In this month’s #CareTalk, John Driscoll and I discuss the protection of vulnerable populations, a particularly timely topic as hurricane season rages on.
A person addicted to drugs might do anything to get their hands on the next dose. Whether that means ‘borrowing’ painkillers from a relative who had their wisdom teeth extracted, breaking into cars to grab small bills and coins, or stealing their mother’s jewelry –all things I’ve seen myself– there are no real limits. So I was saddened but not surprised to read Dying At Home In An Opioid Crisis: Hospices Grapple With Stolen Meds, which highlights the trouble dying patients face in keeping hold of their painkillers.
The Kaiser Health News examples are only anecdotal, but the combination of high quantities of opioids and homebound patients unable to fend for themselves is an ideal setting for diversion. The problem is two-fold: theft of drugs while the patient is alive, and diversion once the patient passes away. Since many patients die within days or weeks of beginning hospice, the second problem is a major one.
The examples offered in the article are heartbreaking:
In Mobile, Ala., a hospice nurse found a man at home in tears, holding his abdomen, complaining of pain at the top of a 10-point scale. The patient was dying of cancer, and his neighbors were stealing his opioid painkillers, day after day.
In Monroe, Mich., parents kept “losing” medications for a child dying at home of brain cancer, including a bottle of the painkiller methadone.
In Clinton, Mo., a woman at home on hospice began vomiting from anxiety from a tense family conflict: Her son had to physically fight off her daughter, who was stealing her medications. Her son implored the hospice to move his mom to a nursing home to escape the situation.
Some hospices are trying to do something about the problem, but it’s not easy. After all, their primary goal is to ease the pain of dying patients. It’s not really their job to keep track of and control everyone else. Some of the ideas being tried include:
- Screening families for a history of drug addiction
- Limiting the amount of meds delivered at any one time
- Drafting agreements with families about consequences for drugs that disappear
- Encouraging the destruction and disposal of drugs after the patient dies
None of these approaches is likely to succeed on its own. The country will have to address the broader opioid crisis in order to bring this part of it under control. However, there are a couple additional steps that could be taken now:
- A few states let hospice employees destroy drugs once a patient dies. That should be expanded nationwide and made mandatory. There is no conflict here with the patient’s needs
- Some patients, who would otherwise be eligible for home hospice, should be moved to facilities such as nursing homes, where controls can be tighter. (Much as I hate to argue against home care this needs to be part of the discussion)
I went down to Copley Square, Boston yesterday to protest President Trump’s Executive Order on immigration. I’m very concerned about the direction the country is taking. Beyond that, I’m also saddened at the lack of appreciation for immigrants in building our economy and helping health care reform succeed. Below is a rerun of my blog post from 2011.
Over the last decade, the United States has intentionally made itself less attractive to immigrants, forgetting that immigration has been a huge driver of the country’s economic success. In a recent article (America needs a 21st century immigration policy), leading entrepreneurs, executives and investors including Steve Case and Sheryl Sandberg said:
To some, the link between immigration reform and economic growth may be surprising. To America’s most innovative industries, it is a link we know is fundamental.
The global economy means companies that drive U.S. job creation and economic growth are in a worldwide competition for talent. While other countries are aggressively creating policies and incentives to attract a highly educated workforce, America has stagnated. Once a magnet for the world’s top minds, America now faces a “reverse brain drain” and is no longer the first choice for many entrepreneurs creating new companies and jobs.
America needs a pro-growth immigration system that works for U.S. workers and employers in today’s global economy. And we need it now.
Openness and encouragement of immigration is vital for the success of health care reform. Why?
- Immigrants innovate and create economic growth. This growth is how the country gets wealthier and better able to support health care expenses without raising tax rates
- Immigrants tend to be younger, so they mitigate the overall aging of the population, making it easier for the country to afford its commitments to older citizens
- Immigrants can use their intellectual capital and training –whether acquired abroad or here– to fill health care jobs such as primary care physician, pharmacist, nurse that would otherwise go unfilled
President Obama actually understands this dynamic, but has to tread carefully since immigrant bashing is so popular on the right. But unfriendliness to immigration is all over in the place. For example in Massachusetts the state has decided –for short-sighted financial reasons– to exclude legal immigrants from subsidized health insurance. With luck, that decision will be overturned as unconstitutional by the state’s Supreme Judicial Court.
I agree with the Republican rhetoric of the need for a “pro-growth agenda.” Low taxes and limited regulation can certainly play a part. But policies that encourage immigration, especially of younger, well educated people, are absolutely essential. We need it for the economy as a whole and for the health care economy in particular.
The Wall Street Journal continues to go soft on us. I just read about “walking meetings,” which are just what they sound like: conducting meetings while walking around. According to the Journal, these meetings are great for combating obesity and diabetes, and improving creativity. With meetings, phone calls and emails taking up more than 90 percent of the workday for some people (consultants like myself included), the Journal touts studies purporting to show the benefits of wandering around at work.
Walking meetings aren’t really new. Kaiser’s Dr. Ted Eytan touted the idea on my blog five years ago.
Sure it’s good to get moving, and taking a walk can be just the thing to clear one’s head, but when I’m in a meeting I’m usually taking notes and often viewing documents. Many meetings are confidential and sometimes they involve 10 or more people. So IMHO most serious meetings are not suitable for walking.
When I was an economics student at Wesleyan in the 1980s, professor Stanley Lebergott told me about a pretty crazy job interview his colleague Douglas Cater had with Lyndon Johnson at the White House –swimming nude in the pool and having to keep up with Johnson while trying to answer questions. Although I believed my professor, you might not, so here’s how it’s recounted in Jack Valenti’s memoirs:
I’ll never forget the day LBJ brought Doug to the White House to sort of interview him. ‘Let’s go for a swim, Doug. Okay with you?’ said the president. Well, of course it was, so Doug, Bill Moyers, and I followed the president to the swimming pool. Doug’s eyes almost popped out when LBJ, Bill, and I threw off our clothes and jumped into the pool, nekkid, as we say in Texas. After a moment’s hesitation, Cater stripped and plunged in, too.
As we splashed around, the president began chatting with Doug about his ideas for making the Johnson administration more effective. I daresay, many of us have been interviewed in odd places, but as Doug said later, ‘Nothing compares with my waterlogged birthday suit interview with the president.’
Compared to this, walking meetings are nothing. Can’t the Journal find something more inspiring or scandalous to write about?
Nuzzel showed me that my friends have been sharing a new athenainsight: Are male patients comfortable with women doctors? The post uses athenahealth billing data to demonstrate that male patients are less likely to return to female physicians than they are to male physicians, but for female patients the sex of their doctor doesn’t make a difference.
Athena’s conclusion is that men may be “less enthusiastic than women about seeing physicians of the opposite” sex. The article links to a Quora exchange, where all the respondents indicate that as patients they are equally comfortable with women as they are with men.
These findings are interesting, but I don’t think they tell the whole story.
When my long-time primary care physician retired I looked for a new doctor. I believe in the value of long-term relationships so wanted to pick someone I could be with for 15 years or more. I wanted someone affiliated with my preferred health system, with excellent clinical and at least decent communications skills, and around my age (late 40s).
My retiring physician recommended a female colleague in a practice close to where I live, who fit the bill. He had been involved in her training and had worked with her.
Like the Quora respondents, I was comfortable with being examined by a female physician. As I’ve written, I’m also comfortable being examined by a physician who is a friend.
But, although it was further down my list of criteria, I did have the sex of the physician somewhere on my list of factors. Why? Because at least on average, men work more hours and retire at an older age, making them more likely to be available to patients when needed. One survey showed that 44 percent of female physicians worked part time, compared with 22 percent of men. Another showed 25 percent of women compared to 12 percent of men.
My personal experience reinforces those statistics. The recommended primary care doctor works part-time. Other female physicians my family sees have taken time off to care for sick family members and attend to other family issues. One retired in her 40s to take care of sick parents. Working less or taking time off doesn’t make them bad doctors or bad people –quite the contrary, it may even keep them fresh or help them stay connected with patient needs– but it does have an impact on availability and longevity of the relationship.
In the end I chose the female primary care physician my retiring doctor recommended, and I plan to stay with her. But I’m also adjusting my expectations about primary care. For one thing I’m focused more on the relationship with the overall practice, rather than just with my personal doctor.
The practice seems to do a reasonable job of working together as a team, and I hope this will serve its patients as well or better in the long term than the more traditional and familiar one-on-one doctor/patient relationship. If it doesn’t turn out that way then my likely next step is to switch to a concierge practice rather than seek out a male physician.
Image courtesy of stockimages at FreeDigitalPhotos.net
The story of how Medicare ended segregation in healthcare settings is a pretty remarkable one. Temple University Professor David Barton Smith’s The Power to Health: Civil Rights, Medicare, and the Struggle to Transform America’s Health Care System brings the events of 50 years ago to light.
“In four months [government bureaucrats] transformed the nation’s hospitals from our most racially and economically segregated institutions to our most integrated,”he writes. “A profound transformation, now taken for granted, happened almost overnight.”
In the early 1960s healthcare was even more segregated than the economy as a whole. In Southern states there were separate hospitals for whites and blacks; there were separate waiting rooms in physician offices, with black patients seen last.
The 1964 Civil Rights Act prohibited racial discrimination in programs that received federal funds. But when Medicare was enacted in 1965, no one really took the provision seriously. After all, the Brown v. Board of Education decision a decade earlier had not led to rapid progress in school desegregation.
And yet Wilbur Cohen and a small team from the Social Security Administration and Public Health Service put together rules that prevented hospitals that discriminated from receiving Medicare funding. Learning their lesson from the failure of Brown’s “all deliberate speed” language, which had let school segregation fester, the team decided to enforce the rules from day 1.
Since hospitals couldn’t afford to forego Medicare, desegregation was achieved in a matter of months. Imagine that.
Image courtesy of podpad at FreeDigitalPhotos.net
I was driving along in Boston last weekend when I heard an intriguing radio advertisement for MassGeneral Hospital for Children, the pediatric division of Massachusetts General Hospital (MGH).
MGH is a world famous hospital, but when it comes to pediatrics it’s much smaller, less well known, and lower ranked than Boston Children’s Hospital –the #1 rated children’s hospital by US News.
I thought MGH picked a clever angle for the ad: highlighting a patient with Crohn’s disease who was diagnosed at age 10 and is now an adult. The message: illnesses that occur in childhood may need ongoing care into adulthood. Therefore why not start with a hospital that cares for children and adults? Boston Children’s isn’t mentioned, but it’s the clear target.
The Crohn’s example is not accidental. It’s a fast growing illness among kids, and it lasts for life. I don’t have the data but my sense is that it must be a highly profitable line of business for hospitals because of the frequent surgeries, endoscopy, and use of biologic drugs. (I would have been surprised if they had uses a common but non-lucrative disease like diabetes.)
The transition from a pediatric to adult gastroenterologist is an important step on the patient journey. A bad transition can be stressful and even lead to worse health outcomes. I’d be interested to learn what processes MGH has in place to make the transition smoother for its patients than what Children’s can offer. (I’ll have to research that.) It’s also unclear how highly to weigh this factor when choosing a place for a child to be treated, especially if that child might move away for and after college.
I don’t want to sound too cynical on this. In my own experience, I’ve seen physicians from Children’s and MGH –including in gastroenterology– collaborate closely to help one another’s patients. If you have a child with inflammatory bowel disease and live near Boston, count your blessings.
Image courtesy of kdshutterman at FreeDigitalPhotos.net