The United States spends more on healthcare than comparable nations, with a spending gap that has markedly increased over the last forty years. However, this additional spending has not translated into better health outcomes for Americans, with the U.S. lagging behind other similar nations. While health policy experts and economists have written volumes analyzing the deficit between U.S. spending and health quality measures, one variable is always missing: the impact of nonphysician practitioners on U.S. healthcare.
Over the last fifty years, non-physician practitioners like nurse practitioners and physician assistants have increasingly assumed roles traditionally filled by physicians. Originally created in 1965 by physicians, these professions were specifically designed to bring primary medical care to underserved areas. Anticipating an impending physician shortage, the U.S. government strongly supported the growth of both professions, and by 1987, the federal government had spent $100 million on nurse practitioner training programs and passed legislation mandating that nonphysician practitioners comprise at last fifty percent of medical professionals in rural clinics.
In 2010, the Affordable Care Act further expanded the role of nurse practitioners, creating nurse-led clinics. By 2020, nearly half the states in the Union have granted nurse practitioners the right to practice independently without physician supervision, with North Dakota recently becoming the first state to grant physician assistants the same privilege.
In 2013, the U.S. ranked 24th of 28 countries in the number of practicing physicians, with only 2.56 physicians for every 1,000 people.
The term Intellectual-Yet-Idiot (IYI) has been popularized by the modern day philosopher/author Nassim Nicholas Taleb as a descriptor for those with many years of education that parlay titles from esteemed universities to form a useless layer of “academico-bureacrats” as unplugged from reality as they are certain of how you should live your life. It is with regret that I find many physicians to be in this most embarrassing of categories. For some reason the male instagram model turned doctor that amassed a large social media following on the strength of photogenic pec shots and the cardiologist son of a doctor that went to the best schools imaginable and knows about hardships from reading about it in a book, have very strong opinions that range from what you should eat to how society’s resources must best be allocated.
That they have little useful practical knowledge of how society works stems from the perch many of them occupy as employees of edifices that see fit to charge $97,000 for an hour’s worth of work to change the battery of a pacemaker. (Medicare re-imbursed a still ungodly $38,000). Many of these dilettantes are poor at the craft of their choosing, but even those with depth in their narrow technical specialty have grand opinions on which political party has the best Syrian foreign policy though they couldn’t find Syria on a map, and think an Alawite must be a dessert at the local lebanese restaurant they happen to be gentrifying. One would think they would have more insight in the realm of health care policy, but many prefer aspirational slogans over hard conversations those slogans should prompt.
In 1995, McArthur Wheeler, a middle-aged, stocky man standing at five foot six and weighing 270 pounds, robbed two Pittsburgh banks in broad daylight. Wheeler wore no mask and did not attempt to disguise himself. When exiting both banks, he looked directly at the surveillance cameras and smiled.
Later that evening, police arrested Wheeler and showed him the surveillance footage. As he viewed himself on video, Wheeler appeared shocked, muttering, “but I wore the juice.” Wheeler later confessed that he had rubbed lemon juice on his skin. He had read that invisible ink was made from lemon juice and believed that applying the juice to his face would render him invisible.
The tale captured the interest of Cornell University psychologist David Dunning and his graduate student, Justin Kruger. The two theorized that some people were at risk for a faulty thinking pattern—the false assumption that their capabilities were far better than they really were. In their landmark study, Unskilled and Unaware of It: How Difficulties in Recognizing One’s Own Incompetence Lead to Inflated Self-Assessments (1999), Dunning and Kruger developed the idea of illusory superiority, a false and undeserved inflated sense of self-confidence. They classified the condition as a form of cognitive bias or faulty thought process.
McArthur Wheeler was not stupid—just outrageously inept. His faulty thinking, or cognitive bias, was that he genuinely believed that lemon juice would make him invisible to surveillance cameras. Wheeler’s misunderstanding of the chemical properties of lemon juice allowed for his identification and capture. This concept of illusory superiority, now known as the “Dunning-Kruger effect,” describes a phenomenon in which people of lower ability overestimate their cognitive capability. Without adequate knowledge, some people are unable to recognize their own ineptitude, and without accurate self-awareness, those who are less capable cannot objectively evaluate their incompetence.
The Dunning-Kruger effect explains why people with the least amount of knowledge may insist that they are correct, instead of being confused, perplexed, or reflective about their erroneous ways. They genuinely believe the illusion of superiority. The effect is seen in the hubris of medical practitioners who have only trained for a fraction of the time as physicians, and yet insist that they are just as good, or that those extra years of training are unnecessary. This false self-confidence is dangerous, and the illusion of competence can lead to failed medical judgment with life-threatening consequences.
The flip side of Dunning-Kruger is true mastery of a subject and includes the humility found in those who are top experts in a field. However, even those who are masters in a field must be wary of the Dunning-Kruger effect, particularly in the sciences. Physicians are vulnerable to becoming stuck in outdated beliefs and practices that are no longer supported by the latest research. To avoid becoming “confident idiots,” as David Dunning terms it, we must constantly challenge our own knowledge and look for gaps in our understanding. Dunning recommends applying a sort-of Socratic Method to challenge our thinking, and that we seek advice by questioning and dialoguing with experts. Recognizing the concept of illusory superiority is vital to avoid ending up like the foolish bank robber. Without insight into our own self-assessment skills, we may act in an irrational, inept, or even stupid manner—like using lemon juice to make ourselves invisible. The key is to continually re-evaluate our competence to avoid being fooled by illusions of our superiority.
Examples of Dunning-Kruger
On Sunday, November 5, 2017, 10-year old Mya-Louise Perrin began vomiting. Two days later, she vomited again and had trouble standing up, so her parents brought her to Cromwell Primary Care Centre on the coast of England where nurse practitioner Ruth Loveday evaluated her. When she arrived at the clinic, the previously healthy child could barely walk down the hall. Despite the severity of her symptoms, this nurse practitioner diagnosed a urinary tract infection and sent the child home. That same night, Mya-Louise died of appendicitis.
At an inquest into Mya-Louise’s death, Loveday noted that at the time she was evaluating the child, she was quite sure that nothing was seriously wrong: “I felt confident my diagnosis was correct.” This is the fundamental element of Dunning-Kruger; nurse practitioner Loveday was overconfident in her knowledge. She truly didn’t know what she didn’t know. It never occurred to her to consider a more serious diagnosis. She didn’t have the experience to realize that simple urine infections don’t cause healthy children to struggle to walk.
Although there was no physician onsite when Loveday examined Mya-Louise, she acknowledged that she always had the opportunity to contact a doctor if she had any questions or concerns. However, she did not have the clinical acumen to realize that she needed to seek consultation with a physician. “With hindsight, I would seek GP advice,” she told the inquest.
Without extensive training, clinicians may experience gaps in their knowledge. Without experience, clinicians may not even realize that they need to ask for help – they don’t know what they don’t know. This lack of insight is particularly dangerous because it may impair a clinician’s ability to recognize a life-threatening problem.
Niran Al-Agba, MD is pediatrician practicing in Washington State.Follow her on Twitter at @Silverdalepeds. Rebekah Bernard, MD is a direct primary care physician practicing in Florida. Follow her on Twitter at @Rebekah_Bernard
So-called black box warnings on prescription medications are supposed to alert people to the possibility that using the medication can cause serious or life-threatening events. They often, but not always, do this well.
The dangerous, outdated black box warning on all antidepressants, including newer, safer SSRI antidepressants (Prozac was the first of these) represents one of the failures of this process. These strident warnings about teens and young adults are required on every container of antidepressants and advertisements for them. The often-exaggerated media reports of the dangers of these antidepressants give them the air of incontestable truth.
More than a decade’s worth of studies have revealed that the warnings on these antidepressants aimed at teens and young adults, which are intended to alert clinicians to be on the lookout for young people having thoughts of suicide at the start of treatment, have actually discouraged teens and young adults from seeking needed care. But their effects have spilled over to older adults.
Healthcare payment in the US has evolved in decades-long sweeps over the past fifty years, as both public programs and employers attempted to contain the relentless rise in health costs. Managed care in the United States has gone through three distinct phases in that time- from physician- and hospital-led delegated risk to “shadow” capitation via virtual networks like ACOs to machine-governed payment systems, where intelligent agents (AI) using machine learning are managing the flow of dollars. Increasingly, care is being managed not by physicians or health systems but by computerized documentation and payment systems governed by artificial intelligence (AI).
Phase I- Health Maintenance Organizations and Delegated Risk
After a lengthy stretch of double-digit health cost inflation following the passage of Medicare in 1965, the Nixon administration launched a bold initiative- the HMO Act of 1973- to attempt to tame health costs. The goal of the HMO Act was to power up prepaid health plans modeled on the Pacific Coast-based Kaiser Foundation Health plans nationwide. The Act provided federal start-up funds and subsidies for HMOs. It also compelled employers to offer HMOs as an alternative to Blue Cross and indemnity insurance. These plans were intended to save money by managing a fixed annual budget for care (the number of subscribers multiplied by an annual premium) vs. the legacy, open-ended fee-for-service system.
While a few HMOs either employed physicians directly on salary (staff models like the Group Health Co-Operatives), or contracted on an exclusive basis with an affiliated physician group (like Kaiser’s Permanente Medical Groups), many more delegated capitated risk to special purpose physician networks- Independent Practice Associations (IPAs)- whose physicians continued in private medical practice. Capitation created a compelling incentive for physicians to economize in care provision.
By 1996, according to the Kaiser/HRET employee benefits survey, HMOs covered 31% of the employer market (roughly 160 million employees and dependents). The impact of HMO growth on overall US health spending remains uncertain, because health spending continued growing aggressively during the next fifteen years, only abating during the mid-1990’s around the Clinton Health Reform debate.
Two things brought the HMO movement to a crashing halt in the late 1990’s. One was a political backlash from workers and their families who were simply assigned to HMOs by their employers, rather than choosing them themselves. This unilateral assignment violated a fundamental principle of HMO advocates like Paul Ellwood, who championed consumer choice. Employees and their families so assigned found their access to care narrowed by the mechanical application of medical necessity criteria to their care. Women, who are the pivotal actors in managing their families’ health and were growing increasingly confident of their political influence, went ballistic.
The other political force that helped quash the HMO movement was angry pushback from physician communities, particularly specialists, who bitterly resented the invasion of their professional freedom by prior authorization and medical necessity reviews. Physicians also resisted pressure to discount their rates to the HMOs, which reduced their incomes. A major concurrent financial blow to HMOs was a sharp downward adjustment in Medicare payment rate for health plans in the Balanced Budget Act of 1998.
In the aftermath of this reaction, closed panel, delegated-risk capitation gave way to open panel “preferred provider organization” (PPO) models which paid physicians and hospitals a discounted fee-for-service. PPOs were basically an industrialized version of traditional Blue Cross, but with allegedly narrower provider networks. PPOs offered patients broad access to physician and hospital networks and somewhat less interference in physician decision making.
As PPOs rolled out, the threat of being excluded from PPO networks led to a lengthy and damaging provider pricing panic. As PPOs spread, their networks broadened to be virtually indistinguishable from Blue Cross networks in many communities. Providers who discounted their rates in the panic to avoid being excluded from PPOs discovered to their horror that their pricing concessions yielded no growth in volume or market share, just reduced revenues.
By 2014, HMO’s share of the total commercial market had shrunk to only 13%, well less than half of its peak. Where HMOs grew, it was through Medicare Advantage and managed Medicaid. There was an important exception to this trend. While the HMO industry shrank nationally, Kaiser saw its enrollment grow to more than 12 million, dominant on the Pacific Coast but a negligible presence nationally. Strong regional HMOs sponsored by health systems and physician organizations competed with Kaiser in the West and in a scattering of non-Western markets against traditional health insurers.
HMOs are not “over”, however. From 2016 to 2019, HMO penetration in the commercial market quietly grew to 19% mainly at the expense of PPO coverage, according to the very same Kaiser/HRET survey. And in 2018, about two thirds of the 22 million Medicare Advantage subscribers are in HMOs. While HMOs by no means disappeared, the “movement” fell short of national reach. HMOs remain a negligible presence in the most rapidly growing parts of the US- the Southwest, South and Mid-Atlantic regions.
Phase II- Managed Care Lite plus Rising Patient Cost Sharing
After the 2008 recession, employers and their health plans shifted strategy from putting physicians and hospitals at risk to putting patients at risk. In the wake of the recession, the number of patients with high deductible health plans nearly sextupled- to over sixty million lives (see earlier cited Kaiser/HRET survey). By 2019, 30% of the “lives” in employer-based plans were in high deductible plans regardless of patient economic circumstances.
At the same time, Medicare moved aggressively to get providers into a new, less politically inflammatory version of managed care for large regular Medicare market (e.g. the non-Medicare Advantage portion). The 2010 Affordable Care Act catalyzed the formation of new, virtual, special-purpose managed care enterprises called Accountable Care Organizations. Two key changes in approach vs HMOs were conditioned by the managed care backlash: Medicare patients were not forced into managed care plans (or even told they were in them), and providers would be insulated from downside financial risk for a lengthy period.
Unlike with HMOs, patients would not be asked to choose an alternative “value -based” care system, nor would they receive any of the savings generated by the presumably better care management. Under ACOs, patients would be statistically assigned retrospectively to ACO panels based on whether their primary care physician was participating. ACO membership was a statistical construct, not a consensual patient panel.
Secondly, Medicare retained the risk, paying for care in the first instance based of the Medicare fee schedule, then retrospectively calculating whether ACOs achieved savings relative to local spending benchmarks. The vast majority of ACOs bore no downside risk, meaning that if they overspent their spending targets, Medicare absorbed the losses. ACOs would earn bonuses, however, based on beating statistically determined savings targets. And as part of the bargain, ACOs had to submit voluminous “quality” information and meet predetermined quality metrics.
Large commercial health plans serving employers shadowed the Medicare program, taking advantage of yet another hospital pricing panic to create new virtual ACO networks based on deeply discounted rates. Most of the plans offered under ObamaCare’s insurance exchanges were of this type. While it was assumed by providers that commercial ACOs would move rapidly toward true delegation of risk, a decade on, the risk mysteriously has not passed over to providers, who have spent at least $10 billion preparing for ACOs. Moody’s Investor Service found that the median US hospital received only 1.8% of their revenues from capitation, and another 1.9% from “two-sided” ACO style risk in 2018, proportions that barely rose in five years from 2014 to 2018. The much hyped movement “from volume to value” has been largely illusory.
Though the ACO “industry”, mainly consultants and investors, continue hyping the idea, the federal ACO program has so far not saved the Medicare program a penny, if one counts the bonuses paid out to successful ACOs, the cost overruns by the ACOs that missed their cost targets, and the cost to Medicare of setting up, administering and monitoring the program. Paid out bonuses tended to be highly concentrated in those fortunate ACOs operating in high Medicare cost markets. Medicare’s ACOs have been, to quote MedPac, a “disappointment” (see “Medpac Medicare Advantage and ACOs Can’t Cut Costs and We’ll Never Know Why” And to no one’s surprise, physician-sponsored ACOs decisively outperformed those sponsored by hospitals. If there have been any savings to anyone or bonuses paid from commercial ACOs to provider networks, they remain a closely guarded secret. Today, perhaps 10% of the US population is in some form of ACO.
Phase III- Machine Driven Managed Care.
The reason for the reluctance of health plans to delegate risk to providers is that not only would they have had to share profits with providers (from reducing the cost trend) , but, crucially, they would have lost much of the new data they were gathering on physicians and patients. This would have meant the loss of a crucial leverage point in containing medical costs. “Value based care” has seen a shift in economic power from hospitals to health plans (see attached graph from Nate Kaufman).
Health Insurance Premium Growth vs Hospital Payment Rate Growth
Much of this trend change was due to the pricing panic referred to earlier- as hospitals and physicians scrambled to avoid being excluded from new “narrow network” plans targeted at the ObamaCare health exchanges and Medicaid managed care. But in addition, health plans markedly increased the use of contractors employing artificial intelligence (AI) – data mining, algorithms and machine learning – to comb through the newly rich medical claims data sets to deny or reprice claims submitted by hospitals and physicians for their commercial, Medicare Advantage and Medicaid managed care patients.
A shadowy industry populated with billion dollar high tech firms no one in the care system had ever heard of – with names like Emdeon (now Change Healthcare), Equian (now part of Optum) , MultiPlan and Cotiviti – emerged to service health plans with automated systems to review hospital and physician claims prior to payment. Many of these firms were founded after the passage of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) whose “administrative simplification” provisions catalyzed a push toward electronic data interchange of medical claims (EDI). These firms ramped up rapidly as ubiquitous broadband replaced expensive dedicated T-1 lines. They marketed their expanded role as part of the war against medical “fraud and abuse”.
A key factor in the wave of denials was the increased centrality of hospital emergency admissions as the main gateway to complex and expensive inpatient care. With primary care physicians withdrawing from hospital practice, decisions to admit patients to hospitals were increasingly made by employed physicians or physician contractors to the hospital. Upwards of 70% of patients in many health systems are admitted through the emergency room and care is rendered to those patients on an urgent basis. “Prior authorization”, a forty year old HMO expense control tool for managing “elective care”, has given way to “prospective pre-payment review” applied after hospitals have admitted and cared for patients and submitted insurance claims.
Hospitals saw, in some cases, a doubling of claims denials or “repricing” in just a twelve to eighteen-month period after 2016 based on these automated “prospective” reviews. This surge of machine-driven denials played a major role in the mysterious 39% plummet in hospital operating earnings seen in 2016 and 2017. These denials often result in unexpected higher bills to patients with high deductible plans as well as significant new administrative expenses for hospitals to track and contest the surge of denials. Many patients were unable to pay these unexpectedly higher expenses, resulting in a rise of “insured self-pay” bad debts.
Hospitals and health systems are getting help pushing back against automated payer-driven AI claims review systems. A private equity funded startup, Olive, has developed its own AI systems to audit hospital claims prior to submission ) Olive and other companies will use robotic process automation (RPA) to manage documentation to make sure they minimize the risk of a costly denial, and to assure “payment integrity”. Thus, the next decade is likely to see an escalating war of robotic provider and payer AI systems managing the filing and adjudication of medical claims.
COVID has produced what seems like a temporary cease fire in this “War of the Robots”. This is because the shutdown of routine care in hospitals has produced a multi-hundred billion windfall in cash flow for health plans. Denying care during a health emergency could produce a lot of ugly headlines, so plans appear to have turned the “denial machine” off, according to colleagues in the revenue cycle industry. This will magically raise their medical expenses (the so-called Medical Loss Ratio or MLR) and lower their political profile. Plans do not want to be socked with a “windfall profits” tax to help fund federal hospital relief efforts. However, when health plans medical expenses MLRs have risen again it is a dead certainty that the denial machinery will crank up again and that the war will resume.
A managed care” movement” which began more than seventy years ago by empowering clinicians to manage care for populations within a fixed budget has devolved, by degrees, into an increasingly data driven payment system run by computers, that shifts costs to physicians and patients without their input. The early stages of this devolution spawned successful, high quality integrated health systems and health plans in some parts of the country. However, the last decade has left the bulk of care providers drowning in documentation busywork and box checking, and burdened by a growing revenue cycle bureaucracy. Their incomes are increasing managed by machines, not colleagues. How this evolution will improve actual care to patients remains to be demonstrated.
Jeff Goldsmith is a veteran health industry observer based in Charlottesville, Virginia and President of Health Futures Inc.
The other day I saw a new patient who used to be on Lamictal, a mood stabilizer. The young man explained that he had gone through a difficult time in his life a few years ago and his primary care doctor put him on Prozac, which, as he put it “hijacked” his brain and made him “ugly, hyper and careless”. The man immediately stopped the Prozac and his doctor prescribed Lamictal, which he stayed with for about a year.
He decided to stop the new medication, because he reasoned that he didn’t have any psychiatric issues. It was just a side effect of the Prozac, which he in retrospect probable hadn’t needed at all.
Since then, he admitted, he had felt sad or unsettled in the spring and fall, but it always passed and he didn’t think his wife or anybody else noticed his seasonal mood changes.
“So, did anybody actually use the word “bipolar” in talking about what you went through?” I asked.
He winced and almost seemed teary eyed. “Yeah, but I don’t think that’s right. How can you put a label on somebody that will follow them for the rest of their life because of what their brain did when, basically and literally, they were on drugs?”
“Who knows how many people might react the same way if you give them Prozac”, he continued.
“I think labels can hurt sometimes, but they can also be a way of understanding how our minds and bodies work”, I began. “I don’t believe diagnoses are as cut in stone as some people like to think.”
He looked quizzical as I continued:
“Take diabetes – this country and Canada have slightly different cutoffs for what a normal blood sugar is. Or blood pressure – every few years the experts pick a different number for what’s good enough and what’s ideal. I believe most things we call diseases are points at the extremes of a spectrum that we all fall somewhere on.”
Now he was the one nodding.
“Take mood”, I continued. “At one end of the mood spectrum there is depression and at the other there is what we call mania. Sometimes that looks like exaggerated happiness and confidence, but sometimes it is more like irritability and agitation. We can all experience any one of those moods, but usually we are somewhere in the middle. So, people are making up disease definitions depending on how far and for how long we deviate from the middle. But if we never move an inch from neutral, that’s not necessarily being healthy – I think of that as definitely abnormal.”
“I see what you mean”, he nodded again.
“As a clinician, I think of labels as a type of shorthand or mental image that I keep in mind when I approach a problem. They help me choose treatments and they help me explain things. But I tend to be slow in sticking labels on patients or in their medical records. I read a book once called ‘Shadow Syndromes’ that makes the point that looking at the extremes of whatever spectrum we are on helps us understand ourselves and can be very empowering.”
“So, Doc, do you think I’m bipolar?” He leaned forward.
“You have the tendencies, yes, but a condition isn’t a problem until someone sees it as a problem. If neither you nor the people around you see your mood variability, not to use the stronger word ‘mood swings’ as a problem, then fine. But I, knowing what you’ve told me about how your brain works, would be a fool to prescribe Zoloft or Lexapro if you ever came to me feeling terribly depressed. I would then think of you as somewhere on the bipolar spectrum, needing a slightly different treatment approach if we wanted to lift your mood.”
“A mood stabilizer, like Lamictal”, I finsished, “can be like an insurance policy against ever having a manic episode in the future, and we usually recommend long term treatment if a person has had an episode out of the blue. But I’m not so sure it’s necessary if the episode was triggered by Prozac or any other antidepressant. I’m sure there are lots of opinions about that, but that’s what I think, especially since your episode was not severe from what you’ve told me.”
On my drive home that afternoon, I thought of the spectra I may have moved along during my lifetime. I remember my mother commenting on how I had turned into such a slob; “When you were little you were so neat, you used to line everybody’s shoes up in the entryway.”
That’s the OCD spectrum, and I guess I narrowly escaped that diagnosis…
President Trump’s wobbly walk down a ramp at his recent West Point visit along with his awkward two-handed drink from a water glass have stirred recent speculation about a possible undisclosed neurologic issue such as early Parkinson’s Disease. Although no specific conclusions can be drawn from these observations, they raise important questions regarding the President’s health.
Trump would not be the first president to conceal health problems. Toward the end of Franklin Roosevelt’s presidency, his blood pressure rose alarmingly. As no drug treatments existed his doctors could recommend only that he stop smoking, lose weight and avoid dietary salt. Less than six months after an un-knowing public re-elected him to a record fourth term, FDR predictably suffered a fatal stroke. The public was similarly unaware of John Kennedy’s Addison’s Disease, a condition that required daily injections to replace the adrenal hormones his body could not make.
The known facts about Trump’s health are concerning enough. Despite taking a statin drug to reduce his cholesterol, Mr. Trump’s age and risk factors at his 2018 physical predicted a 16.7% risk of a heart attack over ten years, as estimated by a standard American College of Cardiology risk calculator. Trump was taking a statin at the time of that exam to lower his cholesterol. As cholesterol levels on a statin may not reflect risk as accurately as un-treated levels, the calculator may under-estimate his true risk. Although Trump’s doctors tout his health they seemed to be concerned about cardiovascular risk as they subsequently quadrupled his statin dosage, placing him highest dose of the most potent statin available. In addition, the President’s annual exam revealed that his weight recently drifted up into the obese range, which means additional coronary disease risk along with an increased chance of stroke, chronic kidney disease, diabetes and several types of cancers.
The halting and uncertain response to COVID in the US is a tragic civic embarrassment. While other countries have snuffed out the Covid-19 virus, the US seems to be grinding on toward 200 thousand deaths despite flinging trillions of dollars at the problem. As summer approaches, the US shows every sign of declaring victory long before the foe has left the field. Americans may be losing interest in COVID but COVID has not lost interest in us.
What happened? Several trillion in lost economic output, massive dislocation of American families and disgraceful disparities in health risks based on race and socioeconomic level all point to a breakdown in a key civic function. No readily deployable testing capability, critical shortages of protective gear, unappreciated and unresolved conflicts between federal and state health authorities, and critical failures in our core federal public health agency, the Centers for Disease Control and Prevention all played a role. In retrospect, it is clear that US public health effort- $93 billion in spending in 2018, or 2.4% of total health spending, for a population of 327 million people- was grossly inadequate for the magnitude of societal risk. We spend nearly eight times as much on the military.
Successful public health requires social solidarity and trust both in science and in government. All are in short supply. Early statements from political leaders about how this is no worse than the common cold or the flu and was going to “just go away”, and the fact that the initial wave was concentrated in greater New York (New Jersey, Connecticut, Long Island, etc.) helped lower the national sense of urgency.
Aggressive early testing would have been confirmed that the disease was, basically, already everywhere in the country by late March, and was not, in fact, just a “Blue State problem”. The failure to deploy testing early led to a far more destructive and costly national economic shutdown than was necessary; the economic cost of a “flash depression” could have been avoided with better planning and more decisive leadership.
But in those parts of the country initially grazed by the pandemic, an uglier reality surfaced. It was not merely a failure of leadership that hurt us but a failure of followership as well. As protests against lockdowns proliferated, the signs told the story. ““My Rights Don’t End Where Your Fear Starts” read one. “Liberty for Safety- No Deal” read another. But a sign at a “Re-open Tennessee” rally in Nashville in late April said it all in just three words: “Sacrifice the Weak”, a jarringly un-American sentiment if ever there was one.
In addition to underestimating their own risks, and failing to embrace measures that reduced risks for others, many of those initially spared the virus rationalized that the immediate and tangible costs to them of COVID countermeasures far exceeded the costs to others of an unchecked pandemic. Those “others” were probably going to die anyway (e.g. older folks, people with chronic disease risks like diabetes, workers in meat processing plants, etc.) in some other part of the country that they didn’t care about. It is easy at a distance to dismiss the reality that the typical COVID fatality lost an average of eleven years of life expectancy!
Thanks to all of this, we are likely not in a second wave but rather a continuation of the pandemic in parts of the country spared the first wave. Eighteen states, including Texas, Florida, Georgia, the Carolinas and California, saw increased COVID caseload over the past week. Leaders in many states will be extremely reluctant to backtrack, and recommit their states to aggressive social distancing, which, again, would not have been necessary if they were well enough organized to test, trace and isolate- the three keys to an effective response to a viral threat.
And it simply isn’t as if a coherent public response to this threat was impossible. Other countries (New Zealand-22 deaths, Taiwan-seven deaths, Hong Kong- four deaths) succeeded in surmounting this threat while we failed. It’s not that the sacrifices demanded in their citizens were somehow less onerous than those that were demanded of us Americans. What these countries did in common: rapid diagnosis of a major threat, decisive action to sever all (not just ideologically indicated) international arrivals, universal and uncompromising lockdowns, aggressive scaling up of testing, mobility tracking and follow up. Most of these countries were also smaller in population, had decisive executive leadership willing to take political risks and showed broad-based respect for authority in the face of the crisis.
Even though this crisis is far from over, the next pandemic is a “when”, not an “if”. Obvious ingredients of a successful response to the next pandemic include: multi-level planning for rapidly scalable viral testing, a secure medical supply chain, generous stockpiles of protective gear, an agreed-upon protocol for care system deployment (to protect ongoing health care functions and workers), recruitment and training protocols for emergency workers and contact tracers and assignment of responsibility for covering high risk “hot spots” such as nursing homes, distribution facilities and food processing plants. A thorough going and bipartisan review of the Centers for Disease Control and a commitment to increase federal as well as state and local public health funding is also essential
In a functioning country, these would be achievable steps. However, logical planning and decisive action may be too great a lift for a fractured, angry and distracted nation. Two key functions- public health and law enforcement- appear to have lost legitimacy with broad swatches of the public. Our largest political party seems to be the “Are You Kidding Me?” Party. A failed state cannot protect its citizens against much of anything.
A society riven increasingly by tribal resentments, fear and suspicion of any leadership is a society at risk. The failure of the US to respond effectively to the COVID emergency is ominous, because it has shown societal divisions deep enough to paralyze the country from responding to other threats, be the other emerging diseases, a deep economic downturn, aggressive and unprincipled foreign adventurers, or terrorism foreign or domestic.
In the Congo, a comprehensively “failed state” if ever there was one, the unofficial national motto is: “Débrouillez Vous”, loosely translated as “Figure it out yourself”. This cannot be where we end up. It seems so obvious that if we are to be an actual country, we need to take better care of one another, and that we are stronger as a country if we trust one another and work together to address our common challenges.
Jeff Goldsmith, Ph.D. is a health policy analyst based in Charlottesville Virginia and President, Health Futures Inc.
Not accustomed to visiting hospital executive suites, I took my seat in the waiting room somewhat warily.
Seated across from me was a handsome man in a well-tailored three-piece suit, whose thoroughly professional appearance made me — in my rumpled white coat, sheaves of dog-eared paper bulging from both pockets — feel out of place.
Within a minute, an administrative secretary came out and escorted him into one of the offices. Exhausted from a long call shift and lulled by the quiet, I started to doze off. Soon roused by the sound of my own snoring, I started and looked about.
That was when I spotted the document on an adjacent chair. Its title immediately caught my eye: “How to Discourage a Doctor.”
No one else was about, so I reached over, picked it up, and began to leaf through its pages. It became apparent immediately that it was one of the most remarkable things I had ever read, clearly not meant for my eyes. It seemed to be the product of a health care consulting company, presumably the well-dressed man’s employer. Fearing that he would return any moment to retrieve it, I perused it as quickly as possible. My recollection of its contents is naturally somewhat imperfect, but I can reproduce the gist of what it said:
We are all reeling from the language of the COVID-19 pandemic: fatality rates, spread, PPE, distancing, pneumonia, anti-viral drugs, ventilators, second wave, vaccines, serological testing, etc. All of this focuses on the infection with the SARS-CoV-2 coronavirus, and for good reason. People are sick and dying from this infection. However, there is murmuring that will grow in volume as COVID-19 subsides: Will this happen again? Is the annual flu season to become more alarming in the future? Will we forever be waiting for vaccines and anti-viral drugs with bated breath?
If we step back and view this nightmare from the perspective of infectivity rather than infection, there may be a way out of this conundrum. Coronaviruses are one of several categories of virus with a proclivity for human respiratory infection. Coronaviruses join Influenza, Ebola, SARS and MERS as respiratory riboviruses. These viruses are tiny bundles, virions, containing a little RNA and not much else. Left alone, little happens. But if they manage to get into a target cell, they commandeer the cell’s metabolic machinery to do their malevolence. They get to their target cell because we inhale them as virions that are aerosolized or carried in the droplets that are produced when infected people exhale. Droplets that are not inhaled settle on surfaces, including surgical and N95 masks, where water evaporates freeing virions to aerosolize unless they are somehow bound to the surface. They are so tiny that even the N95 mesh is an inefficient barrier. One would need filters with such tiny pores that they would impede inhaling.
Infectivity of these riboviruses and probably severity of disease are dose dependent. The more virions one inhales the more likely one is infected. That’s the reason physical distancing is advised. However, these riboviruses retain infectivity for many hours on surfaces during which air currents can launch them and keep them afloat. That’s of little concern out of doors where they are diluted, but not indoors. Modern architectures and civil engineers are well aware of issues that relate to stagnation in built environments. HVAC systems are designed as a compromise between the need to recirculate air for the sake of efficient heating/cooling while turning to filters and air exchanges for the sake of air purity, particularly with regard to inert particulate materials. Concerns about airborne illnesses are seldom primary. In most hospitals, certain rooms are designed as “reverse flow” rooms for patients with contagious diseases with exhaust mechanisms so that the room’s air is released to outside the building, not back into general circulation in the building. Some operating rooms, particularly orthopedic surgical suites, have lamellar flow ventilation to decrease the likelihood of introducing an airborne pathogen along with orthopedic hardware. But otherwise hospitals and other workplaces are not designed with regard to infectivity.
As attractive as it is to think that science exists on a distinctive, untarnished, untrammeled plane, this idealization is dangerously misleading. Science is carried out by real people, within complex social organizations. Debates about science—often civil, occasionally acrimonious—on methods and meaning are the rule.
Which is as it should be: That’s how knowledge advances.
Ignoring what scientists have to teach us about COVID-19 would be a mistake. The virus is not a “hoax.”
But it’s also a mistake to default to the idea that we must “listen to Science,” as if there’s an unambiguous perspective that all researchers share and that all scientific data are established with an equal degree of certainty. This isn’t how science views itself. So we shouldn’t view it that way, either.
Within the universe of the present pandemic, some information seems very well established—the identification of the virus responsible for the condition, for example. Other data, including some very important essential facts, aren’t as clear.
We need to recognize and acknowledge these limitations.
Some people see these limitations are reason not to trust any of the information that comes out of the scientific establishment. For them, the failure of models to perfectly predict the trajectory of the pandemic was enough. What we’ve learned, saidNew York Post columnist Miranda Devine, is that “computer models are unreliable when it comes to predicting the future.” Instead of relying on supposed experts and their supposed models, she says, we should instead “trust the innate common sense of the American people.”
But there are more responsible ways to understand the problems with modeling.
Respected biostatistician Ruth Etzioni, at the Fred Hutch Cancer Research Center in Seattle, recently wrote that the latest version of the Institute for Health Metrics and Evaluation (IHME) model from the University of Washington “makes me cringe.” The changes revised the death projections significantly higher, and Etzioni argues that the modelers got there by making a number of obscure changes to the model, then presented these updates as reflecting simply the consequences of reduced social distancing.
I will be 79 next month. What do I think? I think the country should open back up, albeit cautiously. I’m embarrassed to think that people have to up-end their lives for older people like me. For one thing I’ve lived a hell of a life.I’ve been around the world, I’ve been a mom, a foster mom, and a grandmother, and an entrepreneur besides. I have written a few crummy books.
As one of the vulnerable, I’ve been stuck in the house now for six weeks, learning every detail about the Coronavirus. I have seen only about half a dozen people who are part of my quarantine barrier: people with whom I walk my dogs outside in the morning, my roommate, my barista and the woman who sanitizes my home once a week. And that group is considered too risky for most, but I’ve always been a risk taker and I’ve known my housekeeper for 25 years. I know she will do her best not to cause my death.
What do I do all day? Mostly I exercise, walking or taking Zoom yoga. What do I wish I could do? Hang at the bar at Hillstone. When will I be able to do it? Safely, probably not for two years.
Right now Arizona is on lockdown but we are preparing to re open soon. Our case numbers are not declining although the increase has slowed. We are part of the wild west, and our social distancing is not as strict as California’s, or my daughter’s in London. For example, I took a walk along the canal near the Arizona Biltmore hotel on Sunday and there were couples laying in the grass near the putting green of the golf course. They were drinking mai tais and beers and reinterpreting social distancing in their own ways.
They were young and I’m sure they didn’t perceive themselves as vulnerable. There were also more than 10 of them and they were oblivious to the numbers. I was jealous. I don’t want to be one of the vulnerable. I wanted to join them and have fun.
COVID-19 is a serious crisis and you need to keep away from people and stay at home.
Things are better and we are re-opening restaurants, stores, churches, and hair salons.
The death tolls are an underestimate.
The death tolls are exaggerated.
No need to wear masks, as they don’t help.
You should wear a mask.
100,000 Americans will die.
Make that 50,000.
The virus doesn’t spread through the air easily.
Simply being near someone who is talking can give you the virus.
Young people are basically immune from serious infection.
Anyone can die from it.
Hydroxychloroquine and Zithromax will cure it.
No, those don’t work.
A vaccine is in development.
A vaccine might not be available until late 2021, and it might not work great.
You get my point. It’s confusing and it’s frustrating. It’s like the old joke about the weather: if you don’t like the weather here, just wait 5 minutes. So if you hear something that bothers you, just wait 5 minutes and you’ll hear the opposite opinion about COVID-19. Why is this? Why can’t we agree? Why are facts being replaced by opinions?
The Nature of Science
The first thing I want to sayis that the nature of science is to get things wrong a lot in the path to getting things right. Contrary to popular perception, science is not about finding one answer and sticking with it because it is “true.” No, science is about gathering data through observation and experimentation and coming up with the best explanation for that data. More data often means that old explanations don’t float any more, but that’s OK because eventually, over time, we get things more and more right and come to a (hopefully) more truthful and useful answer.
6 months ago we knew almost nothing about this virus. 3 months ago, most of us were more concerned about fires in Australia, about all the rain we were getting, and about the Astros cheating. Yes, people were sounding the alarm about the seriousness of the virus, but few foresaw what ended up happening. Nobody was pushing for a vaccine 6 months ago, nobody was looking for medications to treat this disease. Nobody was storing away masks or making emergency plans for ventilators.
Burnout has become an obsession in the medical profession. I am almost 75 years old and am not feeling any of the symptoms of physician burnout. I do not state this out of any sense of pride, but I have tried to be introspective about this to offer some advice as to how to avoid this problem.
My approach is fourfold. I shall begin by reviewing the definition of burnout, emphasizing physician burnout. To address the individual issues, I think it is important that we are all on the same wavelength and are using the same definitions. Secondly, I will review some facts about the reality of American medicine as we now experience it. Third, I shall articulate a paradox between what seems to be an epidemic of physician burnout in the context of the reality of American medicine. Finally, I will offer a nine-point set of suggestions, which are meant to help to avoid the symptoms and signs of this syndrome.
Burnout is not a new idea, and it is not specific to medicine. It has been in the psychiatry literature for quite a long time, but it was brought to our attention in medicine in a series of papers by Zeev Neuwirth, who, at the time, was an internist at the Lennox Hill Hospital in New York. He wrote several papers on related subjects and published an article in the lay press in 1999 that was entitled “The Silent Anguish of the Healers.” Since that time, it has become evident that “burnout” is an important issue in medicine that needs to be addressed. Neuwirth and others have defined ”burnout” as a feeling of complete emotional exhaustion characterized by cynicism, depersonalization and perceived ineffectiveness.
An Epidemic of Dissatisfaction
In recent years, many have argued that “burnout” is extremely prevalent; not only in society in general but especially in medicine. It has been said that 50% of physicians have at least one of the three cardinal features: exhaustion, depersonalization and inefficacy. The problem with these kinds of data is that are no adequate controls; especially controls from others in the learned professions. It is probably quite common for many people, at some point or another, to experience one or more of these cardinal features. The real question is whether this is more prevalent than in a control population and whether they are persistent, rather than transient, symptoms. That information is not available. For these reasons, it is likely that the problem of “burnout” is being exaggerated. Nonetheless the problem undoubtedly does exist in an unknown proportion of physicians.
When my daughter Alex was in third grade she had the reigning Marin County (California) Teacher of Year. Her name escapes me (I’ll blame it on the chemo brain). The parents of all the kids in this Tiburon classroom were beside themselves with praise for her. Me … not so much. A big one thing I had a problem with was she encouraged the students to use calculators in her class. Her reason was that it would be good practice for real life – where no one did math long hand anymore. Well, I do.
Now I still use a calculator, but daily I make every effort to do math problems in my head. Percentages, grocery bill estimates, gas mileage … anything and everything. it’s something I’ve always done and probably always will. It’s cerebral exercise, and it’s something I’ve encouraged my daughter to do also. On road trips as a grade-schooler, she’d have to look at the mileage, take in account our speed, and determine when we’d get to the next stop. I don’t know if she liked it … but she did it anyway.
Now I don’t mean to sound like a Luddite. On the contrary, I self-taught myself how to program in college on FORTRAN 77 on my college’s IBM 360/370 (how many of you remember FORTRAN or a 360/370). I’d sneak in to the computer center at night and drop off my boxes of punch cards. I wasn’t so bright that I used a terminal like the other nocturnal geeks in training though. I used punch cards … and for a many months carried around my three boxes of 1400 cards.
I bought my first Mac in 1985 and I was transferring data online before there was an online. My first email address was at the Well in the San Francisco. In fact I gave Well email addresses for Christmas presents. Alexandria was raised on a Mac, and instead of going to college when she graduated high school … she went to Apple.
That said, I didn’t like the idea of supplanting the exercise of the brain for the exercise the fingers hitting the calculator buttons. And the excuse: “they’ll need to learn how to use a calculator in real life when they’re older” is lame. What they’ll need to learn is how to use their brain. And considering who this country elected as president – we’re in short supply of those that either can or will.
Now I’m not blaming calculators and their use in grade school for the clown in the White House and utter disintegration of the democracy before our very eyes … but then maybe I should. Maybe we should look it as a symptom … a touchstone of sorts, emblematic of how we view intellectual development in this country. I get the whole “recognizing the value of tools” thing. But unless the foundation is built for which the tools are to be used (and hopefully complement) – we’re building a skyscraper or citizens’ equivalent of it – on a landfill.
Over Memorial Day weekend 13 years ago, my younger brother, Laith, died in an accident. He was 26 years old. Losing young people in their mid-20’s is particularly devastating because they are embarking on adulthood and their futures hold limitless hopes, dreams, and possibilities. For the survivors, no holiday brings the same joy as it did before. Someone is not there, and never will be.
Wanda Cooper-Jones, the mother of Ahmaud Arbery, has endured unbearable pain. Gregory and Trevor McMichaels shot and killed her son while he was running down the road. They were not arrested and charged with a crime until 74 days later. A third man, William Bryan, stood by and recorded the murder of Ahmaud Arbery on his cellphone for more than 4 minutes. 74 days passed before he was charged with committing a crime. The gruesome facts of this story have enraged me because I know a little something about the unrelenting grief associated with unexpected death.
My brother’s death was accidental, which made me incredibly sad. Wanda Cooper-Jones’ son was ruthlessly lynched and then this week George Floyd was killed in broad daylight by a police officer in Minneapolis, both of which make me unspeakably angry.
Enough is enough. This nation must stop tolerating lynching of black men and women. While racism is difficult to discuss, it is also necessary, valuable, and essential in order to bring about change. My previous column addressed white privilege and ever since, readers have been asking, “What now?”
Now, we need to become allies to people and communities of color.
I was recently speaking with a friend of mine, a pulmonologist at a large academic medical center in the Midwest, about his COVID-19 experience. I was especially interested, in the context of iterative experimentation, to learn how his hospital was working on improving the care of COVID-19 patients, especially those in the ICU, which he oversees.
It’s a real problem, he said. On the one hand, there are specific initiatives he’s trying to evaluate, in a classic, controlled fashion, so he can figure out if the intervention is effective and should become part of the standard of care.
That’s the goal.
In reality, however, here’s what he says is actually happening: most of the front-line doctors are hearing about the very latest approaches, generally from social media (such as Twitter or medical podcasts), and are trying to immediately apply these methods to their patients. As a result, the care patients receive depends (to some degree) on the specific physician involved, as well as the extent to which that physician has been influenced by other opinionated doctors.
At a recent Boston innovation conference (discussed here), Dr. Paul Biddinger, an emergency medicine physician who leads emergency preparedness at the Massachusetts General Hospital, made a remarkably similar observation. He praised the “unprecedented information sharing” associated with the COVID crisis. But he also expressed concern about the “practicing by anecdote,” and more generally the “temptation to fall off what have been the time-proven methodologies of science.”
A number of politically tinged narratives have divided physicians during the pandemic. It would be unfortunate if politics obscured the major problem brought into stark relief by the pandemic: a system that marginalizes physicians and strips them of agency.
In practices big and small, hospital-employed or private practice, nursing homes or hospitals, there are serious issues raising their heads for doctors and their patients.
No masks for you
When I walked into my office Thursday, March 12th, I assembled the office staff for the first time to talk about COVID. The prior weekend had been awash with scenes of mayhem in Italy, and I had come away with the dawning realization that my wishful thinking on the virus from Wuhan skipping us was dead wrong. The US focus had been on travel from China and other Far East hotspots. There was no such limitation on travel from Europe. The virus had clearly seeded Italy and possibly other parts of Europe heavily, and now the US was faced with the very real possibility that there was significant community spread that had occurred from travelers from Europe and Italy over the last month. I had assumed that seeing no cases in our hospitals and ICUs by early March meant the virus had been contained in China. That was clearly not the case.
Our testing apparatus had also largely been limited in the US to symptomatic patients who had been to high-risk countries. If Europe was seeded, this meant we had not been screening nearly enough people. When I heard the first few cases pop up in my county, it was clear the jig was up. It was pandemic panic mode time. There was a chance that there were thousands of cases in the community we didn’t know about and that we were weeks away from the die-off happening in hospitals in China and Italy. So what I told the staff the morning of March 12th was that we needed to start acting now as if there was significant spread of COVID in the community. This meant canceling clinic visits for all but urgent patients, wearing masks, trying to buy masks, attention to hand hygiene, cleaning rooms between patients, screening everyone for flu-like symptoms before coming to the office, and moving to a skeleton staff in the office. I left the office that day wearing a mask as I headed to the ER.
Over the last three decades, health care policymakers in Minnesota, where I live, have gotten into a bad habit: They recommend policies without asking whether there is sufficient evidence to implement the policy, and without spelling out how the policy is supposed to work. Measurement and “pay for performance” (P4P) schemes illustrate the problem. Multiple Minnesota commissions, legislators, agencies, and groups have endorsed the notion that it’s possible to measure the cost and quality of doctors, clinics, and hospitals accurately enough to produce results useful to regulators, patients, providers, and insurers.
But these policymakers did so with no explanation of how system-wide measurement was supposed to be done accurately, and without any reference to research demonstrating that accurate system-wide measurement is financially or technically feasible. The Minnesota Health Care Access Commission (in 1991) and the Minnesota Health Care Commission (in 1993) were the first of several commissions to exhibit this “shoot-first, aim-later” mentality. Both commissions recommended the establishment of massive data collection and reporting systems, and both articulated breathtaking expectations of the “report cards” these systems would produce. According to the latter commission, for example, the data collection and number crunching would facilitate “feedback of data that reflects the entire scope of the health care process, from the inputs or structural characteristics of health care to the processes and outcomes of care.” (p. 134) Yet neither commission offered even the crudest details on how such a scheme would be executed nor what it would cost, and, not surprisingly, neither commission offered evidence supporting their high hopes.
In 2008, two other commissions and the Minnesota Legislature exhibited the same casual attitude toward evidence and details. That year, the Legislature, egged on by the commissions, passed a law requiring the Minnesota Department of Health (MDH) to create a “standardized set” of quality measures for Minnesota that would be used to punish and reward “health care providers” (Minnesota Statutes, Section 62U.02). The law offered a few guidelines (such as MDH should “seek to avoid increasing the administrative burden on health care providers”), but it offered no details on how MDH was supposed to create useful measures.
Covered California released the first national projection of how the COVID-19 pandemic will affect employer health insurance. The report predicts that employer premiums will rise in 2021 by 40 percent or more, absent federal action, which is certain to alarm many employers.
As the former CEO of Blue Cross & Blue Shield of Rhode Island, I disagree with these ominous projections, and believe that in the wake of COVID-19, any rise in health premiums will be minimal, one-time events (which I explain below).
Moreover, I believe it’s time for employers to consider a more important question: whether they should pass any future rate increases to employees, which for years has become a common practice with profound ramifications for both employee well-being and employers’ bottom lines.
As a former healthcare CEO, I’ve taken part in the complexities of health insurance ratings for years. To better understand how the COVID-19 crisis might impact insurance premiums, I consulted with insurance actuaries about changes that may arise in the coming year.
Overall, I believe that COVID-19 will significantly increase claims expenses in line with Covered California’s projections, which will include higher ER intake and ICU overflows, and increased hospital staffing.
The governor has eased restrictions and now we can go to restaurants, go bowling, get tattoos, and visit many of the stores that were previously closed. Churches are now planning to meet again.
This leaves many of my patients wondering what to do. Is it OK to go to these stores, to get your hair done, to join the neighborhood pool, to go out to eat, to go to church? Is it safe to do now?
No. It’s not safe yet. You are at the same risk of catching coronavirus now that you were 2 weeks, or 1 month ago. The change in the policies in both Georgia and South Carolina were not due to a lessening of the risk of the infection; it is an economic decision. It was very reasonable to shut everything down when we didn’t know how full our hospitals, ICU’s, and ER’s would get with a surge in cases. It was important to “flatten the curve,” and that seems to have worked. We do have enough capacity right now to handle the number of critically ill people in our hospitals. But that could change.
So what will happen now that “stay at home” restrictions are going away? It’s very likely that the number of infected people will go up, as will the number of deaths. So why open things back up? Because we cannot keep everything shut down while we wait for 1-2 years for a vaccine to come out. The economy simply can’t sustain that, and people would suffer because of it (economically, emotionally, and physically). We need people working again, and we need to avoid a total collapse of our economy.
But again, do not think it’s now safer than it was before the governor’s decision. Do not think it’s not still important for high-risk people to remain isolated, for people to stop wearing masks, or to stop washing their hands. This virus has killed nearly 75,000 people in the U.S., and the rise in deaths is not seeming to slow at all. A vaccine is unlikely to come out in 2020, so we will have to adjust to the new normal of living in the shadow of this pandemic. It will take a very long time for things to resemble the way things were before this all started.
Our strategy with nursing homes in the midst of the current pandemic is bad. No, make that terrible. Nursing homes and other long term care facilities house some of our sickest patients in and it is apparent we have no cogent strategy to protect them.
I attempted to reassure an anxious nursing home resident a few weeks ago. I told him that it appeared for now that the community level transmission in Philadelphia was low, and that I was optimistic we could keep residents safe with simple maneuvers like better hand hygiene, restricting visitors, as well as stricter policies with regards to keeping caregivers with symptoms home. I was worried too, but optimistic.
I figured the larger medical community would be on the same page if someone did get COVID. It made sense to me to be aggressive about testing staff and residents and quickly getting COVID-positive patients out of the nursing home. So when I heard of the first patient that was positive in the nursing home, my heart sank, but it fell even further when I found out the COVID-positive patient was sent back from the hospital because they weren’t “sick enough” to be admitted.
This is exactly what we do with the general public when they arrive in the ER. If you’re not sick enough, the best place for you to recover from COVID is at home, not the hospital. But treating nursing home patients like everyone else is really not smart. Long term care facilities are not designed with pandemics in mind. They are basically converted dormitories with care staff ratios of 1:10. Isolating patients in these facilities is close to impossible. There are usually no flexible spaces in which to isolate residents, and the staff at these facilities are relatively lower-paid, poorly trained and ill-equipped to suddenly handle a patient with COVID that requires a significantly higher level of care than usual.
Submissions should be between 400-800 words, although we sometimes publish longer pieces. The editors are open to opinion pieces reacting to stories and trends in healthcare, medicine, technology and wellness.
There is no hard and fast format for the posts we publish. Some look like TED Talks. Others look like they belong in the New England Journal of Medicine. Others are traditional opinion pieces that would not look out of place in The New York Times or the Wall Street Journal.
We’re interested in thoughtful analysis of stories in the news, contrarian takes on trending stories and the established order, first person accounts from healthcare workers and people experiencing the joys of the health care system first hand.
Until scientists discover a vaccine or treatment for COVID-19, our economy and our privacy will be at the mercy of imperfect technology used to manage the pandemic response.
Contact tracing, symptom capture and immunity assessment are essential tools for pandemic response, which can benefit from appropriate technology. However, the effectiveness of these tools is constrained by the privacy concerns inherent in mass surveillance. Lack of trust diminishes voluntary participation. Coerced surveillance can lead to hiding and to the injection of false information.
But it’s not a zero-sum game. The introduction of local community organizations as trusted intermediaries can improve participation, promote trust, and reduce the privacy impact of health and social surveillance.
Building Trust with Transparency
Privacy technology can complement surveillance technology when it drives adoption through trust borne of transparency and meaningful choice.
We can try to understand privacy technology from the perspective of decentralization. Decentralization keeps all personally identifiable information under the user’s control, therefore offering total transparency over its use and total choice over how it is used.
Ideally, managing contact tracing, testing, test interpretation, symptom reporting, health records, relationships, and location history should be decentralized. This information should be entirely under the control of the individual, and contribute only aggregated learning to the collective — using differential privacy, homomorphic encryption, and split learning.
While these technologies are still too immature and expensive to be useful for the present pandemic, current technology does not force a binary choice between absolute decentralization and coerced government surveillance. Partial decentralization of technology and technology policy at the level of a cooperative, community, or town can leverage the trust many have in their local relationships and the peace of mind that comes from the ability to choose what information to share with whom.
Two weeks ago, Gov. Jay Inslee announced that Washington will likely reopen in stages. Halfway across the globe, Denmark has already begun a gradual process lifting its nation’s coronavirus lockdown by reopening schools for children in kindergarten up through the age of 11, in an effort to prioritize the education of its youngest students.
Kåre Mølbak, from Denmark’s infectious diseases agency SSI, commented that the decision to gradually reopen was based on the confidence that citizens would continue upholding social distancing and hygiene recommendations. Denmark also plans to reopen in phases, though it will focus next on the return of middle- and high-school students to school by May 10. Restaurants, bars and other businesses will remain closed until “the next phase.” The ban on large festivals and other events, thought to contribute significantly to the spread of disease, will remain in place until much later, reportedly through the summer.
Washington will likely resume activity in the reverse order in which it shut down, however, Denmark might be on to something. Children not only get milder disease, but they also seem far less likely to contract COVID-19. A study published in the journal Nature Medicine screened 745 children who had close contact with patients or family members with confirmed COVID-19 disease and found only 10 children in the entire group tested positive. Of the 10,000 confirmed cases in Washington state, just 3% have occurred in children under the age of 19. Children’s Hospital in Seattle reported in March that out of 660 children tested, only 4 children tested positive. In my office, though I have only sent about a dozen nasal swab tests, not a single child has tested positive either.
As the nation has struggled to cope with the devastation of the COVID-19 pandemic, New York Governor Andrew Cuomo has become the voice so many have looked to for support and leadership
What Cuomo seems both to offer and effectively communicate is not just a mastery of the facts, but also a grounded yet hopeful narrative. The story he projects serves as a resonant, unifying, activating force that helps us to see our collective trauma as a valuable opportunity to grow.
The ability to reimagine your life story in a more constructive way allows some to endure unimaginable suffering and emerge intact, even stronger, in the aftermath.
Such “super-survivors,” David Brooks wrote in 2015, leaning on extensive psychology research on post-traumatic growth by Richard Tedeschi among others, have traits “that enable them to come back stronger than ever. These people are often deluded in good ways about their own abilities, but completely realistic about their situations.” Post-traumatic growth “is not blind optimism, denial, or deception of self or others,” Tedeschi told me. “It does not dismiss distress and loss.” Rather, he argues in his latest book, Transformed by Trauma, which focuses on military veterans, the experience of growth “is a process – a difficult one, and an outcome that is life-changing and worth the struggle.”
By the end of April, the scope of COVID-19 damage to the US hospital system is becoming clearer, measured in tens of billions in lost revenues per month. While governments can issue an “all clear” order in areas minimally impacted by COVID, restoration of normal clinical operations depends crucially on patient acceptance of the safety of the health system. Hospitals’ path to operational recovery is fraught with complexity, and will require a disciplined, systematic approach.
While new COVID cases and deaths seem to be levelling off nationwide, the disappearance of hospital activity is unprecedented- 40-50% reductions in hospital admissions, surgical cases and, most unexpected of all, emergency department volumes, even for cardiac cases. Even before state and federal officials recommended cancelling “elective” procedures, hospital executives acted in an abundance of caution, and urged patients to delay care if possible, in order to prepare for a flood of COVID cases that has thusfar failed to materialize in many places.
Given that re-opening the economy has, sadly, become politicized, and that the public remains skeptical about the adequacy of COVID testing, it is not safe to assume that patients will come thundering back once a governmental “all clear” has been sounded. Patients and their families still have the deciding vote and caution is likely to be the watchword. Given these uncertainties. how should hospital and health system leaders approach restoration of their business?
Widen the Circle of Trust
The essential task is to assure the community, both directly and through clinicians, that the hospital is a safe and infection- free place for medical care. To do this, front line clinical staff, not only in emergency departments and ICUs, but also imaging, laboratory, and regular inpatient units, as well as their supporting cast in housekeeping and food service, must feel safe and protected coming to work. This feeling of safety presupposes the hospital’s supply of PPE meets or exceeds demand, and that it maintains a robust and aggressive testing regime that finds both symptomatic and asymptomatic COVID cases among the workforce for isolation and treatment.
Hospitals and health systems are frequently the largest employers in their communities. If caregivers and support staff feel safe coming to work, and believe threat of infection has been contained, they will communicate that feeling of safety to their friends and neighbors, both by word of mouth and social media posts. This widening circle of trust is a far more powerful force for restoration of normal operations than press releases, public service announcements, news broadcasts or paid commercial messages.
Actively Engage Physicians
Practicing physicians, whether employed by the health system or in independent practice, still control the decision about when to resume normal clinical activity. Physicians are anxious to return to work, but will need to communicate with patients that may have delayed receiving care, and confirm that they want to move ahead.
To make sure that the resources they need to practice are available to them when they need them, re-opening operating suites, catheterization laboratories, imaging and other services must be tightly coordinated with physicians to assure that the health system can staff and manage the renewed volume. This complex task will be complicated by the ease with which furloughed or laid off workers can be reclaimed from unemployment and return to their supporting roles. Particularly for lower paid healthcare workers, it may be financially stressful to return to work before unemployment coverage expires. Availability of child care will also be a constraint, as will the work schedules of spouses or domestic partners.
For these reasons, practicing clinicians must be closely consulted and actively participate in the phased resumption of clinical operations. To simply fling open the doors fully staffed for normal operations and assume patients will show up is not prudent planning.
Woody Allen once commented that life is composed of the horrible and the miserable, with the latter offering merely lesser calamity. The COVID epidemic seems to be following “Allen’s Law” as its course diverges in different localities. Current evidence suggests that measures taken by California and Los Angeles civic authorities as well as by residents and health care providers succeeded in “flattening the curve” and are leading LA toward a merely “miserable” epidemic like Korea’s rather than an explosion like New York’s or Italy’s. Local epidemiologists have been slow to draw conclusions from the emerging data, perhaps out of concern that even a hint optimism on the last few weeks’ battle might lead the public to believe the war is over when it still just beginning.
With extensive testing limited by a shortage of test kits, tracking the epidemic requires extrapolation from the number of hospitalizations and deaths. This week LA’s largest medical center continued to see a stable census of COVID-19 patients at a time that they “should” have been skyrocketing were LA headed for a New York style surge. We now understand that the typical incubation period for COVID-19– the time from exposure to onset of illness — is about five days and the typical time from exposure to hospitalization, when it occurs, is about twelve. So, hospitalizations provide insights into COVID transmission about two weeks prior. The stability over that period confirms the success of the lockdown. In the three weeks since the state’s lockdown order there have been no athletic events, no movies and no crowds at restaurants nor malls. So, there were markedly fewer opportunities for person to person spread.
Additionally, the stability of the epidemic in LA should persist while social distancing remains in place. As those less compliant with social distancing become progressively infected, the remaining pool of the uninfected is increasing composed of people more attentive to risk and less prone to future infection. In addition, with the new requirement to use face masks in public, increasing civic policing of public venues and with health systems’ improved ability to protect healthcare workers and non-COVID patients from infection, the future risk should trend downward. Perhaps the main risk of a break-out would be new infections occurring in populations that have been relatively isolated but lack the ability to practice individual social isolation. This would include nursing home patients, prison inmates and the homeless. However, in a metropolitan area of thirteen million, these populations are probably not large enough to impact the overall course of the epidemic in LA.
In the past few weeks, I have seen a lot of heroism from my colleagues. Just the other day, an email went out asking whether people would be willing to volunteer extra shifts in the hospital, should the worst situation happen where a large part of the staff could become either sick or quarantined from the coronavirus. Immediately, I saw the Google Spreadsheet fill with names, despite the fact that we already work close to 80 hours a week, some of those being 28-hour shifts. Yet, I continue to see my fellow residents step up for each other.
However, there is another emotion that is palpable and spoken about openly: fear. For the first time in our medical careers as trainees, we have come within arm’s length of a fairly unknown infectious disease, with mortality estimates ranging from one to as high as four or five percent. And each of us has heard of at least one young person in a critical care unit from the virus. Furthermore, given we are working in the medical field, we are also acutely aware of the fact that we are among the high-risk groups (the six-feet rule is impossible when you are trying to assess when someone is having a stroke or not), and we know there are doctors who have contracted COVID-19 in critical condition1. Though we entered this field knowing that there were to be risks involved, while studying for Step 1, that reality was less imminently tangible.
Measuring and reporting in health care has gone through three phases corresponding roughly to the 1990s, 2000s, and 2010s. During the 1990s, policymakers claimed “report cards” on the quality of clinics, hospitals, and insurance companies should be published so that “consumers” could avoid the bad actors and patronize the good ones. The doomed hospital mortality report card (dubbed the “hospital death list”), published for a few years in the early 1990s by the former Health Care Financing Administration (now CMS), and the useless report card on Minnesota insurance companies published by the Minnesota Health Data Institute in 1995, are examples.
In the early 2000s, by which time it was obvious report cards had accomplished little because “consumers” didn’t use them, Minnesota and federal policymakers decided that if report cards were not going to shift market share from the bad actors to the good, then payers (insurance companies, government programs, and self-insured employers) should punish and reward doctors and hospitals directly with bonuses and financial penalties based on report card scores. This new use of report cards was dubbed “pay for performance” (P4P) circa 2003. By the late 2000s, quality scores on report cards were being arbitrarily smooshed together with cost scores to create scores that allegedly measured “value.” With a few exceptions (Consumer Reports, CMS’s website), insurance companies were now off the hook; in the new millennium, P4P would apply only to “providers” (doctors, hospitals, nursing homes, etc.).
We have implemented an interesting approach to prevent hospitals to be overwhelmed with #COVID19 cases in The Netherlands. This may be useful for others to consider. It is based on spreading of the burden of disease for hospitalized cases over larger areas.
As we have observed in China and Italy, COVID-19 often present in hotspots while other areas are affected less severe. In The Netherlands the first case was found on February 29 in the Province of Brabant (2.5 million inhabitants). On March 15 we had 24 people who had died from COVID on a National level and 21 originated from Brabant. Hospitals in this area were seeing an increasing amount of cases and prepared for larger numbers.
Based on a mathematical model that estimated the number of infected people based on recent deaths it was anticipated that the number of cases would soon be too high for the local hospital and especially the ICU’s.
Health systems all across the United States are reeling from a once-in-a-working-lifetime crisis brought about by the COVID-19 epidemic. Hospitals, care systems and physician practices are hemorrhaging cash in the face of an expected oncoming flood of COVID patients. Like the prelude to a tsunami, where the tide goes out a half mile, health system revenues have fallen 25-40% month over month, as normal patient care operations have receded.
Patients have been reluctant to use hospitals over concern about their infection risk, and fresh worries about their ability to pay their share of the cost. It is likely that the earnings impact will be much worse, since cases being cancelled are relatively high margin elective cases from patients with private insurance coverage that pays more than it costs to take care of them.
Even with recent increases in Medicare payment rates for care for the COVID cohort, and an increase in federal Medicaid match to support state payments for the indigent and “differently abled”, hospitals and the health systems will come tens of billions short.
Balancing hospitals’ safety net function of hospitals with their routine care mission is always tricky, particularly in communities with no public hospitals. The United States commits less than 3% of total health spending on public health, and has chronically underinvested in mental health, infectious disease surveillance and disaster preparedness.
My first possible COVID-19 case came nearly three weeks ago, before there were any cases in our city. He was a healthcare professional who presented with fever, sore throat, and cough. We did the usual strep and influenza testing, both negative, but I thought that he looked different. He had some diarrhea, stomach pain, and a different look to his face that I couldn’t place.
“You might have it,” I said. “You might have coronavirus.”
He looked at me nervously, obviously having thought the same thing. “Is there anything I can do about it? Can you test me?”
No, there were no tests anywhere at that point. Few states had access to any testing, so I knew all we could do was to wait. I sent him home and told him to go to the hospital if he developed shortness of breath, and that we’d get him tested as soon as possible. That seemed to be a short time, as my nurses contacted the national lab we work with and they told us that collection kits for COVID-19 were “on the way” and would get to us in 1-4 days. Perfect.
That was the start of a long odyssey of growing frustration, helplessness, and anger at the testing for this deadly disease. Those kits never showed up. By the time we had local access to testing, the patient had gotten completely better and was asking to go back to work. He works around very vulnerable patients and we told him to let his employer know about my suspicions and to get him tested. We never heard anything.
Of course, since then every cough has been a worry to my patients. Fevers are watched with dread. We have been directing people to contact our local academic hospital to be triaged for COVID-19 testing. A couple of them have been accepted, none has tested positive. Some of them have seemed suspicious to me, but the lack of adequate testing has the triage center restricting tests to the very vulnerable or the obviously sick.
What are the most important pieces of professional advice you’ve ever received?
I remember one of mine clearly: It was in late 2004, and my colleague Bill told me that it was “time to have an idea.”
I had hired in as the first employee at a small consulting company in early summer. The founders had been handing me pre-specified projects for a few months. These early projects appeared on my desk ready-made, with the Statement Of Work (SOW) already written, the scope negotiated, and the customer interested mostly in when the resource (me) could be scheduled.
Now it was fall, and it was time for me step up my game and spec my own work. I realize now that they were tired of carrying me.
In the spirit of “learn by doing,” they dumped me on the phone with a prospective customer, the IT department for Stanford.
That, in itself, was an incredible opportunity.
Rookies look down on “sales.” I know now about the grinding work that leads to calls like that. The series of interactions with gatekeepers whose only options are to say “no” or else to continue the conversation. The people on the other end of this call could say “yes.”
Technology has been hailed for its ability to connect us; we’ve tended to view this is a positive development, but as rare, high-impact events like the coronavirus epidemic reminds us, a densely-networked world may also be more fragile.
The mixed blessing of interconnectivity was acknowledged back in 2005 by New York Times columnist Thomas Friedman, who observed:
“…we are now in the process of connecting all the knowledge pools in the world together. We’ve tasted some of the downsides of that in the way that Osama bin Laden has connected terrorist knowledge pools together through his Qaeda network, not to mention the work of teenage hackers spinning off more and more lethal computer viruses that affect us all. But the upside is that by connecting all these knowledge pools we are on the cusp of an incredible new era of innovation, an era that will be driven from left field and right field, from West and East and from North and South.”
For techno-optimists like Erik Brynjolfsson and Andrew McAfee, authors of The Second Machine Age, improved interconnectivity catalyzes what they call “recombinant innovation.” This is the idea that “the global digital network” enables us to “mix and remix ideas, both old and recent, in ways we never could before.”
They continue: “Digitization makes available massive bodies of data relevant to almost any situation, and this information can be infinitely reproduced and reused because it is non-rival. As a result of these two forces, the number of potentially valuable building blocks is exploding around the world, and the possibilities are multiplying as never before.”
Joe, a semi-retired 81-year-old, never expected his Italy guys’ trip to thrust him into the front ranks of COVID-19 patients. Joe’s story goes against the grain of news about the coronavirus now gripping the world and providing epidemiologists and public health experts with the challenge of their professional lives.
Joe is a patient of a medical colleague, and he and his wife gave me permission to tell their story. It started with a ski vacation for 14 friends, united by their connections to the real estate industry, who flew from Sweden, San Francisco and Los Angeles to a rendezvous in Munich. From Germany they traveled to Selva di Val Gardena, a ski resort in the Dolomite mountains of northern Italy. Arriving on Feb. 21, they began their usual regimen of morning ski runs and afternoon lounging.
Before long, they could tell something was off. Joe’s friend Peter was the first to develop a cough and general malaise. Some of the others soon noted more shortness of breath than usual on the slopes. In the evening, normally robust appetites faded. By the time the trip ended, Peter was seriously ill with a cough and fever. He was hospitalized in Munich with pneumonia. Although Joe felt unwell, he was able to continue to Los Angeles.
By the time Joe arrived at LAX on March 1, he realized that he might have been exposed to COVID-19. He called Dr. Jonathan Weiner, his primary care doctor, from the airport. Weiner, aware of the public health implications of a potentially infectious patient in a public setting, directed Joe to head home and arranged follow-up care there with the Los Angeles County Department of Public Health.
Joe tested positive for COVID-19 as have all the other trip participants. He has no idea how they could have been exposed, although he thinks back to a crowded tram ride. Since testing positive, Joe has been isolated from all direct interpersonal contact. Confined to a bedroom at home, he communicates with his wife, Barbara, by cellphone, text and Facetime. Barbara is quarantined too. Because test kits and lab time remain limited, and because she exhibits no symptoms, she hasn’t been tested and she won’t be unless she develops a fever or cough.
As the globe faces a novel, highly transmissible, lethal virus, I am most struck by a medicine cabinet that is embarrassingly empty for doctors in this battle. This means much of the debate centers on mitigation of spread of the virus. Tempers flare over discussions on travel bans, social distancing, and self quarantines, yet the inescapable fact remains that the medical community can do little more than support the varying fractions of patients who progress from mild to severe and life threatening disease. This isn’t meant to minimize the massive efforts brought to bear to keep patients alive by health care workers but those massive efforts to support failing organs in the severely ill are in large part because we lack any effective therapy to combat the virus. It is akin to taking care of patients with bacterial infections in an era before antibiotics, or HIV/AIDS in an era before anti-retroviral therapy.
It should be a familiar feeling for at least one of the leading physicians charged with managing the current crisis – Dr. Anthony Fauci. Dr. Fauci started as an immunologist at the NIH in the 1960s and quickly made breakthroughs in previously fatal diseases marked by an overactive immune response. Strange reports of a new disease that was sweeping through the gay community in the early 1980’s caused him to shift focus to join the great battle against the AIDS epidemic.
The first reported cases of AIDS were reported in the United States in the 1981 Morbidity and Mortality Weekly Report. 5 young men, all previously healthy and all active homosexuals were found to have Pneumocystis carinii pneumonia, a disease that prior had been restricted to the severely immunocompromised. An avalanche of clinical reports subsequently woke the nation to a disease that appeared to have a predilection for the gay community. The remarkable subsequent successes of medical therapies that followed to make AIDS a manageable disease to grow old with are now a matter of history, but in the early years this success seemed anything but inevitable.
The charge leveled against the establishment of the day by a public becoming aware of the tragedy of young, previously healthy individuals dying by the thousands was that there was an attempted cover up of a ‘dirty’ disease in a community America would rather not talk about. But from the first description of the disease by the medical community, the activity in the research industry (both public and private) was intense. It took 2 years for two labs to simultaneously identify the HIV virus that appeared responsible for the development of AIDS. Elaborating the mechanism by which the virus destroyed the body’s immune system lead to the discovery of potential therapies.
The Trojan Horse is a tale about subterfuge. After a decade of war, the Greeks had made
little progress against the Trojans so they constructed a huge wooden horse and
hid a select force of men inside. Believing the Greeks sailed away, the Trojans
pulled the horse into their city as a victory trophy. That night the Greeks crept
out of the horse and unlocked the gates for their fellow soldiers, who had
sailed back secretly. The Greeks ended
the war by destroying the City of Troy.
COVID-19 is our Trojan Horse. It has snuck inside the gates and attacked. How do we fight against an enemy we don’t entirely understand?
When the first presumptive positive case was reported in Kitsap County this week, my clinic began screening patients and their parents for fevers. As a result, not a single febrile person has stepped through my front door since last Monday, March 9. There is a temperature triage station set up under a Seattle Seahawks tent in front of my clinic. For the record, I am no fan of professional football, and I never imagined it would serve as a triage station.
If a patient has a fever, they are asked to return to their
car for what is now called a “car visit.” During the measles outbreak, I did “car
screenings” to make clear patients to come in to the clinic if they had a
rash. Examining young children out in
freezing temperatures while standing outside a car is a whole different thing
There is no precedent here.
For a “car visit,” I leave my office and walk into an empty
building next door. In there, I put on a different jacket (in lieu of a gown,
which I don’t have), safety glasses and an N-95 mask, pick up my leather doctor
bag—which contains its own set of medical equipment, pen, prescription pad, and
other essentials—and walk to the patient’s car, which is waiting in a makeshift
“drive through” spot next to my clinic.
Hello, and welcome to our new world! Sports has been cancelled, concerts have been cancelled, toilet paper is scarce, and don’t you dare cough in public! The new catch phrase is “social isolation,” which is difficult for many, but easy for some. At last, a crisis that favors the introvert!
Update on Current Situation
To date, there have been over 140,000 documented cases of the virus worldwide, and more than 1800 in the US. More than 5800 people have died, 41 of whom were in the US. Countries have shut down social gatherings, have limited travel, and the president has declared a state of emergency.
To date, there have been no cases in our local area, but I’m fairly certain the infection is everywhere, as it spreads easily from person-to-person and so containment is difficult. We have had suspicion of infection in our patient population, and are moving to get testing supplies so we can confirm or disprove the diagnosis.
The current public health goal is to decrease social contact to slow the spread of the virus. This is why the enormous sports industry has shut down, despite huge financial losses incurred by doing so. This is why conferences, concerts, and even family gatherings are being cancelled. This is why everyone is washing their hands frequently (and hoarding hand sanitizer).
I have no idea why people are hoarding toilet paper.
Things are developing regarding the spreading epidemic/pandemic and so here is an update to let you know the state of things, what we are doing, and what you should do.
There have now been more than 120,000 cases worldwide, with over 1000 in the US. Italy (as an example of what could happen here) is in crisis, with more than 10,000 documented cases and ER’s and hospitals flooded with very sick patients. Schools across the US (including Atlanta) have closed to decrease the spread of the virus. The pattern of illness remains the same:
People present with a flu-like illness (fever, body aches, cough) with focus of infection more on the lungs.
Children are largely spared from the severe disease, with the majority of deaths being in the elderly or otherwise high-risk individuals.
The problem we face here is twofold:
We don’t have a good test available to diagnose COVID-19 in a clinically useful way (rapid and simple)
Even if we did, there is no clear treatment for COVID-19, other than supportive care.
How We Are handling patients with Flu-like Symptoms
We are trying to identify patients who may have coronavirus and treat them outside of our clinic. While we want to help people who are sick, we don’t want to expose high-risk people to the virus. So…
We ask that if you have a fever or flu-like symptoms, that you do not come into the office. Instead we ask you to contact us via phone, email, or via Spruce. Be patient, as we are likely very busy with other sick people!
Please tell us about your symptoms and we’ll guide you in what to do next. This may include triage and evaluation in our parking lot. Remember that we cannot diagnose you, and we cannot give you any treatment if you do have the virus. Yes, that makes things very difficult for all of us, but it is the situation we face.
Also understand that we may have high-risk people at the office with other problems. Infected individuals in our office may spread the infection to others, so please understand, and don’t demand special treatment.
If possible, do not come to the office if you are a high-risk person:
I’m writing this for the ER doc who I have a feeling I’m going to be meeting one day soon.
I thought I’d introduce myself.
I’m the one who is going to be triaged: 78 years old, comorbidity of hypertension, not enough useful life left to bother with.
How do I feel as one of the people in the at-risk category? Awful. Mentally awful. There’s no way to escape this virus. Not the virus, but the knowledge that the country is in a state of chaos, doesn’t have enough hospital beds or ventilators, and will be resorting to triage, even though nobody is admitting it yet. I hear the dire predictions about people dying in hallways in my sleep.
Which is not, of course, how I viewed my life two weeks ago.
That person I saw in the mirror? Still self-supporting, a yogi and a denizen of the gym. Flexible and fit. Walking 4 miles a day. Still pretty mentally sharp. 3 dogs and a huge network of social connections. Three or four invitations to lunch and dinner every week.
But now my life has been turned upside down. Outside of walking the dogs, I’m a shut-in. If I have to go to the grocery store, I go just as it opens, and I wipe my cart down carefully. I run into the house, put the bags down on the table, and wash my hands. I feel like I have taken an unnecessary risk for navel oranges, vegan cheese and salt free snacks.
I’ve done all the reading. Virologists are the worst for making people fearful. They deal in worst case scenarios. Then come the engineers, who are good at predictive analytics. Many of my younger friends are in Silicon Valley, and they’re hunkering down. They took their kids out of school weeks ago.
In sunny Arizona, day after day they tell us we have nine cases. They’ve canceled all our tourist season, so other than community spread, we won’t have outside infection. Or will we? Or do we already?
I know too much. I’ve been in health care one way or another for most of my working life, either married to a physician or helping health-related companies get started, or marketing them. So I know that although I’m taking all the precautions I can, I’m never totally sanitized. I feel like climbing into the shower and staying there. I put vaseline at the end of my nose every morning. I pray to my nasal passages: cilia, keep me free. I order immune-boosting herbs.
I’d like to call a local emergency room and find out if they are overrun. I’m starting to look for ER docs in my network, just to see what’s really happening, because they have the best chance of knowing.
The women I walk dogs with in the morning have differing political beliefs. We argue a lot, partly because we disagree, and partly because it’s the only fun we have. I’m the yogi, the one who keeps pointing out that we’re stuck with each other for the next six months at least, and we have to get along.
You can imagine what my political beliefs are. I have become some sort of fanatical conspiracy theorist. But this is wrong. Why should it be President Trump’s responsibility to come up with a plan? Where is the healthcare industry? They’re the ones who decide the number of beds we will have, and how to spend money they could have spent on ventilators and respirators. If they’ve spent it on their own salaries and profits, that’s not his fault. I’ve fallen down a rabbit hole trying to get back to first causes. If we had universal coverage, if we had pandemic planning, if we had more money given to health and less to the military, if,if,if…
But we are where we are. I’m going to put on some disco music and do some floor exercises at home, all while wondering how clean my floor actually is.
Ironically, the same electronic health records (EHRs) initially designed as a tool to help physicians diagnose diseases have largely evaded diagnostic scrutiny. Talk to physicians who utilize them on a daily basis, however, and it becomes abundantly clear that today’s EHRs are ailing. They are adding hours to the physicians’ workday, siphoning attention from patient care, and sowing the seeds of demoralization across the profession of medicine. To address this problem effectively, physicians need to shift their focus from the symptoms associated with EHRs to the underlying diagnosis.
A key to arriving at the most accurate diagnosis is to cease treating EHRs as information technology problems and instead regard them as organic problems, not so different from the categories we would use in diagnosing a patient. Specifically, we need to seek out a known disease or diseases onto which many of the problems with EHRs can be mapped. In so doing, it is not our intention to stigmatize any disease or the patients who suffer from it, but instead to help physicians peer more deeply into the nature of the electronic malady with which they are wrestling.
After a decade dominated by ObamaCare- its enactment in 2010, the fraught implementation, its near repeal in 2017, and the welter of inconclusive experiments with Medicare payment reform – healthcare in the 2020s is likely to be reshaped by technological and scientific advances, as well as continued political struggles over societal and family cost. We can expect major change in seven areas:
1. Rising Patient Safety Risks.
Two emerging patient safety risks will spike in seriousness during the 20s. One risk, that of drug resistant bacterial infections, boiled under the surface for more than two decades, with the rise of MRSA, Candida aureas, Clostridiodes difficele and more than a dozen other agents.
Nearly three million people were infected with these agents in 2017, and more than 48 thousand died. While hospital infection control has improved, and deaths from hospital infections fell during the 2010’s, antibiotic drug development has lagged, and the potential for one or more breakout infection risks is highly likely in the 2020s. The Economist published a chilling and entirely possible scenario in July, 2019.
The second major risk has resulted from the confluence of two information technology (IT) trends- the migration of health system clinical and financial operations to the Cloud and the 5G-enabled connectedness of medical devices and hospital infrastructure to the Internet, the so-called Internet of Things (IOT). These two linked migrations opened a gaping digital “back door” in hospitals and systems to “black hat” hackers.
The fall of 2019 saw two major health systems-Tuscaloosa-based DCH Health System (AL) and Hackensack Meridian (NJ) – succumb to ransomware attacks that paralyzed clinical operations for days before the system paid cyber-extortionists to stand down. However, there is a more threatening risk of mass patient casualty episodes in hospitals if hackers gain control over critical life support functions like respirators, infusion pumps, oxygen systems, HVAC and electrical systems.
The virtually unmanaged spread of connected devices and systems in hospitals is a significant threat to patient safety. Health systems and regulators will be playing catch up in both these patient safety domains during the 20s as the degree of patient risk becomes more clearly understood.
“What diagnosis do you want to use for those ear drops you sent on Mr. Johnson,” Jenn texted me. “ICD-L21.8 for seborrheic dermatitis?”
Sigh. Welcome to prior-auth hell.
These are generic ear drops I ordered for presumed fungal infection of the external ear. The cash price for the drops is $15 for a 10 milliliter bottle (I checked before prescribing them). “No,” I responded, “it would be ICD-B36.9 for otomycosis.” (translation: ear fungus)
Jenn tried submitting this new diagnosis without success. She then noted that this medication was supposed to be authorized without need for authorization, so she called the pharmacist, who ran the 30 milliliter bottle through the computer system and the medication was authorized. That size bottle goes for $27 cash.
Rob bangs head on wall.
But Jenn didn’t yell. She didn’t say any profanity (that I could hear). Jenn’s a saint. She lost 30 minutes of her life to this nonsense, as did the pharmacist. As for me, I just got a little extra blood pressure points, a little acid corrosion of my stomach, and a stronger desire for beer when I get home this evening.
While my practice doesn’t accept money from insurance companies, we do serve our patients for the sake of their health. This means that we advocate on their behalf in a system that seems hell-bent on making care less accessible. Prior-auth hell is one example of this wall that has been built up between people and reasonable care. Electronic medical record hell, pharmacy trickery hell, specialist non-communication hell, bloated hospital gouging hell, media non-story hype hell, and opportunist alternative medicine hell are all contributors to the hell-fire heat we are all feeling.
Leading lights of the health insurance industry are crying that Medicare For All or any kind of universal health reform would “crash the system” and “destroy healthcare as we know it.”
They say that like it’s a bad thing.
They say we should trust them and their cost-cutting efforts to bring all Americans more affordable health care.
We should not trust them, because the system as it is currently structured economically is incapable of reducing costs.
Why? Let’s do a quick structural analysis. This is how health care actually works.
Health care, in the neatly packaged phrase of Nick Soman, CEO of Decent.com, is a “system designed to create reimbursable events.” For all that we talk of being “patient-centered” and “accountable,” the fee-for-service, incident-oriented system is simply not designed to march toward those lofty goals.
A machine for creating reimbursable events
The health care system is a machine for creating reimbursable events. This means that its systemic business aim is to maximize reimbursable events and to increase their price, that is, to maximize the energy the system can draw in from its customers.
The news was bad. Mimi, a woman in her early 80s, had been undergoing treatment for lymphoma. Her husband was being treated for bladder cancer. Recently, she developed chest pain, and a biopsy showed that she had developed a secondary tumor of the pleura, the space around one of her lungs. Her oncology team’s mission was to share this bad news.
Mimi’s case was far from unique. Each year in the U.S., over 1.6 million patients receive hospice care, a number that has been increasing rapidly over the past few years. What made Mimi’s case remarkable was not the grimness of her prognosis but her reaction to it.
When the members of the team walked into Mimi’s hospital room, she was lying in bed holding hands with her husband, who was perched beside her on his motorized wheelchair. The attending oncologist gulped, took a deep breath, and began to break the news as gently as he could. Expecting to meet a flood of tears, he finished by expressing how sorry he was.
To the team’s surprise, however, no tears flowed. Instead Mimi looked over at her husband with a broad smile and said, “Do you know what day this is?” Somewhat perplexed, the oncologist had to admit that he did not. “Today is very is special,” said Mimi, “because it was 60 years ago this very day that my Jim and I were married.”
The team members reacted to Mimi with astonishment. How could an elderly woman with an ailing husband who had just been told that she had a second, lethal cancer respond with a smile? Compounding the team’s amazement, she then went on to share how grateful she felt for the life she and her husband had shared.
Cigna conducted a survey on 20,000 of their members.
54% said they always or sometimes feel that no one knows them well.
56% reported they sometimes or always felt like the people around them “are not necessarily with them.”
40% felt like “they lack companionship,” that their “relationships aren’t meaningful” and that they “are isolated from others.”
It’s probably no surprise to most people that it’s actually pretty hard to make friends, especially after college. It’s felt so universally that it’s become an extremely popular genre of meme.
As a thought experiment, what would you do if you moved to another city where you didn’t have an existing network? It’s a pretty daunting proposition without a ton of options (Work friends? Sports league? Meetups?).
We have online tools to connect and organize better, but it feels like they’re creating relationships that are more hollow and circles that are more insular.
Can we use them to make it easier to make friends?
For several years now, I’ve been the social media curmudgeon in medicine. In a 2011 New York Times op-ed titled “Don’t Quit This Day Job”, I argued that working part-time or leaving medicine goes against our obligation to patients and to the American taxpayers who subsidize graduate medical education to the tune of $15 billion per year.
But today, nine years after the passage of the Affordable Care Act, I’m more sympathetic to the physicians who are giving up on medicine by cutting back on their work hours or leaving the profession altogether. Experts cite all kinds of reasons for the malaise in American medicine: burnout, user-unfriendly electronic health records, declining pay, loss of autonomy. I think the real root cause lies in our country’s worsening anti-intellectualism.
People emigrated to this country to escape oppression by the well-educated upper classes, and as a nation we never got past it. Many Americans have an ingrained distrust of “eggheads”. American anti-intellectualism propelled the victory of Dwight Eisenhower over Adlai Stevenson – twice – and probably helped elect Bill Clinton, George Bush, and Donald Trump.
Don’t make the mistake of thinking that American anti-intellectualism today is exclusive to religious fundamentalists and poorly educated people in rural areas. Look at the prevalence of unvaccinated children in some of America’s most affluent neighborhoods, correlating with the location of Whole Foods stores and pricey private schools. Their parents trust Internet search results over science and medical advice.
Remember when physicians were heroes?
For a long time, physicians were exempt from America’s anti-intellectual disdain because people respected their knowledge and superhuman work ethic. The public wanted doctors to be heroes and miracle workers. The years of education and impossibly long hours were part of the legend, and justified physician prestige and financial rewards. Popular TV series in the ‘60s and ‘70s lionized the dedication of Ben Casey, Marcus Welby, Dr. Kildare, and Hawkeye Pierce. In real life, heart surgeons Michael DeBakey, who performed the first coronary bypass operation in 1964, and Christiaan Barnard, who performed the first heart transplant in 1967, became famous worldwide.
The unofficial mantra of silicon valley entrepreneurs may well be fake it ‘til you make it, an approach of resilient bravado that’s led to a slew of ultimately successful tech giants – and also to frank deceptions like Theranos.
Recently, I heard from VC Marc Andreessen (on the a16z podcast, here) what must be the most forthright explanation of this approach, a sales technique Andreessen calls “evangelistic selling.”
Andreessen was responding to a question about how do you sell into businesses that aren’t intrinsically receptive to change (i.e. essentially every large established business, including those dominating healthcare).
The Evangelistic Sale
First, you can see why some view Silicon Valley denizens as merchants of hype – this is, if not explicitly what Andreessen is championing, perhaps an inevitable outcome of his approach: entrepreneurs and (other) salespeople talking up an often-fantastic vision of a yet-to-be realized future.
Andreessen also points to the example of Elon Musk and Tesla; Musk is often criticized for overselling, says Andreessen, but argues Musk had to paint a vision not only of a car you could plug in, but also a whole system of superchargers along freeways, and his vision had to be compelling enough so he could actually sell enough cars “into that vision” to afford to start installing the chargers he described, and enable the vision to become a reality (which, initially, it wasn’t). Andreessen likens it to selling the first fax, which obviously wasn’t especially useful until and unless it was adopted by others.
Steve Jobs: “Taking LSD was a profound experience, one of the most important things in my life. LSD shows you that there’s another side to the coin, and you can’t remember it when it wears off, but you know it. It reinforced my sense of what was important – creating things instead of making money, putting things back into the stream of history and of human consciousness as much as I could.” (ref 1)
Woodstock (Chip Monck): “To get back to the warning that I received. You may take it with however many grains of salt that you wish. That the brown acid that is circulating around us isn’t too good. It is suggested that you stay away from that. Of course it’s your own trip. So be my guest, but please be advised that there is a warning on that one, OK?” (ref 2)
Warning: The final few paragraphs of this post contain language that some may find offensive. I included it for a reason. In 30 years of practice and in my real life – I have found that many people talk this way. If profanity offends you don’t read the end of this post.
Everywhere I turn these days – whether it is a blog or more traditional media I am struck by the same stories on hallucinogens. If you believe what you read out there, hallucinogens are magical drugs in that they are almost totally benign, consciousness expanding, and they can treat your anxiety or or depression. They have been actively discriminated against like other illegal drugs and that is the only reason we have not done the research to prove that they can treat many problems. Back in the 1970’s we would have said that “The Man” is restricting access to valuable consciousness expanding drugs and if “The Man” was overthrown – the world would be a much better place. I have briefly reviewed the same lines of rhetoric that occur with cannabis. I have not heard similar arguments with ketamine, probably because fewer people have experience with it and it is a more difficult drug to use, even in a medical setting where the drug has a known concentration and purity.
Backache is an intermittent predicament of life. No one is spared for long. Furthermore, no approach to avoiding the next episode has proven effective when submitted to scientific testing. To be well is not to avoid backache; it’s to have the wherewithal to cope effectively and repeatedly.
Almost all of the people we will be talking about in this book were afflicted with regionalbackache, and that is the only type of backache we will consider here. I coined that term for an editorial in The New England Journal of Medicine over twenty years ago.1 Regional backache is the back pain experienced by people who are otherwise well. It comes on inexplicably, usually suddenly, in the course of activities that are familiar, and customarily comfortable. This is the common, everyday backache. We will spend some time considering some of the more frequent complications of a regional backache, particularly the “pinched nerve,” which can cause pain to radiate down the leg. We are not going to consider the unusual causes of backache such as metastatic cancer, infections, or inflammatory diseases of the spine. Nor will we consider the back pain that can result from accidents and other traumatic events.
While I am talking about what this book is not, let me say that it is not a self-help manual. Nor is it a medical textbook. Backbone is an exposé of a contrived “disease” and the enormous enterprises it has spawned that conspire to its “cure” and provide fall back when a “cure” is elusive. That industry has developed a life of its own despite a robust and compelling body of scientific investigation that points toward backache as a socially constructed ailment. The American notion of health, the American’s wherewithal to cope and persevere, and the American pocketbook are paying a heavy price.
Medical historian Stanley Reiser wasn’t kidding when he entitled his best-known book, “Medicine and the Reign of Technology.” To a large degree, technology has taken over medicine. I am not talking primarily about our increased reliance on such technologies as advanced imaging equipment or assistive procedural devices. In such cases, the technology remains largely a tool, and the wielder remains basically in charge. I am talking about a far more pervasive and insidious form of technology whose very name tells a good part of the tale – health information technology.
Many physicians and other health professionals find health information systems clunky, perverse, and intrusive, but their problems go far deeper. Underneath unwieldiness lies the temptation that we begin relying on such indicators to such an extent that we stop attending to our internal resources. Consider the case of the patient said in his admission note to be “status post BKA” – below the knee amputation – but who turns out on rounds to have ten toes. What happened? DKA – diabetic ketoacidosis was mis-transcribed into the medical record as BKA, and the error simply propagated like a virus.
At stake is what we mean by knowledge. Is what we know defined by our own experience – what we have seen, heard, felt, and perhaps even intuited in the presence of the patient? Or do we instead rely on what is represented on a computer screen? Which is a more likely occasion for us to exclaim, “That can’t be right!” – when what the computer screen indicates does not comport with what we have observed of the patient, or when what we have observed in the presence of the patient does not jibe with what the computer is telling us?
For over a decade Washington DC has been busy with fixing health care. For over a decade, the same government bureaucracy, the same advocacy (read lobbying) organizations, the same expert think tanks, the same academic centers, the same business associations, with the same people hopping around from one entity to the next, have been generating and applying the same “innovative solutions” differentiated solely by their aggrandizing names. The result? Health care is more expensive than ever. More people than ever can’t afford to seek medical care. More doctors are disheartened, to the point of committing suicide. All this while the illustrious transformers of health care are accumulating fame and riches, probably exceeding their own expectations, with no end in sight.
It is no secret that back in 2016 many of us voted for Donald Trump hoping that he will “drain the swamp” or at the very least blow it all up into a spectacular artesian fountain of filth. He didn’t and he won’t. The swamp won. Our special health care swamp is deeper and wider than most, and the Trump administration is making it deeper and wider than ever before. The single payer lobby is simply proposing to move the existing health care swamp to a bigger and more noxious location, so it has plenty of room to expand in the future. The swampy strategy for fixing health care has always been, and by the looks of it will always be, a game of hot potato. The potatoes are us.
At the core of the guileful verbosity of health care transformation there is nothing more than an elaborate effort to shield corporations, and the governments that serve them, from financial risk. It’s really that simple. We pay our premiums and our payroll taxes, month after month, year after year, and when the time comes, if it comes, they’d much rather not pay the medical bills they are contractually or statutorily obligated to pay. Blame sick people for being sick. Blame the sick for not shopping the clearance aisle. Blame doctors for treating the sick. Blame hospitals for admitting too many sick people, too often and for too long. Punish them for the errors of their ways. Teach them a lesson or two. And most importantly, make them pay until it hurts.
Three weeks ago I posted a comment here about a decision by the Minnesota Supreme Court in the case of Warren v. Dinter. In that case, the court held, by a 5-2 margin, that hospitalists (and, therefore, the hospitals they work for) can be sued for malpractice even if they were not in a treatment relationship with the patient. I took the position that that decision was the right one. (If you haven’t read my first article, I urge you to do so to understand the facts of the case.)
The ensuing discussion about my article focused primarily on which, if any, of the three health care professionals involved in the decision not to hospitalize Susan Warren were culpable. The question of whether other parties – the hospital, the chain that owned the hospital, Accountable Care Organizations (ACOs) established by the chain, and insurance companies – should be subject to liability received relatively little attention. Two who did comment explicitly on that issue made it clear they thought even asking about third-party culpability was verboten.
In this sequel to “Why did Susan Warren die?” I want to focus on the question, Shouldn’t third parties who make, veto or influence medical decisions be exposed to malpractice lawsuits? My answer is yes. If the answer is yes, then we must support the Warren v. Dinter decision. Imagine if the Minnesota Supreme Court had taken the opposite position. Imagine that the court decided that injured patients cannot sue third parties unless the employee of the third party (the doctor or nurse) who made the decision in question was in a treatment relationship with the patient. Is it not obvious that such a decision would slam the courthouse doors on all patients injured by employees working for insurance companies, hospitals, hospital-clinic chains, and ACOs who were not treating the patients?
This post is my chance to share some relevant data, add my perspective, and ask for your input.
First, the data from a 2018 Hopelab/Well Being Trust study I helped write:
71% of female teens and young adults say they have tried mobile apps related to health, compared to 57% of males. Three in ten (30%) females say they currently use a health app, compared to two in ten (20%) males.
Fully 48% of females ages 18- to 22-years-old and 25% of teen girls say they have used a period tracking app, compared with 2% of males.
Sixteen percent of females use a meditation app, compared with 5% of males.
Two bills that are called “Medicare for all” bills by their supporters have just been introduced in Congress. On February 27, Representative Pramila Jayapal introduced the Medicare For All Act of 2019, HR 1384 , in the House of Representatives. On April 10, Senator Bernie Sanders introduced a bill bearing the same name in the Senate, S 1129. The cost-containment section in Representative Jayapal’s bill will cut health care costs substantially without slashing the incomes of doctors and hospitals. Senator Sanders’ bill cannot do that.
In this article, I explain the differences in the cost containment sections of the two bills and call upon Senator Sanders to correct two defects in his bill that minimize its ability to reduce costs. Defect number one: S 1129 authorizes a new form of insurance company called the “accountable care organization” (ACO). Defect number two: S 1129 fails to authorize budgets for hospitals. Representative Jayapal’s bill, on the other hand, explicitly repeals the federal law authorizing ACOs, and it authorizes budgets for individual hospitals.
I write this essay as both a long-time organizer, writer and speaker for a single-payer (the older name for “Medicare for all” system) and a strong supporter of Senator Sanders. Bernie’s enthusiastic support for a “single payer” solution to the American health care crisis has added millions of new supporters to the single-payer movement. But precisely because he is now the most recognizable face of the single-payer movement, it is extremely important that all of us, whether we’re already in the single-payer movement or we just long for a sane and humane health care system, encourage Bernie to fix the defects in his bill.
To explain the two defects in S 1129, I must first explain why a single-payer bill like Representative Jayapal’s will be effective at cutting the high cost of American health care. I begin by explaining the origin and meaning of the “single payer” label. I will then describe the two defects in S 1129 in more detail.