does not encompass the full principles of the value-based decision making model, TMA resolutions on Cost Effectiveness (110.002)10 and Cost Containment (110.007)11 reinforce the need for cost-effective utilization of care.

On the federal level, exceptions to key legislation have been enforced recently to further advocate for value-based healthcare options. In November 2020, the CMS and Department of Health and Human Services Office of the Inspector General (OIG) released new exceptions to the Anti-Kickback Statute and the Stark law, effective January 19, 2021. These exceptions now allow more providers to participate in coordinated and value-based care arrangements that can improve quality and outcomes, lower costs, and increase health system efficiency, without the fear of severe criminal or civil legal backlash.12

The practice of value-based health care, although strong in theory, is not without flaws. The primary weakness of this system is that physicians are often responsible for things out of their control, such as referred providers’ costs and pre-existing conditions.13 This system requires widespread buy-in from all providers in order to collectively reduce costs and increase quality of care—effectively changing the culture of health care. Notably, this system inherently disincentivizes caring for patients of low socioeconomic status, particularly minorities, who inevitably generate higher costs due to health disparities.14 Weinick et al. emphasize adding a metric to the value-based healthcare system that addresses equity in health care. Their guide illustrates how to utilize value-based health care to reduce racial disparities, primarily by appending equity in pay-for-performance models.15

Goals of the Medical Student Section include staying informed about current policies regarding value-based health care since these policies are constantly changing and significantly affect reimbursement rates. Medical students are afforded the opportunity to learn about the principles of value-based health care from the very beginning of their training. Knowing the alphabet soup of value-based care (MIPS, APM, MACRA, etc.) will benefit patients and providers alike by improving outcomes, reducing costs, and maximizing reimbursements. In an effort to emphasize value-based health care early in the practice of medicine, the American Board of Internal Medicine sanctioned the Dell Medical School Value Institute for Health & Care’s STARS (Students and Trainees Advocating for Resource Stewardship) program. Over the past few years, student representatives across the country have met to learn about the principles of high-value care, review the Choosing Wisely campaign, and start their own initiatives at their respective medical schools. In Texas, students at UTHSC San Antonio’s Long School of Medicine created an ongoing Value-Based Health Care elective and degree distinction pathway. Dell Medical School offers online instructional modules and is a leader in patient-centered outcomes research. Medical students have a tremendous opportunity to impact high-value care through education, research, and student-led initiatives.

References:

  1. Porter ME, Teisberg EO. Redefining Health Care: Creating Value-Based Competition on Results. 2006. Boston, MA: Harvard Business School Press.
  2. Liu TC, Bozic KJ, Teisberg EO. “Value-based healthcare: person-centered measurement: focusing on the three C’s.” Clin Orthop Relat Res. 2017;475:315–317.
  3. https://www.choosingwisely.org/
  4. https://www.acponline.org/clinical-information/high-value-care
  5. https://amjmed.org/advancing-high-value-health-care-a-new-ajm-column-dedicated-to-cost-conscious-care-quality-improvement/
  6. https://www.cms.gov/newsroom/fact-sheets/quality-payment-program
  7. Texas Medical Association. Policy Compendium. Evidence-Based Medicine 265.018.
  8. Ibid. High-Value Care in Undergraduate and Graduate Medical Education 200.054.
  9. Ibid. Choosing Wisely Campaign 265.023.
  10. Ibid. Cost Effectiveness 110.002.
  11. Ibid. Cost Containment 110.007. 
  12. Modernizing and Clarifying the Physician Self-Referral Regulations Final Rule (CMS-1720-F). CMS. Accessed May 27, 2021. https://www.cms.gov/newsroom/fact-sheets/modernizing-and-clarifying-physician-self-referral-regulations-final-rule-cms-1720-f.
  13. Burns, J. “What’s the downside to value-based purchasing and pay for performance?” Association of Health Care Journalists. September 6, 2014. https://healthjournalism.org/blog/2014/09/whats-the-downside-to-value-based-purchasing-and-pay-for-performance/.
  14. “Value-Based Health Care Must Value Black Lives,” Health Affairs Blog, September 3, 2020. DOI: 10.1377/hblog20200831.419320
  15. Weinick, Robin & Rafton, Sarah & Msw, & Walton, Jim & Do, & Hasnain-Wynia, Moderator & Flaherty, Katherine & Scd,. (2021). Creating Equity Reports: A Guide for Hospitals.
Categories
Clinical General Healthcare Cost Healthcare Costs Healthcare Disparities Innovation Patient-Centered Care Primary Care Quality Improvement

Let Me Be Brief: Medicaid Expansion

A series of briefs by the Texas Medical Students

By: Ammie Rupani and Alwyn Mathew

In 2019, 18% of Texans had no form of health insurance.1 650,000 Texans have lost their health insurance due to unemployment during the pandemic. The rate of uninsured Texans is staggering and has only been worsened by the pandemic. During this critical time, we must talk about Medicaid Expansion and the potential solutions for millions of people with no health insurance. As a medical student, I have seen patients defer life-saving medications such as insulin in order to afford rent or groceries. Consequently, these choices have brought such people to the Emergency Room in diabetic ketoacidosis, which could have been easily avoided with regular insulin treatments. Stories like this are far too common in Texas, and it is important to recognize such outcomes are easily preventable with improved access to health insurance coverage. How can we as students learn to treat people, when the system we are bound to  practice in is perpetuating their very diseases?

Retrieved from Texas Comptroller

Medicaid is a health insurance program managed through the Federal Centers for Medicare and Medicaid Services (CMS). Medicaid is currently jointly funded by the Federal and State governments with the Federal government matching each dollar the State spends. Texas Medicaid is primarily a fee-for-service model that has poor reimbursement rates and high administrative burden that discourages physicians from accepting Medicaid in their practice. Currently, Texas Medicaid coverage is only offered to children, pregnant women, seniors, and people with severe disabilities, who also fall below a certain income threshold. For example, a single mother making minimum wage at her  full-time job is not eligible for Medicaid because she earns too much. However, she does not qualify for Federal subsidies covering some of the insurance cost because she does not earn enough. The Patient Protection and Affordable Care Act of 2010 would help address this woman’s dilemma since Medicaid Expansion would cover all individuals with incomes up to 138 percent of the Federal Poverty Level, amounting to $16,643 for individuals and $33,948 for a family of four. Medicaid Expansion would provide a health insurance option to an estimated 2.2 million uninsured low-wage Texas adults.2

Although the original arguments against Medicaid Expansion in Texas focused on States’ rights and limiting Federal dependence on funding, the primary opposition to this program was the Federal mandate. In 2012, the US Supreme Court ruled that the Federal government could not mandate the Expansion of Medicaid in any State, leading to Texas and several States opting out of the program. Realizing the benefits and improvement in health outcomes, several States have since adopted the Expansion program offered through CMS, including Arkansas (2014) and Louisiana (2016). Currently, Texas spends nearly $40 billion (State and Federal funds) for the Medicaid program, with a 60-40% distribution between the Federal and State Government respectively.3 Expansion would be fiscally sound for Texas as it will reduce the strain on our State budget and draw in more Federal resources. Looking past the dollar amount, it is crucial that medical students and other healthcare professionals recognize the benefits of improved access and early medical intervention that can be achieved through Medicaid Expansion.3

TMA’s Legislative Recommendations4
  • Develop a meaningful, statewide health care coverage initiative using federal dollars to:
    • Extend meaningful coverage to low-income uninsured working-age adults, and
    • Establish a state-administered reinsurance program to reduce premiums for people enrolled in marketplace
  • Provide 12-months’ comprehensive coverage for women who lose Medicaid 60 days
  • Establish 12-months’ continuous coverage for children enrolled in Medicaid, the same benefit given to children enrolled in the Children’s Health Insurance Program.
  1. Accounts TCof P. Uninsured Texans. Retrieved from- https://comptroller.texas.gov/economy/fiscal-notes/2020/oct/uninsured.php
  2. How Many Uninsured Adults Could Be Reached If All States Expanded Medicaid? – Tables. KFF. https://kff.org/report-section/how-many-uninsured-adults-could-be-reached-if-all-states-expanded-medic aid-tables/. Published June 25, 2020.
  3. Federal and State share of Medicaid Spending, 2019, Kaiser Family Foundation- retrieved from – https://kff.org/medicaid/state-indicator/federalstate-share-of-spending/?dataView=1&currentTimeframe=0 &sortModel=%7B%22colId%22:%22State%22,%22sort%22:%22desc%22%7D
  4. Provide Meaningful Health Care Coverage for Uninsured Texans. Texmed. https://texmed.org/Template.aspx?id=55300.
  5. Status of state medicaid expansion decisions: Interactive Map, 2021. Retrieved from- https://kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/
Categories
Clinical General Public Health

Let Me Be Brief: Vaccine Hesitancy

A series of briefs by the Texas Medical Students

By: Grayson Jackson, Kate Holder, and Whitney Stuard

Vaccine hesitancy refers to when an individual refuses or delays receiving an available vaccine, primarily due to misinformation, lack of health literacy, or fear.1 This issue—especially in the setting of the COVID-19 crisis and growing misinformation about science and medicine nationwide—is of great importance for medical students as future physicians and scientific communicators. Widespread vaccine refusal may result in untold public health consequences, including outbreaks of vaccine-preventable infectious diseases and rising healthcare costs. Vaccine hesitancy is often observed by quantifying nonmedical vaccine exemptions from state-mandated immunizations. In Texas, these exemptions have tripled since the 2010–11 school year.2 Data compiled by the Centers for Disease Control show that during the 2018–19 school year (the most recent available), Texas reported 2.2% of kindergarteners with a nonmedical exemption, amounting to 390,000 exempted children second only to California.3

The ongoing health crisis caused by COVID-19 has placed tremendous hope on vaccine compliance as the most practical way to stifle the global pandemic. Scientific facts have become increasingly politicized, and vaccines represent one of the key topics in which such facts have become distorted and polarized. Some questions (i.e., whether vaccines cause autism) have persistently circulated among vaccine-hesitant groups for years, whereas the COVID-19 crisis has heightened the risk of disinformation as vaccines by Pfizer, Moderna, and others are rolled out nationwide. It is incumbent upon us as future physicians to engage in the responsible dissemination of correct information about vaccines’ safety and efficacy. However, one should also avoid rushing to condemnation or judgment of vaccine-hesitant patients and parents which may only intensify their opposition.4

The Texas Medical Association (TMA) has worked to actively combat vaccine hesitancy and problems with vaccine availability throughout the state. The TMA has been working to support vaccinations including influenza, HPV, MMR and others throughout its history. TMA’s current vaccine advocacy agenda is still working to advocate for flu shots during the ongoing COVID-19 pandemic. The TMA Medical Student Section (MSS) has also continually supported vaccine availability to all Texas residents and promoted Be Wise Immunize chapters throughout the medical school within the state. In addition to TMA’s Be Wise Immunize program, TMA has published a variety of policies supporting vaccinations to increase overall vaccination rates. Policy such as 135.012 Immunization Rates in Texas, 260.072 Conscientious Objection to Immunizations, and 135.022 Adolescent Parent Immunizations all work to increase vaccination rates within the state, promote the Texas Vaccines for Children Program and the Adult Safety Net Program, as well as combat vaccine hesitancy. In addition, during the COVID-19 pandemic TMA has encouraged the #ThisIsOurShot campaign to combat vaccine hesitancy.

The TMA Medical Student Section supports widespread vaccine availability in a prompt and timely manner to all Texas residents. The MSS supports incorporation of the COVID-19 vaccine into the mandatory vaccine category once it is federally authorized beyond emergency use. This may become increasingly important as we see young people and college students, who deny the vaccine due to not fearing the less negative COVID-19 health outcomes, become the population disproportionately responsible for COVID-19 spread.

As a medical student, you have probably heard countless friends and family members discuss their hesitancy to receive the COVID-19 vaccine. Many people have vehemently opposed the COVID-19 vaccination simply because they have fallen victim to false information. As medical students and advocates, we should commit to broadcasting truth and combating misinformation in our local communities. We have the wherewithal and the voice to endorse the COVID-19 vaccine.

1 MacDonald NE; SAGE Working Group on Vaccine Hesitancy. Vaccine hesitancy: Definition, scope and determinants. Vaccine. 2015;33(34):4161-4164. doi:10.1016/j.vaccine.2015.04.036

2 https://www.texmed.org/Template.aspx?id=55299#_ftnref1

3 https://www.cdc.gov/vaccines/imz-managers/coverage/schoolvaxview/data-reports/exemptions-reports/2018-19.html

4 Please visit https://www.ama-assn.org/delivering-care/public-health/3-ways-physicians-can-improve-vaccine-conversation.

Fast Facts

  • The COVID-19 vaccine cannot give you the coronavirus or make you test positive for the coronavirus.
  • Even if you have already recovered from COVID-19, you should receive the vaccine to prevent reinfection.
  • The COVID-19 vaccine will not alter your DNA or impair your ability to have children.
  • The COVID-19 vaccine is demonstrably safe and effective and tested through rigorous clinical trials.
Categories
General Healthcare Cost Humour Lifestyle Opinion Pharmacology Psychiatry Psychology Public Health Reflection

Well, Well, Well: Products and services compete for shelf space in trendy wellness market, but are they worth your money?

When a friend recently asked me to join them for a class at Inscape, a New York-based meditation studio that New York Magazine described as the “SoulCycle of meditation”, I was skeptical. On the one hand, I usually meditate at home for free, so paying almost $30 for a meditation class seemed a bit silly. On the other hand, my meditation practice had dropped off considerably since the beginning of the year. Maybe an expensive luxury meditation class was just what I needed to get me back into my regular practice. Stepping off bustling 21st Street into the clean modern space, I heard the sounds of, well…nothing. It was incredibly quiet. Before getting to the actual meditation studios, I had to pass through Inscape’s retail space. The minimalistic shelves hold a variety of supplements, tinctures, and powders that include unique ingredients like Reishi medicinal mushrooms and cannabidiol extract. Many contain adaptogens, herbal compounds that purport to increase one’s resistance to stress, though their efficacy has never been quantitatively proven.[1] These products’ promises run the gamut from shiny hair and stress relief to aura cleansing. I may be a super-skeptic, but even I am not immune to the lures of top-notch marketing. With great consideration, I purchased one of the many magical powders for sale labeled as ‘edible intelligence.’

Since wellness has become trendy, a considerable space in the retail market has opened for associated products dedicated to helping people live their best lives. As Amy Larocca pointed out in her June 2017 article The Wellness Epidemic, “[In the wellness world] a loaf of bread may be considered toxic, but a willingness to plunge into the largely unregulated world of vitamins and supplements is a given.” Even a recent episode of Modern Family poked fun at the wellness trend when Haley Dunphy applied for an ultra-competitive job with fictional wellness guru Nicole Rosemary Page. During her interview at Page’s Nerp company headquarters, Page laments, “People say that Nerp is nothing more than a con-job, a cash grab vanity project from a kooky actress. I want to turn Nerp into the next Disney-Facebook-Tesla-Botox. It’s a world changer.” Though Page is a fictional character, I can’t help but wonder whether the character was inspired by the very real Amanda Chantal Bacon, the founder of Moon Juice, which bills itself as an adaptogenic beauty and wellness brand. Bacon’s Moon Dusts retail for $38 a jar and come in varieties such as Spirit, Beauty, and Dream.

The bottom line is that a sense of well-being needn’t come at the price of thirty-plus dollars an ounce. In fairness to those who choose to spend lavishly, I believe that plunking down a chunk of cash might create an intention to use and derive value from a product, thus positively influencing one’s perception of how well the product works. Rest assured, however, that living with intention and gratitude can be just as easily accomplished without spending any money at all. Carving out time in the day to create a small ritual for yourself can be as simple as spending a few minutes in the morning listening to jazz as you drink your first cup of coffee or allowing yourself to become immersed in a good book before drifting off to sleep. These simple acts allow us to bestow kindness upon ourselves that is especially important in our stressful and busy lives as medical students. My suspicion is that by performing such rituals with intention, we derive much of the same benefit whether our mug is filled with the trendy mushroom coffee or just plain old Folgers.

I’m always thinking about ways I can improve my own well-being, but as graduation approaches I also find myself thinking about how these practices might help my patients as well. One of my fundamental goals as a future psychiatrist will be to help my patients see the value in themselves and in their own lives. I predict that for many of my patients, achieving this goal will depend perhaps on medications but also on the deployment of simple wellness tactics such as I described. I’m not going to lie…I’m still intrigued by many of the wellness products that can be found in places like Inscape, Whole Foods, and the Vitamin Shoppe, especially when I think about the potential benefits they might have for my future patients. I figure that if these products do even half of what they promise to, some of them might even be worth the money. So what happened when I added a sachet of intelligence powder to my usual morning smoothies? Pretty much nothing. At one point, I got excited when I began to feel my fingers getting tingly. Then I realized I had been leaning on my ulnar nerve. Not so brainy after all.

[1] Reflection Paper on the Adaptogenic Concept, Committee on Herbal Medicine Products of the European Medicines Agency, May 2008.

 

Photo credit: Open Grid Scheduler / Grid Engine

Categories
Clinical General Healthcare Costs Law Opinion Patient-Centered Care Primary Care Public Health Reflection

Discontinuity in Care

My resident tries fairly hard to take care of his patients. When he is with them, I catch him paying attention to all sorts of details that he could have easily let slip past. So it made it all the more difficult when I saw him enraged. When he opened up his list of clinic appointments one morning, on the list was a patient he did not want to see. It was not just that she was a new patient to him. It was not just that her problem list went on like a run-on sentence. It was that both were true, and my resident was still expected to see her in only 15 minutes.

While chart reviewing, he learned that the only consistency in this patient’s medical care at our clinic had been a history of inconsistent providers—and based on their notes, none of them had the complete story. “Why am I even seeing her?!” my resident asked rhetorically, as he frantically searched for answers he knew he did not have the time to find. I wondered, too. This visit seemed to benefit no one except the Billing Department, and even that would depend on whether the Medicare reimbursements actually made it through.

That patient’s experience was hardly unique, though. While rotating through various specialties as a medical student, I have met several patients who were passed from one provider to another. Maybe the provider had to switch services. Maybe they left the institution for better opportunities elsewhere. The reasons were myriad. Stories like those suggest that continuity of care may still only be a priority in primary care literature.

I think one reason for this reality is a lack of incentives to keep doctors and patients together. In any field, including medicine, we see money driving people’s attention and vice versa. Since our country has historically kept primary care on the back burner, there is little evidence to believe that practical incentives for continuity of care will spontaneously appear in the near future.

So, for the primary care fans out there, it might be worth it to start speaking up.

 

Photo credit: Norbert von der Groeben/Stanford School of Medicine, posted by National Center for Advancing Translational Sciences

Categories
General Public Health

Human Trafficking: A Brief Guide for Physicians

Human trafficking. Like many things we hear about or read in the news, it seems like a problem of developing countries like Cambodia and Thailand. However, what we fail to realize is that human trafficking, also known as modern slavery, is alive and well within the United States and affects children and adults across all socioeconomic statuses. A harrowing fact is that up to 85% of people forced into human trafficking saw a physician at some point and more than 60% had at least one ER visit1. However, most physicians have not been trained on how to identify and help patients who are potential victims of human trafficking2. This article will hopefully provide more insight into what human trafficking is, how to identify a victim, and most importantly, how to help them.

The State Department of the United States indicates that human trafficking consists of domestic servitude, forced labor, debt bondage, as well as sexual exploitation3. While these are different types of human trafficking, warning signs that a potential patient is a victim to these crimes tend to be very similar. The U.S. Department of Education has provided some common identifiers for physicians in all states to be aware of, including a patient who:

  • Makes references to frequent travel to other cities or towns
  • Exhibits bruises or other signs of physical trauma, withdrawn behavior, depression, anxiety, or fear
  • Lacks control over her or his schedule and/or identification or travel documents
  • Is hungry, malnourished, or inappropriately dressed (based on weather conditions or surroundings)
  • Shows signs of drug addiction4

Victims are often in attendance with their abuser, whether this is a pimp or “employer”, so it is important to speak to the patient alone to elicit a thorough history and help the victim. An excellent resource for all health care professionals in the emergency room is a phone app called “Sex Traff”5. It is designed by two physicians with the intent of helping health care professionals identify potential victims of sex trafficking using a simple screening questionnaire.

As the awareness of human trafficking increases, there is also an increase in health professional training sessions available in several cities across the nation, as well as online training available through the national human trafficking hotline: https://humantraffickinghotline.org/material-type/online-trainings. It is important that healthcare providers of all ranks be informed of this pervasive problem, as well as how to respond. Please share this information with your staff and colleagues, so that we can do our part to combat human trafficking.

Source(s):

1https://wire.ama-assn.org/delivering-care/how-physicians-can-identify-assist-human-trafficking-victims

2https://www.reuters.com/article/us-sex-trafficking-recognition/doctors-not-trained-to-spot-sex-trafficking-victims-idUSKBN0MC1XE20150316

3 https://www.state.gov/j/tip/what/index.htm

4https://www2.ed.gov/about/offices/list/oese/oshs/factsheet.html

5 https://play.google.com/store/apps/details?id=com.ncpl.sextraff

Photo Credit: Thomas Wanhoff Source: Flickr

Categories
disability Emotion Lifestyle Patient-Centered Care Psychology

Nodding Along

My grandmother was a strong and compassionate Egyptian woman, a mother of three, and a pathologist. On a glass slide, exactly like the ones she used daily, cells from her colon biopsy were identified as undifferentiated, and within days she was diagnosed with Stage IV Colon Cancer.

Although I am learning how to care for people in sickness and health, someday, the chest compressions will be applied to my chest. Disease knows no discrimination, and death unites us all. Thousands of cancer diagnoses and precise and growing knowledge of cancer cell types did nothing to protect my grandmother from that which she knew so much about.

In Egypt, cancer is called ’the bad disease’, and bad it is. Over the next couple months, we watched as the bad disease took our beloved grandmother away from us. During that time, my family members, and my grandmother, had to make a series of challenging decisions that they were very obviously not prepared to make.

Medical advancements, although the main reason we are living longer lives, have caused the complexity and variety of end-of-life decisions to be ever increasing. Uneasy about the series of decisions that my family had to make and handicapped by my ignorance, I found myself reading Being Mortal by Atul Gawande. Atul Gawande led me through a vulnerable and imperfect but inspiring conversation about death and dying, exposing our medical system’s inability to understand health beyond the one-dimensional, and presumptuously noble, endeavor to prolong life at any cost.

While reading Being Mortal, I found myself enthusiastically nodding along, agreeing with the theme of the book: we need to change everything about our simple but destructive approach to aging and our increasing elderly population. Our singular approach to prolonging life simplifies complex social and medical decisions. It seems the attitude now is that longer life is all that matters. Ensuring nutrition and shelter is our only standard for a viable living environment for the elderly. We are failing our parents and grandparents.

Atul Gawande’s presentation of ideas changed how I perceive aging and our healthcare decisions at the end of life. I became a strong advocate of having conversations about the inevitability of our death and the choices we want to be made during our end-of-life care. I was convinced that society and healthcare should ensure that the elderly remain the authors of their own stories for as long as they are willing, and actively empower them to do so. Nutrition, shelter, and minimizing fall risk are minimums of care, not acceptable standards.

The Literature in Medicine Student Interest Group at my school decided to read Atul Gawande’s Being Mortal, and I could not be more excited. In the middle of our meeting discussing the book, as I was passionately sharing my ideas, it occurred to me that although I was full of strong opinions, I had done absolutely nothing to be a part of the solution. My grandfather had come to live with us after his wife of 55 years, my grandmother, passed away from colon cancer, and my only roles/concerns in his care have been to ensure food, sleep, and meds. My strong opinions had not inspired my actions.

Nodding along to Atul Gawande’s criticisms of our medical system is easy, but having an honest conversation with my grandfather about his priorities and end-of-life care preferences as he reaches 90 years of age is not so easy. How might I empower my grandfather to continue to be the author of his story? Believing that healthcare is a right and not a privilege is easy, but carrying out the responsibility that this belief invokes is not so easy. How might I work to help provide all my neighbors with equal access to high-quality care? Practicing the invaluable intervention of presence is not easy, and working day after day to hone my abilities at the art of empathy is not easy. How might I overcome my doubts, fears, and insecurities, and avoid being frozen into lack of compassion?

Too often my strong opinions do not inform my actions. Too often my hate for dysfunctional and unjust systems overshadows my love for the people in the systems. I call myself to love my neighbors more than hate the systems, for love is actionable and hate is stifling and tiresome. Let love fuel the tank, for compassion-based activism is the only kind that goes the distance.

Photo Credit: Dan Strange

Categories
Clinical Patient-Centered Care Psychiatry Public Health

If you don’t ask, you’ll never know

On the first day of my first rotation as a medical student, my preceptor shared this bit of wisdom: if you don’t ask, you’ll never know.  In the nearly 18 months that have followed, I think about those words on a daily basis. To my mind, asking questions does more than just help us gather data. Asking questions establishes the type of relationship we are going to have with our patients. There are so many questions I wish I would never have to ask, whose affirmative answers are often indicative of the cruelty of this world. But when I ask about things like whether a patient has been the victim of abuse, I hope it sends the message that the relationship we are about to embark upon is one that can withstand such unpleasantness.

Not only can it be excruciatingly frustrating when other practitioners don’t share this point of view, it potentially has grave consequences. Unfortunately, patients with mental illness often seem to be the victims of physician “brush-off.” As someone who plans to devote her life to working with the mentally ill, I can only hypothesize as to why the same patients I find so much joy in working with are often given sub-par medical care as compared to their non-mentally ill peers. Perhaps physicians feel uncomfortable providing care for patients who come across as different than the norm, or perhaps their medical problems are too frequently attributed to psychiatric causes.

I recently cared for a patient who was two weeks post-partum from the birth of her first child. Though she was being seen for psychiatric admission, multiple aspects of her health were addressed during our initial evaluation.  When asked about her post-partum health, she denied having been scheduled for a post-partum visit with her obstetrician. Casually, she mentioned that she was having some malodorous green discharge since giving birth. It doesn’t take a medical degree to know that green, foul-smelling discharge is not a good sign, let alone when it occurs in the immediate post-partum time period. We were able to secure a next-day appointment with our hospital’s obstetrical practice, and with the patient’s permission, called ahead to the clinic to alert them of her complaints.

The next day, the care team gathered around to read the note from the obstetrician who had seen our patient. The note comprised all of five lines.  There were no pending labs. There was no mention of a physical exam.

There was no mention of the discharge at all.

The American Congress of Obstetricians and Gynecologists (ACOG) states, “It is recommended that all women undergo a comprehensive postpartum visit within the first 6 weeks after birth. This visit should include a full assessment of physical, social, and psychological well-being.”[1] The issue here, though, isn’t really about post-partum care. The issue here is about how we as health care providers need to provide equal care for unequal bodies and minds, and how we need to protect and advocate for our patients.

Patients with mental illness undeniably have poorer overall health. The average lifespan for an American adult with mental illness is a striking 30% shorter than for a non-mentally ill individual.[2]  While it is known that mental illness itself creates difficulty in accessing the healthcare system, for mentally-ill patients who do access healthcare, their quality of care is demonstrably lower than it is for those without mental illness. Literature consistently demonstrates that patients with psychiatric diagnoses receive fewer preventative health measures and have overall poorer quality healthcare than patients without psychiatric diagnoses.[3],[4] No matter what field of medicine you are in, you will see patients with mental illness. For these patients who sometimes cannot speak for themselves, the role of the physician in patient advocacy becomes even more crucial.

I will never know exactly what transpired during that appointment between my patient and the obstetrician, but I do know that obstetrician did not ask the questions that needed to be asked, and therefore did not ascertain the information necessary to appropriately care for the patient. At our request, a different practitioner saw the patient again. This time, the appropriate questions were asked, the appropriate testing was completed, and ultimately the patient was diagnosed with a sexually transmitted infection. Left untreated by the first obstetrician, this infection could have caused my patient systemic symptoms and permanent infertility.

As future physicians, it’s important for us to keep asking questions. So often, I have been surprised by the information I find when I ask a question about which I almost kept silent. Equally as important as asking the questions, however, is doing something with the information that you receive. The good doctor isn’t necessarily the one that stops the green discharge; they’re the one the identifies the problem in the first place and advocates on behalf of the patient to get the best people for the job.

[1] https://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Optimizing-Postpartum-Care

[2] http://europepmc.org/abstract/med/19570498

[3] http://journals.lww.com/lww-medicalcare/Abstract/2002/02000/Quality_of_Preventive_Medical_Care_for_Patients.7.aspx

[4] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2951586/

Photo credit: airpix