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Opinion and Commentary from TMA

Nearly 600 – and Counting – U.S. Health Workers have Died of COVID-19

(Public Health) Permanent link

Covid_19_Prep

Editor’s note: The following article was published by Kaiser Health News. The opinions expressed are those of the author, not of the Texas Medical Association.

Nearly 600 front-line health care workers appear to have died of COVID-19, according to Lost on the Frontline, a project launched by The Guardian and KHN that aims to count, verify and memorialize every health care worker who dies during the pandemic.

The tally includes doctors, nurses and paramedics, as well as crucial health care support staff such as hospital janitors, administrators and nursing home workers, who have put their own lives at risk during the pandemic to help care for others. Lost on the Frontline has now published the names and obituaries for more than 100 workers.

A majority of those documented were identified as people of color, mostly African American and Asian/Pacific Islander. Profiles of more victims, and an updated count, will be added to our news sites twice weekly going forward.

There is no other comprehensive accounting of U.S. health care workers’ deaths. The Centers for Disease Control and Prevention has counted 368 COVID deaths among health care workers, but acknowledges its tally is an undercount. The CDC does not identify individuals.

The Guardian and KHN are building an interactive, public-facing database that will also track factors such as race and ethnicity, age, profession, location and whether the workers had adequate access to protective gear. The database – to be released this summer – will offer insight into the workings and failings of the U.S. health care system during the pandemic.

In addition to tracking deaths, Lost on the Frontline reports on the challenges health care workers are facing during the pandemic. Many were forced to reuse masks countless times amid widespread equipment shortages. Others had only trash bags for protection. Some deaths have been met with employers’ silence or denials that they were infected at work.

The number released today reflects the 586 names currently in the Lost on the Frontline internal database, which have been collected from family members, friends and colleagues of the deceased, health workers unions, media reports, unions, among other sources. Reporters at KHN and The Guardian are independently confirming each death by contacting family members, employers, medical examiners and others before publishing names and obituaries on our sites. More than a dozen journalists across two newsrooms – as well as student journalists – are involved in the project.

Many of the health care workers included here studied physiology and anatomy for years. They steeled themselves against the long hours they’d endure. Emergency medical technicians raced by ambulance to help. Others did the cleanup, maintenance, security or transportation jobs needed to keep operations running smoothly.

They undertook their work with passion and dedication. They were also beloved spouses, parents, friends, military veterans and community activists.

None started 2020 knowing that simply showing up to work would expose them to a virus that would kill them.

This project aims to capture the human stories, compassion and heroism behind the statistics. Among those lost were Dr. Priya Khanna, a nephrologist, who continued to review her patients’ charts until she was put on a ventilator. Her father, a retired surgeon, succumbed to the disease just days after his daughter.

Susana Pabatao, one of thousands of Philippine health providers in the United States, became a nurse in her late 40s. Susana died just days after her husband, Alfredo, who was also infected with COVID-19.

Dr. James Goodrich, a renowned pediatric neurosurgeon, acclaimed for separating conjoined twins, was also remembered as a renaissance man who collected antique medical books, loved fine wines and played the didgeridoo.

Some of the first to die faced troubling conditions at work. Rose Harrison, 60, a registered nurse, wore no mask while taking care of a COVID-19 patient at an Alabama nursing home, according to her daughter. She felt pressured to work until the day she was hospitalized. The nursing home did not respond to requests for comment.

Thomas Soto, 59, a Brooklyn radiology clerk faced delays in accessing protective gear, including a mask, even as the hospital where he worked was overwhelmed with COVID-19 patients, his son said. The hospital did not respond to requests for comment.

The Lost on the Frontline team is documenting other worrying trends. Health care workers across the U.S. said failures in communication left them unaware they were working alongside people infected with the virus. And occupational safety experts raised alarms about CDC guidance permitting workers treating COVID patients to wear surgical masks ― which are far less protective than N95 masks.

The Occupational Safety and Health Administration, the federal agency responsible for protecting workers, has launched dozens of fatality investigations into health workers’ deaths. But recent agency memos raise doubts that many employers will be held responsible for negligence.

As public health guidelines have largely prevented traditional gatherings of mourners, survivors have found new ways to honor the dead: In Manhattan, a medical resident played a violin tribute for a fallen co-worker; a nurses union placed 88 pairs of shoes outside the White House commemorating those who had died among their ranks; fire departments have lined up trucks for funeral processions and held “last call” ceremonies for EMTs.

The Lost on the Frontline death toll includes only health care workers who were potentially exposed while caring for or supporting COVID-19 patients. It does not, for example, include retired doctors who died from the virus but were not working during the pandemic.

The number of reported deaths is expected to grow. But as reporters work to confirm each case, individual deaths may not meet our criteria for inclusion – and, therefore, may be removed from our count.

You can read our first 100 profiles here. And if you know of a health care worker who died of COVID-19, please share their story with us.

KHN (Kaiser Health News) is a nonprofit news service covering health issues. It is an editorially independent program of KFF (Kaiser Family Foundation), which is not affiliated with Kaiser Permanente.

COVID-19 Doesn’t Have to Be Mentally Overwhelming

(Mental Health, Public Health, Under Pressure) Permanent link

Physicians have been under an extraordinary amount of stress because of and related to the COVID-19 pandemic.  

Although it is a labor of love, caring for people – either their physical or behavioral well-being – always can be stressful. 

 Thomas_KimBut COVID-19 has created a new level of stress: Long hours, uncertainty about how to care for and test potential and confirmed patients, and concerns about how to protect yourself, your staff, your patients, your family, your friends, and your community while caring for the sick. An ongoing lack of personal protective equipment adds another layer of frustration and stress.

Meanwhile, because of decreased patient visits and revenue, some physicians have had to make difficult business decisions to keep their practice afloat.

All of this can take its toll on you and your colleagues.

To help give you some perspective – as well as some insight and tips – into taking care of your own mental well-being, the Texas Medical Association reached out to Austin psychiatrist and internal medicine physician Thomas Kim, MD.

Dr. Kim, who serves on TMA’s Council on Legislation, Committee on Health Information Technology, and Subcommittee on Behavioral Health, spoke at length about what causes stress and ways to overcome it. The opinions expressed are those of Dr. Kim, not of TMA.

Listen to the entire interview via this recently published podcast, and check out the excerpts below. Dr. Kim even made a playlist, tapping into song to capture emotions that might feel familiar to physicians during COVID-19.

Help is Available 24/7

 

What about our current situation puts even the most resilient physicians at risk of wearing down mentally? 

Our current reality during COVID-19 is so much more than an infectious disease pandemic or mass casualty disaster. We are all experiencing insecurity across every life domain including personal, professional, physical, psychological, social, and spiritual. I am at a loss for recalling a previous time when so many have experienced sustained insecurity and the end is not yet in sight.  

What I know is that I am grateful to belong to a profession dedicated to the well-being of others. To borrow from (Austrian neurologist) Viktor Frankl, “Purposeful work is one of three paths to a meaningful life.” Purpose can bolster our resilience to overcome seemingly impossible challenges. Thinking about my colleagues in ERs and ICUs everywhere, I am humbled, but unsurprised. Having survived the rigors of medical training in an increasingly complex world, physicians are resilient by design. But this very resilience can also put us at risk. A friend of mine who is a critical care pulmonologist recently reached out to me to process how to manage 50 patients in need of a ventilator when his unit only had 16. Because the buck typically stops with physicians, physicians might be assumed to be the final arbiter in all situations, especially in a health care crisis. The result is that physicians are being relied upon for impossible decisions in equally impossible situations. This will undoubtedly have lasting effects long after the stay-at-home orders have lifted. 

For all attention to the situation “on the front lines,” the warfront analogy seems to fall short in accounting for our colleagues practicing outside of hospital settings. I am especially concerned for small-practice physicians who are struggling to care for their patients in our new reality and don’t have the financial security of larger health systems. What they see are equally formidable challenges with no clear targets, no safe quarter in the rear, and the hits feel like they’re coming from every direction. 

I’m certain that small-practice physicians are worried for their patients, but they now have the added concern for their staff, their families, and themselves. It’s important to remember that these concerns are not strictly occupational. How exactly are we supposed to balance caring for patients and ensuring our staff remain safe all while keeping the lights on? How is someone with small children supposed to navigate doing a more hazardous job while attending to their child’s well-being and education? How do you decide between running your practice at a loss in order to sustain your staff versus furloughing them knowing that staffing back up in the future might be far more costly? I imagine these are the questions that haunt many of us every day as we endure this pandemic. And to be clear, this is the reality for every small-business owner and employee in Texas and around the world. 

How does the human body respond to intense stress? 

I like to remember that the stress response is what keeps us alive. The stress response is what saved our forebears from tigers coming out of the jungle. The stress response is what helped me navigate running my first code in training. And the stress response helped me survive the first three months of my son’s life when I thought he was trying to kill me by sleep deprivation. 

The stress response is also an elegant cascade of hormonal responses along our Hypothalamic-Pituitary-Adrenal axis. The result is our primary stress hormone, cortisol, which mediates a whole host of physiological “fight or flight” responses that influences most of our major organ systems. 

Stressful situations are not by themselves a bad thing. But sustained chronic stress is very much so. There are a number of stress and trauma-based diagnoses such as PTSD or Generalized Anxiety. What these diagnoses share is a hijacking of the stress response, resulting in sustained and elevated levels of cortisol. And as with most things, too much of it is a bad thing. A helpful analogy I often share with patients is to consider chronic stress as the equivalent of driving on the highway in first gear. For those who don’t know how to drive a manual transmission, this may not resonate, but driving like this will burn out the engine. 

Chronic stress negatively impacts every aspect of our lives both mentally and physically. Understanding and recognizing our own stress responses can help us develop ways to cope with it. 

How can physicians prepare for a long, sustained period of intense stress?  

Being prepared isn’t just for Boy Scouts, and preparedness can be enormously powerful to help ready ourselves against most anything. My thoughts on the value of preparing for intense stress are framed much like we frame the value of primary care: managing a heathy weight and diet is far superior to treating type 2 diabetes. 

Preparedness starts with a readiness mindset; to respond rather than react. Most everyone around our state has been doing their best to be ready. Readiness leads to checklists, protocols, and aligned expectations which can mitigate the difficulties that lie ahead, particularly when things go wrong – and they will.  Cultivating specific and practiced routines helps us maintain a positive challenge state with enhanced performance in the face of extreme stress and uncertainty.  

The challenges we face may seem overwhelming and even paralyzing. Many physicians may be feeling lost in the enormity of everything that’s going on. And while no one can predict nor promise a specific future, there is only one way to eat an elephant: one bite at a time. Approaching momentous challenges step by step has gotten us to the moon among, other remarkable achievements, and it will help us persevere and overcome the current pandemic.

As our experience in the pandemic proceeds, stressors will begin to mount. What can physicians keep in mind during times of mounting stress to help maintain resilience?  

When life inevitably hands us a lemon, finding hope in the positive aspects works to minimize negative distortions in thinking and identify constructive response strategies. The beauty of “making lemonade” is that it is a strategy most of us were familiar and have practiced before the pandemic, and something that we can build upon now. 

Right now, most everywhere we look there’s a lemon. While our current situation is especially difficult, we may find there is still lemonade to be made. Staying at home has reminded us of the importance of familial and social ties. Many are turning to video chats to host virtual board game or puzzle nights, even at a distance. Without the crush of modern living pulling us in every direction, some people might have found occasion to rekindle personal interests, such as playing an instrument, exercising, or baking bread. On a more macro scale, our collective pause from life may be having a positive environmental impact. I understand Mumbai and Bangkok have never looked so beautiful.

But because of the enduring uncertainty and need for ongoing support, we may need to lead with the old-school approach of simply caring for each other. When I hear about people helping with food or medicine delivery so that a high-risk neighbor doesn’t needlessly have to venture out, I see a lovely and powerful benefit in both directions. Through simple acts of grace, we create a bit of security and hopefully remember that we get through these things together. 

As a specific example, the challenge of educating our children is a particularly poignant example for me. I have discovered that I am a terrible middle school teacher. Despite finishing the 26th grade, fancying myself to be a lifelong learner, and having specific knowledge about brain development, it’s been tough for me to help my son continue his education in these uncertain times. That said, my wife, my colleagues, and my friends have been an enormous source of support for me. As a result, I have persisted, come up with new strategies, and we seem to be having fewer cross words and tears this week. I imagine next week will be better. And the week after better still. A big part of the strategy is continually reminding myself that we are in this together – and together, we will be OK. 

How do you suggest physicians provide support to colleagues who may be struggling during this time?  

Right now, it is so important for us to remember the ties that bind us. Expressing care and concern for one another is always the right call. Outside of a crisis, things go unsaid because the observer may be pre-occupied with their own life. They may be concerned about offending or alienating the person in distress. They may also hesitate to turn over this rock for fear of what they might find. 

I suggest starting by simply asking “How are you?” or “Are you OK?” Borrowing from the literature around relationships, the two qualities that that have been found to support long-lasting romantic relationships are kindness and generosity. I think there is some generalizable value here with all relationships and recommend that we strive to be kinder and more generous with one another. 

Of course, there is the concern of severe distress management. I wish to be clear that if anyone is unable to cope with their severe stress, please seek out or offer immediate assistance to the best of your ability. Do not hesitate to use or share the crisis hotlines, emergency mental health resources, and other supports available 24 hours per day. 

As an example of “making lemonade,” what are your thoughts on the widespread uptake of telemedicine brought about by COVID-19?  

We have remarkable technologic tools at our disposal that can support our continued work in caring for patients during this pandemic. 

It took a global pandemic to re-evaluate some of the historic barriers preventing meaningful growth in telehealth, such as geographic restrictions and the lack of reimbursement parity. These desperate times have given us the opportunity to realize we have been holding on with both hands to a system of care that has limited bang while still costing a lot of bucks. Staying at home has freed up a hand to now grab for something potentially better.  

Many physicians are likely to discover that telehealth improves health care delivery for patients and providers alike. It is my hope that expectations around care delivery will be forever changed for the better. 

Alongside my enthusiasm is a gnawing sense of dread. This concern stems from the potential pitfalls of making decisions in a crisis. The current hullabaloo around Zoom security issues is an excellent example of why we should be more thoughtful and strategic around cultivating this new skill of delivering telehealth care. Another concern is around failing to see the true value of telehealth as connecting you to your doctor rather than simply a doctor. Mistakes will inevitably be made, and my hope is that when the dust settles, we strive to learn and grow from any missteps rather than try to put the genie back in the bottle and return to health care as usual. 

I should highlight that the TMA has a wonderful resource page on its website that can be helpful in navigating the many strategic decisions to be made in order to provide telehealth services. If anyone should have a question not answered on the site, they are most welcome to contact me. 

What is “mental health first aid” and why is this a beneficial skill set for physicians to have?  

Mental Health First Aid is a training program designed to help people who have recently experienced a major trauma or are in acute crisis. It begins with teaching you how to identify mental illness and then how to supportive engage a person in crisis until such time they can access formal treatment, or the crisis resolves. 

Even outside of a pandemic level crisis, being familiar with mental health first aid is a broadly useful skill much like CPR. This is because in addition to helping to overcome an acute crisis, mental health first aid has been shown to reduce stigma around mental illness by dispelling misconceptions and negative attitudes. 

I would say that this is a beneficial skill for all physicians especially if they do not typically treat mental illness. Before the pandemic, I frequently joked that all physicians treated mental illness – just not well. Moving forward, I predict the need for mental health support will be greater than ever before, and mental health first aid can be vital to supporting everyone who needs help.          

At some point, the immediate crisis will be over. What do you expect are going to be the long-term effects on physician mental health?  

Mental health issues around crises typically follow a two-wave progression. The first wave peaks during the acute setting when everything is going sideways. Fortunately, the protective nature of our stress response and a challenge state of mind has been shown to blunt this phase as folks go into “crisis mode” and does what needs to be done. This is taxing work, and not everyone can be expected to manage this phase well. Attention to sleep, water, and food is critical to surviving this phase.   

Once the crisis subsides, the second phase of mental health concern typically has a longer time of onset with a higher peak of intensity. The timing and intensity are directly influenced by how well-equipped the environment is to address the aftermath. If the infrastructure and resources are reasonably intact post-crisis, we can be more optimistic about recovery. If the environment has been critically devastated, recovery becomes more difficult and prolonged. 

I don’t think we can currently speculate on how this pandemic will play out beyond epidemiologic modeling and evidence of when the pandemic surge will peak. If we remain in lockdown too long, the impact on essential and non-essential industries will leave us with limited capacity to recover quickly. If we end the restrictions too soon, we risk another round of infections with potentially more devastating impact in terms of loss of life and prolonged time course. And with no great potential futures moving forward, the challenge before us is formidable. What I do know is that we are all working towards better understanding the problem, which is the first step to finding a solution. 

On the other side of this pandemic, it is likely that some of us will continue to feel distressed long after others appear to have gotten back to “normal.” In this situation, I would say that “normal” is largely an illusion. Following a crisis of significant magnitude, a return to normal – whatever that word might mean – is not a return to our best days of the past but is rather moving forward with intention and positivity. We will be bruised and scarred as a result of this pandemic. Those that get up off the mat will be the ones who are OK, and not everyone will find themselves in that group. The key takeaway here is that you do not have to do this alone. Asking for help is one of the hardest things a person can do. If anyone finds themselves struggling to find their path forward … we can and should rely on one another.  

It’d be great to hear some of your thoughts on stigma. What can be done to reassure physicians that it is normal to need help processing this situation?  

A helpful way to frame our new reality is to acknowledge that everyone is in the same boat. Regardless of history, status, or circumstance, we see rising levels of mood and anxiety distress in most everyone right now. This situational reaction to the pandemic reveals that we all experience symptoms associated with mental illness. I predict that this will have a positive effect on dispelling stigma long-term. 

Being distressed in the face of crisis is not a character failing. Asking for help is an act of bravery. If we can remember these lessons once we get back to living our lives, we have an opportunity to address some long-standing societal challenges around stigma, mental illness, health disparities, and more. Once we see ourselves in each other, we will be better and stronger for it. 

How can physician leaders help their colleagues and communities stay optimistic and resilient?  

To be honest, I’m not sure my colleagues could do more. Both here in Texas and everywhere I look, I see my colleagues admirably fulfilling their professional oaths in some of the direst circumstances. 

I hope that my responses have demonstrated a thoughtful balance of candid pragmatism and hopeful optimism. Lemonade isn’t made by ignoring the lemons. Lemonade comes from intention, effort, attitude, and other qualities that collectively boils down to choice. Choice always reminds me of the Cherokee legend of the two wolves. Put simply, a young boy learns that we all walk with two wolves, a good wolf and a bad wolf, who are constantly battling each other. When he asks his grandfather which wolf wins, the grandfather replies, whichever wolf you choose to feed. I choose to feed my good wolf as much as possible.  

If I had one piece of encouragement for my colleagues, it would be to go easy on themselves. I would remind them that they are not alone and in the words of my son’s former PE teacher and archery coach: “We are all we got, and we are all we need.” I am confident that together we will make it through this pandemic. 

Thomas Kim, MD, is a psychiatrist and internal medicine physician from Austin, who serves as principal for AGMP Telehealth. He has clinical expertise caring for a wide range of vulnerable populations including disaster victims. Dr. Kim serves on TMA’s Council on Legislation, Committee on Health Information Technology, and Subcommittee on Behavioral Health, and was also appointed to the governor’s newly formed Broadband Development Council.

 

Becoming a Better Physician ”Thanks” to Cancer

(Public Health) Permanent link

The last thing a nonsmoking asymptomatic female physician expects during her usual hourly aerobic exercise is a phone call from her internist about a “spiculated lung nodule.” There was no need for the rest of the radiologist’s sentence: “suspicious for malignancy.”

Kang_BlogShock. Denial: Can’t be! Wrong patient? Perhaps it’s benign. It has to be. I have never been a tobacco smoker; I maintain a healthy lifestyle, exercise, take my medications, eat right, (try to) sleep enough. I do all the “right” things. Anger: God! I cannot possibly have lung cancer! So UNFAIR!

Jumping onto “Dr.” Google Scholar, I found a reputable book chapter summarizing lung cancer in never-smokers. Lung cancer is the leading cause of cancer-related mortality in the world. Of 1.37 million annual deaths or 18% of all cancer deaths, 71% of lung cancers are caused by smoking. However, approximately 15% of men and 53% of women are never-smokers, or have smoked fewer than 100 cigarettes in their life. Aside from this remarkable gender bias, lung cancer incidence rates are higher and more variable among East Asian women. East Asian females who do not smoke tend to have adenocarcinoma on the periphery of the right upper lung. A nagging cough or shoulder pain that develops gradually is shrugged away – until the primary lung cancer rears its ugly presence by way of hemoptysis or seizures.

Rationally accepting that lung cancer can occur even in nonsmokers, I wanted action: Cut out that cancer pronto before it metastasizes!

As an academic physician, I have the privilege and responsibility to help train future physicians. How often do patients have the luxury to watch the surgical and anesthesiology resident physicians develop into capable attending-level physicians? I knew and trusted both my personal anesthesiologist and my thoracic surgeon.

Within 18 days of learning of that spiculated lung mass, I underwent video-assisted thoracoscopy (VAT). (Mercifully gone is that painful long slash between the ribs of an open thoracotomy.) I was still bargaining with God that the pathologist would diagnose a benign tumor or some noncancerous, infectious “-oma.” I still have so many things I want to do on this Earth, places to travel, young people to see grow up. Please, God, spare me the bitter cup of cancer!

I remember a jumble of activities, of being moved, people’s faces, then darkness. Awakening, I found myself in the ICU. Smacking my right chest and chest tube, I grinned: no pain – for now.

I gained new perspective and empathy for asthmatics and emphysema patients. Losing the entire right upper lung to adenocarcinoma left me starved for air-despite “normal” pulse oximetry readings off my finger. Catch-22: I felt short of breath but couldn’t inspire deeply due to a dull internal stabbing sensation. (Note to self: Visceral pain still hurts.) My unwillingness to cough warred against the relentless bodily reflexes to clear out bronchial secretions. How can COPD or cystic fibrosis patients with their preoperative air hunger tolerate the post-thoracotomy feeling of oxygen deprivation?

I understand better now why patients become delirious in the ICU: sleep deprivation. The compression stockings alternately squeezed my legs all night long. The noninvasive blood pressure monitor throttled the life out of my left ulnar nerve every hour. Demonically timed as I drifted asleep were the temperature probes under the tongue and monitor alarms (which never brought any human monitors to bedside). The chest tube preventing my usual right lateral sleeping position, I tried the left lateral position only to have my Foley and the chest tube tugging from the opposite side of the bed. Flattening out the bed increased my air hunger. Taking a sip of air triggered violent coughing. At 3 am (why?), the nurse drew blood out of my peripheral IV for lab work. Since the door to my illuminated ICU room did not close appropriately, I listened all night long to Fiesta celebrations at the nurses’ station.

Medical practice has changed. Instead of seeing the surgeon at the end of a long day of surgeries, I saw the surgical team the following day. I was prepared to be scrutinized on Postop Day 1 at the crack of dawn – before operating rooms start. The surgical residents stuck their heads in, said hello but did not examine. So I examined my chest tube drainage (minimal), my Foley (excellent diuresis), and my chest dressings (dry). The nurse practitioner (NP) made her rounds midmorning. I was freed of my Foley to walk two laps around the ICU with the physical therapist with only the chest tube to drag around. Observing the intubated comatose patients, I felt grateful to be alert and talking.

Still starving for food and sleep, and wishing to avoid hospital-acquired infections, I begged for day-one discharge from the surgeon. He wanted more observation time after the painless removal of the chest tube.

As I nestled under the clean sheets, after a blissful hot shower, ready to fall asleep to the muted television, at 10:15 pm, another very young nurse entered, flicking on the concentration camp room lights. She began undressing the clean IV infusion pump, announcing that she needed to give me my IV antibiotic. Was this another facet of the new medicine: patients receiving IV antibiotic the night before discharge in the morning? I asked the name of this miracle antibiotic as she scanned my arm band prior to hanging the medication. “Zosyn” was the reply, followed by a pregnant pause, then the slow utterance of “Oh, you’re not the one to get the Zosyn.” I was internally spastic. Did that near adverse event get self-reported? Maybe another entry about obnoxious physician/patient?

The problem of being a physician/patient is awareness of unintended consequences. Hence my thought: “Thank you, God, for the requisite zapping of my name band!” I could have received an unnecessary medication. I could have developed anaphylactic shock. Another patient would not have received the necessary antibiotic to ward off infection.

I was ready to fly the coop by 7 am on post-op day two. Midmorning the NP wrote the discharge orders and instructions. The paperwork stated breast cancer. Again, aware of unintended consequences of incorrect medical information living in perpetuity inside electronic medical records, I refused discharge until the inaccuracies were corrected. I have faced patients who adamantly denied medical diagnoses listed on their EMR. Mine was going to be accurate: lobectomy, not mastectomy!

The outpouring of love and affection after cancer surgery is heartwarming. Having cancer makes one feel vulnerable. Mortality becomes more palpable. Nurses, scrub techs, anesthesia techs, my administrative assistant, anesthesia resident physicians, medical students, even my elementary school to university classmates covered me with warm emotional support. The flowers, cards, notes, even groceries with flannel pajamas were wonderful to counter my depression. I attribute to these lovely people my recovery to return to work after six weeks.

The nagging fear of cancer recurrence stays constant. I literally and figuratively hold my breath for a low dose CT of the chest every three months awaiting the radiologist’s verdict. Negative. A sigh of relief. Another CT … Wait! What do you mean the insurance company refuses to authorize the sixth-month CT? My internist appealed the denial. I tried, equally unsuccessful. My sixth-month CT finally occurred in the seventh month. Not looking forward to the next battle with the insurance company.

An authorization for medically necessary procedures or tests is not a guarantee of payment of insurance benefits. The letter from the insurance company says that. I can undergo the tests or procedures, but surprise, it determines how much it wants to pay. I have to suck up the rest of the bill. Balance billing become more personal as a patient. It is more of a shock than a surprise. The physician part of me also gets shocked from the arbitrary low value assessment of our services. How can the typical patient pay? A secretary friend who also has suffered a bad health year answered that question. She can’t. Her paycheck barely covers essential necessities. She stopped opening the latest bills. Our health care system and insurance coverage need massive overhauls. What’s the right answer?

The practice of medicine has changed since I started in 1980. I have benefitted from my personal compassionate and competent physicians. As a physician/patient I have knowledge to protect myself from the cookbook practice of medicine and potential medical errors. Most of our patients do not. Having undergone the trials of being a patient and sharing with you my experiences, I pray that we physicians remain vigilant in protecting our patients. But first, please, get your CXR!

Wendy Kang, MD, is a clinical professor in the Department of Anesthesiology at UT Health San Antonio Long School of Medicine.

I Won’t Take the Nurse Practitioners’ Bait

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EHR_guide

The American Association of Nurse Practitioners (AANP) is obviously intent on picking a fight with physicians. No thanks. We’ll take the high road, fully aware of the dangers of their plans, and stick with what we know is best for our patients: the physician-led health care team. 

In a recent commentary published in USA Today, two of AANP’s allies repeated the trope that authorizing independent practice for nurse practitioners would somehow solve the shortage of physicians we all know America faces. In their misguided quest, the authors have twisted and misinterpreted the research they cite, and in the end hurt the very patients they say they want to help. 

Fleeger_MugI won’t rebut, point by point, the authors’ argument. I’ll leave it at this: My problem is not with NPs. They are an integral part of the health care team. We need them on the team to help with disease management and education. Indeed, it is hard to imagine our health care system without them. My problem is with independent practice and the false argument that this will somehow improve access to and decrease the cost of medical care for our patients. The data are clear: Regardless of whether or not they work in states that allow independent practice, the vast majority of NPs locate just where physicians do – in the big cities. Without appropriate supervision, they order more tests and consultations to compensate for a more limited diagnostic knowledge base.  

Meanwhile, members of the American Medical Association’s Scope of Practice Partnership shared an insightful slide presentation from a recent AANP meeting. I was drawn to one slide that lists AANP “Board Initiatives.” Parts of it are repeated in more detail in the AANP’s 2019 strategic plan. I call your attention to two bullet points on that slide: 

  • “Patients nationwide will have full and direct access to high-quality care and will choose NPs as their health care provider” (emphasis added); and
  • “NPs will have parity with physicians and other providers in reimbursement, payment, and government funding.” 

These kind of statements might be good for AANP membership, but they’re awful for our patients. A nurse is not a doctor. And a doctor is not a nurse or physical therapist or an audiologist or any other type of clinician on the team that has to work together on behalf of our patients. 

As I stated when I proudly took my oath to become your TMA president, “It is because we are professionals that we lead, supervise, educate, and monitor the other members of our health care team. They do not know what we know. They cannot do what we do.” 

Nonphysician practitioners work with physicians – but under our direction. That’s not a put-down. It makes little sense to create more fractionation in our already confusing health care “system.” That’s what we work for at the Texas Legislature, in the U.S. Congress, in the courts, and in regulatory agencies. That’s why we defeated more than 20 scope-of-practice expansion bills during the 2019 legislative session. Your association – and I – remain firm in this principle. (See our strong letter opposing President Trump’s plan to grant NPs payment parity in Medicare.) 

In 2013, with the full support of the nurse practitioners and physician assistants here, the Texas Legislature passed a groundbreaking law that replaced the old site-based restrictions for prescriptive delegation and supervision with a more flexible, collaborative model for physician-led, team-based care. 

Our legislators understand that our patients benefit when each member of the team brings his or her special talents, skills, and training to the bedside. They understand that the path to independence is through education, not legislation. We will not stand by and watch the AANP and their supporters try to pretend that our years of medical school training and residency do not make a difference. No one has the skills and education that physicians have that qualify us to lead the patient care team. And ultimately, we have the responsibility for our patients’ health. 

I won’t take the bait. I’ll just continue to stand up for Texas physicians and our patients. 


Expanding APRNs’ scope of practice will increase the cost of care   

• Research comparing APRNs to physicians found a 41-percent increase in hospitalizations and a 25-percent increase in specialty visits among patients treated in the same setting by APRNs.1  

• Collaborative care models, such as the patient-centered medical home, have demonstrated reductions in emergency department visits of up to 29 percent2, reductions in hospitalizations up to 40 percent3, and reduction in total medical costs by 9 percent.4  

Sources:  

1 Hemani A, Rastegar DA, Hill C, et al. “A comparison of resource utilization in nurse practitioners and physicians.” Effective Clinical Practice 1999 Nov-Dec; 2(6):258-265. 

2 Reid R, Fishman P, Yu O, et al. “A patient-centered medical home demonstration: a prospective, quasi-experimental, before and after evaluation.” American Journal of Managed Care, September 2009.  

3 BD Steiner et al, “Community Care of North Carolina: Improving care through community health networks.” The Annals of Family Medicine 2008;6: 361-367.  

4 Geisinger Health System, presentation at White House roundtable on Advanced Models of Primary Care, August 10, 2009. 

Making Prescribing Less Painful for Physicians

(Legislature, Public Health) Permanent link

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No one likes to be told what to do. 

We physicians, especially, are tired of government agencies and insurance companies and hospital administrators telling us how to take care of our patients. So I won’t be surprised if physicians around the state are feeling a little angst and anger over the coming March 1 requirement for physicians to check the Texas prescription monitoring program (PMP) before writing prescriptions for opioids, benzodiazepines, barbiturates, and carisoprodol. 

Fleeger_MugI don’t fault them one bit. This is just one more administrative burden placed on physicians. But I want all of you to understand just how much worse it would have been without the intervention of the Texas Medical Association. 

TMA began our work to simplify physicians’ administrative burden when prescribing opioids and other controlled substances early in the last decade. We claimed two important successes during the 2015 session of the Texas Legislature. Until that point, Texas doctors needed both a state controlled substances registration (CSR) permit and a federal Drug Enforcement Administration permit to write prescriptions for any controlled substance. Also, until that point, the state PMP was a law enforcement tool housed in the Texas Department of Public Safety. And, physicians who wanted to check a patient’s controlled substance history had to perform that task personally. 

Thanks to TMA's advocacy during the 2015 session, the CSR permit was eliminated, the PMP was moved to a new online system created by the Texas State Board of Pharmacy, and physicians were authorized to delegate checking the PMP to members of their staff. (That's a valuable time saver for our doctors that I encourage you to use.)

As the opioid abuse epidemic raged across the country, elected officials clamored for a crackdown on prescribing practices. In 2010, Colorado, Delaware, Louisiana, Nevada, and Oklahoma were the first states to require prescribers to search patients' drug histories before prescribing. By January 2017, when the Texas Legislature was ready to convene, 26 more states had imposed that mandate. (Currently, that number is up to 43 states.) 

Political pressure to do something was growing here in Texas. State lawmakers already had filed some extremely onerous pieces of legislation. It was obvious that Texas was about to join the list. It became TMA’s job to buy time for you and make sure the state was pushing a useful clinical tool for physicians, not another useless administrative burden. 

As we do so often, TMA and organized medicine went to work educating senators and representatives about the real-world impact of the bills they had filed. We pushed back hard against a proposed sweeping mandate for physicians to check the PMP before issuing prescriptions for any controlled substance. We persuaded lawmakers to limit the requirement to the four drug classes I mentioned above. And we won a two-year delay in the mandate so physicians, the Pharmacy Board, and other key players could prepare for this massive change. 

Finally, during the 2019 legislative session, we obtained two more big improvements for physicians. While at that point, most of the major electronic health record (EHR) vendors were working to integrate the PMP into their systems, they were not likely to be done with their work before the Sept. 1, 2019, deadline. We persuaded lawmakers to delay the mandate until March 1, 2020, to give physicians and EHR vendors time to properly integrate their systems with the PMP. Plus, the legislature appropriated an additional $5 million for the Pharmacy Board to upgrade the PMP to make it easier to integrate, as well as to cover the integration licensing fees for all state prescribers and pharmacists. 

To use a bad pun, this mandate is still a pain, but it hurts far less than it could have because TMA has been there for you. We also have a new PMP Resource Center on the TMA website that includes all the background on the mandate and a way to check if your EHR is connected to the PMP. We put together a webinar with 1.25 hours of CME (free to TMA members) to make using the PMP easier for you and the staff you delegate the task of checking the database, and more beneficial for you and your patients. We also are working on a public campaign to make sure your patients know the PMP mandate is coming and what it may mean the next time they visit their doctors. 

My hope is that because of all the work we’ve done, the PMP will actually be a valuable tool to help physicians prevent drug abuse, drug diversion, and doctor shopping, and that it will not delay, thwart, and complicate care for our patients.

Beyond Burnout: Docs Decry Moral Injury From Financial Pressures of Health Care

(Under Pressure) Permanent link

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 This story was originally published on the Kaiser Health News website. Illustration by Maria Fabrizio for Kaiser Health News.

Dr. Keith Corl was working in a Las Vegas emergency room when a patient arrived with chest pain. The patient, wearing his street clothes, had a two-minute exam in the triage area with a doctor, who ordered an X-ray and several other tests. But later, in the treatment area, when Corl met the man and lifted his shirt, it was clear the patient had shingles. Corl didn’t need any tests to diagnose the viral infection that causes a rash and searing pain.

All those tests? They turned out to be unnecessary and left the patient with over $1,000 in extra charges.

The excessive testing, Corl said, stemmed from a model of emergency care that forces doctors to practice “fast and loose medicine.” Patients get a battery of tests before a doctor even has time to hear their story or give them a proper exam.

“We’re just shotgunning,” Corl said.

The shingles case is one of hundreds of examples that have led to his exasperation and burnout with emergency medicine. What’s driving the burnout, he argued, is something deeper — a sense of “moral injury.”

Corl, a 42-year-old assistant professor of medicine at Brown University, is among a growing number of physicians, nurses, social workers and other clinicians who are using the phrase “moral injury” to describe their inner struggles at work.

The term comes from war: It was first used to explain why military veterans were not responding to standard treatment for post-traumatic stress disorder. Moral injury, as defined by researchers from veterans hospitals, refers to the emotional, physical and spiritual harm people feel after “perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations.”

Drs. Wendy Dean and Simon Talbot, a psychiatrist and a surgeon, were the first to apply the term to health care. Both wrestled with symptoms of burnout themselves. They concluded that “moral injury” better described the root cause of their anguish: They knew how best to care for their patients but were blocked from doing so by systemic barriers related to the business side of health care.

That idea resonates with clinicians across the country: Since they penned an op-ed in Stat in 2018, Dean and Talbot have been flooded with emails, comments, calls and invitations to speak on the topic.

Burnout has long been identified as a major problem facing medicine: 4 in 10 physicians report feelings of burnout, according to a 2019 Medscape report. And the physician suicide rate is more than double that of the general population.

Dean said she and Talbot have given two dozen talks on moral injury. “The response from each place has been consistent and surprising: ‘This is the language we’ve been looking for for the last 20 years.'”

Dean said that response has come from clinicians across disciplines, who wrestle with what they consider barriers to quality care: insurance preauthorization, trouble making patient referrals, endless clicking on electronic health records.

Those barriers can be particularly intense in emergency medicine.

Corl said he has been especially frustrated by a model of emergency medicine called “provider-in-triage.” It aims to improve efficiency but, he said, prioritizes speed at the cost of quality care. In this system, a patient who shows up to an ER is seen by a doctor in a triage area for a rapid exam lasting less than two minutes. In theory, a doctor in triage can more quickly identify patients’ ailments and get a head start on solving them. The patient is usually wearing street clothes and sitting in a chair.

These brief encounters may be good for business: They reduce the “door to doc” time — how long it takes to see a doctor — that hospitals sometimes boast about on billboards and websites. They enable hospitals to charge a facility fee much earlier, the minute a patient sees a doctor. And they reduce the number of people who leave the ER without “being seen,” which is another quality measure.

But “the real priority is speed and money and not our patients’ care,” Corl said. “That makes it tough for doctors who know they could be doing better for their patients.”

Dean said people often frame burnout as a personal failing. Doctors get the message: “If you did more yoga, if you ate more salmon salad, if you went for a longer run, it would help.” But, she argued, burnout is a symptom of deeper systemic problems beyond clinicians’ control.

Emergency physician Dr. Angela Jarman sees similar challenges in California, including ER overcrowding and bureaucratic hurdles to discharging patients. As a result, she said, she must treat patients in the hallways, with noise, bright lights and a lack of privacy — a recipe for hospital-acquired delirium.

“Hallway medicine is such a [big] part of emergency medicine these days,” said Jarman, 35, an assistant professor of emergency medicine at UC-Davis. Patients are “literally stuck in the hallway. Everyone’s walking by. I know it must be embarrassing and dehumanizing.”

For example, when an older patient breaks an arm and cannot be released to their own care at home, they may stay in the ER for days as they await evaluation from a physical therapist and approval to transfer to rehab or a nursing home, she said. Meanwhile, the patient gets bumped into a bed in the hallway to make room for new patients who keep streaming in the door.

Being responsible for discharging patients who are stuck in the hallway is “so frustrating,” Jarman said. “That’s not what I’m good at. That’s not what I’m trained to do.”

Jarman said many emergency physicians she knows work part time to curtail burnout.

“I love emergency medicine, but a lot of what we do these days is not emergency medicine,” she said. “I definitely don’t think I’ll make it 30 years.”

Also at UC-Davis, Dr. Nick Sawyer, an assistant professor of emergency medicine, has been working with medical students to analyze systemic problems. Among those they’ve identified: patients stuck in the ER for up to 1,000 hours while awaiting transfer to a psychiatric facility; patients who are not initially suicidal, but become suicidal while awaiting mental health care; patients who rely on the ER for primary care.

Sawyer, 38, said he has suffered moral injury from treating patients like this one: A Latina had a large kidney stone and a “huge amount of pain” but could not get surgery because the stone was not infected and therefore her case wasn’t deemed an “emergency” by her insurance plan.

“The health system is not set up to help patients. It’s set up to make money,” he said.

The best way to approach this problem, he said, is to help future generations of doctors understand “how decisions made at the systems level impact how we care about patients” — so they can “stand up for what’s right.”

Whether these experiences amount to moral injury is open for discussion.

Cynda Rushton, a nurse and professor of clinical ethics at Johns Hopkins University, who has studied the related notion of “moral distress” for 25 years, said there isn’t a base of research, as there is for moral distress, to measure moral injury among clinicians.

But “what both of these terms signify,” Rushton said, “is a sense of suffering that clinicians are experiencing in their roles now, in ways that they haven’t in the past.”

Dean grew interested in moral injury from personal experience: After a decade of treating patients as a psychiatrist, she stopped because of financial pressures. She said she wanted to treat her patients in longer visits, offering both psychotherapy and medication management, but that became more difficult. Insurers would rather pay her for only a 15-minute session to manage medications and let a lower-paid therapist handle the therapy.

Dean and Talbot created a nonprofit advocacy group called Moral Injury of Healthcare, which promotes public awareness and aims to bring clinicians together to discuss the topic.

Their work is attracting praise from a range of clinicians:

In Cumberland County, Pennsylvania, Mary Franco, who is now 65, retired early from her job as a nurse practitioner after a large corporation bought out the private practice she worked in. She said she saw “a dramatic shift” in the culture there, where “revenue became all-important.” The company cut in half the time for each patient’s annual exam, she said, down to 20 minutes. She spent much of that time clicking through electronic health records, she said, instead of looking the patient in the face. “I felt I short-shrifted them.”

In southern Maine, social worker Jamie Leavitt said moral injury led her to take a mental health break from work last year. She said she loves social work, but “I couldn’t offer the care I wanted to because of time restrictions.” One of her tasks was to connect patients with mental health services, but because of insurance restrictions and a lack of quality care providers, she said, “often my job was impossible to do.”

In Chambersburg, Pennsylvania, Dr. Tate Kauffman left primary care for urgent care because he found himself spending half of each visit doing administrative tasks unrelated to a patient’s ailment — and spending nights and weekends slogging through paperwork required by insurers.

“There was a grieving process, leaving primary care,” he said. “It’s not that I don’t like the job. I don’t like what the job has become today.”

Corl said he was so fed up with the provider-in-triage model of emergency medicine that he moved his ER clinical work to smaller, community hospitals that don’t use that method.

He said many people frame burnout as a character weakness, sending doctors messages like, “Gee, Keith, you’ve just got to try harder and soldier on.” But Corl said the term “moral injury” correctly identifies that the problem lies with the system.

“The system is flawed,” he said. “It’s grinding us. It’s grinding good docs and providers out of existence.”

A Plan for the Uninsured in Texas

(Legislature, Public Health) Permanent link

Uninsured_Blog_Fleeger

I have a book that is very dear to me. It is not a rare book, nor a valuable book. 

But this book on World War II military campaigns means a lot to me because it was given to me by a patient. After many office visits we had learned of our mutual interest in history. My patient, knowing my father went to West Point, gave me the book as a token of his appreciation of my care. The relationship that all of us have with our patients is a special one, and I know my fellow physicians have similar stories that demonstrate the mutual respect inherent in the patient-physician relationship.

But, of course, there is more to this story. For my patient had been experiencing rectal bleeding for over nine months. He worked on a food truck selling snow cones, and was poor and uninsured. By the time he presented for medical evaluation he had metastatic disease. All I could do for him was give him a colostomy. My colleagues gave him chemotherapy to no avail. He ultimately passed from metastatic rectal cancer.

I’ve always wondered if my patient lived in a state with ACA expansion would he have been covered by Medicaid? Would he have had access to a primary care medical home? Would he have had access to a screening colonoscopy that could have prevented his disease? Would he at least have had access to early diagnosis and treatment with a greater chance of survival?

But we live in a state where that is not possible. We live in a state where 17.7% of Texans are uninsured. That’s 5 million Texans. That makes us 51st. That makes us last. We live in a state where 873,000 children – and growing – are uninsured. This represents 20% of all the uninsured children in the country.

I’m not telling you anything new. You – we – see this in our clinics, hospitals, and emergency departments every day. But as I’ve traveled around the state as your Texas Medical Association president, I’ve met many who feel the situation has reached a critical stage. It has become more difficult for Texas doctors to sustain this unwritten tax on ourselves, our clinics, and our hospitals as we care for the uninsured poor.

Yet our state seems to expect this from us.

Likewise, insured patients and employers and local property taxpayers are becoming increasingly more vocal about the cost shifting that occurs to pay for the care of uninsured patients.

And yet when we go to the Capitol, we tiptoe around this issue because we don’t want to offend the legislative majority.

It is the policy of our TMA that our patients have universal coverage.

It is the policy of our TMA that we draw down the tens of billions of dollars that Texas has passed up since the ACA became law a decade ago.

Yet, is it a TRUE goal of our TMA?

When we sit down with our legislators, do we ask them if they are going to use a waiver, or block grants, or expansion to help the uninsured? And exactly WHEN are they going to do that?

I understand the political realities. They are difficult.

We, as an association, can’t change this alone. We will need to build a coalition with county medical societies and specialty societies, along with hospitals, other health care professionals, patient advocacy groups, leaders in city and county government, the leaders of the major employers in Texas, and, yes, even the health plans.

I call for our TMA to bring all of these groups together to directly address the issue of the uninsured in Texas, to plan a strategy, and to put it in motion.

I believe we can, as an association and as a profession, create the change that our patients need and deserve.

I believe we can do so in a fiscally responsible manner.

I believe it is OK for legislators to feel the same discomfort I feel when I see an uninsured patient who can’t get good care in a timely manner because she is poor.

I know that if we stay true to our core values of uncompromising and unconflicted regard for our patients’ benefit and best interest that good things can and will happen … and I hope you believe the same.

(Dr. Fleeger’s made these comments at TMA’s 2020 Winter Conference on Jan. 25.)