Albert Provocateur: March 2009

Sunday, March 15, 2009

Making the Grade

For those of us who are baby-boomers and old enough to remember, taking a bad report card home engendered a great deal of fear and trepidation, during what seemed an endless walk or school bus ride home. Perhaps that is the way hospital CEOs currently look at the issue of transparency and public disclosure, as they closely guard their respective institutions’ financial and clinical secrets, and damn or withhold any revelation destined to transform stockholders into what amounts to angry parents.
Healthcare consumers, the U.S. federal government, and third-party payers, however, demand the highest standard of care from our nation’s hospitals, as well as reliable performance measures to assure quality. Furthermore, such measures must be applicable to all hospitals, whether they reside in the high-tier or low-tier category. There is much evidence to support the contention that hospital report cards, based on objective performance measures, improve the overall healthcare of patients.
The Hospital Quality Alliance (HQA), based on provisions in the Medicare Prescription Drug, Improvement and Modernization Act (MMA) of 2003 and instituted by the U.S. Department of Health and Human Services (HHS), was, indeed, initiated precisely to that end. By collecting data on key measures of hospitals’ management and quality of care (for example, the care provided, the resources consumed, the total costs of care, and the resulting outcomes), the HQA can tabulate report cards to motivate change and hopefully improve overall patient healthcare. Also, the recently proposed Deficit Reduction Act (DRA) of 2005, by instituting financial incentives to entice our nation’s hospitals to “make the grade” by adhering to established measures of performance, and expanding them when necessary, serves as an additional built-in safeguard to our nation’s health.
High performance scores on HQA performance indicators have been associated with up to 15 percent reductions in the odds of death for common clinical conditions such as acute myocardial infarction, congestive heart failure, and pneumonia. So, the initial results are in, and perhaps only a bit of tweaking and several more performance indicators are required before hospital report cards become a diffuse functioning reality.
Who would have ever thought that the long bus ride home would be good for one’s health!

Return of the Scarlet Letter

Nathaniel Hawthorne is alive and well, and currently residing in the State of South Dakota, where his “Scarlet Letter,” “A,” now represents abortion, not adultery. In July 2008, under the laws of South Dakota, physicians there were henceforth required to tell prospective candidates that abortion is the termination of a living human being’s life, to give women a description of the risks of abortion, to provide them with the age and state of development of the fetus, to answer all women’s abortion questions in writing, and to certify in writing that the women mentioned received and understood all the above information. Failure on the physicians’ parts to comply with the statute might result in medical license suspension or revocation, as well as the possibility of being charged with a class 2 misdemeanor. The South Dakota law had been heretofore suspended by a federal injunction, successfully sought by Planned Parenthood, that was lifted on June 27, 2008 (Planned Parenthood Minnesota v. Rounds). That, and the recent U.S. Supreme Court case of Gonzales v. Carhart in 2007, in which it was noted that some women had come to regret their choice of abortion, and might not have chosen abortion, had they been better informed, paved the way for the implementation of the South Dakota abortion law, with its contained informed-consent requirements.
The South Dakota statute, however, will have repercussions far beyond its state borders, as it rallies dormant state legislatures to continue where they left off, enacting laws and seeking legal means to restrict abortions, in the wake of a series of Planned Parenthood setbacks. Physicians, patients, and believers in the sanctity of the physician-patient relationship should, indeed, be worried. The posture taken by South Dakota violates physicians’ First Amendment rights, not only by forcing them to be the couriers of the state’s anti-abortion message, but also by making them part of that message, via a certification process that, in essence, relegates them to the position of guarantors of their patients comprehension of the state’s law. Some legal scholars have gone so far as to conclude that the South Dakota abortion law, and similar legislation drafted by other states, employ “informed consent” as a means to eliminate abortions.
Were that not enough, the controversy surrounding the South Dakota statute has led to some hard questions regarding violation of the constitutional rights of the aborted fetus, punishment of women who do so, and prosecution of physicians “unable” to explain the multivariegated codicils of the statute. Furthermore, some of the scientific information contained in the South Dakota abortion law is inaccurate, at best, and has not been confirmed by the medical literature in regard. To force physicians to dispense such information, without allowing them enough “wiggle room” to provide alternative, more accurate, or perhaps even contradictory scientific material on abortion to their patients is to violate the Hippocratic oath, informed consent, and the physician-patient relationship.
The subject is complex and emotional, and no resolution will be forthcoming soon. Pro-choice, however, is walking a proverbial tightrope, with no safety net below, and its proponents might as well wear large “Scarlet A’s” on their chests, for their redemption is not at hand.

Saturday, March 14, 2009

"I'm so Hungry, I'm Fat!"

Food insecurity, or “the unlimited or uncertain availability of nutritionally adequate and safe foods or limited or uncertain ability to acquire foods in socially acceptable ways,” is the exclusive domain of the poor, and it affects 12.6 million U.S. households, with obvious repercussions on young and old alike. It is a “no-brainer” to deduce that hunger, or “a prolonged, involuntary lack of food, that results in discomfort, illness, weakness, or pain that goes beyond the usual uneasy sensation,” is an obvious consequence of food insecurity. And if that were not all, food insecurity and food insufficiency have been found to contribute to increasing incidences of psychosocial and cognitive difficulties, suicidal symptoms, and depressive disorders.
So, we are left with the dilemma of not only how to feed the poor, but of how to provide them with healthy foods that reverse the startling trend toward obesity in that population, and in the greater part of the U.S. middle and upper classes, for that matter. The latter two facets of the U.S. population, however, are not burdened by the heavy anchor of food procurement around their necks. The socially and economically indigent must employ a series of strategies to obtain food, any food, and those procurement methods run the gamut from the legal to the illegal, namely, food stamps, WIC program, shoplifting, selling food stamps, using coupons, pawning personal items, selling plasma, scavenging from dumpsters, and asking friends and strangers for food. We must ask the question, therefore, of how it is possible for the poor, with all the hardship inherent in their individuation, purchase, and procurement of food, to become obese? In fact, studies have shown that the highest obesity rates occur in poor communities, that food-insufficient older females have a higher risk of being overweight than food-sufficient females, and that high body mass indices (BMI) are common among low-income adults and youth. How do we account for this counterintuitive hunger-obesity paradigm? Why do we see such numerous examples every single day of stereotyped, racially profiled individuals (known by deprecatory terms such as “white trash,” “trailer trash,” “beaners,” “niggers,” and a slew of others), of lower socioeconomic status (SES), who give credence to the saying, “I’m so hungry, I’m fat?” There appears to be a disconnect. How can hunger possibly be associated with obesity? While the question is intriguing, the answer is not so exotic. Increased portion sizes, diets based on fast food, and food insecurity, or the memory of it, are strong inducements to the indigent and socially emarginated to overeat tasty food, or any food, for that matter, when it becomes available.
The question of whether or not to tax high-fat foods, in order to make healthier foods, the fruits and vegetables, more attractive to limited pocketbooks, is a controversial one. While the issue is difficult to address, and leaving questions of civil liberties aside, there are some of us who feel that the taxing of unhealthy foods might place undue hardship on indigent, obese populations (of low SES) already hit hard by a failing U.S. economy and financial hard times. In that light, it might not be a realistic road to follow. On the other hand, although increased taxing of high-fat foods might, in the short term, pose financial hardship for the indigent and trigger subsequent increased government spending to sustain nutritional programs and financial solvency for them, in the long haul increased spending might be more than compensated for by the savings incurred by U.S. taxpayers as a whole consequent to the reduced incidence and prevalence of psychosocial, cognitive, depressive, and suicidal symptoms and disorders tied to food insecurity and hunger in the poor.
While questions abound and results may not be immediately forthcoming in this extremely important issue, there is no doubt that intervention at the societal and community level must begin in childhood, possibly through the school system, as a history of food insecurity in the young has a way of “snowballing” into obesity in adults.

Friday, March 13, 2009

Primum Non Nocere, Secundum Treat Patients Not Diseases

There is a battle raging behind the scenes over how to address the shortage of primary care physicians in the current climate of diminishing revenues, increased patient loads, and lack of universal health care coverage. Enticing recent graduates of U.S. medical schools to enter the field of primary care has become an exercise in futility, as the amount of student loan debt accrued by newly trained physicians warrants entrance into more lucrative fields of specialization, such as those which are procedure-oriented and provide substantial reimbursement for instrumental and invasive therapies. While primary care is, indeed, a rewarding arena of endeavor, the current number of board certified primary care practitioners is hardly sufficient to buttress even the “tip of the iceberg,” which is beginning to topple, as older physicians leave the field for retirement and other pursuits, and as the few remaining go home on a nightly basis worried to death that they’ve made mistakes or not completed their work. If that were not enough, the increasing amount of paperwork inherent in the profession, the growing number of therapeutic options and new drugs available, and the added responsibility of providing continuous preventive care to patients whose socioeconomic backgrounds often pose additional limitations to an already complex patient management scenario often render job satisfaction a non sequitur. And for those of you out there who say that, “It’s all about the Benjamins” (Franklins, that is, and money, in short), there is much more to this story than financial remuneration. It has been found, for example, that when payments to primary care physicians are increased, they work no harder, and, in fact, reduce the number of patients they see. So, perhaps there are things more influential than money as motivators to primary care physicians to do a better job, and to neophyte physicians to enter the field of primary care. They might be, namely, a sane life, more leisure time, and the value of a job well done. For those who have truly dedicated their lives to the study and practice of medicine, no price tag can be placed on the latter.
We know the problem. Where does it all fit in the public health arena, and what can we, the public, policymakers, legislators, medical school faculty, state medical boards, and the Department of Health and Human Services do to increase the allure of primary care medicine, or to “conscript” new physicians into the ranks, perhaps in exchange for student loan debt forgiveness or other inducements? What we already know is this, that the current U.S. health care system is chaotic and in utter disarray, and that unless we, both the public health and clinical professionals “in the trenches,” come up with suitable and workable solutions to the primary care shortfall, provision of first-line health care is destined to worsen.
Solutions have not been immediately forthcoming, and the call to arms has been hampered by the sheer enormity of the undertaking and statistics showing that, in many cases, patients are cut off and interrupted by their physicians due to time concerns after an average of only 23 seconds of explaining their problems, that 50 percent of patients leave office visits not understanding what the physician has told them, and that it would take 18 hours per typical workday for primary care physicians to provide all the preventive and chronic cares services needed by their patients. Recently, two solutions have come to the fore, and perhaps it would be wise to look at them closely. One idea proposed has been to reduce daily patient load for primary care physicians to 10 patients per day. That would allow them more time per patient, but would most likely aggravate the already acute shortage of primary care physicians. The second solution, which appears more sage, would be to adopt a team approach to primary care. As a medical degree is not needed to perform all the daily tasks of a primary care physician, the latter might be delegated to ancillary staff. Physicians would become team leaders, seeing fewer patients per day, consulting with team members, handling telephone and electronic encounters requiring a physician, and ordering medication changes. All other duties currently managed by primary care physicians would be transferred to “health coaches” on the team, and their tasks would run the gamut from contacting patients and explaining changes made by the physician to their treatment regimens to listening to patients’ concerns and following up on patient compliance to treatment plans.
The solutions mentioned here are in their experimental stages, and nothing is written in stone. However, without serious attention turned to the monumental problem of primary care, the numbers of those physicians will most likely continue to dwindle, with obvious repercussions on the concern for hurt (nocere) inflicted on patients and with the little physician involvement available for patient care directed at numbers and diseases, not at living, breathing human beings and the plethora of interactive elements composing their well being as a whole.

Albert Provocateur

Sunday, March 15, 2009

Making the Grade

Return of the Scarlet Letter

Saturday, March 14, 2009

"I'm so Hungry, I'm Fat!"

Friday, March 13, 2009

Primum Non Nocere, Secundum Treat Patients Not Diseases

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