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Sunday, July 9, 2017

House Calls, STAT!

Just up at THCB:
Should Doctors and Nurses Be Patient Activists?

…Like most doctors and nurses, I try to keep the outside world firmly outside the exam room. I don’t talk about politics, religion, money, or sports. I don’t even gripe about the mayor. Most medical professonals avoid political activism for the same reason. But could that reticence be harmful to our patients?

I grappled with this over the past few weeks, as the House passed its American Health Care Act and then the Senate put forth its Better Care Reconciliation Act. As one detail after another was revealed, I began to worry about my patients. The cuts to Medicaid would do real damage to them. I had a number of fragile patients in mind who could die if their care was disrupted.

What would I do, I asked myself, if I started to notice a dangerous side effect of a medication that my patients were taking. The answer, of course, is easy. And it wouldn’t even be a question; it would be an obligation. If I see a threat to my patients’ health, it’s in my job description to speak up.

The ACHA and BCRA suddenly seemed like the same thing—a threat to my patients’ health. Yes, I value political neutrality, but this no longer seemed like politics to me. It was a medical threat…

If I suspect that one of my patients is suffering abuse at home, I am obligated—in fact, legally mandated—to speak up.  If I suspect that my patients’ health will be harmed by legislation, I believe we are equally obligated to speak up…

I’ve thought long and hard about whether this violates my commitment to political neutrality with my patients and I’ve concluded that it does not. I do not discuss these efforts with my patients, and I continue to keep the exam room as neutral as possible. When patients bring up politics—which they do frequently these days—I steer the conversation back to their medical issues because that is my job as their doctor. When I leave the hospital, I start calling Senators about BCRA because that is also my job as their doctor.

Right now it is estimated that 20,000 Americans will die each year because of the loss of insurance coverage and Medicaid from BCRA. To me, that’s a clear medical threat to our patients. It’s a medical emergency, and medical professionals need to behave as such.
I have cited the eloquent and empathic Dr. Ofri many times on this blog. See, e.g., here, here, and here.

Dr. Ofri's new book:

"Despite modern medicine’s infatuation with high-tech gadgetry, the single most powerful diagnostic tool is the doctor-patient conversation, which can uncover the lion’s share of illnesses. However, what patients say and what doctors hear are often two vastly different things.

Patients, anxious to convey their symptoms, feel an urgency to “make their case” to their doctors. Doctors, under pressure to be efficient, multitask while patients speak and often miss the key elements. Add in stereotypes, unconscious bias, conflicting agendas, and fear of lawsuits and the risk of misdiagnosis and medical errors multiplies dangerously..."
 Not read it yet. Into the never-ending queue it goes.

In her THCB post, she alludes to the #HouseCallsCampaign.

Every day, we medical professionals advocate on behalf of our patients.

Right now, millions of our patients stand to lose their health insurance if the Senate passes their healthcare bill. This would be disastrous for their health.

When a new drug comes on the market, we ask ourselves whether it would harm our patients before prescribing it. We need to think the same way about healthcare legislation.
If you think that the proposed legislation could harm your patients, join doctors, nurses and medical caregivers across the country who are calling the Senate. (We’ve named this the HouseCalls Campaign even though it’s the Senate that needs our medical opinion right now!)

As we all know, advocating for patients is as much a part of medical care as the medical care itself. It  takes only a few minutes to make a call.

"Right now it is estimated that 20,000 Americans will die each year because of the loss of insurance coverage and Medicaid from BCRA. To me, that’s a clear medical threat to our patients."

I don't think you'd have to look far these days to find a Republican who might allude to it as "culling the herd" if he thought he was speaking off the record. We seem to be rather firmly in the hard-hearted political nadir grip of the "Persecutor" phase of the "Rescuer - Victim - Persecutor Triangle."

The other day I saw an estimate of the U.S. medically uninsured rising to a total of 49 million or so in a decade should the GOP BRCA bill pass and become law. I did a quick Excel sheet.

Assume a blended annual compounding health care cost increase of 5% (current 1.9% "core" inflation plus general cost health sector increases above and beyond the inflation rate).

The latest per capita estimate per the NHE is ~$10,500. By 2021 the annual cost of just the uninsureds (assuming a total of 38M by then) approaches that of the entire U.S. Defense Budget. By 2026, assuming 49M uninsureds, the yearly price tag rises to about $800 billion --- with a "B."
And, yes, I know that this scenario further assumes that the per capita health care burden of the uninsureds is roughly reflective of the aggregate average (and, it's not much of a stretch to make the case that this overwhelmingly poorer demographic is and will be more costly). That's why you spreadsheet this stuff, to play with the various parameter estimates.
These costs (whatever their precise out-years magnitude) will get paid for one way or another.

Or, maybe not. We could just "cull the herd." Hey, I know! -- Rand Paul could introduce a bill to Repeal the EMTALA. And, "Rationing by 'Price'." (As in "priced out.")

Once again, I tout Elisabeth Ronsethal's excellent book "An American Sickness." See also my review of "ObamaCare is a Great Mess."

Make some House Calls.



"Yes, I fully appreciate the sentiments here and I believe doctors, like all other individuals, should be politically active. The health care legislation issue may feel more like an Ebola, but is it really? And isn’t this a bit late to the political “saving lives” game?

Without further ceremony, and please forgive me, but where were all concerned physicians during the last few decades when American workers had to watch their wages deteriorate to the point of having to rely on Medicaid and all sorts of other charity just to survive? Where were all the doctors when successive administrations traded away the U.S. middle class at the behest of global corporations and deranged activist billionaires?

Where were the doctors when our education system turned into third world crap, our inner cities collapsed and entire generations of boys and men of a certain color got carted away to prison? Where were the doctors when wars were/are fought for imaginary excuses and when the goddamn “resistance” is beating the drums of war with the largest nuclear power out there?

Where were the doctors when tech companies pushed their sick and addictive products on millions of children, who are wasting their lives powering the tech exploitation machine? And recommending optimal “screen times” doesn’t count. Speaking of addiction, where were the doctors when America plunged into an opioid addiction and mortuaries in small towns began to overflow with victims?

So my question is why now? Why is health insurance different than the other horrific events where your patients were/are literally being killed, not just estimated to maybe be killed in 2037?

Perhaps if I would have seen doctors marching against poverty, worker exploitation, slave-labor importation, environmental destruction, and such, this newfound political activism would not look so peculiar. And maybe, just maybe, if doctors started marching against those patient-killing evils decades ago, we wouldn’t have to march today.

Other than that, excellent article, as usual."
Yikes. From Donald Trump's Bolshevik in Chief. I have no way to know whether she's a seasoned front-line veteran of the Occupy Social Justice barricades or just another affluent First Chairborne Division Keyboard Commando.

Doctors and Nurses Need to Treat BCRA as a Medical Emergency
This isn’t about politics, it’s about health.
By Danielle Ofri 

Illness is not something most healthy people think about regularly. And they shouldn’t. Although as a physician I want to help my patients make smart choices to preserve their healthy state, I also don’t want to deny them the blissful innocence that comes with taking good health for granted.

However, just as the disability community coined the term “temporarily able” to refer to those without disabilities, the reality is that those of us who are healthy are only “temporarily healthy.”

A random encounter with an unprotected partner or a nasty stomach bug or the Second Avenue bus could bring anyone at any age into contact with the health care system. Just getting older and acquiring hypertension or arthritis can do it. And then suddenly you learn. You learn what your insurance does or does not cover. Or you learn what it means to get sick without insurance. You learn that you are not invincible.
For Americans who are still temporarily healthy, the politics of health care can feel distant. The details of the House and Senate’s health care bills can feel arcane and overly partisan...

Most senators have only a passing knowledge of what actually transpires when people make medical decisions. It is the people in the clinical trenches—nurses, doctors, physician assistants, med students—who know. These are the people who understand what happens when patients lose access to medical care. These are the people who will care for those 20,000 ill-fated patients—not in primary care clinics but in emergency rooms, ICUs, and morgues...
BTW, Michael Millenson posted the best comment under the THCB post that gave rise to this one of mine:
"Doctors always believe that the alarms they raise about any action by federal or state government, insurers, employers, health plans, hospitals, other medical specialties, other doctors in the same specialty who aren’t as smart/competent/ethical as they are and anything else related to health care are actions undertaken altruistically out of concern for patients.

As a result, some doctors warn that a single payer system, a la Canada, will kill patients, while other doctors warn just as sincerely that failing to adopt such as system will kill patients. While other doctors, of course, have every other opinion in between.

Because so many doctors, like Danielle Ofri, are eloquent writers, I believe all of them all at once all of the time."
With ‘shame on you’ chants and harsh tweets, nurses union pushes single-payer bill

To some, the California Nurses Association’s political tactics in pushing for a single-payer health system seemed a bit, well, New Jersey-ish.

Never mind the raucous demonstrations it brought to the state Capitol in recent weeks, the “shame on you” chants in the hallways, the repeated unfurling of banners in the rotunda despite admonitions from law enforcement.

To further the nurses’ cause, the union’s executive director, RoseAnn DeMoro, tweeted out a picture of the iconic California grizzly bear being stabbed in the back with a knife emblazoned with the name of a powerful state lawmaker who stalled the single-payer bill sponsored by the union.

Before and after that tweet, the legislator — a Democrat — said he was besieged by death threats.

Meanwhile, the union’s public relations guy blasted a blogger for Mother Jones magazine — named after the famous union firebrand — for being insufficiently liberal in his single-payer coverage. “Maybe you can recommend the name of your magazine be changed … to Milton Friedman, which would better reflect your class sympathies,” communications director Chuck Idelson wrote acidly…

Things are getting increasingly heated.


In addition to the 11th Annual Health 2.0 Conference (link at the top right of this blog), this should be on your calendar.

Registration link here
In the last 10+ years, Precision Medicine has seen a multitude of advances in the areas of diagnostics, computing, and consumer tools. The ongoing quest to better understand disease predisposition and prevention through genomic and environmental factors is key to increasing the quality and length of life. The Technology for Precision Health Summit, this coming October, will explore and showcase specific technology that tackles these issues and more.

Speaking of human health writ large, I give you a frightening, depressing article:

The Uninhabitable Earth
Famine, economic collapse, a sun that cooks us: What climate change could wreak — sooner than you think.
By David Wallace-Wells 

I. ‘Doomsday’

Peering beyond scientific reticence.

It is, I promise, worse than you think. If your anxiety about global warming is dominated by fears of sea-level rise, you are barely scratching the surface of what terrors are possible, even within the lifetime of a teenager today. And yet the swelling seas — and the cities they will drown — have so dominated the picture of global warming, and so overwhelmed our capacity for climate panic, that they have occluded our perception of other threats, many much closer at hand. Rising oceans are bad, in fact very bad; but fleeing the coastline will not be enough.

Indeed, absent a significant adjustment to how billions of humans conduct their lives, parts of the Earth will likely become close to uninhabitable, and other parts horrifically inhospitable, as soon as the end of this century...

IV. Climate Plagues

What happens when the bubonic ice melts?

Rock, in the right spot, is a record of planetary history, eras as long as millions of years flattened by the forces of geological time into strata with amplitudes of just inches, or just an inch, or even less. Ice works that way, too, as a climate ledger, but it is also frozen history, some of which can be reanimated when unfrozen. There are now, trapped in Arctic ice, diseases that have not circulated in the air for millions of years — in some cases, since before humans were around to encounter them. Which means our immune systems would have no idea how to fight back when those prehistoric plagues emerge from the ice.

The Arctic also stores terrifying bugs from more recent times. In Alaska, already, researchers have discovered remnants of the 1918 flu that infected as many as 500 million and killed as many as 100 million — about 5 percent of the world’s population and almost six times as many as had died in the world war for which the pandemic served as a kind of gruesome capstone. As the BBC reported in May, scientists suspect smallpox and the bubonic plague are trapped in Siberian ice, too — an abridged history of devastating human sickness, left out like egg salad in the Arctic sun.

Experts caution that many of these organisms won’t actually survive the thaw and point to the fastidious lab conditions under which they have already reanimated several of them — the 32,000-year-old “extremophile” bacteria revived in 2005, an 8 million-year-old bug brought back to life in 2007, the 3.5 million–year–old one a Russian scientist self-injected just out of curiosity — to suggest that those are necessary conditions for the return of such ancient plagues. But already last year, a boy was killed and 20 others infected by anthrax released when retreating permafrost exposed the frozen carcass of a reindeer killed by the bacteria at least 75 years earlier; 2,000 present-day reindeer were infected, too, carrying and spreading the disease beyond the tundra.

What concerns epidemiologists more than ancient diseases are existing scourges relocated, rewired, or even re-evolved by warming. The first effect is geographical. Before the early-modern period, when adventuring sailboats accelerated the mixing of peoples and their bugs, human provinciality was a guard against pandemic. Today, even with globalization and the enormous intermingling of human populations, our ecosystems are mostly stable, and this functions as another limit, but global warming will scramble those ecosystems and help disease trespass those limits as surely as Cortés did. You don’t worry much about dengue or malaria if you are living in Maine or France. But as the tropics creep northward and mosquitoes migrate with them, you will. You didn’t much worry about Zika a couple of years ago, either.

As it happens, Zika may also be a good model of the second worrying effect — disease mutation. One reason you hadn’t heard about Zika until recently is that it had been trapped in Uganda; another is that it did not, until recently, appear to cause birth defects. Scientists still don’t entirely understand what happened, or what they missed. But there are things we do know for sure about how climate affects some diseases: Malaria, for instance, thrives in hotter regions not just because the mosquitoes that carry it do, too, but because for every degree increase in temperature, the parasite reproduces ten times faster. Which is one reason that the World Bank estimates that by 2050, 5.2 billion people will be reckoning with it...
Read all of it.

More to come...

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