Thursday, November 20, 2014

Ebola Hits Home: What We’ve Learned So Far


by Todd Pollock, MD
Dallas County Medical Society President

It is days before the deadline and I am staring at this month’s President’s Page that seems meaningless in light of recent events. The first patient to develop Ebola in the United States walked into a Dallas hospital. A little over two weeks later, that index patient, Thomas Eric Duncan, has died and two nurses who cared for him were diagnosed with the disease. I feel compelled to put aside the essay I was working on and discuss this crisis. Never mind that by the time this goes to press, many of the unknowns will be known. Many of the burning questions will have been answered, and new questions will have arisen. We will learn a great deal when we dissect this experience, but I offer some contemporaneous observations.
Dallas has not been under such scrutiny since the Kennedy assassination in 1963, and I suspect that the nerves of the city and of the country were equally raw at that time, although for much different reasons. The World Health Organization calls the current African Ebola outbreak the “most severe, acute health emergency seen in modern times.” Until Sept. 28, Ebola was just a frightening disease in West Africa that we saw on the nightly news. But modern air travel makes Africa a plane ride away and makes the question of Ebola in this country not “if” but “when.” And that “when” is “now” as Mr. Duncan presented to the ED at Texas Health Presbyterian of Dallas on Sept. 28. Paraphrasing a hearsay quote of a THD administrator (who was paraphrasing Humphrey Bogart), “Of all the hospitals in all the world, he had to walk into ours.” 
I remember first learning of Ebola in Richard Preston’s 1994 book “The Hot Zone,” which was based on true events. For some reason, just the name, Ebola, evokes fear. The first known infection occurred in 1976 deep in the jungles of Zaire near the headwaters of the Ebola River for which it was named. As with many viruses, Ebola jumped from its animal host to man where the jungle met society. Over the years, outbreaks would spring up periodically and remit spontaneously, likely due to the isolation of the affected villages. This most recent outbreak has gotten out of control in West Africa, killing more than 4,500 people to date. WHO projects this number to grow exponentially unless the virus can be effectively contained and controlled. Containment efforts to prevent spread outside of Africa have been hotly debated. Specifically, the controversy centers around screening methods, travel bans and mandatory quarantines of travelers from those affected West African countries.

Big-Picture Lessons We Have Learned to This Point 
Our biggest enemies are ignorance and fear.
Margaret Chan, general director of the World Health Organization, said that “fear of infection has spread around the world much faster than the virus” and that 90 percent of economic costs connected to the virus “come from irrational and disorganized efforts of the public to avoid infection.” Many examples of this can be seen in Dallas. We have seen patients cancelling appointments and surgeries. Concerns have been generated about using public transportation, air transportation, and even ambulance transportation. We have seen children turned away from schools because their parents work at Presbyterian Hospital. DART stations shut down because a commuter became ill. Ambulances and airplanes have been taken out of service and cruise ships turned away from ports. The cure for this irrational action is factual information.

The media must remain responsible in its reporting.
In a situation like this, the media should be our greatest ally in satisfying the public thirst for information. Fact-based reporting is helpful in allowing the community to understand its risks, avoid infection and, we hope, quell fears. Unfortunately, 24-hour news and the competition created by the great number of news sources have left the public to sort out good information from the abundance of poorly sourced material, misinformation, speculation, and half-truths. We have seen too many examples of the media second-guessing and finger-pointing in the name of investigative journalism. We have seen dramatic on-camera reporting worthy more of an Oscar than a Pulitzer. This has resulted in an atmosphere of unwarranted public fear, distrust and irrational behavior. 
Fortunately, some in the media have recognized the importance of their role and made efforts to spread fact-based information. John McCaa and WFAA launched the “Facts, Not Fear” campaign to promote dissemination of scientific information and to fight fear mongering. Efforts like this should be commended. I also found several of Jacquielynn Floyd’s columns in The Dallas Morning News to have a refreshingly level-headed message. To other members of the media who are committed to responsible journalism, I commend their efforts, as well.

Physicians, hospitals and public officials must maintain the public’s trust.
I am very proud of the actions of everyone at Texas Health Presbyterian Dallas who bravely and professionally carried out their duties in the face of this frightening situation. But, despite valiant efforts to be prepared and close adherence to CDC protocols, we cannot deny that errors were made. It is easy to play Monday morning quarterback, but we should not have to apologize for the fact that we don’t have a lot of practical experience with this situation. Unfortunately, PR mistakes by the hospital hurt public confidence. Putting out information before details are known breeds mistrust. Confidence is built through forthright honesty. Errors and mistakes are more readily accepted when presented in an up-front manner. Over the last several years, the admission of medical and surgical errors has been promoted as a best practice that should be communicated along with appropriate apologies. Hospitals have championed this concept. They need to take their own advice. 
Unfortunately, many efforts made to calm fears only led to public doubt and concern. This occurred when what was said conflicted with actions taken. For instance, the public was told that passengers on airplanes that carried an asymptomatic, exposed person had no chance of catching the disease. Yet, these planes were taken out of service and deep cleaned, often multiple times. Similarly, the apartments of the infected nurses were treated like a hot zone, but the neighbors were told they were not at risk. Although I understand that these efforts were made to be extra cautious and to be reassuring to the public, the conflicting message created suspicion and distrust.  
Public officials and trusted community leaders should be committed to comforting the public through fact-based comments. This is not a time for these trusted individuals to advance speculation, fear mongering or politics.  Community leaders who publicly blamed Mr. Duncan’s initial ER discharge and fatal outcome on his race and insurance status made absurd allegations that generated unnecessary and unwarranted fear.

Healthcare officials must remain unified in action and voice. 
When mistakes are made, the media begins its unrelenting probing for blame, and those involved have a natural defense of pointing fingers. This unproductive exercise drives a wedge between agencies, organizations and individuals. No one stands alone in these complex situations and everyone has their roles. Breakdown of cooperation invites disaster, and an inconsistent message will further public mistrust and fear.  

Physicians’ actions must be based in science, not fear.
As healthcare workers, we are on the front line of patient care, and when a disease as horrific as Ebola potentially is in our community, it is normal to fear for the safety of our staff, our families and ourselves. It is imperative that we base our actions and words on science and not fear. We are role models in matters of health, and our patients listen to what we say and watch what we do.  

We must learn from our experiences, both triumphant and tragic, and make changes when appropriate.
In light of the infection of two healthcare workers who cared for Mr. Duncan, the CDC has changed some of its protocols. This has generated criticism from the media, leading to the undermining of public trust. But we cannot let this criticism derail us from what we always have done — advancing medicine through careful examination of our successes and our failures. We all share the experience of M&M conferences or the like, wearing our failures on our sleeves but coming out the better for it. The public must understand that Ebola is a disease that never has been on our soil, that few physicians in our country have seen a case, and that a relative few physicians in the world have any significant experience in treatment. Additionally, we cannot let our pride get in the way of admitting error and need for change. The head of the World Health Organization said, “Hubris is the greatest danger to the wealthy countries.” As usual, we must face our errors head-on, determine what we did both right and wrong, and make changes as indicated. 

We must hold up as heroes those whose professionalism placed the care of the patient above themselves.
We all owe a great debt of gratitude to the paramedics, nurses, lab techs, janitorial staff, and host of others who selflessly cared for those stricken with Ebola. We also must appreciate the first responders, the ER staffs and office staffs who interact each day with the public, never knowing if they may be dealing with the next Ebola victim. The nurses who contracted the disease while caring for Mr. Duncan deserve our deepest praise and our most heartfelt prayers for recovery. Those who cast blame on these individuals should be ashamed.  

DCMS plays an important role in health-related issues of our community.
DCMS has been actively involved in the Ebola situation from the beginning. Our members have played roles in everything from directly caring for the victims at Presbyterian Hospital to participating in the development of a regional medical disaster plan. We have manned the Dallas Emergency Command Center and given counsel to city officials and schools. One of the stated goals of the society is to be the “definitive source of healthcare information in North Texas.” To this objective, DCMS has been a key source of fact-based medical information to city officials, the media and the public. A page on the DCMS website* provides up-to-date information and references. Our members have participated in interviews, town hall meetings, and social media Q&As. We all can be very proud of DCMS and its members for meritorious participation at every level as Dallas navigates this frightening and potentially disastrous ordeal.  

*www.dallas-cms.org/community_health/ebola.cfm

 This post first appeared as the President's Page in the October 2014 Dallas Medical Journal.
   

US Health Care vs The World: Quality Part II

by Todd Pollock, MD
Dallas County Medical Society President

Last month, I wrote about the recently released Commonwealth Fund study that compared the US healthcare system to that of 10 other industrialized countries. The study concluded that, according to its quality indicators, the US healthcare system ranked last. A critical examination of this study reveals flaws in its methodology and bias in data chosen as quality indicators; these errors cast doubt on the study’s conclusion. The study also found the US healthcare system to be too expensive. On the surface, it is shocking that the US per capita healthcare expenditures are so much greater than in other countries. The United States spent $2.7 trillion in 2011 (the year reported in the study), or $8,508 per capita, compared to $5,669 for the next highest country reviewed (Norway). Although total cost lowered our rankings in this study, many other factors should be considered.

Aging Population
For instance, the population of Americans over age 65 is our fastest growing demographic. This represents more than 40 million people (or 13 percent of the population), and that number is expected to double in the next 25 years. This increase is due to longer life expectancy and the aging of the populous baby boomers. According to UN statistics, the population of people age 65+ across the world is increasing and, on average, is rising faster in the United States than in Europe. With advanced age comes more chronic disease and increased healthcare cost. When looked at by age, the United States spent $18,424 per person (Health Affairs, May 2014) on older citizens. In a sense, cost increases are a product of our healthcare success.

Social Factors
Other factors that are not specifically a flaw of the healthcare system contribute to the high cost of US healthcare. For example, obesity rates in this country are the highest in the world. According to the Organization for Economic Cooperation and Development, almost 28 percent of adults and 17 percent of children are obese. Social factors such as dietary trends, decreased physical activity levels, and increased automobile dependence correlate with the rising obesity rates in the United States as compared to Europe. Treatment of obesity and its sequelae, such as cardiovascular disease and diabetes, have significant effects on our healthcare spending, as do other social factors including higher rates of violent crime, motor vehicle accidents, and drug and alcohol abuse. None of these are associated with flaws in the healthcare system itself.

Malpractice Litigation
One cannot assess the cost of US healthcare without considering the effects of medical malpractice litigation. Many people consider this to be central to high US healthcare costs. For one, there is a mentality in this country that with any negative outcome, someone must be to blame and someone must pay. An estimated 85,000 to 100,000 malpractice suits are filed annually.
A 2011 study in the New England Journal of Medicine reported that 75 percent of physicians in low-risk specialties and 100 percent in high-risk will be sued during their careers. Although 80 percent of claims are dropped or result in no payment, a Harvard study found an average cost of more than $23,000 to defend a suit that doesn’t go to trial; that cost skyrockets if the case goes to court. Fear of lawsuits has led physicians to order tests and treatments solely to guard against what might be criticized in retrospect — so-called defensive medicine.

According to a Gallup poll, one in four healthcare dollars (or $650 billion to $850 billion) is spent annually on defensive medicine. The US system does little to deter improper claims. By contrast, in Canada, the United Kingdom and most of Europe, trial costs are lower (a med-mal trial in Canada costs 10 percent of a trial in this country), awards are substantially lower, judges have more leeway in directing a jury trial, and the loser of the suit is responsible for the legal fees of the winner. This has kept litigation in check in those countries.
In Texas, we were fortunate to have enacted tort reform in 2003. This significantly has decreased unwarranted malpractice lawsuits and cut malpractice insurance premiums in half. Unfortunately, change has been slower in the practice of defensive medicine. According to a 2012 survey, more than 70 percent of Texas physicians report they have not changed their defensive medicine practices since the enactment of tort reform. National reforms are needed to repair our malpractice system in order to change the litigious climate and curb defensive medicine practices.

Unfortunately, the Affordable Care Act ignored this issue. This is an area in which we can learn from the Canadian and European systems, but change will be difficult due to the politically influential and well-financed trial attorney lobby. Waste, Fraud and Abuse Improper insurance payments play a role in the high cost of US healthcare, including fraud (knowingly cheating), abuse (bending rules or carelessness), and waste (unnecessary or ineffective care). The Center for Medicare and Medicaid Services estimated that in 2011, $98 billion was wasted on improper payments for Medicare and Medicaid. Improper payments generally are believed to make up 10 percent to 15 percent of all CMS payments. When we think of Medicare/Medicaid fraud, we tend to think of the perpetrator as a healthcare provider. But this type of fraud is so lucrative that it has drawn criminals at all levels, including Russian and Nigerian mobs and home-grown crime syndicates.

Private insurance companies fare better, with about 1 percent to 1.5 percent of payments being “improper” and resulting in rising premiums. In an attempt to clamp down on this huge monetary waste, CMS is moving away from the “pay and chase” model because recovery efforts are expensive and the money usually is long gone by the time they catch up to the criminal. Rapidly changing and overly complex rules (for example, ICD-10) put even the physician walking the straight and narrow at risk of accusation of waste and abuse. (I covered some of this in my July 2014 President’s Page.)

Innovation Costs
Another area with significant bearing on healthcare costs in this country is the cost of innovation. Let’s take pharmaceuticals as an example. The United States develops more than half of all drugs approved worldwide.
We lead the way in most important subcategories, such as innovation of drugs with unique mechanisms (vs modification of already known compounds called “metoos”), drugs for unmet medical needs, and almost all biotech-related drugs. The average direct cost to bring a new drug to market is $1.3 billion. However, a high risk is inherent in pharmaceutical development and only one in 10 drugs developed actually makes it to market. Because of this, most industry experts believe the cost of the failures must be considered when determining the actual cost of drug development (cost of all drugs developed/drugs that make it to market). This makes the cost of a successful drug development more like $4 billion to $12 billion.
Shockingly, we are the only major country that allows drug prices to be set by the marketplace. In the UK, Canada and Europe, the prices are regulated (and limited) by their governments. In other words, our prescription drug spending subsidizes the rest of the world, and not just the developing world. The Congressional Budget Office reports that the “average prices for prescription drugs in the United States are 50 percent to 100 percent higher than in other industrialized nations.” The ACA is attempting to lower drug prices by exhibiting increasing control over the pharmaceutical industry. Although this may save US citizens on their prescription costs, it will inhibit drug innovation.

Out-of-Pocket Costs
Despite countries having governmentrun universal coverage, the consumer often faces significant out-of-pocket expenses. According to the Organisation for Economic Cooperation and Development, a source of financial data in the CWF study, the United States has one of the lowest out-of-pocket costs for health care in the world. In this country, the out-of-pocket proportion of total healthcare expenditures is 13 percent; the average in the industrialized world is 20 percent, and every country evaluated in the study was higher than the United States. Yet, because of shortcomings in their systems, Europeans are turning more and more to private insurance and private pay to supplement health care provided by the government.
In the UK, 6 million British citizens spend $14.5 billion to purchase private health insurance despite paying $3,500 annually for every man, woman and child, according to Stanford’s Hoover Institute. This trend is seen in other study countries, as well. Sweden, considered one of the most successful socialized healthcare systems, costs about $20,000/household annually in taxes. Yet 12 percent of Swedes bought additional private insurance in 2013 because of treatment backlogs in the government system.

Tax Increases
Another consideration is the increase in overall taxes when government gets in the middle of health care. According to a KPMG report, the United States is in the middle of the pack for personal income tax rates, ranking 55 among 114 countries with “advanced economies.” In addition to a lower income tax, overall taxes in the United States are lower because we don’t have a national sales tax (value-added tax) as seen across Europe. Comparing taxes by country is best done by looking at the proportion of all taxes to the overall economy or gross domestic product. US federal taxes are 27.3 percent of GDP; the average among all industrialized countries is 36.2 percent. In all countries reviewed in the CWF study, taxes, as a proportion of GDP, were well above the US average. In other words, citizens will pay the tab for health care one way or another. The added bureaucracy and waste which is seen when government gets in the mix is significant in considering cost. We already have seen significant tax increases related to the ACA, and with further maturation of this law, US taxes are anticipated to catch up to European levels by 2020.

Conclusion
There is little doubt that the US healthcare system is expensive and appears to be much more costly than in its peer countries. However, looking superficially can be deceptive and lead to false conclusions. This can lead to solutions that are ineffective and, in the case of something as complex as health care, result in unintended consequences such as paradoxical lowering of quality, increasing cost and stifling of innovation.
Let’s face it — health care is an incredibly intricate system with innumerable interrelated parts. How our current path through the Affordable Care Act will affect overall cost of our health care remains to be seen. Canada and Europe have struggled with “socialized” medicine for 40 years, and it is far from a panacea. Yet, this is the path the ACA appears to be nudging us down. I have great concerns that the ACA will be detrimental to both the cost and quality of US health care. But I return to the same conclusion I reached last month: Our system is in need of real improvements. But real improvement only comes with real, honest, reliable data and not pseudo-scientific, opinion papers with a political agenda.

 This post first appeared as the President's Page in the September 2014 Dallas Medical Journal.

US Health Care vs The World: Quality Part I


by Todd Pollock, MD
Dallas County Medical Society President

Without question, the US healthcare system has its problems. It is overly bureaucratic, inefficient and expensive, to name a few. But is it really the worst healthcare system when compared to 10 other industrialized countries, as concluded by the Commonwealth Fund study “Mirror, mirror on the wall” (June 2014)? The study found that, despite being the most expensive system among its peer countries, the US healthcare system performed the poorest in almost all categories while the United Kingdom topped the chart. Headlines included “US health care ranked dead last compared to 10 other countries” (Forbes), “US healthcare system ranked lowest in international survey” (CBS), and “US health care ranked worst in the developed world” (Time). The results seemed wrong empirically, so I looked into it further.

While reading the study, my initial impression was that it read like an editorial and not a scientific study. I considered whether a bias existed. Let me start with an admission: I am biased. Being a US physician, I take this criticism personally, and I tried to keep this in mind as I looked further into the study. In reviewing the Commonwealth Fund study methodology and the data points selected, I began to suspect that bias existed on the study’s part, as well.

The CWF study primarily is based on patient and physician opinion surveys. However, opinion is not an indicator of quality and is inherently flawed by cultural differences, perceptions and expectations. I suspect this is even more true when comparing opinions internationally.

Coincidentally, I came across a study published in the August 2014 Proceedings of the National Academy of Sciences that looked at happiness using fMRI and complex formulations. It got me thinking about the results of the CWF study. As it turns out, happiness isn’t so much about what happens to you but whether what happens to you is better or worse than you expected. As the adage goes, “Expectations are future resentments.” US consumers are notoriously demanding and have high expectations. In countries that have healthcare service with famously poor reputations (such as the UK’s National Health Service), expectations likely are lower. Therefore, it would stand to reason that if the services provided outperform the expectations of the consumers, they may be happy with them. Thus, survey results may indicate the level of satisfaction but shouldn’t be interpreted as higher quality.

The CWF concedes this, stating, “Patients’ and physicians’ assessments might be affected by their experiences and expectations, which could differ by country and culture.” It also says that “any international comparison of health care is subject to inherent weaknesses… . Different measures, moreover, are given equal weight in the rankings and are not weighted based on independent evidence of what patients value most highly.”
I also considered whether the CWF cherry-picked the data points it selected in order to produce a predetermined conclusion. The data points measured seemed to be weighted to benefit the universal coverage of the European systems, emphasizing “access to care” and “equality.” Although these certainly are important qualities for a healthcare system, simply having access to care does not mean that care is available nor indicates the quality of care. Case in point, the UK’s newspaper, The Times, reported in August that the NHS will miss its treatment goals by a mile. The target of 18 weeks to treat patients is backlogged to well over a year. Plans have been developed to manage this backlog but fall in the category of robbing Peter to pay Paul, as resources are taken from one pot to bail out another. The British Medical Association has accused the UK government of trying to “disguise” rationing of care. The BMA says, “The NHS is lurching from one missed target to another with the government failing to get to grips with the root of the problem.” These reports seem to leave doubt about the UK’s top finish in timeliness of service.

This accusation of rationing has been leveled at other areas of the UK healthcare system, such as surgical services, cancer treatment and services for the elderly. Many of these factors, if considered in the study, likely would have favored the United States and bolstered its rating. An investigation by the Royal College of Surgeons discovered rationing of surgeries “by imposing arbitrary rules governing access to routine surgery.” Clare Marx, president of the RCS, says that the motivation for this may or may not be financial, but “it is clear that the UK health system does not commission services using clinically accepted, evidence-based guidance.”
International cancer survival rates are well studied, and the United States leads the world in survival rates. The CONCORD study published in The Lancet; Cancer found a 5-year survival rate of 91.9 percent in the United States in all cancers reviewed, compared to 57.1 percent in Europe. Other cancer studies have shown similar results. And, care to older UK citizens frequently has been criticized, with one report claiming 130,000 older patients die each year due to lack of appropriate or timely treatment. Another glaring absence is an assessment of healthcare innovation, in which the United States is a world leader. These were just a few things I found with a quick Internet search. I can’t say if the data points used were deliberately selected to support their conclusion. I can say that the data points they used were incomplete in their representation of healthcare quality.
What about the conclusions reached by the CWF? For instance, the study states that “this examination provides evidence (emphasis mine) of deficiencies in the quality of the US system, as reflected by patients’ and physicians’ experiences.” Based on this study’s methodology, the conclusion may be that gaps exist between patient and physician expectations relative to those of other countries, but I don’t believe one can conclude deficiency in quality.

In lauding the UK for the number one ranking in efficiency, the CWF states that “the widespread and efficient use of health information technology in the UK plays a large role in its high score on the chronic management indicators, as well as its performance on system aspects of preventive care delivery.”

Yet, in looking into the UK’s health information technology, the NHS-National Programme for IT (named Lorenzo) cost almost $20 billion; has been continually plagued by problems, delays and cost over-runs; and was labeled “unworkable” by the House of Commons Committee of Public Accounts. It subsequently has been all but scrapped and yet continues to “incur significant costs” to the tune of a forecast $16.2 billion, calling it “the biggest IT failure ever seen.” (This makes healthcare.gov, which has cost only $840 million, according to the most recent GAO report, a comparative success.) This conclusion alone casts real doubt on the report.
The Commonwealth Fund’s recent study concludes that US health care is costly and poor, relative to its peer industrialized countries. However, when examined critically, this study has many flaws, including suspected bias, erroneous methodology and unfounded conclusions. Critical assessment by the media is sorely lacking these days, settling for sound bites and shocking headlines, and taking the study at face value. I didn’t intend to be hypercritical of the UK, but because it was found to be the leader in healthcare quality, I used it as an example to demonstrate problems with the study.

In fact, I believe that health care in all of the countries studied is excellent and the difference between number one and number eleven is small. I’m sure that each system has exceptional parts along with their failings. Our system is far from perfect, and in need of real and ongoing improvements. But real improvement comes only with real, honest, reliable data and not think-tank opinion papers that support organizations’ political objectives.

The study found the US healthcare system to be the most expensive, by far. Next month, I’ll compare the cost of US healthcare to its peer countries.

This post originally appeared in the President's Page of the August 2014 Dallas Medical Journal.

Friday, August 15, 2014

Physicians can refer patients to new no-cost YMCA Diabetes Prevention Program



Do you want to help senior patients avoid type 2 diabetes, but aren’t able to ensure they make the appropriate lifestyle changes? 

All it takes is a simple blood test to refer them to the YMCA’s Diabetes Prevention Program, which includes a free year-long membership to the YMCA.


More than 50 percent of people over 65 years old are at risk to develop type 2 diabetes, but many don’t even know they’re at risk. The YMCA’s Diabetes Prevention Program was created to help people who are at high risk of developing diabetes make the necessary adjustments to their diet and exercise routine through personalized coaching.
The best part? All you, as a physician, have to do is order a blood test and then recommend that the patient enrolls in the program. In order to qualify for the program at no cost, a participant must have healthcare coverage through Medicare, be overweight (BMI ≥ 25), and have a hemoglobin A1c value between 5.7 and 6.4 percent or a fasting plasma glucose (mg/dl) between 100 and 125. 
Dallas is one of 17 communities chosen to participate in the initial launch of this project, which is funded by a grant from CMS’ Center for Medicare and Medicaid Innovation. The American Medical Association is working with the YMCA in six cities to pilot programs that will improve access to diabetes prevention coaching, but Dallas is not on that short list.
Mona Roach, MD, is a family physician in Minnesota who was frustrated with the limited program options for patients at risk for diabetes. Although she referred patients to see a dietician or to enroll in a paid program such as Weight Watchers, the cost of those options could be prohibitive. 
“You try to give as much encouragement as you can, but, ultimately, it’s up to the person,” she says. “I could talk to somebody once in the office about it, but then they leave and do what they want.”
Last year, Dr. Roach encouraged two of her patients to participate in the year-long YMCA Diabetes Prevention Program. One of her patients lost 25 pounds through the lifestyle modification program and saw her blood glucose drop nine points.
“The YMCA program really combines the diet and exercise and education elements,” Dr. Roach says. “It’s definitely the best tool we have.”
Linda Funk was one of the first patients in Dallas to enroll.
“Even though I have had weight issues most of my life, my yearly test results were pretty much in the normal category,” she says. “But last fall, my doctor told me that my glucose level was too high and that I was at high risk for developing diabetes.  Type 2 diabetes was suddenly a very real — and frightening — possibility.”
Through enrollment in the YMCA Diabetes Prevention Program, she learned the changes she needed to make in order to avoid diabetes. 
“At each meeting, I received specific suggestions on how to make changes to my life that could delay or even prevent the development of type 2 diabetes,” she says. “The program is not a magic potion — I still had to make the decision to implement those changes — but now, armed with the knowledge and support that I have gained from the weekly meetings, I have been able to turn my outlook around.”

For more information about the YMCA’s Diabetes Prevention Program, including promotional materials you can distribute to your patients, call DCMS at 972-948-3622 or email steven@dallas-cms.org.

Wednesday, August 6, 2014

How Emotions Can Affect Your Practice


by Todd Pollock, MD
2014 DCMS President

I hate complications! I assume this is true for all physicians. Fortunately, as a plastic surgeon, my patients typically are healthy and complications are uncommon. But no matter how careful we are, complications eventually will occur.
Rachel (a pseudonym) was a healthy woman in her mid-40s with two kids and an active lifestyle. She fit squarely into the statistical norm of my patient demographic. Her abdomen showed the typical physical sequelae of having two kids and included a C-section scar. Rachel and her husband were pleasant, upbeat people who worked full-time jobs, exercised regularly and chased their young kids around. I felt an instant rapport with them. She underwent an uncomplicated abdominoplasty and spent one night in the hospital. The next day and at the one-week follow-up, the surgical site looked great from both a postsurgical and an aesthetic standpoint. 
About three weeks out from surgery, Rachel called my office complaining of a severe headache, malaise and a fever of 102° F. I saw her immediately. Despite knowing that I had done the procedure appropriately and that this was an unusual timeframe for a postoperative infection, feelings of fear and guilt settled in my stomach as I took her chart from the door of the patient room. Rachel looked ill, but her surgical site looked appropriate for three weeks post-op and she showed no signs of a surgical site infection. An instant feeling of relief coursed through me. I did sympathize with her and how ill she was, and considered what might be the cause. This occurred near the peak of flu season, and her symptoms fit that bill. I contacted her primary care physician, who agreed. After seeing her, he called and told me that, despite a negative rapid flu test, he believed the symptoms were so classic that he started her on Tamiflu® empirically. Again, I felt relief and a little pride in making the medical diagnosis. 

Complications
My boosted spirit was short-lived. The next morning, Rachel showed up at my office looking similarly ill, but her abdomen was markedly swollen, fluctuant and bright red from pubis to umbilicus. My feelings of fear and guilt from the previous day returned; I felt as if I’d been punched in the gut. Ever-so-briefly, my head fogged and my expression showed my shock. Luckily, she didn’t notice, as she was recumbent and staring blankly at the ceiling in a febrile haze. I recovered quickly and got her to the operating room. Upon opening the incision, I was met with a sea of foul-smelling pus, a cavernous wound and the terrifying degree of devitalized tissue. My feelings overwhelmed me and my head swam. I paused briefly to collect myself and forced down my emotions as I had been trained. 
After two returns to the OR for further debridement, the better part of a week in the hospital for twice-a-day painful dressing changes, two months of very close follow-up, and a revision of the scar, I can tell you that the end result was positive. Surprisingly, the final result was aesthetically as if the infection had never happened. Isn’t Mother Nature amazing? Possibly even more surprising, I had a happy patient singing my praises and an abundance of lessons learned. Most of these lessons were not regarding medical care (despite reviewing every detail in my head hundreds of times), but were about my emotions and how they affected my delivery of that care.
The feelings of physicians as they journey through their careers, from medical student to seasoned physician, was the subject of the 28th annual Conference of the Professions held in May and hosted by DCMS. This annual conference brings together members of the area’s medical, legal and theological professions to explore shared challenges. The host rotates among the professions; other groups participating were UT Southwestern Medical School, Dallas Bar Association, SMU Dedman School of Law, SMU Maguire Center for Public Responsibility, and SMU Perkins School of Theology. 
This year’s topic, “Agony and Ecstasy: How Your Emotions Affect Practice,” was presented by Danielle Ofri, MD, PhD, an internist at NYU by day and a prolific author by night. Her area of interest is the emotions of physicians, which she analyzes and covers extensively in her most recent book, “What Doctors Feel; How Emotions Affect the Practice of Medicine.” This book is an excellent read and I highly recommend it to all practicing physicians. It opened my eyes to the complex backdrop of emotions that engulfs us through our medical practices, and helped explain the myriad of feelings, experiences and issues we physicians share.  

Empathy is Central 
Classical medical education has emphasized that physicians must remove emotion to avoid clouding their judgment. Renowned medical educator William Osler, MD, in an address to the University of Pennsylvania 1889 medical school graduating class, stressed that “a certain measure of insensibility is not only an advantage but a positive necessity in the exercise of a calm judgment.” Yet, as humans, all of our interactions are encased in a milieu of emotion. Modern-day psychology has shown that we cannot separate cognition from emotion. The quality of the care we deliver can be affected in a positive or negative way based on if and how we choose to understand and process these emotions. I guess even old Osler recognized this as he wrote later in his career that “it is much more important to know what sort of patient has a disease than what sort of disease a patient has.”
The physician’s emotional understanding of the patient’s perception of his or her illness describes empathy, something we all discussed in our med school application essays and display to varying degrees in our practices. Dr. Ofri defines empathy as “recognizing and appreciating a patient’s suffering.” This seems central to the practice of medicine, and yet demonstrations of empathy can vary widely among physicians. The Jefferson Scale of Empathy has shown that a patient’s perception of his doctor’s empathy can have effects beyond their personal relationship. Remarkably, treatment outcomes have been linked to physician empathy. Improved controls of patient blood sugar and cholesterol as well as better oncologic outcomes all have been linked to physicians who have higher degrees of empathy. Empathy is the element that creates the subtle difference between curing and healing a patient. A cookbook algorithm, so common in medicine today, may be able to cure a patient; only an empathetic physician can heal one. I could have cured my patient’s infection with the proper medical protocol alone, but I suppose that my empathy was what made her a happy patient in the end.
The roller coaster of emotions that we experience in our medical practices affects, consciously or subconsciously, our decision making and treatment choices. My teachers echoed this. The wise Dr. Robert McClelland said that we spend our careers learning through academic sources and base our practices on our last patient. I suppose that is the “art” part of medicine. But that also is our emotions over riding our intellect.
The late and beloved Dr. Gary Purdue said that every rule in the Parkland Burn Unit has a resident’s name and the mistake he or she made attached to it. (I know the rule that has my name attached, but that is for another day.) He was saying that we learn from our mistakes, and we make adjustments or rules in our practices based on those mistakes.  
A 2000 Institute of Medicine report estimated that each year medical errors result in between 44,000 and 98,000 preventable deaths and 1 million excess injuries. These numbers have been disputed, but it shouldn’t surprise anyone that errors in medicine occur. After all, we are human and, thus, fallible. But it is the emotions that surround these errors and how we handle those emotions that make us better or worse physicians in our future interactions. Studies have shown that doctors retain strong emotions many years after a negative incident. This can surface as behavioral issues (from being generally ill-tempered to disruptive), burnout (leaving practice early), as well as drug and alcohol abuse.

Overcoming Imperfection
Review of errors is important in our growth as physicians. But, how we review errors can have a greater effect on us than we may realize. The old-school M&M probably did more harm than good. Dr. Ofri says that we experience two inherent and distinct emotions in a poor patient outcome — guilt and shame. Guilt is associated with a particular incident and resolves as the issue resolves. She says that shame, however, is an emotional reaction to the experience of failing to live up to one’s image of oneself. Shame means that we have to accept ourselves as imperfect, and humility is not a common characteristic of the stereotypical doctor. However, if our failings are driven in too hard, we may lose confidence. Although a more temperate intervention and review of an error can reinforce the lesson and make for a more careful and better physician, harsh treatment can be very destructive. For instance, many excellent physicians never emotionally recover from the harsh insult of a lawsuit, even when absolved of wrongdoing.
Our daily practice of medicine is immersed in a complex web of emotions — empathy, fear, shame, joy. And while animals may act on instinct alone and machines purely on data, humans cannot help but be affected by emotions. This especially is true in the physician-patient relationship where often we are involved in the most intimate parts of our patients’ lives: births, deaths, life-changing diagnoses, and even complications of our own treatments. Understanding the effects, both positive and negative, that our emotions play is important in how we practice, how our patients perceive us, and how they respond to our care. In the simple words of Dr. Francis Peabody, “The secret of the care of the patient is in caring for the patient.”

This post originally appeared in the President's Page of the August 2014 Dallas Medical Journal.

Wednesday, July 23, 2014


The Sunshine Act: Is it just another attack on the physician's character?

I’m concerned about what is happening to the image of physicians in this country. Throughout history, physicians have enjoyed a stellar reputation as noble, trustworthy and selfless professionals who champion their patients. Although times have changed over the millennia since Hippocrates, I see the embodiment of this spirit in my colleagues every day. Of course, like all human endeavors, we have our share of those who work on the fringe, who use their position and the trust instilled in them to take advantage of the system or the individual. That, too, I have witnessed.

I contend that these make up only a fraction of the profession and truly are outliers; however, several recent instances have spotlighted this fringe element of medicine, painting physicians as a whole in a negative light and trampling our good reputation. These things, initiated by our government, have come in the form of statements, regulations, policies, and laws which, intended or not, all potentially damage the image of the physician by implying our across-the-board complicit dishonesty, greed and abuse of the healthcare system.

I don’t know if this is the absolute genesis or just when I began to take note. In the summer of 2009, President Obama was working overtime to drum up support for his signature healthcare reform bill. He traveled across the country speaking multiple times a day to groups large and small. His passion was palpable and he was clearly well-prepared. At a press conference in late July 2009, the president told the press corps: “Right now, doctors — a lot of times — are forced to make decisions based on the fee payment schedule that’s out there. Your child has a bad sore throat or repeated sore throats. The doctor may look at the reimbursement system and say to himself, ‘You know what? I make a lot more money if I take this kid’s tonsils out.’ ”

What? Did he really just say that? Surely this man, who is basing his legacy on reforming the healthcare system of the United States, knows better. Surely he has competent advisers. He must have misspoken in the heat of the moment. But less than one month later, at a town hall meeting in Portsmouth, NH, the president went in for another jab. After detailing the medical treatment of a diabetic patient, which he states “might reimburse a pittance,” he said, “But if that same diabetic ends up getting their foot amputated, that’s $30,000, $40,000, $50,000 — immediately the surgeon is reimbursed.”

There are so many things wrong with that statement, starting with whether internists are letting diabetics get worse for the financial benefit of their surgical colleagues and progressing through a series of increasingly absurd statements to the side-splitter that “immediately the surgeon is reimbursed.” This is from the mouth of the president of the United States, with all of his resources and all of his advisers and all of his presumed knowledge of this system he is determined to completely redesign. Why would he say something so damaging to the trust between doctor and patient?

This past April, we saw the fed’s public release of raw, unverified Medicare physician payment data that showed tens of billions of dollars paid out to physicians. No explanation was given of the work that was done for those payments. This incited a media dog-pile that focused on a tiny fraction of physicians who collect millions of dollars, creating an air of suspicion without justification. Never mind the meager reimbursements for the work we performed or the flawed (SGR) system for determining payments that Congress refuses to permanently fix. Despite the nobly declared intention of rooting out fraud and abuse, this data dump seemed to serve no real purpose other than to paint physicians as greedy and to foster ill will. 

Brace yourselves, as the next salvo soon will be cast across the bows of medicine in the form of the Physician Payments Sunshine Act under the National Physician Payment Transparency Program.

The Sunshine Act, a part of the Affordable Care Act, requires manufacturers of pharmaceuticals, medical devices, medical agents, and supplies to report “payments or other transfers of value” greater than $10 (or $100 aggregate annually) to the Center for Medicare and Medicaid Services. The payments will be posted on an Open Payments website to let the sun shine on possible conflicts of interest. Those in the medical industry have been required to track these payment and so-called “transfers of value” to physicians since Aug. 1, 2013. These include consulting fees, honoraria, food, education, research, royalties, grants, and current or prospective ownership to physicians or their relatives. Physicians need not do a thing. Just sit back and take it.

As of January, physicians could begin registering with CMS for the ability to review, in advance of publication, the payments they allegedly have received over the year. There will be a 60-day review period prior to the Sept. 30 publication date. That is 45 days to review the information and 15 days to correct any errors. The physicians must work directly with the manufacturers to correct any inaccuracies. CMS washes its hands of any verification or corrections. If the dispute isn’t settled by the publication date, the payment in dispute is published anyway but with an asterisk. Despite being electronic, the data will be revised only once a year — so, whatever goes up on the website, you, the physician, owns for that year.

I tried to register on the CMS website, and I believe that CMS hired the same company that created healthcare.gov. I spent more than an hour trying to find the physician registration after meandering through page after page. Once I found the registration page, it was not a problem. So, for those of you who have stuck with me through this diatribe, here is my gift to you: https://portal.cms.gov. It took two attempts and cost me a few handfuls of hair, but I did it. When you register, be sure to have plenty of time and Propecia. 

These government actions raise several questions:

What effect will this Sunshine Act have on physicians? 
It’s hard to say. For a while, we’ll think twice before letting a drug rep into the office with a box of donuts. The Act may slow the dissemination of information on new drugs and devices. Front-page newspaper stories will feature physicians who are bringing in big bucks from the medical industry. But in the end, implementation of The Sunshine Act simply will be another waste of taxpayer dollars, another bureaucratic hurdle for manufacturers that will add to the cost of drugs and medical devices, and another sucker-punch to the eye of medicine. A more fruitful effort would be implementation of a Congressional Sunshine Act, but we all know that will never happen.

Why would there be an image campaign against doctors? 
The vast majority of physicians are honest, but a small number are not. These certainly are outliers, so must Congress think only of these outliers as it legislates? It is clear that the federal government wants deeper involvement in health care, and some people have suggested that in order for the government to justify involvement in an area not specifically within its duties, it must demonstrate a need, such as protection of the public (see Michael Crichton’s book, “State of Fear”). Perhaps the vilification of physicians is a tactic to gin up public concern and thus support government’s deeper involvement in health care. Certainly the complex and ever-changing rules and regulations of Medicare, OSHA, HIPAA, and the looming ICD-10 are making it more difficult for physicians to walk the straight and narrow, and making each of us just one step away from a breach.

How should physicians respond to these actions? 
We must continue to keep in contact with our state and federal legislators, and encourage them to press for elimination of those laws and regulations that have little real value and are costly and destructive. We must support the efforts of our physician advocacy groups, such as the TMA. We must do our best to keep up and comply with this ever-changing sea of regulations. We must maintain good relationships with our colleagues because together we stand and apart we will, no doubt, fall. We must continue to practice good and ethical medicine. But most importantly, we must continue to maintain close relationships with our patients so they will know us as we truly are and will see through the smoke-screen.

This post originally appeared in the President's Page of the July 2014 Dallas Medical Journal.


Tuesday, May 27, 2014

Is North Texas prepared for a disaster with mass casualties?


by Todd Pollock, MD, 2014 President

“Hope for the best; prepare for the worst.”
—Roger L’Estrange, 1702

Hurricane Katrina formed over the Bahamas on Aug. 23, 2005, and strengthened to a Category 5 hurricane in the warm gulf waters before striking New Orleans on Aug. 29. The city survived the initial assault, but death and destruction followed the catastrophic failures of key levees. The hurricane left 1,833 people dead and untold numbers of people injured, despite the city’s mandatory evacuation and prearranged evacuation centers, such as the Superdome, that housed more than 25,000 people who could not evacuate. The world watched helplessly on cable news as the tragedy played out.
In April 2009, an outbreak of influenza began in Veracruz, Mexico (later research points to ground zero possibly being in Asia), and Mexican authorities tried to contain the spread. Their efforts were unsuccessful and a worldwide pandemic ensued. This H1N1 influenza, similar to the virus responsible for the 1918 pandemic, mutated to kill not just the weak but also the previously healthy and strong by causing pneumonia and ARDS in a small but significant number of its victims. When the virus finally relented, more than 284,500 deaths were confirmed. However, likely more than 500,000 people had died, based on estimates that included deaths that were not confirmed by laboratory testing or were in people who did not have access to medical care. 
On April 15, 2013, at 2:49 p.m., two pressure-cooker bombs exploded near the finish line of the Boston Marathon. Three people were killed and 264 were injured in the blast set by two Russian-born brothers with extremist Islamic beliefs thought to be in retribution for US military involvement in Afghanistan and Iraq. A subsequent plot to attack Times Square was uncovered in the bombing investigation.
A little more than a month later, on May 20, 2013, tornados touched down west of Newcastle, Okla., at 2:56 p.m. and headed east, striking Moore, Okla. (pop. 57,000). Staying on the ground for 39 minutes, the tornado created a path of destruction 17 miles long and nearly 2 miles wide. With wind speeds of more than 210 mph, the EF5 tornado caused incredible damage. The National Weather Service had issued a tornado watch for the area at 1:10 p.m. and upgraded it to a warning at 2:40 p.m. It struck Moore proper around 3 p.m., giving this seasoned tornado-alley town more than 30 minutes to prepare. Despite this, 24 people were killed and 377 were injured.
Whether a warning is issued weeks, days or hours before an event, or not at all, many challenges exist in the organized and ethical distribution of first aid, triage and medical care; prevention of secondary infections; and utilization of limited resources.
Physicians have to make tough decisions in the heat of a crisis. Without planning or predetermined guidance, decision-making becomes even more daunting.
The North Texas Mass Critical Care Task Force was formed to address this. This regional collaboration is led by physicians and includes public health leaders, hospitals, ethicists, clergy, legal professionals, emergency management professionals, and elected leaders. The mission of the task force is the adoption and implementation of nationally recognized clinical guidelines for healthcare providers to use uniformly across North Texas in the event of an overwhelming disaster.

Beginnings
Efforts began in 2009 when the Dallas County Medical Society’s Community Emergency Response Committee asked the DCMS board for permission to address this issue. Under the chairmanship of John Carlo, MD, the committee began its work by focusing on the efforts of Robert Fine, MD, and the Baylor Health Care System, which had adopted a systemwide set of clinical guidelines based on the Institute of Medicine’s recommendations.
Soon after the committee started its work, DCMS became aware of the efforts of the Tarrant County Academy of Medicine Ethics Consortium, which had been working since 2006 to address ethical issues that might arise during a widespread infectious outbreak that strains healthcare resources. This led DCMS and the Tarrant County Medical Society to create the regional task force with Drs. Carlo and Fine, and two physician leaders from the Tarrant County Medical Society, Drs. Sandra Parker and Kendra Belfi, as the four cochairs.

Where the System is Vulnerable
The task force focused on two choke points in the critical care system — indications for emergency care/hospital admission and for ventilator allocation. Having consistent guidelines for these areas would better distribute the scarce resources and ensure the maximum number of survivors. Unfortunately, the state was nowhere near offering statewide guidelines, and task force organizers decided the group should not delay its work.
Fairness and consistency must be the ethical basis of any framework that allocates treatment in the face of limited resources. Therefore, the task force developed a decision-tree algorithm that protects patients by ensuring all are treated equally, regardless of considerations such as economic, social or political status.
The algorithm also protects the physicians who must make the difficult decisions.
In the aftermath of Katrina,
physicians were second-guessed and allegations of mistreatment, malpractice and even murder made headlines. Uniform guidelines give providers a well thought-out, predetermined and ethically based algorithm to follow to avoid Monday-morning quarterbacking.

The North Texas Mass Critical Care Task Force was guided by four goals:
to ensure maximum survival of individuals,
to ensure appropriate treatment is provided fairly and consistently,
to identify “best practices” in the use of the limited resources, and
to recruit the necessary leadership.

These guidelines are intended for use in Dallas, Tarrant, Denton, and Collin counties, and are to be activated only upon the governor’s declaration of a state of emergency. They do not trump individual physician judgment, but rather provide a well-reasoned and uniform framework for clinical decision-making and resource allocation in the fog of a disaster.
Draft Guidelines
After years of work, the task force has developed both adult and pediatric guidelines which provide a protocol for triage of patients, and make the best use of hospital and ICU resources that can be overwhelmed in a disaster. This draft has been approved by all involved county medical societies, hospital systems and county health departments, and the state has sent a letter of support. The protocols are based on three levels of incident severity or triage levels. Level 1 is early in a disaster or pandemic and is more preparatory in nature; Level 3  is worst-case scenario in which the strictest measures are implemented.
To ensure that the greatest number of patients survive, a modified Sequential Organ Failure Assessment (SOFA) scoring system — an objective and evidence-based formula — is used to determine an individual’s survivability. This score considers pulmonary, renal, hepatic, cardiac, and neurologic indicators to generate a score of 0–24. This score determines algorithmically the priority for hospital admission and for ventilator use, if indicated. Patients are considered low priority for hospital admission and/or mechanical ventilation if they have a low severity of illness (SOFA = 0) and thus a high chance of survival without treatment. Patients also are considered low priority for hospital admission and ventilator use if they are too severely ill (SOFA > 11) with a low chance of survival even with aggressive intervention. The most intense interventions are focused on those with the greatest clinical need and with the highest chance of survival with intervention. Every patient who needs care will receive care, although that care may strictly be palliative. The recommendations vary based on the triage level.

Your Guidelines, Your Voice
These guidelines, while fairly complete, continue to evolve and remain open for changes based on feedback and new ideas. It would be ideal if the Legislature passed safe-harbor protections for people who follow these guidelines. Unfortunately, challenges in regionalized legislation make this unlikely, and we must await a statewide plan before legislation will be considered. The Texas Department of State Health Services has notified the task force that it intends to create a statewide plan over the next two years and has invited us to participate in its development.
Feedback from physicians is most critical because we are the ones who must follow these guidelines. We must understand the basis of the guidelines and be comfortable that they are in the best interest of our community. Our patients will turn to us for answers when disaster strikes and medical care is sought, and we must be familiar enough with these guidelines to properly advise them and speak with a unified voice.
The draft guidelines, background material and minutes from task force meetings are available at www.dallas-cms.org/community_health/mcc/tfmcc.cfm.
It is important that your voices are heard before disaster strikes. Please look over the guidelines and contact Connie Webster, senior vice president of operations, at 214.413.1426 or connie@dallas-cms.org if you have questions or suggestions. Let’s hope that we never have to face a crisis of the magnitude that would stress our abundant healthcare resources. But if we do, we can rest a little easier knowing that we have prepared for the worst.