Blogged Arteries

Opinion and Commentary from TMA

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

(Public Health) Permanent link


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.

Making Prescribing Less Painful for Physicians

(Legislature, Public Health) Permanent link


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.

A Plan for the Uninsured in Texas

(Legislature, Public Health) Permanent link


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.)

Why I am Hopeful for Health Care (And You Should Be, Too)

(Public Health) Permanent link


This story was originally published on Sarah Fontenot’s blog, Fontenotes.

As the visiting associate professor for health law in the Health Care Administration program at Trinity University, I am responsible for teaching our students about multiple legal issues – from criminal liability associated with billing and kickbacks to patient rights regarding consent, end-of-life choices, and privacy; medical malpractice to Medicare/Medicaid; state regulation v. federal initiatives such as the Affordable Care Act and beyond. It is a chock-full semester.

As we approach the end of our time together, I assign a brief memo so the students can each describe their vision of the future of the field they are entering.

Every year, their enthusiasm is inspiring in equal measure to the difficulty of the field they have chosen.

The role of a hospital administrator

To understand why the positivity of my students impresses me, I must explain the role of a hospital administrator for those of you who might not know.

Being a health care executive is a career of stress and change.

A hospital represents the worst fears and the highest hopes of your community. You need to be ready every day to face the intolerable tragedy of the death of a car-crash victim on one floor while celebrating small steps (literally) on the stroke unit, or another day lived in your oncology clinic.

An administrator must manage the non-technology/homey ambiance in labor and delivery favored by young parents, while also supporting the cockpit-like machinery of the ICU next door.

You are the face associated with the entire enterprise – especially in a smaller community where you embody all of these intensely human moments every time you are seen in a restaurant or are addressing your local civic organization.

As a health care executive, you are a huge employer – in rural America, second only to the public-school system. You must care for your caregivers: from your professional staff to those who maintain your physical plant at the highest standard of cleanliness and safety.

As a hospital executive you are running a city. Issues regarding power (keeping the respirators alive if the electric grid fails), transportation (how to safely and compassionately roll patients through miles of hallways), traffic and access (can you take more ambulances in your ER or do you need to divert trauma to other hospitals?), public health (controlling infectious diseases), communication (continually updating and protecting digital records that allow all members of the team to understand each patient’s needs), and law enforcement (are you ready for the combative patient in drug withdrawal or an active shooter in your ER?).

Increasingly the public expects you to do all this while maintaining a facility with delicious food options and a lobby plucked from a high-end hotel.

You invest in technology that is quickly made obsolete in an environment where the physicians you depend on to care for your patients can be lured away by a shiny new toy at another radiology or surgical suite. And you can’t fight back with offers of any financial benefit to those same physicians – that would be illegal.

Speaking of which, the number of laws on both the state and federal level that dictate how you perform most of your processes would shock other business executives. Compliance with all is critical. Many of those you employ will never touch a patient: They exist to keep your facility within legal bounds to avoid all the penalties, both civil and criminal.

Those penalties could close your doors permanently because you are running your enterprise with a trajectory of decreasing revenue and tighter profit margins (I use the term “profit” lightly when referring to publicly owned and community hospitals).

To be a leader of a hospital requires inordinate skill in managing finances and budget.

What you charge is never what you are paid. Government programs and private insurance companies are continually changing your payment (always lower) without the negotiation standard in other industries.

And in this world, health care executives face each day’s list of priorities knowing that invariably there will be a crisis waiting to sabotage all other essential duties – loss of internet service because a road repair team nearby cut your cable, a sheriff serving your hospital with a medical malpractice complaint, a surprise visit from an auditor or Medicare-required compliance review (the unscheduled accreditation team from The Joint Commission will be on-site at least three days).

Then, of course, there is always the possibility of mass casualties streaming in from the explosion of a nearby plant, responding to an environmental hazard from a chemical spill at a local train crash, or transporting your patients from an incoming weather disaster such as a hurricane or tornado.

And all this time, 46% of surveyed physicians don’t trust you, you must address accusations that you don’t sufficiently appreciate your nursing staff (nurses are increasingly joining unions in the U.S.), and the majority of the public has no idea what you actually do.

This is the career my students have decided to enter.

What my students say

Understanding all of what I have said about being a health care executive, these are samples of what my students say when asked about the future of American health care:

1) They are excited about technology that can make health care more humane – not less so:

“Health care in the U.S. is notorious for being clunky and confusing … The only way that these problems can truly be solved is through utilizing data in a thoughtful manner and pairing it with technology that works for patients, rather than for administrators.”

“The expansion of technology in medicine has created more access to health care and, therefore, to information … as our consumers become more informed, our care delivery will have to adapt to become more patient-centered.” 

2) They view their role as administrators as facilitators for the greater good:

“To stay relevant, health systems will need to adapt to fit the patient’s experience and convenience, rather than the provider’s schedule.” 

“Health care in the U.S. may be fragmented and siloed, but now is the time to fix it. I believe aligning incentives and controlling costs are the key components to solving this problem.”

3) They demonstrate compassion for the patients who are the reason why:

“We need to move back to a time where physicians, patients, and their families were responsible for making important medical decisions, not the individuals taking and giving money for that care to be administered.”

“I believe that quality of life and conversations about what patients value are going to be more common … I see people being more comfortable with having these conversations and more forward in asking for them. I think it will be a shift in both physician training and patient culture that will help move us forward in this area.”

4) They see themselves as guardians of the future:

“For me personally, beginning my career at this time in the scheme of health care in America, I am excited and anxious to be a part of the changes we will experience over the next 10-20 years … How will we, as new [master’s in health administration] students, be able to affect such a large complex system? I believe it will come through the support we offer to new ideas, and the new ideas we will bring to our companies during residency.”

“I believe that health care will have vast changes midway through our careers in 2040 and towards the end of our careers in 2060. The way we mine and utilize data, improvements to technology, and changes to patient and provider behaviors will drive the outlook of our health care delivery system over the next 50 years.”

The positivity, professionalism, and commitment demonstrated by my class at large (and each student therein) leave me every December with a smile on my face and a confident outlook for American medicine.

Sarah Fontenot is both a nurse and an attorney. Today, as a professional speaker, she travels the country, helping people understand how health care is changing and what it means for them as consumers.

Electronic Health Records: The Dream vs. the Reality

(Public Health) Permanent link


This story was originally published on Sarah Freymann Fontenot’s blog, Fontenotes.

Last week, I sat with my 95-year-old mom in the exam room with her primary care doctor. I watched Dr. T sit with a small digital tablet on her lap, knee to knee with my mom. 

Throughout the visit, Dr. T’s fingers skittled over the screen as she accessed lab reports, other doctors’ records, mom’s medication list, and any other necessary data. By the end of the visit, without ever leaving her chair, Dr. T had provided mom with a full review of the status of her health, with details about every other physician’s involvement in her care. In the process, she had ordered one medication, changed a dosage on another, ordered homecare and records from a physician mom saw before she moved to Texas. The pharmacy, lab, physician offices, and assisted living center where mom lives had all received orders, faxes, and release forms under Dr. T’s capable fingers on the little tablet.

This, I thought, was the epitome of all we hoped for in a “paperless” medical world in 2004, when I first started teaching about the possibilities and pitfalls of electronic health records (EHRs).

Two days later, an article from Kaiser Health News and Fortune hit my desk: “Death By 1,000 Clicks: Where Electronic Health Records Went Wrong.” It is an extensive, brutal, revealing account of all the ways EHRs are leading to increased costs, inefficiencies, and opportunities for fraud. Lack of interoperability causes critical orders and records to be dropped or missed; the article tells the tale of many people who have been injured or killed by these lapses. For more than 15 years, doctors have complained about the tedium of data entry that takes them away from patient care and is a considerable component of physician burnout.

In summary, the article is a damning report on the status of the drive toward integrating health information technology (HIT) into American medicine.

The contrast between my experience at mom’s side and the world depicted in the article is startling.

Which version is true? Is it possible both are?

Electronic Health Records: The Vision

There is no doubt the paper medical-record system that spanned ancient Greece to the 1990s (and still now) needs to be replaced. Unintelligible handwriting – long the most common joke about physicians – leads to patient injuries. Information in one setting (such as the doctor’s office) is unavailable in another (such as in the emergency department). Paper is inherently at risk of destruction – such as from a spilled cup of coffee, or on a regional level as seen during Hurricane Katrina when tens of thousands of patient records were swept away.

Paper records are cumbersome to write out longhand, and therefore can be incomplete. Documentation is critical for billing government programs or private insurance companies – so those same incomplete records mean many physicians (particularly primary care) leave money on the table because they do not have time to write everything they did on every patient every day.

People often have difficulty accessing a copy of their medical chart, and if their paper file is misfiled (a possibility with even the best record clerks), their information could be lost forever.

The “silo” nature of a paper medical office also makes monitoring physicians for quality of care, licensure violations, and fraudulent billing practices by both state and federal authorities more difficult.

Population-based research (can we cure the common cold?) is impossible in a paper world.

EHRs were going to change all of that.

The Slow Move Toward a Paperless Health Care System

The vision of a “Paperless Health Care System” began in 1972, but it wasn’t until the development of the internet in the 1990s that communication technology became relevant to health care.

Switching from a paper-based medical system has a long history of support from the White House. In 1991 President George H.W. Bush championed a model electronic record, and that same year the Institute of Medicine (IOM) suggested all physicians switch to a computer-based record by 2000. The U.S. Health and Human Services Department proposed the first national standards to protect patients' medical records under the Clinton Administration in 1999, in keeping with the HIPAA Privacy Act passed in 1996. President George W. Bush “pushed” computerized medical records in 2004; Barak Obama “proposed a massive effort to modernize health care by making all health records standardized and electronic” when he was still president-elect.

However, even with the push from Washington, adoption, especially by individual physicians, has been slow.

From the outset, money has been a significant barrier (an electronic record system cost $32,606 per physician 15 years ago). Third parties that may have been willing to help physicians purchase systems could not do so because of anti-kickback law.

Not only was the cost of a new system expensive, the necessary ongoing technical support added to the ballooning overhead for most physician offices. Training costs for all office employees, plus compliance with wave after wave of security concerns and privacy protection regulations, added exponentially to the initial investment.

As this transition was occurring, 30% of physicians were “boomers” who frequently lacked adeptness at a keyboard and felt stymied in their documentation and access to patient information.

From inception, adoption of an electronic record system has been voluntary (and remains so today). Multiple federal initiatives added incentives (and increasingly penalties) for doctors that said “no.” But many, with a conviction mirroring that of the late Charlton Heston, continued to hold their pens in their “cold (ok, alive) hands.”

The first real boost to physician adoption of EHRs came with the HITECH Act (part of the Recovery and Reinvestment Act of 2009), which offered the first financial incentives to physicians and hospitals investing in EHRs. By 2017, 86% of office-based physicians were electronic, and 96% of nonfederal acute care hospitals were on board as well. (It is worth noting that some physicians, admittedly a small minority, are reverting to their old paper records.)

However, as depicted so well in “Death By 1,000 Clicks,” the achievement of near 100% participation in electronic health care records did not alleviate the problems with the technology. In many cases the issues have become more entrenched. The top five the article discussed in detail are:

  1. Continuing patient harm;
  2. Ease of fraudulent billing;
  3. Gaps in interoperability and access;
  4. Doctor burnout; and
  5. Secrecy due to policies that “keep software failures out of public view.”

David Blumenthal, President Obama’s national coordinator for health information technology and an “architect of the EHR Initiative,” reflects the disappointment – the gap from the vision to EHRs in 2019 – in this quote: "EHRs have not fulfilled their potential. I think few would argue they have.”

Why Does Dr. T’s EHR Work for Her?

Looking back on mom’s visit to Dr. T, how can I reconcile that technology-driven excellence in delivering care with all the above?

I believe there are five reasons why Dr. T’s EHR experience avoids so many of the problems with EHRs encountered nationally:


  1. Length of use: Dr. T has been on an EHR for more than 15 years. She is “an early adopter.” The standard rule of thumb on EHR adoption is it will take a physician (and the staff in a medical office) two years to fully acclimate to this new model of recordkeeping and communication. Partly Dr. T’s skill can be attributed to her years of experience.
  2. Proper IT support/upkeep: Dr. T works in an office with multiple physicians, who collectively invest in readily available IT support. Many physicians can’t sustain the cost of on-site HIT support, notably the 15% that remain in solo practice.
  3. Mobility (tablet) and eye contact: Another major complaint about EHRs from physicians is they detract from the closeness of the traditional physician/patient relationship; lack of eye contact is the No. 1 patient complaint about EHRs. The small tablet Dr. T referenced from her lap allowed her to sit knee to knee with my mom and establish the connection necessary to leave them both satisfied. However, tablet models of EHRs only became available in the past decade (the University of Chicago was the first hospital to work with tablets on a large scale in November 2010).
  4. Recent technology: As is true with all technology, EHRs modify and advance significantly – and rapidly. In 2012, many EHRs were on their second, even third, iteration. Dr. T represents a physician who has continued to update her technology as advances came on the market. However, the cost of new HIT software will keep many physicians holding onto older technology as long as possible.
  5. Interoperability (at least within her system): As explained in detail in the "Death By 1,000 Clicks," arguably the biggest disappointment about EHRs in 2019 is the continuing lack of interoperability. Globally, that is also true in our hometown where Dr. T practices. Many hospital systems (large) and individual hospitals/medical communities (small) have conquered interoperability within their system. In a rural community where all providers are interwoven, local connections mimic what was imagined on a grand scale. Sitting in her office, Dr. T was connected to all the doctors and labs she was referencing in mom’s care (save the one doctor in Rhode Island from before mom’s move). The vision of EHRs can’t be realized without true interoperability across all barriers local, state, and federal. But in the interim, Dr. T can work happily on a local level.


How Do We Address the Problems with Our EHRs?

We are approaching 30 years from the birth of a vision for a national electronic medical recordkeeping system, and we are almost 20 years beyond IOM’s 2000 due date for complete adoption.

Nonetheless, and as extensively detailed in ”Death By 1,000 Clicks,” the problems with EHRs are enormous. But even those authors do not suggest the answer is to return to paper. The problems encountered in the old system are untenable in our technology-driven world.

The only way forward is to continue to improve the electronic record system we have, but to do so with a vigor we have not expended to date. We need a significant increase in federal funding and to draw the best minds in technology to build a fully integrated system. We need significant input from physicians and nurses to create EHRs that are intuitive, efficient, and reliable.

Most of all, we need to make technology companies responsible for true interoperability across the nation – with consequences if they fail.

Unfortunately, we also need more time.

Sarah Fontenot is both a nurse and an attorney. Today, as a professional speaker, she travels the country, helping people understand how health care is changing and what it means for them as consumers. Visit her website.