[Rebecca Schmitt]

Question #1: Why can’t the US just import or export Healthcare Systems? Explain two limitations of direct comparisons.

It is not possible to simply import or export US healthcare systems for several reasons. Our healthcare system often has drastically different expectations and capabilities in our country compared to another. This is particularly relevant to LIMCs that have very little resources in terms of medical care.
As an example from the article, the US has a strong “lead-time bias” in conditions, such as assessing cancer survival rates. We have the privilege to have readily available and easy access to screening tools for diagnoses such as cancer. Those tools have not been as readily available in LIMC, so therefore we are not able to appropriately compare survival rates.

Abi brings up an interesting point about litigation. Unfortunately, US healthcare providers have to be concerned about that fear and are cautious about change.

[Rebecca Schmitt]

Question #1: Describe the three most important characteristics to you in selecting your own care provider and if ‘Prescription for the Future’ has impacted these and why.
The three most important characteristics I use in selecting my own care provider is:
1) Ability to truly listen to my concerns and show genuine caring of my health and wellbeing.
2) Having trust and confidence in their medical knowledge.
3) Receiving positive ratings in the community 
“Prescription for the future” provided good points when discussing factors in choosing a PCP, however, some of the points did not quite resonate with me in terms of what is important in making that decision.
I agree with Christina that in order to have a positive patient experience, it is vital to have a front office staff/nursing team that is well trained and caring.

[Rebecca Schmitt]

An example of the US healthcare system that may be applied to LMIC is AIDS management. Since the early 80s when HIV was first recognized and was deemed an epidemic, there have been huge strides in terms of preventing, diagnosing and treating HIV globally. However, this improvement has been much more successful in developed countries, including the USA. These strides include, but are not limited to, education of people regarding AIDS in general, means of transmission, importance of consistent condom use, easy access to testing, recommended routine screening, access to PREP (pre-exposure prophylaxis) medication, easy access to proper treatment and management. HIV cases have not shown as steep of a downtrend in developing countries as is in the developed world. Implementation of more robust, high quality, low cost HIV programs for the LIMC will pay off huge dividends. 
The best example of LIMC system that may be applied to the USA is a single-payer system. The USA has by far the highest national health expenditure as a percent of GDP than any other country in the world. Given this, we should be able to support a single-payer system.
I agree with Abi that the EMTALA act in the USA is a great response that can be well utilized in LIMC countries. As he stated, this will significantly reduce many deaths and complications from delayed or denied treatment of medical condition.

[Rebecca Schmitt]

Christina made a good analogy based on the principles of “Switch”, stating that in terms of the elephant and the rider, bringing a system like Kaiser to the East Coast would need something more than just telling the rider it saves money and works well. 

[Rebecca Schmitt]

Question #1: Describe any specific healthcare process and the potential for virtual medicine to improve quality and reduce cost. Provide supporting evidence and address potential problems with this approach.I did find it very interesting to read this chapter given where we are today post-COVID pandemic. Prior to the pandemic, there had already been discussion of telemedicine that institutions were trying to implement, but with the assumption that it would take years to come to fruition. However, this change was forced to happen nearly overnight during the shut down.Given the severe mental health crisis we live in today, we are in desperate need of better access to behavioral health services. These services would be beneficial in multiple ways. Generally speaking, these visits do not typically require a comprehensive physical exam, which makes them a good candidate for virtual medicine. Virtual visits also entirely eliminate the possibility of running into someone you may know in the same waiting room, which for many can be quite anxiety provoking. Virtual visits also may be beneficial particularly to lower income patients who may not have reliable transportation to the clinic. However, a potential problem of this approach would be that a patient may feel restricted as to what they disclose during the visit if they have a family member in the household that might be overhearing what is being said.

Question #2: Is “all healthcare local”? Agree or disagree and provide one supporting argument for both positions.A lot of healthcare does tend to be local, but not all. The explanation of both is quite multi-faceted. As an example from my own practice working in a small town, there are only two health networks available. With this limitation, it may be viewed as a “forced faithfulness” to that given local clinic, however most primary care practices in general work as such.For patient access to pediatric sub specialists, they must travel elsewhere for care. There are two main locations for most of these services. One location is only 35 minutes away, but a much smaller institution, and the other is 1 hr 30 minutes away, and is a very well-renowned institution. Depending on multiple factors, both the care provider and the family may choose to go to one vs the other.

[Rebecca Schmitt]

As stated by several of you above and what I had highlighted, the strong desire to keep the relationship with your current healthcare provider that you have is arguably the biggest barrier in my opinion.

[Rebecca Schmitt]

Question #1: Outgoing President Trump promised price transparency in healthcare. What are the barriers and intended outcomes? Is this supported by available evidence?
Although the idea of price transparency appears to be desirable as well as useful for patients, the article interestingly presents that its research does not support the use of this tool.
There are several barriers that are at play. One of the most obvious would be that a lot of patients have a strong relationship with their existing healthcare provider, so they would not have any desire to consider switching to another one. For those that rarely go to the doctor, their likelihood of utilizing this tool would be expected to be quite slim. Although it may seem like a helpful tool, a lot of patients just may not find it very compelling and do not necessarily have an incentive to utilize it.

[Rebecca Schmitt]

Question #1: Provide an example (from current events, home, school or work) of the promotion or ‘contagiousness’ of desirable behavior (Positive Peer Perception/Pressure).
Working in the field of pediatrics, Halloween time is always exciting. Throughout all of my training, including my current peds practice, it is encouraged (and somewhat expected) to dress up for Halloween. In my peds residency, we always picked a specific theme per class. All 10 of my co-residents in our class dressed as Minions one year. And one of our attendings dressed as Gru! Most, but not all, residents from the other peds classes dressed up as well. Our class got the most praise since we had 100% participation.

Question #2: What health and wellness problems might a behavioral health provider address and how could co-locating with physicians improve care quality? Provide a specific example of success.
The world we live in unfortunately has a ton of people struggling with anxiety, depression, drug addition and other mental health problems. Mental, emotional and physical health are so closely intertwined as we all know. Oftentimes the patients who would benefit the most from easy access to a behavioral health provider may easily get lost to follow up. So being able to capture them at a clinic/hospital visit for something other than mental health is a huge bonus if they have those services located under the same roof. This will greatly improve quality of care.

Just as Tony and Abi stated, we are also allowed, and encouraged, to dress up for game days both in football and baseball. This united team spirit helps a lot with overall positivity and enjoyment at work.

[Rebecca Schmitt]

The complexities of the ACA are quite multifaceted and is thus challenging to assess whether it is a viable option for the future of medicine.
A huge argument for the ACA is the huge financial burden it takes off the shoulders of millions of Americans. The last thing a patient and their family should have looming over their head when they or their loved ones are ill is the thought of a large medical bill. The Oregon Health Insurance Experiment that utilized a randomized, controlled trial of health insurance coverage is a perfect example of this. One of the biggest contributors of arguments against the ACA is the governmental role in healthcare, which is based on the fact that the vast majority of our citizens do not trust their government. J E Dalen, K Waterbrook, J S Alpert. Why do so many Americans oppose the Affordable Care Act? Am J Med. 2015

Unfortunately with Tony’s example of his cousin, patients can fall through the cracks and end up losing all financial security they once had prior to their medical illness.

[Rebecca Schmitt]

I have had similar experiences as Abi in terms of some people that I trained with. There have been situations where the initial relationship with my colleague was strained and uncomfortable, but once you “proved” yourself so to speak, that relationship blossomed and became much more pleasant and manageable. 

[Rebecca Schmitt]

Question #1: Define the “Fundamental Attribution Error” and provide one illustrative example from your experience.
The fundamental attribution error is when a person attributes someone’s behavior to their personality as opposed to the situation they are in. As an example, there have been several patients during COVID that presented to me with concerns of ADHD. The symptoms they exhibited, including inability to focus, concentrate and sit still during school, indeed do mimic symptoms of ADHD, however, when doing a comprehensive evaluation, do not meet diagnostic criteria. Their symptoms are oftentimes due to the forced environment they were in when doing at-home schooling.

Question #2: Describe one treatment approach that may benefit from greater patient-informed, shared decision making and propose two strategies to attain it.One of the examples in my practice that pop up in terms of greater patient-informed, shared decision making is the treatment and management of painful, heavy or irregular periods. The patient, in addition to the parent, may come into the office already set in their mind as to what they want for treatment. If they desire to start birth control, the pill is the most commonly known form. The mother (or patient) may be reluctant to do this, as it may be thought of as primarily for contraceptive use (and may think that this is inappropriate if the teenager is not sexually active). But I always emphasize that I hate the term “birth control”, as it always is a great treatment option for multiple issues: including painful, heavy or irregular periods, PCOS, acne, etc.I educate the family about the various non-hormonal and hormonal options. Non-hormonal management includes: 1) scheduled NSAID use 2) staying very well hydrated 3) heating pads and 4) some form of light physical activity. Hormonal management includes: 1) the pill 2) the patch 3) the Depo injection, 4) Nuvaring 5)  Nexplanon and 6) IUD. I strongly counsel them on side effects and the duration of how long it may take to come into full effect. The family is often very appreciative of the comprehensive discussion, when indeed they may have walked into the office with just one treatment modality in their head. 

[Rebecca Schmitt]

Question #1: Describe two examples of deliberate strategies pursued by your school or employer to encourage a dispositional affect that contributes to the mission
-Regardless of one’s medical setting, there is often a positive dispositional effect when it comes to pediatrics. It’s inherent to have a special, universal feeling of innocence when it comes to caring for children. The more difficult part of the job is facing challenges of working with the parents/guardians. There can be a slew of emotions that may arise when a parent comes in with their sick child. We need to be able to understand and empathize with their situation. There are a lot of people that can be involved in the care of one child, so it is important for a provider to be able to read the room of a peds patient and have good emotional intelligence.In our clinic, as is most clinics, we have various different things given out to our children. At every well visit, each child gets a book to go home with to promote reading up until their 5th birthday. Having tangible items in the clinic that we can give away helps create a positive experience, when coming to the doctor may typically be seen as a “scary” experience. In general, our entire peds team exhibits a positive dispositional affect.

Abi, wow that is wonderful that KUMC has developed programs on unconscious bias. I think that we all, regardless of profession, would greatly benefit from a program like that. It is important to actively try and identify these biases we have, which as the name implies, we don’t even know they exist within us.

[Rebecca Schmitt]

Question #1: How does your school or workplace intentionally encourage a sense of identity and individual development?
-At my current institution, at the beginning of most meetings, regardless of size and department, we are asked to recognize any employee in the network for something they had done that went above and beyond the confines of their normal duties. And to take that one step further, in our physician council meetings, we would write a special thank you/recognition letter to those individuals. This simple act went a long way in order to encourage our team to continue to shine.
 
Question #2: Select one transformational office-based practice and describe a change you would implement in your own context.
-One of the most important transformational office-based practices that I believe help make the patient experience as seamless as possible is scheduling. When I first joined my practice, the scheduling for our pediatric patients was completely separate from the entire network. I quickly realized this was a luxury that not a lot of other offices had. However now, unfortunately, they switched to a fully centralized scheduling system. Our triage nurses and pediatric front desk staff know our patients very well, and are therefore much better at appropriately scheduling the patients for the right time slot (Ex: a chief complaint of cough for an otherwise healthy kid vs a child who is chronically ill). Now with our new central schedulers, we don’t have that luxury. This change has driven extreme frustration to our patients and their families, and it is one of the biggest complaints that we get in their overall clinic experience.

As to Christina’s point, it has also been frustrating in our clinic for standardization of care. For the most part, my partners and I align relatively closely in terms of medical management of our patients. However, since the advent of the COVID pandemic, there has been some differences in our way of practice in terms of testing patients as well as counseling for the COVID vaccine.

[Rebecca Schmitt]

Question #1: Select one of the seven practices of ‘producing profit through people’ and provide an example of its implementation and outcome in your own context.
The practice that grabbed my attention the most was “Reduction of Status Differences”. This often is a challenging one for people to try and actively reach towards, especially when there are plenty of people in various roles with big egos. As the article states, “organizations perform at a higher level when they are able to tap the ideas, skill and effort of all of their people”.
I strive to create an equal level of respect and appreciation towards people in all areas of our healthcare network, and at large. One of the highlights of my clinic day in regards to interactions with those I work with is at the end of the evening when I am finishing up charts. The only other person in the building at that hour is the cleaning lady. I love talking to her and we often times have great conversations.

During the COVID pandemic, this was very evident (as stated by many of us in the book discussion) in regards to the importance of the collective team caring for our patients, with emphasis particularly on nurses, nurse aids, respiratory therapists, and more.

I agree with Tony in regards to the importance of selective hiring. It’s vital that applicants fit the role not only on their CV, but also someone that will be a good cultural fit and have good camaraderie with the rest of the team.

[Rebecca Schmitt]

Question #1: What example can you provide of an early success story related to any ongoing change you are actively participating in?
When in residency, I did a QI project for my pediatric co-residents in regards to birth control methods and the resident’s knowledge and comfort levels of prescribing the various different forms.  I discovered that the knowledge from the majority of residents was quite limited, with the pill being the most known. I did a pre and post-QI questionnaire regarding their knowledge and comfort levels of all the options: the OCP pill, the Patch, DepoProvera shot, Nuvaring and the two forms of LARCs (long-acting reversible contraceptives): the Nexplanon and the IUD (intrauterine device). In addition to teaching them the types, I also worked on debunking the thought that birth control always meant contraceptives. As these can also be used for period control (heavy, painful and irregular), acne, gender dysphoria, PCOS and more. Based on the post-QU questionnaire, it did indeed make a mind-shift change in their practice. This QI project was quite successful. 
Prior to me starting at my current clinic in Wisconsin, the majority of our teen patients would immediately get referred to OBGYN if they were going to be started on one, however given my knowledge, understanding and comfort levels, I have been able to prescribe directly to the majority of my patients. 

Question #2: Describe two lessons that may be learned from the COVID-19 pandemic and how this crisis may catalyze transformation.
I have seen a shift in mindset in several areas of life since the COVID pandemic started, both of which I hope catalyzed longterm transformation and change.
1) There are several lessons of adaptability that came out of the pandemic. An example of this is through various communication tools, including virtual meetings. During the beginning of the pandemic, all our healthcare network meetings were via Zoom/Microsoft Teams. Prior to this, if someone was not able to attend a meeting, they typically missed it all together. Now, attendance is up higher, as one can join while remaining in their personal office or even from the comforts of their own home. This also creates a more personable experience.
2) Another lesson that can be learned from the pandemic is prioritizing what means most to us in our lives and truly reevaluate what this looks like. For me, as is a lot of people, the importance of nourishing relationships with loved ones became the #1 priority. I hope this indeed continues on forward long-term.

Tony, I too had a health scare that catalyzed major change in my life. It occurred in residency, much of which could have been prevented had I prioritized a health lifestyle. The biggest shift for improvement was prioritizing good sleep hygiene. (Our joke was that as a resident, we barely had time to pee, let alone sleep!) I went from consistently getting 5-6 hours a night to a solid 7.5-8 hours sleep. 

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