Category Archives: Health Care & Legislation

Healthcare Culture: Everything Hurts and I’m Dying

There are a lot of issues being discussed in healthcare today.  One point I don’t hear a lot about, but see everyday comes directly from our patients mouths.  They come in to clinic with the mindset of “everything hurts and I’m dying”.  What this means is that if they have a headache they think and know that they have a brain bleed and they need and MRI.  If their child has a cough they definitely need an antibiotic.  They woke up sick this morning or have an ache in their shoulder x1 day: everything hurts and I’m dying.  

The undertone of this statement that they don’t directly say: And you BETTER do something– better yet– what I think you need to do. 

Now, let me be clear it isn’t that I’m not empathic to patients who are feeling ill or in pain.  However, there is this culture out there that extreme measures, investigations and treatments need to be taken if you have a headache.  Are there the small percent of people who do need these measures? ABSOLUTELY.  That is why we do history and physical exams to weed these people out and send them for these tests.  

Why does this matter? What is this causing in medicine? Cost. Waiting room lines. The emergency department being used for non-emergencies (sorry people this was not created for you to get a pregnancy test free or score some morphine for back pain– it was meant for people with asthma exacerbation, CHF, PNA amongst so many others). 

How does this effect providers? We also have to act like someone who thinks they are dying are dying.  If we don’t they’re not satisfied. Re-assuring patients has become the most difficulty part of my job.  We all know when we have this person in front of us.  I always make sure to do a full physical exam.  I talk them through it saying “your ears are clear–no infections, airway is patent– tonsils are not enlarged, no lymph node enlargement, lungs sound great, your neurological exam is completely normal, vital signs completely within normal limits—– etc etc”.  But for some people they just aren’t satisfied.   

What else are we to do?  Patients who push for further intervention, I tell them I cannot treat an infection that is not there or worry about signs or symptoms that you do not have.  I tell them this is good news.  

My question is where are we going wrong? It seems like more and more people are lacking basic concepts about colds, headaches and belly aches.  I do my best to educate my patients.  Viral bronchitis is a BIG one.  I tell them 98% of bronchitis is caused by a virus. The cough can last 3-4 weeks even after you begin feeling better.  I state “Scary symptoms that you DO need to be concerned about are persistent fever or coughing up blood streaked sputum.” I ask them EVERY TIME “do you have any questions”.  I usually ask this twice. Yet somehow there are still people who come back a week later cause they have a dry lingering cough?  

Would love to hear thoughts from students on rotation and practicing providers with how you best handle these situations.  As well as suggestions.  May this serve as a reminder to always educate your patients as much as possible!

“Being Healthy is Expensive”

This is a statement I hear ALL of the time.  It is also one of the things that frustrates me to no end.  As someone that does CrossFit, I’m faced with people continually saying “Yea, but its just SO expensive”.  We hear it all of the time “Eating healthy costs more”. Then you have gym memberships, Yoga, Barre, Running, CrossFit, Orange Theory, etc, etc.

My open argument to people who support the overarching theme of “It’s too expensive to be healthy” gather around the following questions:

  1. How much is the handbag you are currently carrying and how many of them do you own? How many pairs of designer boots or jeans do you have in your closet?
  2. How many times have you stopped at Starbucks or “refilled” your Starbucks app this month (by the way I have a Starbucks app and the minimal refill is $25 dolla dolla bills)
  3. How much money have you spent on booze this month? Its expensive to drink alcohol.  If you went out for two drinks 4 times this month you would have approximately spent 58$ (this is assuming 6$ drinks with tip and that you didn’t eat anything)
  4. How much do you spend weekly on dining out?
  5. So, eating healthy and exercising has potential increasing costs.  I hear you.  But, please tell me how much a year your diabetes or heart disease is costing you–please. Doctors appointments, medications, meeting your full deductible, etc.
  6. What about indirect costs.  For example, basically if you are on one chronic medication it raises your premium for life insurance.  Or the complications from diabetes or heart disease including expensive surgeries, chronic wounds and hospitalizations.

I hear the fundamental principal that eating healthy does truly cost more–up front.  The costs in the end I truly think are more astronomical.  Also, I’m not saying you have to go out and get a personal trainer or a CrossFit membership for $150/month.  Last time I checked the road is available and free to walk on. Globo gyms as I call them offer memberships as low at $19 dollars a month.  Thats like 4 Starbucks drinks.

My point is this: Yes, upfront costs can be obnoxious and you would rather buy another pair of boots.  I get it, I like boots too.  However, it’s planning for retirement.  The  more you work ahead the better your life and health with be in the long run!

 

 

 

 

Women In Medicine?

I read an article recently regarding the sayings surrounding women, their lives and careers and what would happen/how ridiculous it would sound if we applied them to men. For instance “Men in Medicine” or “Men, how to have a career and family”.  May favorite were the beauty remarks regarding wrinkles and weight.  It sounds absolutely ridiculous when you apply it to men–so why do the majority not see it as ridiculous when the latter are applied to women? It is kind of appalling when you think of it, at least it was to me.

To me these statements suggest a lot of things. First, that women are not a majority in advanced positions in medicine–which is false and also that as women we need to push for some type of movement to raise awareness that women can be health care providers, too.  Don’t get me started on the career and family balance.  In our country it is always always assumed that the woman is not the bread winner and if a man and a woman both have great careers the woman should be the one to make the sacrifice.  False.  Some personal stats for myself.  For my first job I worked with a group of 5 male and 5 female physicians–2 of the women whom brought home the sole salary.  All 3 of the mid level providers were also women.  So, why do people continue to be shocked that I’m a PA? Or that the female physician who is seeing them is actually the doctor.

How about some numbers?

Medical schools are supposedly comprised of a majority (>50%) women, so I have been told.  However, the best supporting statistics I found for that were from the AAMC from 2013-2014 stating 47% of medical students were female and 46% of medical residents were women.

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As for PA’s, the tale tells it that the profession was dominated by men.  Now, per a qualitative study conducted by the NCBI greater than 60% of practicing PA’s are female.  The statistics they utilized for this study was the AAPA Census Survey and over 16,000 PA’s were a part of the study.  I also read numbers that suggested up to 72% of today’s practicing PA’s are female, although I cannot quote a direct source.  The NCCPA Statistical Profile of 2014 revealed of the total 101,963 practicing PA’s, 67,901 were female, 66.6% total.  It does reveal the trend that when the profession first emerged it was in fact male dominant (if we are assuming older PA’s have been practicing longer which is not always the case).

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I realize some people may think that I am just perpetuating the cycle by talking about the subject; but, there is a part of me that thinks there hasn’t been much attention to this concept.  I guess my whole point–or even question is by making statements such as “women in medicine” are were fighting the stereotype or enabling it? Honestly, I’m not really sure. I do think that when you apply phrases directed towards women and replace it to represent men it sounds pretty off to say the least.  Until later, I guess it’s just something to think about and I would love to hear feedback!

Name Change? Physician Assistant to “PA”?

Below I’ve included an article from the most recent PA Professional regarding the interest in changing the name of the ‘Physician Assistant’ profession and renaming us to just “PA/PA’s”.  I’m incredibly interested to receive feedback from others on this article.

For myself, I have to say overall, I’m not excited about this and I do not think it will have the positive effect the powers to be anticipate. However, it has also made me think about how I can contribute to helping the public and my patients understand who PA’s are and our scope of practice (because that is what really matters, right)? Perhaps it doesn’t really matter what we are called, it matters how we treat out patients and how well we perform our jobs.  I do want patients to have a better understandinfg of who we are and what we do, overall I feel as though the AAPA should be working on promoting awareness for “who are Physician Assistant’s/PA’s?” As opposed to just changing our name.

So, I decided to focus on what I directly–meaning with patients–have the capacity to affect.  Tonight, at work prior to interviewing my first admission I asked myself how I could incorporate a short (30 seconds or less) dialogue in my introduction that would bolster patients understanding of who we are and our role in the health care system.

I will preface this story with the fact that this probably was not the best patient to try this out on for two reasons: 1. She was in obvious distress (chest/abdominal pain/lactic acidosis) 2. She was a retired RN–so she wasn’t exactly your baseline audience.

Regardless, I entered the room introduced myself starting with my usual sphiel “My name is Danielle, I’m a Physician Assistant and I work with the medical service here at the hospital”.  Instead of stopping there I proceeded with “I work with the medicine team here and collaborate with a Physician to determine a plan of care and treatment”.  I wish I could say I had feedback, but it was pretty brushed over.  In her defense I would have brushed me over and demanded some pain meds too–she looked uncomfortable.

However, I think it is something worth continuing to do in my daily practice and to think about.  I hope that I get some opinions back on what this article means to other PA students and practicing PA’s out there!
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False Sense of Health?

I haven’t talked much about my personal life or what I do in my spare time. I like to lift heavy shit for time. AKA CrossFit.  I’m really into being healthy and personal betterment, whether it is intellectual, physical or whatever.  I was a personal trainer for a while before PA school, I’ve ran 10+ half marathons, I did one triathlon and played sports virtually all of my life.  You get it–it’s important to me.
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Being a health care provider can be somewhat frustrating at times for anyone who is health conscious.  Most of the people I see and treat are super sick.  They take 10-20 medications daily, have no idea what medications they are taking or purpose they serve. Most of you have probably experienced it on some level. I remember being super impressed with a 93 year old patient I had who could tell me when his last echocardiogram was and his ejection fraction.  I may have high fived him, he pretty much rocked.
I think the overall state of our health is rapidly declining. I also think patients do not have a clear understanding of what is occurring with their health. Seriously though–as a Nation we are in bad health. Why is this happening? I believe there are innumerable reasons and road blocks.  Some of which I am going to venture to explore today.  All of the reasons are too complex to mention in one post-I’m sure I will touch on a lot of them as time goes on, as for now, I’ll leave it to what I believe are the massive red flags.
I can’t help but wonder if a false sense health and wellness is being created.  What are the forces behind this potential false sense of health and wellness? Driving forces include health care providers, sensitivity and political correctness, the new average/normal health state of society, as well as screening tests and advanced technology inadvertently reassuring bad habits.
A substantial number of patients with chronic conditions that we know and treat are not improving.  In fact from my experience it can be the opposite.  Their diseases are getting more concerning, hemoglobin A1c’s are rising, ejection fractions are dropping and the number on the scale is going up.  Consistently on my rotations I watched providers ignore the BMI, edit out “obesity” on patients discharge summary or simply just add medications or increase insulin regimen without talking to the patient about what was going on or why it was happening. Patients begin seeing medication as getting rid of their illness as opposed to masking it.
imagePeople no longer think they are diabetic because they take insulin, or that they don’t have high blood pressure because they take metoprolol.  Instead of having important, difficult conversations with patients about their weight and other various aspects of declining health We slap medicine on it to fix the numbers. But, is the quality of life of our patients improving?
Now, let’s be clear I’m not shaming medical providers.  However, suggesting that we do have a small part in perpetuating the epidemic of illness. That small part entails not succumbing to a ridiculous level of political correctness that we neglect to broach difficult conversations with our patients.  We need to talk to our them about difficult topics and make sure explain that just because they are taking a medication doesn’t mean they don’t have a disease.  I know we are all short on time it’s hard to cram all this stuff into a 15 minute appointment.  What I do ask and suggest is that we don’t see it and brush it to the side because it’s “taboo” to help your patients hold themselves accountable.  Talk to that patient who has put on 15 pounds since their last appointment.  Tell the new patient who has a BMI > 40 that their weight is adversely effecting them, and if it hasn’t yet it will–warn them of the adverse effects. Heart disease, diabetes, stroke, joint ailments/chronic pain–all of which can lead to more damaging and expensive side effects.
Sick is the new standard.  Yea, kind of like orange is the new black.  Whether or not any of us want to admit it we are a culture that for most of us–we follow a general range of societal norms.  What is average is normal, and the more people who are a certain way the more normal it is therefore the more accepted.  When things are “acceptable” there is no sense of urgency to do anything to change.  Meaning that because having multiple chronic diseases have become the norm, it is becoming very acceptable to simply just life with these diseases.
Diabetes. According to the CDC in 2002 5.5 million people had diabetes.  In 2014 22 million people were estimated to be afflicted with the disease. The cost for diabetes direct and indirectly in 2012 was 245 BILLION dollars.  That absolutely blew my mind.  I asked my colleagues this same question and their responses were not even close.  Their guesses included 2 and 3 MILLION dollars.
Obesity. An estimated 34.9% aka 78.6 million adults are reported to be obese.  Ready for the cost annually?  147 BILLION in 2008.  Again yes, BILLION. We wonder why our country is in a ridiculous amount of debt—–a post for a whole other day.  The CDC reports that the medical costs for obese individuals are 1,429 higher per year than a person with a BMI WNL.  Anyways, this is not supposed to be about cost.
Heart disease. Kills 610,000 individuals annually.  Coronary Artery Disease (CAD)–which I swear every patient I admit has–kills 370,00 0 each year (for the love of god people take your Lipitor I don’t care if your muscles hurt–kidding kidding). Again, the modifiable risk factors that have the possibility of having a positive impact on patient morbidity and mortality if addressed are numerous.
Stroke.  800,000 hospitalizations in 1989 and that number is now up over a million.  Cost per year in 2008: 18.8 billion.
I have simply highlighted several diseases that were easy access on CDC and that I know from clinical practice are incredibly common.  The sad part about these diseases is that there are more modifiable risk factors as opposed to non-modifiable.  Physical inactivity, obesity, smoking, medication compliance (one could argue if this is truly “modifiable” or not).
My point is that the numbers of chronic diseases are rising at a ridiculous rate.  I would venture to guess that if you combined the category of overweight and obese individuals together they would comprise >50% of the population. I’m also willing to bet that >80% of hospitalized patients are either overweight or obese.  I can’t remember the last time I palpated an abdomen of normal size.  The madness needs to stop.  People need to get off the merry-go-round.  Providers need to start having difficult conversations.  Patients need to start having accountability and the iron armor of political correctness needs to be sloughed off.  I’m not saying bully people with chronic diseases.  I’m simply suggesting we attempt to become catalysts for change instead of simply allowing our patients to accept poor health standards.
So, we are now led to the point where we have all of these chronic diseases that have quite the laundry list of potential negative effects.  What do we do? Create a screening tool, which has positives and negatives.
Smoking for example. Smoking kills.  We all know this, there’s this thing called the surgeon general warning.  Because of this, in the health care field we have (and by we I mean the powers that be—The USPTF) decided that we should “preventatively screen” individuals 55-80 who have a minimum of a 30 pack year smoking history or have quit within the past 15 years. What we are doing for them is giving them a one time dose of low radiation CT scan to screen for lung cancer.  There are results that can be found on the USPTF website if you want more information on the study USPTF LDCT Lung CA Screening.  There are various additional  links on this page you can click to read more about the screening and evidence to support  this standard of care.
imageNow, my initial response was–what a great idea we can catch cancer early, less money spent on chemo, radiation and maybe show patients that yes–smoking does kill.  However, there was an article published in a recent article of JAAPA suggesting that perhaps we are giving smokers a false sense of “it is ok to smoke” because so few of these tests are turning out to be positive.  Meaning patients with a significant smoking history has the test completed and it comes back negative–what this translates to for a patient is this: ” Oh, well I smoke but I had my screening done and everything is ok so I guess I can continue to smoke”.  There is question being raised if we are have created a phenomenon of false security. FYI the USPTF is reporting that there is clinical significance to benefit patients from performing he LDCT.
On a related note, we have a lot of different sophisticated measuresimage these days that can track out calories, what we eat, how much energy we exert, etc.  I’ve developed this notion in my head and I’m not sure who else shares this proposition with me, that devices such as fit bits also contribute to a false sense of health.
DISCLAIMER: I know very little to nothing about these devices.  My extent of knowledge on them is that they electronically can track your steps, you can set up step goals, face off against your friends to see who does the most steps and that some of them claim to be a let o track sleep activity.  Here is my beef.  Say your step goal is 5,000 for the day and your work in a hospital. It’s very likely that you are able to get those 5,000 or more steps in your 8, 10 or 12 hour day.  However, taking this many steps throughout the duration of time previously mentioned is not the same as someone who goes out and continually moves/exercises for 30-45 minutes.  The person who gets their steps or activity in through 8-12 hours does not sustain an elevated heart rate to produce the same cardiovascular and metabolic benefits as someone who continually goes for runs, swims or does Crossfit, etc.
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I’m not suggesting take the elevator everywhere and that walking wherever and whenever you can to keep moving is a bad thing.  My point is that I don’t think it suffices to count for working out and I think a lot of people who use these devices can tend to be of the mindset that “oh I don’t need to go to th. gym/run/swim/Zumba or whatever it is you do because I walked 5,000 steps today”. I just cannot buy into this mindset and I think a lot of people do.
Why is this important? Less activity leads to more people being over weight and obese.  Obesity puts more people at risk for multiple chronic diseases, diseases which are leading to the acceptance of our current state of health as a nation.  We need to start with ourselves as providers by doing our best to institute change and provide support to our patients. In return hope that our patients are able to accept some sense of self responsibility, realize a change needs to be made and begin to take steps toward better health outcomes one person at a time.
I would love to hear what others think, drop a comment and let me know what you think!!