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1. one argument for and one against repeal of ACA: One argument for repeal of the ACA is that expansion of healthcare coverage does not save lives. The evidence for this comes from studies by Kronick 2009 and Finkelstein et al 2012 who were unable to demonstrate improvement in mortality with private insurance coverage and with Medicaid coverage. An argument against repeal of the ACA is that coverage by insurance increases utilization of care (Finkelstein et al 2012). It’s a difficult discussion because we will be disappointed if we expect what the ACA or other insurance coverage cannot deliver. The things that have brought health and longevity to my personal life have very little to do with insurance or lack thereof. The life practices that I began when I was very young- regular exercise, no tobacco or alcohol or stimulants, growing a garden, pursuing an attitude of well-being, peace and purpose- have contributed far more to my health than insurance could ever do. I say this as someone who serves many uninsured patients, but who tells his patients to try their best to hang onto their insurance if they have coverage, and is about to enroll in Medicare.
Suzanne, thanks for the illustration of the newborn LP. That is a difficult conversation. It makes sense to have a standardized method for informing the parents with illustrations of what for them is a very scary procedure during a very emotional time in their lives when the great majority have never met you and need to trust that you are doing everything you can to provide the best care for their newborn.
2. shared decision making example and strategies: hypertension management is one chronic condition which could benefit from shared decision making. There are times in a patient’s disease progression when information about lifestyle interventions would be effective in reducing hypertension risk and progression. Including the patient in such discussions is often helpful in helping patients to understand the significance of the disease and importance of treatment. One strategy to achieve shared decision making is to negotiate buy in by presenting options for self care and lifestyle interventions which the patient may be willing to commit to. Often these are low risk interventions such as exercise, walking program, relaxation, weight management, eating more potassium rich foods, reducing stimulant intake and stopping nicotine products which will help with general health in addition to reducing hypertension risk. When drug therapy is necessary, a second strategy is to offer 3 or so options for first drug choices which gives the patient the opportunity to weigh the options and determine which they may wish to try first based on their values- low cost, side effect profile, exercise intolerance, for example.
1. Fundamental attribution error: this is the error of ascribing to someone a deep seated character flaw when in fact it is a situation that causes a given response. When I worked in Malawi, one of the medical assistants (like a PA in the US) working at a remote clinic had done something terribly disturbing that frightened everyone on the campus where he worked. This action destroyed the peace on the campus and I was called on to sort it out. It turns out that he had consulted with a witchdoctor who told him that he needed to pronounce a vile curse on the campus in order to bring healing. He did this, and everyone ended up avoiding each other. It was tempting to think that he was an inherently evil man, but in fact he wasn’t much different from the rest of us. His 16 year old daughter was suffering from headaches, hypertension, seizures and bleeding from the nose, and he didn’t have the money to seek the care needed (this was in the ’80’s and there were no CT scans available in the country). The witchdoctor led him to believe that the cause for his daughter’s suffering was the many witches on campus (principle, pastor, teachers) who had put a curse on his daughter. I was able to see past the chaos that resulted from a “bad character” to a desperate father who loved his daughter and would do anything to save her.
Juby, I like the celebrations that the school creates, which must have a positive mood effect for the students and staff.
2 examples of strategies to change affect. In our clinic in Colville, we have monthly team meetings, which, though we sometimes need to talk about tough things, we also work on building our team. We see this as very important to the well being of the organization. We have an “azungu award,” where someone nominates one member of our team who has exemplified values of the team- honesty, integrity, compassion, going the extra mile, etc. The nominee each month gets an extra large chocolate bar, which they can share or keep for themselves. Another example is in the way we conduct our yearly reviews with our employees. We ask their peers and the employee to rate how they are doing, and we give feedback from management’s perspective. There are opportunities for growth, but we try to sandwich those deficiencies with statements of affirmation and building self confidence and skills we see in development. We believe that this is an intentional means for building improved affect. Finally, in reminding folks that care for our patients begins at the front door, we believe we are providing positive means for improving affect in the workplace since everyone’s job is important. (we also play calming music in the waiting area, to reduce anxiety for staff and patients).
2. One transformational practice: We have implemented a different style of patient centered appointment scheduling at our clinic. We attempted, for a time, to allow patients to schedule themselves, but it was tricky because access to our schedule meant keeping patient confidentiality and there was the risk of two people scheduling at the same time for the same appointment slot. Only a couple of patients in our context felt it was really valuable, so we dropped the idea. We do have registration on line through our EMR, so patients can enter their medical problems and medicines, etc. prior to being seen. It seems like a good idea, but many patients really don’t know what they are taking and they are quite incomplete in their reporting of medical problems and history. The most important and transformative aspects of scheduling transformation are that we only preschedule about 14 patients a day, meaning access to same day appointments is easy (we see about 25 patients a day, which is not overwhelming in a 10 hour day). We schedule half hour appointments to allow physicians to make phone calls and take care of messages in between. We schedule as many phone appointments as is reasonable. Patients appreciate it because they don’t need to physically come in. Often these appointments are for stable conditions such as chronic pain or medicine refills, or for phone follow up visits for pneumonia. These are always at the physician’s discretion. The other efficiency which cannot be overemphasized is the ability of our patients to address more than one problem in a single visit. If the patient can talk about more than one issue, it improves their satisfaction, since they no longer need multiple appointments to address their concerns and it improves the physician’s scheduling availability, since the same patients aren’t glomming up the schedule for multiple unnecessary visits when really they could deal with all of their issues in one visit.
Juby, I like the red baskets idea. it is a visible acknowledgement of an accomplishment that everyone would recognize and could celebrate with the student who is being recognized. I also like the idea of regular, weekly check ins for foreign students who are not accustomed to the cultures and environment.
1. sense of identity and individual development: In our clinic, we hold monthly team meetings at which we review our mission to the community. We ask three questions regularly: what did you experience in caring for patients? how did that feel? how can we do better as a team? Each person is encouraged to give input to the leadership and to their teammates. This reinforces our sense of identity as an organization. Additionally, those team members with deficits are encouraged to study and improve their skills so that they become more valued members. Their improvements are regularly measured and encouraged.
Abanda, thank you for sharing this insight into the UN organization’s healthcare system. It raises additional questions about how they achieve this goal of being nimble and adaptive. I assume that they must give considerable freedom to those in the field who are on the ground making decisions about how best to carry out the mission of providing healthcare to those in their charge. I am interested to know how such a large organization is able to carry out such flexibility.
Employment security: Whenever a potential candidate for employment comes through our doors or contacts me by some other means with a job application, it creates significant anxiety among the rest of the team. This gives me the opportunity to address those concerns during our monthly team meetings. I tell our team that loyalty is more important to me than having the most skilled candidate to replace any of them. I tell them that the integrity of our team and the building of the members of our team is more important than firing someone and replacing the weakest member with someone with better credentials. I have this conversation fairly regularly as our organization grows and becomes a more desirable place to work. Our workers get the message that each of them is valued, that their jobs are not at risk, that the team is more important than any one individual, and that even the weakest employee is an opportunity for building our team. This attitude trickles down to the managers, and they take the cue and respond by building the rest of the team.
Suzanne, thank you for your insight. I like the reminder about the meat packing plant experience during the pandemic. Weird, most of us wouldn’t have thought of a meat packing plant as a great source of viral spread. this is also a good example of incentivizing one thing, but getting a completely unexpected outcome.
I hear what you are saying about the racial divides during this pandemic. On the other hand, many of us, regardless of our ethnicity, were willing to take considerable risks to our health for the sake of saving as many as possible. We didn’t stay safely in our homes and provide virtual visits. As a private physician, I worked directly with the public health department as an extension of their work to visit covid positive patients in their homes in order to off load the burden on the ER, providing in home treatment whenever feasible. We were willing put our lives on the line for the sake of our patients. I’m sure that you did the same.2. lessons learned from covid 19: the first lesson that comes to mind is that high quality access to care may occur virtually. We do a lot more virtual visits now than we ever did prior to Covid 19. Often, simple medical issues can be cared for by phone without compromising care. We use this model now to provide care whenever it is reasonable to do so.
The second lesson is that people are highly vulnerable to misinformation over the internet, including by social media. This became so critical in our community that my wife and I began an hour long covid 19 weekly update, frequently with guest speakers, in order to provide accurate, up to date, scientifically valid information to anyone who wished to join us on Facebook. People could ask questions in real time and our county health officer or other guest would address the issues raised. This pandemic definitely polarized our community, but by being a voice of reason and balance in our community, we believe that we helped many to make better choices.1. early success story: when we created Heartland Medicine Colville Clinic, we had several idealistic goals for relieving suffering in our community: membership based primary care; urgent care for non members; fairness and transparency in pricing; expanded, timely access; patient centered high quality care; justice for those without insurance; giving back to the community. There were considerable upfront investments, and we didn’t pay ourselves for a couple of years. But our membership grew, and we stopped advertising because word of mouth was sufficient. Now we have 800+ members and a budget of over $600,000 a year, expanded hours and busy days with an average of 25 patient encounters plus phone calls. Reduced cost of medicines, labs and imaging studies, negotiating for fair pricing for our patients, consistently positive reviews by our patients, and stories of patients whose lives we have impacted tell us that the changes we have made in healthcare delivery in our community are significant and revolutionary.
Suzanne, really good example of how large systems just don’t get it when they insist on shooting themselves in the foot and wonder why doctors don’t cheer for their administrative decisions. You will all become experts in billing practices and neglect the education of the next generation of doctors. It’s not rocket science. What do you think this will do to the quality of physicians in the future? I’ll bet the hospital system receives considerable Medicare dollars for teaching as well. If they would just allocate the Medicare dollars given to them for education, it would make a sizeable difference for those who are shouldering the burden of educating physicians.