Progress Notes

Did you know today is National Doctor’s Day? There’s an official proclamation from President George H.W. Bush and everything. Today is the day us non-physicians are to take time to thank the physicians in our lives for poking and prodding us or for giving us the straight-talk about needing to exercise more (I’m working on it.), but for Avi, Annie, and myself, National Doctor’s Day means so much more.

Every day we come in to the Doctors for America office and see just how wonderful physicians and future physicians really are in this country. We’re the lucky staffers who get to help and support the over 16,000 physician and med students who make up Doctors for America in their efforts to improve the healthcare system they see fail their patients far too often. They’ve taken that frustration and put it to work.

In addition to spending their days and/or nights treating their patients, they spend their free time fighting for their patients outside the exam room.

Whether it’s fighting the campaign of misinformation about the Affordable Care Act (aka “Obamacare”), working to expand Medicaid to their low-income patients and neighbors, fighting to ensure action is taken to prevent gun violence, making their communities more walkable, or going on a 2-week bus tour demanding politicians put Patients Over Politics, we’re constantly amazed by the time and effort Doctors for America physicians and med students put in to fix that system.

We’re always saying thank you to the DFA family who really plan and drive this entire organization (I’d love to insert a medical metaphor showing how important you all really are, but I’ve never taken an anatomy course.), but we’d like to take time today to really say a special thank you.

Thank you to the amazing Dr. Alice Chen who is not only the Executive Director of Doctors for America, but also a practicing hospitalist at UCLA as well as Dr. Vivek Murthy who is a practicing physician and the President/Co-Founder of Doctors for America (I'm still not sure how you both do it).

To the Executive Board, our State Directors, Regional Leaders, State Co-Directors, bloggers, educators, petition-signers, LTE-writers, and all the other physicians and medical students who make up the Doctors for America family: Thank you.

Thank you for taking those anatomy classes to become physicians.
Thank you for seeing a broken system and fighting to change it.
Thank you for inspiring us every day.

We can’t wait to see you at our National Leadership Conference in April.  

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(Note: This post was originally written on February 9, 2013.) 

The National Rifle Association and the American Psychiatric Association  displayed remarkable agreement in recent testimony before congress. The NRA has mercifully backed away from equating mental illness with lunacy and evil, as it did immediately after the Newtown massacre. In formal testimony (1/31/2013) the organization called for expanded preventive mental health treatment, reform of commitment laws, and  overriding the privacy standards that separate mental health records from the National Criminal Background Check System. James Scully, testifying for the APA, similarly, pled for greater focus on early intervention/prevention and for implementation of a targeted registry of people with mental illness who should be barred from purchasing firearms. Both groups deplored the glut of violent media that may desensitize children and adolescents to the humanity of victims of violence.

All that is necessary to restore sanity to public debate is for the NRA to sincerely support its more reasonable public positions.  Instead of putting its financial firepower behind the campaign to place armed guards in schools, the organization could finance programs against media violence and promote programs that ensure access to early intervention for people at risk for mental illness. A serious commitment to gun safety would require the NRA to use its political muscle in campaigns to overturn state laws that forbid doctors from recording their discussions with families about gun ownership and to actively support President Obama’s executive ruling that restores the capacity of the CDC to conduct research into the effects and prevention of gun violence. To quote Hamlet, for such strange bedfellows as the APA and the NRA, ‘twould be a “consummation devoutly to be wished.”

Julia Frank, MD, is a professor of psychiatry at the George Washington University School of Medicine. 

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Attending the Million Moms Against Gun Violence Rally at the Chicago Temple last week provided a stark glimpse into the two communities represented there. There was a group of individuals drawn to the rally by the recent public and media uproar over gun violence alongside the parents and siblings of street violence victims. The ten-year-old boy who described a brother whom he would never know, a mother whose six year old daughter was killed by a random shot while playing on the front porch. The tears flowed freely as one could not resist the sadness for the victims of senseless violence. Even as the hundreds of people met and shared stories within that sacred space, a few blocks away two more names were added to the list of 89 people whose lives were lost to gun violence this year in Chicago. One month in Chicago is one Newtown, one Aurora, one Littleton.

The common theme was a bullet that took a life too short.

Craig Whitney, a New York Times editor, said ‘Americans identify themselves in part by metaphors and symbols based on firearms and myths whose power derives from their basis in truth’, citing the gunslingers of the American West and the many other images that we have grown up with. Those images have now been replaced with movies such as ‘A Bullet to the Head’ and video games like Mortal Kombat and Medal of Honor. We do not know if violent video games cause mass shootings and gang violence but we do know that playing those games leads to certain desensitization to violence, the anonymity of a victim. The streets and schools have become shooting galleries, except the victims are our children.

While some would say this is about the Second Amendment, the U.S. Supreme Court has already denied that approach. The Court has decreed that the right to bear arms necessary to a well regulated militia apparently overrides the right of my children to life, liberty and the pursuit of their dreams. Even Justice Scalia has stated that the Second Amendment right to own firearms is not unlimited. So this should not be about the ability of an individual of sound mind who passes a background check to own a gun for protection or hunting. This is about assault weapons whose sole purpose is to kill people.

In the summer of 1968, following the assassinations of Martin Luther King and Robert F Kennedy, Senator Joseph Tydings of Maryland appealed to the nation for effective gun violence prevention legislation, ‘It is just tragic that in all of Western civilization the United States is the one country with an insane gun policy.’ What was true in 1968 is even more apparent in 2013. Little has changed except that the list of victims has grown exponentially. Do we have the resolve to address the issue of gun violence? We say, ‘Enough is enough.’ It is time to move on.

Dr. Mark Rosenberg, MD FAAP, is an Illinois pediatrician in community practice and has been involved with the American Academy of Pediatrics and Voices for Illinois Children.

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We need to talk about gun safety. Really.

At a typical well-child visit, pediatricians talk to parents and kids about everything from nutrition to proper seat belt use. Our advice is based on evidence: What, statistically, is the most common scenario for a toddler drowning in a pool? (Entering it from their own home through an unlocked door.) What is the most common method of suicide in teenage boys? (A firearm.) Doctors rely on good information and an unimpeded communication between doctor and patient in order to be effective.

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More recently, gun-rights advocates were successful in shaping a provision in an amendment to Title I of the Affordable Care Act, called Title X, Protection of Second Amendment Gun Rights, which prohibits the collection of data on gun ownership at doctor visits. A few of the provisions are just silly posturing. For instance, we cannot require disclosure of gun ownership or storage. Well, no kidding. A doctor visit relies on self-reporting. Patients can lie about anything from smoking to how many doughnuts they eat if they want to, but the reality is that most parents, including gun owners, are more than willing to talk openly to their doctor about anything that affects the safety of their child.

A more concerning provision is that, while not explicitly preventing the doctor to talk about gun safety, the law prohibits doctors from collecting or maintaining that information in a record -- effectively putting a gag on the health record instead of directly on the doctor. Data collection, even without research and analysis, is critical. Data gathered by the CDC reveals that 42 percent of gun owners with teenagers in their household do not keep their guns locked up. When there are younger children in the household, 29 percent of gun owners do not lock their guns. Those sobering statistics give us focus for discussions with parents. Measures to suppress this kind of information have no place in a health care law.

This is an excerpt from Dr. Maggie Kozel's must-read article titled: "Putting a Gag on Doctors: The Wrong Approach for Gun Rights" which can be read in its entirety on The Huffington Post.

Are you a health care provider or professional who wants to take a stand against gun violence? We agree. Join us by signing our petition to Stop Gun Violence Now.

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I’ll never forget one of the couples I took care of as a fourth-year medical student.  The wife was a beautiful, petite, white-haired marble sculptor.  She was a dreamer and had a twinkle in her eye even as she laid in her hospital bed.  Her husband was a well-build stoic engineer originally from Germany.  He sat at her bedside reading her the paper, caring for his wife of over 50 years with the love of a young man and the devotion of a lifetime together.

She was in the final months of her struggle with breast cancer.  They spent every day together in the hospital.  With a generosity of people who have loved deeply, they let me into their life.  I spent afternoons sitting at my patient’s bedside listening to their stories of how they managed to be in love after so many years. 

One day, she took my hand and told me that the one thing she wanted most in the world was to see her granddaughter again.  They had a 3-year-old granddaughter in Florida who was the embodiment of joy for both of them.  But they hadn’t seen her or heard from her in months.  Their only daughter had fallen into a troubled marriage, and their son-in-law had convinced her to cut off all communication with them.   Phone calls went unreturned, and gifts came back in the mail unopened.  But still, their love for their daughter and granddaughter never waned.  Not one bit. 

Though I briefly contemplated flying to Florida to talk some sense into their daughter, I knew I did not have the power to make things perfect for my patient.  I could not bring their daughter and granddaughter back into their lives, nor could I give her ten more years of life with her husband.  

But I could ease her symptoms and help fend off complications so they could spend more time at home together.  I could make sure they knew that to me, they were not a list of pathology and medications and laboratory results, but a beautiful pair of human beings who had so much wisdom to share with a young medical student.

To this day, I picture their room with a magical glow created by their relationship and their kindness.  The same glow in ever changing hues is the heart of medicine, the profession I love despite its warts and challenges.  It is the glow of a care partner who finds time in her afternoon to give a manicure to a patient with unexplained severe weakness in her arms and legs who longs to go home to her 4-year-old son.  It’s the glow of a nurse hugging patients goodbye as they wheel out the hospital homeward bound. 

We often think and write about our health care system as glitzy pharmaceutical ads and the bottom line and state budgets and the count of votes in Congress.  But in this holiday season, we are reminded as we are every year that one of the most important and fundamental things in life is the relationships we form with family, friends, and even perfect strangers.  In medicine, we have the privilege of being let into patients’ worlds at their darkest hour and helping them through to the best of our ability.

To all who serve patients and all the patients who allow us to care for you, thank you for being a part of something worth fighting for – a kinder, more compassionate, more innovative and wondrous health care system where the heart of it all is our care for one another.

To everyone in the Doctors for America community, thank you for daring to care, for challenging the way things are, for dreaming about the way things should be, for taking action in the face of uncertainty, for being a part of what makes me proud to be a doctor today and every day.

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Like most of the country, I have spent the past week deeply pained and horrified by last Friday’s killings in CT, and  have asked myself how such a horrible event (and all the previous mass killings of innocent people) could have happened?

As a psychiatrist, the only reasonable answer that comes to me, is the presence of mental illness, or—to put it another way--of the deep and dark psychological and emotional troubles that plague many of our fellow citizens.  So often this suffering goes unidentified and uncared for, which is why we need to fix our broken mental health system now and for everyone.

Note: I don’t at all mean to imply here that all –or even most—mentally ill people are dangerous; this is in itself a dangerous and discriminatory idea we need to guard against.  In fact, most of the harm done by emotional illness is inflicted on the sufferers themselves (consider, for example, suicide, which is now the 3rd greatest killer of young people in our nation). 

On Monday, a colleague forwarded me the article by Ms. Liza Long entitled “I am Adam Lanza’s Mother.”  While this piece (which has since gone viral) has generated a huge amount of controversy, the powerful issues and questions it generates remain deeply relevant.  

In her article Ms. Long describes her brilliant, angelic and apparently mentally ill son, who she reports is subject to sudden fits of violent rage that put both herself and her other children in serious danger.  After describing some of her son’s “episodes,” Ms. Long goes on to share her struggles to find the help her son desperately needs, and describes the insurmountable obstacles she faces in doing so. She recounts being told by her son’s social worker during their last visit to the hospital that “the only thing I could do was to get (my son) charged with a crime.  ‘If he’s back in the system,’ the social worker reportedly continued, ‘they’ll create a paper trail; that’s the only way you’re ever going to get anything done.  No one will ever pay attention to you unless you’ve got charges.’”  Ms. Long correctly notes that a huge portion of our mentally ill citizens are currently in prison, which now houses the largest mental health facility in the nation!

Unfortunately, this situation is disturbingly similar to that of parents of developmentally ill children who are told that their best option is to give up custody of their children to the state in order to “get them into the system” where they can get the help they need.

As a psychiatrist in New York, I feel fortunate to be practicing in a state that provides some of the best care to the poor and uninsured in the country.  However, even in this relatively “good” state,  I have had to deal casualties of our inadequate system:  a young man  who was rushed  to his local hospital after attempting to slash his throat with a kitchen knife, only to be released the next day because the hospital was not “in network;” or the public hospital patients who are admitted and readmitted to the hospital (at a cost of $1500/day), because the community services they used to rely on have been decimated by budget cuts; or the sweet and smart college student I admitted emergently to prevent her from jumping in front of a subway train, who emerged from this lifesaving hospitalization with a $50,000 hospital bill because her insurance company insisted (erroneously) that the hospitalization had not been “pre-authorized!

As healthcare providers, we know we have to work to change the ignorant, phobic and dangerous attitudes toward mental illness in our communities; however, as socially aware providers and citizens, we also know that this is not enough.  We know we also need to work to fix our very broken healthcare system (which is even more broken when it comes to mental health), so that our emotionally troubled family, friends and neighbors can be identified and get the support and care they need.  How many people need to suffer or die because funds for school counselors, public hospitals, and community health centers have been cut?  Or because they’re not eligible for Medicaid? Or their insurance doesn’t adequately cover behavior health? 

As providers, our care does not end with our individual patients; we also need to care for our societies and communities.   The Affordable Care Act (also known as “Obamacare”) contains valuable provisions to improve care for the mentally ill; I believe we need to work to increase understanding and implementation of this ground-breaking law among our colleagues and in our communities.  However I—like many others—also believe this law does not go nearly far enough and therefore we also need to work to extend full  and adequate care to all citizens, including those who suffer the ravages of mental illness.

Yes, we desperately need gun control and health care providers need to stand up for it now.  We also need to strengthen-- not cut-- Medicare and Medicaid.  We need to restore funds for hospitals, community mental health centers, and counselors in our schools-- not further cut the few bare-bones programs that still exist.  We need to ensure insurance companies (as is done to some extent in the Affordable Care Act) cover all illness for all people-- including mental illness and psychological suffering.  Last but not least, we need to show love and respect to our troubled citizens and give them the care they need. 

If you are a doctor, nurse, medical student, nursing student, or other public health provider, please sign our petition urging lawmakers to pass gun safety legislation and stop gun violence now.

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If there were a disease killing tens of thousands of Americans and injuring many thousands more every year, would you be concerned? If most of our international peers had successfully controlled this disease, would you demand action from our politicians? If this disease wasn’t a virus or bacteria, but one of our own making – gun violence – would you still feel the same way?

Every year, around twelve thousand people die of firearm-related homicide and another eighteen thousand of suicide, for a total of over thirty thousand – more than die of prostate cancer. Even worse, the victims of gun violence are often young, meaning the burden borne by our society in total years of life is likely greater than breast cancer as well. And yet there are no months dedicated to the many victims of gun violence, no ribbons to raise awareness of their plight, and no fundraisers dedicated to finding the cure to this stubborn problem.

Apparently, we can only bring ourselves to talk about this issue when its victims are forced into our consciousness the way the 20 children and 6 adults of Newtown, Connecticut were last Friday.

It is not as though we have no idea how to solve this problem. Countries around the world have firearm related deaths rates that are a fraction of our own. In 2008 Japan, which has all but outlawed guns, experienced just 11 gun related homicides in a nation of one hundred and twenty million. In the United States, there are three times as many every day. And, despite frequent claims that if guns are regulated criminal access will be unaffected, many bosses in the Japanese mafia have forbidden use of guns by their men in response to strict enforcement measures.

In 1996, in the wake of the Port Arthur massacre that left 35 people dead, Australia instituted strict gun safety laws and initiated a government buy-back of already existing weapons. Since then, the gun homicide rate fell by 59 percent, and the gun suicide rate fell by 65 percent.

This trend is not restricted to just a few countries either. Studies have repeatedly found that a reduction in gun availability leads to less homicide and suicide, and that this holds true whether one examines trends across countries or states.

Perhaps the most frustrating aspect of the debate over gun safety is not the starkness of these studies and statistics; it is that opponents so rarely acknowledge the costs to our society of widely available and easily accessible guns. It is as though after learning of the strong association between cigarettes and lung cancer, we had listened to the tobacco companies as they claimed it was solely an issue of personal freedom, rather than the doctors who insisted it was an issue of public health.

For few other issues would we tolerate this state of affairs. If tens of thousands of Americans died every year of an infectious disease and there was no policy response, there would be a public outcry. If research clearly demonstrated that there were simple solutions to prevent all these deaths and still nothing changed, public health experts would be furious. It is time for us to recognize that we must take action to save thousands of lives and demand change from our politicians.

If you are a doctor, nurse, medical student, nursing student or other health professional, sign our petition demanding gun safety legislation here.

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For those of us who have been champions of health care reform and advocates for the first step in the project, the Affordable Care Act (ACA), the progress we’ve made is most heartening.  But here in Utah our state political leadership is planning more obstruction with hopes that the ACA (also known as “Obamacare”) will eventually wither on the vine and go away.

Utah’s Governor Gary Herbert, a recently re-elected Republican, has been a consistent opponent of the ACA.  But more problematic for the hope of establishing a Utah-run exchange, that would allow thousands of Utah’s small businesses and citizens to purchase private insurance, is the widespread opposition to such a proposal by the state legislature.  Last month, Utah House Speaker Becky Lockhart, a nurse by vocation, announced that she would not touch a state run exchange for the ACA “with a ten foot poll.’  Other state legislative leaders have had even more negative reactions to the idea.  Nationally ACA opponents, still grasping at legal straws, hope federally run exchanges will be overturned in court challenges citing possible errors in the ACA’s legislative language.

Last week, Herbert asked for Utah’s current health insurance exchange, recently branded as ‘Avenue H’, to be approved as an ACA-compliant State-based exchange.

Utah’s political leadership has been very proud of their efforts to set up Avenue H despite evidence that it has largely been a failure in expanding access to health insurance.  Limited to small businesses, Avenue H has offered insurance products generally more expensive than those available through private insurance brokers.  Only a small fraction of Utah businesses have found it to be of any value in efforts to insure their employees leaving 400,000 Utahns still uninsured. Many observers feel the only hope to bring down exchange costs would be to open access to individuals as prescribed by the ACA.  Thus, Avenue H’s success may hinge on its ability to adopt the ACA exchange model—something Governor Herbert is opposed to.

Even more dismal than the prospect for a state-run insurance exchange is the chance that Utah will expand Medicaid next year.  Utah’s legislators, rather than insure thousands of uninsured Utahns, would rather cross their fingers and hope that funds for the Medicaid expansion eventually succumb to the ongoing federal budget wars or that the ACA is overturned. 

Such will be the tactics and strategy in many states in the coming years.  Only a successful implementation of state-run exchanges in other states and evidence that Medicaid expansion brings down costs will sway the bitter ACA opponents who, like unreconstructed confederates in post-1865, can’t believe their side lost and will continue to resist.        

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While I support without reservation the call to reduce or eliminate firearms in the civilian population, I am uneasy about making this tragedy a call for mental health law reform. Over the past decades, mental health laws have focused more and more narrowly on reducing dangerousness as the main justification for treatment and the only legitimate grounds for involuntary treatment. Our hospital beds are now largely reserved for people who seem dangerous (many aren't but have to claim to be to gain access.) Quite often, as soon as someone says he or she is no longer on the verge of suicide or targeted aggression, the person is released far sooner than is reasonable to experience a true treatment response. As a consequence, too many inpatient wards are little more than holding pens, where vulnerable and aggressive people are confined together for brief, ineffectual interactions with professionals.  

Many dangerous people do not merit verifiable psychiatric diagnoses. The vast majority of people who are mentally ill are not dangerous. Indeed, they are more likely to be the victims than the perpetrators of violence. They do, however, suffer in ways large and small, and many are severely disabled. The emphasis on control of dangerousness, if anything, limits rather than expands access to mental health care for the majority of people who would benefit.  Expanded access to treatment in general and expanded grounds for brief commitment are both needed. This requires both legal reform and funding.

More people would accept care voluntarily if hospitals were more therapeutic and the intensive outpatient care more available and affordable. The grounds for involuntary treatment for brief periods-- subject to early court review-- should encompass people with illnesses in which hopelessness, lack of insight, internalized stigma, or fear of what hospitals have become makes them reluctant to request voluntary admission. Even now, many patients quickly change their minds and would stay longer if they could.

Focusing our reform efforts, psychiatric treatments, institutions, and resources so narrowly on people who might commit terrible acts of mass violence causes us to neglect the much, much larger population of people who need and would benefit from a much broader range of mental health services.

Are you a doctor, nurse, med student, nursing student, or other health provider? Sign our petition demanding gun safety legislation here.

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The presidential election has passed.
After spending $6 billion dollars on the federal elections-the most expensive election in history--everything in Washington D.C. remains exactly the same as before election.  Almost.
President Obama remains the president.
The House remains Republican.
The Senate remains Democrat.
The Supreme Court of the United States remains SCOTUS.

There is one difference.  A major one.

We know now that health reform will move forward.
 
States will scramble to catch up with preparing for the health insurance exchanges, which WILL move forward.  States will decide whether, and how, to expand Medicaid coverage. Hospitals will continue to figure out how to optimize handoffs of patients to the doctors outside their hospital doors--to prevent the quick bounceback, the unnecessary (and soon to be unpaid for) return within a month to the same hospital for the same condition, when meds are not bought and follow-up doctors not seen. Every American citizen will be expected to have health insurance by January 1, 2014.

Between here and then, we have a fiscal cliff to deal with.  As a society, we desperately need to slow down our health care spending, a shocking 17.5% of our federal budget.

In the 1970s, spending on health care and education were on par. Not so today.  "Compare the physical conditions of schools and hospitals,” medical historian and sociologist Paul Starr asked a group of medical educators last week in San Francisco. "How much further can we let this go? The resources are coming out of other things."

The be all and end all of health reform cannot be ensuring access to Americans to the highest level of care for the diseases that plague American society today.  70% of our $2.7 trillion healthcare spending is on diseases of lifestyle.  It is estimated that by the year 2020, a full 20% of federal spending will be on diseases of lifestyle.  If our health plans only focus on ensuring every American has access to gastric surgery, we will all get fat and sick before spending lots of money to get better.

Instead, to save America money, we need to change our lifestyles.

More walking. More fruits and vegetables. Less soda.

An important part of healthcare reform is funding for prevention and public health measures.  Right now in America, only 4% of our healthcare spending goes to public health.  We spend $250 to keep people healthy in comparison to over $8500 for direct medical care on average for each American.

We need to shift our spending from a sickcare system to a healthcare system that begins by creating a built environment that promotes healthy habits where we live, work and play.  Then every American can be healthy, and our federal budget balanced.

Now that we know healthcare reform is moving forward, we need to make sure healthcare reform moves in the right direction--away from a disease-oriented pay-for-procedures system, and towards a health-oriented system that pays for wellness.

Best wishes for the next 4 years, Mr. President! Be well, and help us to be well too.

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