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White Coats For Black Lives: Toward Racial Equality In Health Care

Kaitlyn Veto/flickr

Kaitlyn Veto/flickr

Acknowledging the public health impact of racism and deep disparities in the quality and accessibility of medical care for patients of color, a national organization, White Coats for Black Lives, says it’s launching a new effort today, in celebration of Martin Luther King, Jr.

Dorothy Charles, one of the group’s organizers and a first year medical student at the University of Pennsylvania’s Perelman School of Medicine, offers some context in an email:

Racism profoundly impacts people of color: the black-white mortality gap in 2002, for example, accounted for 83,570 excess deaths. As future physicians, we are responsible for addressing the perpetuation of racism by medical institutions and seek policy change to eliminate disparities in outcomes.

Here’s a statement from the White Coats for Black Lives National Steering Committee:

Upon matriculating in medical school, students recite the Hippocratic Oath, declaring their commitment to promoting the health and well-being of their communities. On December 10, 2014, students from over 80 medical schools across the United States acted in the spirit of that oath as we participated in a “die in” to protest racism and police brutality. In our action, we called attention to grim facts about the public health consequences of racism, acknowledged the complicity of the medical profession in sustaining racial inequality, and challenged a system of medical care that denies necessary treatment to patients unable to pay for it, disproportionately patients of color.

Today, in celebration of the legacy of Dr. Martin Luther King Jr., we announce the founding of a national medical student organization, White Coats for Black Lives. This organization brings together medical students from across the country to pursue three primary goals:


1. To eliminate racism as a public health hazard

Racism has a devastating impact on the health and well-being of people of color. Tremendous disparities in housing, education, and job opportunities cut short the average Black life by four years. Physicians, physician organizations, and medical institutions must therefore publicly recognize and fight against the significant adverse effects of racism on public health. We additionally advocate for increased funding and promotion of research on the health effects of racism.

2. To end racial discrimination in medical care

We recognize that insurance status serves in our healthcare system as a “colorblind” means of racial discrimination. While it is illegal to turn patients away from a hospital or practice because of their race, patients across the country are frequently denied care because they have public insurance or lack health insurance. We support the creation of a single payer national health insurance system that would give all Americans equal access to the healthcare they need. Such a system would create a payment structure that reflects the fact that “Black lives matter.” Moreover, ample evidence suggests that patients of color receive inferior care even when they are able to see a doctor or nurse; we therefore advocate for the allocation of funding for research on unconscious bias and racism in the delivery of medical care. Continue reading

Got A Headache? Study Finds Flaws In Treatment, ‘Alarming’ Rise In Imaging Tests

(19melissa68/Flickr)

(19melissa68/Flickr)

Sometimes less really is more. A case in point: the treatment of routine headaches.

Doctors are increasingly ordering pricey, advanced imaging tests and referring patients to specialists, which, it turns out, offers little help to headache sufferers, a new study concludes.

Researchers from Boston’s Beth Israel Deaconess Medical Center suggest that patients might be better served (and the health care system might save money) by instead focusing more on lifestyle changes for people seeking headache relief.

For the study, published online in the Journal of General Internal Medicine, researchers used a nationally representative database to analyze practice patterns among physicians treating headache patients.

I asked the lead author, John N. Mafi, MD, a fellow in the Division of General Medicine and Primary Care at BIDMC, to sum up the bottom line results. Here (slightly edited) is his emailed response:

“…We found alarming rises in use of advanced imaging (CT/MRI), referrals to other physicians (presumably specialists), and a decline in first-line recommended life-style modification counseling, meant to prevent headaches. We also saw no change in use of discouraged medications, with opioids and barbiturates ordered in about 18% of visits throughout the study period.

These findings represent alarming trends in the management of headache, and to me, they reflect a larger trend in the U.S. healthcare system where over-hurried doctors are ordering more tests, more medications, more referrals to specialists and less time talking and connecting with their patients.

To me this suggests that the visit-based model of healthcare is broken, Continue reading

Boundary Crossing: When Doctors And Patients Get Personal For Better Health

A diabetes patient and her doctor sit down to talk as part of a novel program aimed at improving the patient-provider relationship.

A diabetes patient and her doctor sit down to talk as part of a novel program aimed at improving the patient-provider relationship.

By Dr. Annie Brewster and Jonathan Adler
Guest Contributors

As a patient you’ve no doubt had moments when you feel like your doctor just doesn’t get you, or, that you don’t get your doctor.

If you’ve never felt rushed, ignored, overlooked or vulnerable during the course of your medical care, you’ve probably never been a patient in the U.S. health care system.

And if you’re a doctor, or another type of health care provider, you’ve probably felt hassled, frustrated, and powerless to help your patient, despite your best intentions.

In today’s medical system, the patient-doctor relationship is often challenged, in large part because there’s no room for us to actually engage with each other as people, to hear each other’s stories.

In medicine, there are unspoken but clear rules about what is appropriate behavior within the context of the patient-doctor relationship: doctors should never reveal intimate details about their own lives, and patients should never ask. Patients, meanwhile, should stick to the facts of whatever is ailing them, giving their provider the data for diagnosis and treatment planning, without superfluous anecdotal detail.

Professional boundaries are certainly important. There is validity to the argument that doctors need to keep distance in order to make clear medical decisions, striving to minimize the biasing impact of emotion. And perhaps it is also true that patients benefit from some distance, in thinking of their doctor as an authority figure rather than a friend.  But this obsession with boundaries has conspired with the pressures of efficiency and economy that constrain the health care system to remove some very personal (and important) elements of the patient-provider relationship.

We are far from the small town medicine of the past, when patients and doctors knew the details  of each other’s lives because their worlds intersected outside of the exam room.

Nowadays, in the 15-20 minute appointments that we are alloted, the patient-provider relationship can feel sterile and robotic. At its worst, it can feel antagonistic. Doctors are over-loaded and time constrained, with fear of litigation and the rules of HIPAA pressing in on them, and a payment model that rewards quantity over quality.

Patients often feel hurried and neglected; overwhelmed by the task of presenting the frightening aspects of their health in the right way to get answers and treatment. Physician burnout is ubiquitous, as is patient dissatisfaction.

It is our belief that by highlighting the humanity of both individuals in the relationship, the patient-doctor bond can be strengthened, with increased satisfaction all around.

Taking it one step further, we believe that reviving the humanity in this relationship will ultimately lead to better health outcomes.

So, here at Health Story Collaborative we’ve designed a program in which a patient and a doctor come together to share and listen to one another’s personal narratives. This new patient-provider model is a variation of our already existing Healing Story Sessions program. In short, our goal is to create a space where both patient and provider can be human.

We recently launched this project in collaboration with the Cambridge Health Alliance, with a grant from the Arnold P. Gold Foundation. We met on a Tuesday evening recently with Tracey Pratt, a woman with diabetes and her health care provider of many years, Dr. David Baron. As they shared their stories, an audience, including other diabetes patients, Dr. Baron’s wife and other medical providers, listened on.

We worked with both speakers in advance to craft their narratives, encouraging personal refection as well as their thoughts about the their mutual relationship.

Tracey talked about her passion for teaching, her travel to the Great Wall of China, and about learning Merengue in Havana, Cuba. She also detailed some of the difficulties she had managing her diabetes.

David told stories about growing up in rural Ohio, picking corn in the fields as a teenager, about his time in the Peace Corps in the Dominican Republic, and his journey to becoming a doctor. Continue reading

A Prescription For Better Teaching, Stronger Doctors

The author's stethoscope from medical school stethoscope. (Courtesy)

The author’s stethoscope from medical school. (Courtesy)

By James Morris
Guest Contributor

Medicine, in many ways, is changing. Patient-centered care is all the rage and the old, iconic image of the all-knowing doctor is fading away.

In one concrete example of this shift, a new Medical College Admission Test (MCAT) is just around the corner. Starting in spring 2015 for the class that will enter medical school in the fall of 2016, the new MCAT promises a “better test for tomorrow’s doctors.”

Among other changes, it will have a new section focusing on the social determinants of health — essentially asking students to consider how income and social status, education, home and work environments and other factors shape health outcomes.

Premedical education takes place at the undergraduate level. I went to medical school, but now spend most of my time working with undergraduates in the classroom.  I often think about what I learned in medical school and how it translates — or doesn’t translate — to teaching, and why it matters.

Of course, there are the obvious connections. One of the classes I teach is comparative vertebrate anatomy, and I use what I learned about anatomy in medical school directly in this class.

But there are other lessons that don’t apply. Doctors often use three-letter abbreviations in their notes. HPI is the history of the present illness, the patient’s narrative of what brought them to the doctor’s office or hospital, as heard and interpreted by the physician.

CAD is coronary artery disease. TIA is a transient ischemic attack, a “mini-stroke.”

There is a saying I remember from medical school: Physicians are especially fond of TLA’s … three letter abbreviations.

I don’t use many acronyms in my teaching. But sometimes, it’s helpful: For problem sets, I sometimes use “PS.” However, when I do this, I am inundated with emails and questions asking what they mean.

In medical school, mnemonics are also widely used to help aspiring physicians learn and remember all kinds of information. The 12 cranial nerves can be recalled using the mnemonic “On Old Olympus’ Towering Top, A Finn And German Viewed Some Hops,” where the first letter of each word of the saying is the first letter of each of the cranial nerves: olfactory, optic, oculomotor, trochlear, trigeminal, abducens, facial, auditory, glossopharyngeal, vagus, spinal accessory, and hypoglossal.

Or, for Harry Potter aficionados, there is “Only Owls Observe Them Traveling And Finding Voldemort Guarding Very Ambiguous Horcruxes.”

These are handy, but I learned so many mnemonics in medical school that I often had trouble remembering which mnemonic was used for what kind of information. Is that the mnemonic for the cranial nerves, or the bones in the wrist, or the femoral triangle, or the major branches of the aorta? Continue reading

Viewpoint: Consider Tough Penalties To Boost Disabled Patients’ Access To Care

We already know that patients with disabilities face major obstacles when trying to access basic medical care. Now, a team of researchers are proposing some novel strategies to help fix the system, including withholding payments to health care organizations and making accreditation contingent on compliance with disability law.

The researchers, Dr. Tara Lagu and colleagues at Baystate Medical Center, Tufts University School of Medicine, and a Massachusetts not-for-profit organization, the Disability Law Center, suggest that this is the first time these types of strategies have been proposed.

“The goal of this paper was to start the conversation,” says Dr. Lagu via email.

Dr. Tara Lagu, M.D., MPH (Courtesy)

Dr. Tara Lagu, M.D., MPH (Courtesy)

Lagu’s groundbreaking earlier study on access to care for people with disabilities found that even in the current high-tech health care environment, many elements of routine medical care — like getting a patient on to an exam table — remain elusive.

The latest article, published in JAMA Internal Medicine, describes the range of barriers, including:

“…physical barriers to entering health care establishments, lack of accessible equipment, lack of a safe method for transferring the patient to an examination table, and the lack of policies that facilitate access.The barriers persist despite 2 federal laws (the Americans With Disabilities Act [ADA] of 1990 and Section 504 of the Rehabilitation Act of 1973) that explicitly state that health care settings must be accessible to patients with disabilities.

And here, Lagu offers some possible solutions:

As our study last year reported, patients with disabilities face real difficulties when they try to access health care. This suggested that our current strategy for enforcement, lawsuits, have fallen short. In part, this is because patients don’t want to bring lawsuits against doctors with whom they have an existing relationship and because lawsuits are extremely unpopular with physicians. More importantly, lawsuits have failed to initiate system-wide change: it is not clear that, in recent years, there have substantial improvements in access to care for patients with disabilities.

For these reasons, we believe that novel strategies are needed. As we considered what such strategies might look like, we considered other mechanisms of enforcement that have been successful at motivating change in health care settings, and we came to four possibilities: withholding payment, making accreditation contingent on compliance, regulation, and lawsuits at the state or national level aimed at initiating large-scale policy change. Continue reading

12 Tips For Nurses And Doctors Treating Transgender Patients

Massachusetts is drafting rules that will define the transgender services insurers will be required to cover. The Association of American Medical Colleges (AAMC) has just released guidance on training doctors to treat lesbian, gay, transgender and gender nonconforming patients. And Boston University Medical School has what Dr. Joshua Safer, a professor there, says is the nation’s first transgender medicine curriculum focused on the biology of gender identity.

Dr. Joshua Safer and Dr. Jennifer Potter (Courtesy photos)

Dr. Joshua Safer and Dr. Jennifer Potter (Courtesy photos)

Like I said: brand new stuff. But what do all these new rules mean for the doctor or nurse, in an examination room, who meets their first transgender or gender-fluid patient?

Here’s some advice from Dr. Safer, associate professor of medicine at Boston University Medical School, and Dr. Jennifer Potter, associate professor of medicine at Harvard Medical School. (Dr. Potter is a co-author of the AAMC guidelines.)

1) When greeting a new patient, or one you haven’t seen for some time, you cannot assume anything about their gender identity based on the masculinity or femininity of their appearance or the timbre of their voice. To avoid making mistakes, ask each new patient how they identify, what name they prefer to be called and what pronouns they want you to use. Note: Pronouns may be male (he), female (she), they or another gender-neutral option. Continue reading

Report Shows Stark Care Disparities, More Amputations Among Black Diabetics

Dartmouth Atlas Project

Dartmouth Atlas Project

Consider this alarming statistic: The rate of diabetes-related amputations is nearly three times higher among blacks compared to other Medicare beneficiaries.

This, according to a new report from the Dartmouth Atlas Project, located at the Dartmouth Institute of Health Care Policy and Clinical Practice. This is the influential consortium that issues eye-popping reports detailing often painfully unfair regional and ethnic variations in medical care. Here are some of the findings from the report, “Variation in the Care of Surgical Conditions: Diabetes and Peripheral Arterial Disease” released today:

•Amputation rates vary fivefold across U.S. regions among all Medicare patients with diabetes and peripheral artery disease.

•Amputation rates in the rural Southeast, particularly among black patients, are significantly higher than other regions of the country. (Think Mississippi.)

•The amputation rate for black patients is seven times higher in some regions than others

•There is an eightfold difference across regions among blacks in the likelihood that they undergo invasive surgery to increase circulation in the lower legs. In a news conference announcing the report, Marshall Chin, MD, a leading expert on racial and ethnic disparities in health care and a professor at the University of Chicago called these types of diabetes-related amputations “entirely preventable.” “In some ways,” Chin said, “these disparities are hidden unless we look for them.” And here’s more from the Dartmouth news release:

There are significant racial and regional disparities in the care of patients with diabetes. According to a new report from the Dartmouth Atlas Project, blacks are less likely to get routine preventive care than other patients and three times more likely to lose a leg to amputation, a devastating complication of diabetes and circulatory problems…

Amputation rates vary fivefold across U.S. regions among all Medicare patients with diabetes and peripheral artery disease (PAD), the report found. Amputation rates in the rural Southeast, particularly among black patients, are significantly higher than other regions of the country. Furthermore, the amputation rate for black patients is seven times higher in some regions than others and there is an eightfold difference across regions among blacks in the likelihood that they undergo invasive surgery to increase circulation in the lower legs. Continue reading

‘Good Death’ Still Eludes U.S. Health System Despite Decades Of Debate

reclaimedhome/flickr

reclaimedhome/flickr

By Richard Knox

Death is back in the news again. And it should be.

Death comes to us all. And in the U.S. at least, it’s increasingly likely to be inhumane, institutional and full of misery. That’s according to a growing body of evidence, including:

•A report last month from The National Institute of Medicine called “Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life.” It’s a 500-page indictment of U.S. end-of-life care.

•A new book by Boston writer-surgeon Atul Gawande on the subject called “Being Mortal: Medicine and What Matters in the End.”

•And recently, a must-read New York Times article — a powerful case study of how the American way of death has gone badly awry.

From these and other sources, one thing is clear: Too many Americans are still dying in hospitals and nursing homes; getting aggressive but futile care; and suffering more from the complications of treatment than from the pain of dying.

And with about 10,000 Baby Boomers turning 65 every day, it’s way past time to do something about it. “What is it going to take to ensure that patients in this country are receiving the right care at the right time in the right location, consistent with the right to choose?” Dr. Joan Teno wonders. “These are the things that keep me up at night.”

Teno, a Brown University faculty member, is among 21 authors of the recently issued Institute of Medicine report on dying in America. Continue reading

WSJ: Women At Risk, Doctors Split On Procedure Linked To Rare Cancer

Here’s another excellent Wall Street Journal report on the controversial procedure known as “morcellation.”  Reporter Jennifer Levitz notes that even after the FDA issued a warning on the practice (which involves a “laparoscopic power morcellator” that allows for less invasive surgery to remove fibroids by slicing them up, but can also potentially spread a rare type of cancer through the body) doctors are split on how to proceed.

According to the report:

The FDA said women undergoing surgery for what look like benign fibroids actually have a 1 in 350 risk of hosting an undetected cancer called a uterine sarcoma. Morcellating these tumors can spread cancerous tissue internally and significantly worsen the odds of long-term survival, the agency said.

So what are women to do when the medical community itself is divided? From the WSJ:

(wikimedia commons)

(wikimedia commons)

A number of doctors believe the FDA overreached, and think the cancer risk is so small that gynecologists can go an entire career without seeing a case. Others call the advisory a necessary precaution.

Hospitals and private practices are taking an array of approaches. The University of Pittsburgh Medical Center system, which has more than 50 obstetrics and gynecology practices, opted to continue using the device.

The medical system changed its informed-consent forms to include wording on cancer risk and told doctors to discuss the risk with patients. But Allen Hogge, chairman of obstetrics, gynecology and reproductive sciences there, questioned the data behind the FDA’s estimate. The FDA began looking at the issue after media reports late last year about a prominent Boston doctor who discovered she had sarcoma after morcellation.

“I think this is mostly public relations and not science,” Dr. Hogge said. In response, the FDA said it conducted a rigorous analysis of published literature.

The common practice of morcellation, which is often used for hysterectomies, came under fire when Dr. Hooman Noorchashm, a cardiothoracic surgeon at Brigham and Women’s Hospital and his wife, Dr. Amy Reed, an anesthesiologist at Beth Israel Deaconess Medical Center launched a publicity campaign aimed at stopping the procedure, Continue reading

The Global View: Lessons For Mass. Health Care From Abroad

By Dr. Jonathan D. Quick
Guest contributor

A study released last week found that insurance is saving lives in Massachusetts. Expanded coverage will mean 3,000 fewer deaths over the next 10 years. We have state-of-the-art health facilities and are among the healthiest of Americans. Despite the fiasco of our failed enrollment website, the state maintains near-universal health coverage, and inspired the Affordable Care Act.

Our example is heartening not just for America, but for the many low- and middle-income countries around the world working toward universal health coverage. These countries aren’t just taking a page from our book, though — they have valuable lessons for us, too.

Dr. Jonathan Quick (Courtesy)

Dr. Jonathan Quick (Courtesy)

Here are four things Massachusetts could learn about health from developing countries:

1. Bring health care to the community level

Community health workers (CHWs) have been a staple of health systems in developing countries like Ethiopia for decades. Community members trained in basic prevention and treatment interventions, such as oral rehydration for childhood diarrhea and family planning education, are making a big difference. Although not as specialized as doctors or nurses, they work in places where those professionals either aren’t present or are overburdened. CHWs are not only cheaper to train and deploy, but they are also trusted neighbors, who don’t require the four-hour walk necessary to reach the nearest health facility.

CHWs are now catching on in Massachusetts and other places in the U.S. In NPR’s “A Doctor’s 9 Predictions About The ‘Obamacare Era,’” an American physician predicts “A new category of health worker will flourish: the community health worker.” Few Americans face long walks to health facilities, but many face other challenges, such as mental or physical disabilities, chronic pain, lack of transportation or difficulty navigating the health system. CHWs provide low-cost outreach that helps patients deal more effectively with these barriers.

2. Make it convenient

Another approach used in global health is accredited drug dispensing outlets. When people get sick in Tanzania, their first stop is a local drug shop. Although cheaper and more convenient than seeing a doctor, they often get the wrong drug, of poor quality, and at a high price. Through training and licensing, drug sellers are able to provide live-saving treatment for common problems like malaria and childhood diarrhea at reasonable prices. Not only has this model been successful in improving access to essential medicines, but drug sellers quickly proved they could do more to improve health: advise on HIV/AIDS prevention, check symptoms for tuberculosis, and dispense some forms of contraception.

Similarly, in the U.S. programs like CVS’s MinuteClinic and Walgreens’ Healthcare Clinic are broadening the role of pharmacy services from flu shots to screening, treatment, monitoring and other basic health services. Like the accredited drug dispensing outlets, these services are more affordable and more convenient. They are a shrewd business move by the pharmacies, but also a paradigm shift in how we provide health services.

3. Generate revenue while saving lives

Developing countries have also been figuring out how to make the most of limited resources. In Mexico, a tax on soda is providing new revenue for public health — with the added bonus of reducing consumption and improving health outcomes. Continue reading