tag:blogger.com,1999:blog-38313620752306842892024-02-19T18:35:16.629-05:00Life in Underserved MedicineOne family doctor's life in medically underserved communities.RichmondDochttp://www.blogger.com/profile/17928931511086527042noreply@blogger.comBlogger161125tag:blogger.com,1999:blog-3831362075230684289.post-51813186752066083882016-12-25T13:38:00.000-05:002016-12-25T13:44:54.369-05:00The Coming HarmPosting this here, because I don't think my local newspaper will actually publish it.<br />
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To the Editor;<br />
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The Republican leadership in congress and President-Elect Trump have pledged to repeal the Affordable Care Act (ACA) as soon as they are able. They make this pledge without any plan to replace the ACA, though they have conveniently set a date for repeal to go into full effect after the 2018 mid-term elections so as to avoid political exposure from the harm that will occur upon the ACA's repeal. In Virginia, repealing the ACA risks 685,000 Virginians' losing their health insurance coverage, and 319,000 losing the Federal subsidies that help them afford health insurance purchased on the ACA's exchanges. These changes risk reversing the 26% decrease in uninsured Virginians since the ACA went into effect. Congress and the President-Elect have spoken of their desire to retain important protections in the ACA (such as guaranteed issue, which removes the risk of denial of coverage for preexisting conditions), but have not presented any plan to do so that would keep insurance affordable or accessible to the average person. Some of those who voted for Mr. Trump may have done so believing that his call to repeal the ACA was political bluster, and that now that Americans are seeing benefits from the law, it could not be repealed. If so, they committed an awful error: the Congressional leadership has been voting to repeal the law since its passage, and now will have a sympathetic ear (and pen) in the White House. The vote to to repeal the ACA will come as soon as the first week in January, and millions of Americans will face the coming harm on their own, hoping an already stressed safety net may help catch those who again fall through the gaps. Physicians and health care providers like me will do our part to help those caught in an unnecessary trap of our politicians' own creation, while those politicians celebrate a political victory without regard to the harm they will have done. All Americans deserve that our politicians do their part and present a planned replacement for the ACA before thousands are harmed by its repeal.<br />
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Sources:<br />
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http://familiesusa.org/product/defending-health-care-2017-what-stake-virginia<br />
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http://www.politico.com/story/2016/12/obamacare-republicans-repeal-replace-232025 <br />
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http://www.vox.com/science-and-health/2016/12/13/13848794/kentucky-obamacare-trumpRichmondDochttp://www.blogger.com/profile/17928931511086527042noreply@blogger.com2tag:blogger.com,1999:blog-3831362075230684289.post-36950014615213764122016-11-13T09:57:00.001-05:002016-11-13T09:57:06.177-05:00Join and support the National Physicians AllianceI am currently in Washington, DC for the Fall Board of Directors meeting for the National Physicians Alliance (NPA). Given the recent election results, this meeting feels more important than ever.<br />
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I joined NPA in 2010 or so, and then became a member of the Communications Committee during the time that Affordable Care Act (ACA) was being debated, passed, opposed, sued, defended, and enacted. I later became the organization's Vice President of Communications, and have continued sharing NPA's mission and message as the <a href="https://www.washingtonpost.com/posteverything/wp/2016/10/11/the-affordable-care-act-is-covering-people-holding-down-costs-and-not-killing-jobs/?utm_term=.6e1632c8ecc1" target="_blank">ACA began providing health access to millions of Americans in the context of better care and lower costs</a>.<br />
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NPA focuses on service, integrity, and advocacy, and is <a href="http://npalliance.org/about/guiding-principles/" target="_blank">guided by principles</a> emphasizing health justice. Health as defined broadly, as more than the absence of disease: it is a state of wellness, and is influenced by the both the medical system and s<a href="http://www.who.int/social_determinants/en/" target="_blank">ocial determinants of health </a>such as the environment, available educational opportunities, housing, transportation, etc.<br />
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With the results of the recent presidential election, many of the core values many of us hold dear are going to be under great pressure. If the ACA is repealed, up to <a href="http://www.rwjf.org/en/library/research/2016/06/the-cost-of-aca-repeal.html" target="_blank">24 million Americans risk losing insurance</a>. Women's access to reproductive health care <a href="http://www.businessinsider.com/donald-trump-abortion-womens-health-platforms-positions-2016-11" target="_blank">risks being severely limited</a>. Medicaid expansion would be rolled back as part of the repeal of the ACA, but the <a href="http://khn.org/news/millions-could-lose-medicaid-coverage-under-trump-plan/" target="_blank">Medicaid program could be fundamentally restructured and lead to more coverage losses</a>. Even Medicare, a program which has bedrock support, might be changed dramatically (information <a href="http://www.pbs.org/newshour/making-sense/what-clinton-trump-propose-social-security-medicare/" target="_blank">here</a>).<br />
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NPA is preparing for the fight to come in the next few years. We must protect access to healthcare. We must ensure that women's access to all aspects of reproductive health remains in place. We must ensure that vulnerable individuals, communities, and populations are protected. We must do all this as we continue to advocate for a more equitable and just healthcare system.<br />
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The task is daunting, and it appears that the fight will be long and challenging. And: NPA is prepared and committed to be a voice for physicians and for our patients for the duration of the fight. We need volunteers, we need contacts, we need support, and we need funding.<br />
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<b>Join us.</b> Membership is free: <a href="http://action.npalliance.org/o/1021/content_item/signup">http://action.npalliance.org/o/1021/content_item/signup.</a><span id="goog_1396255986"></span><br />
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<b>Support us.</b> Your support allows us to carry out key advocacy work without restrictions from outside funders: <a href="https://org.salsalabs.com/o/1021/donate_page/contribute-to-npa" target="_blank">https://org.salsalabs.com/o/1021/donate_page/contribute-to-npa.</a><br />
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These are uncertain, frightening times. But it is not the time to retreat. Now is the team to stand up, come together, and tell those who aim to harm our patients and our profession: #NotOneStepBack.<br />
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<br />RichmondDochttp://www.blogger.com/profile/17928931511086527042noreply@blogger.com0tag:blogger.com,1999:blog-3831362075230684289.post-961106902747629552016-11-09T23:45:00.003-05:002016-11-10T00:06:20.824-05:00Aquí estaré, por lo que valeAmanecí esta mañana con una sensación de desesperación y furia. Yo pensé que este país, con ocho años de trabajo y progreso había llegado a un punto que un candidato racista quien atacaba a imigrantes, la comunidad LGBT, de otras creencias y fés no podría llegar a ser presidente de este país.<br />
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Me encontré gravemente equivocado.<br />
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Y lo siento. Lamento mi parte en esta decisión. Yo voté en contra de Trump, pero temo que quizás no hice suficiente para oponerlo.<br />
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Yo regresé a Richmond in 2007 con la meta de trabajar en comunidades de bajos recursos, y especialmente con la comunidad Latina. Pero, en estos ultimos cuatro años me he encontrado afuera de la clínica y más en la clase, como docente de estudiantes de medicina.<br />
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Y quizás abandoné el trabajo que era necesario. Y quizás mis esfuerzos no eran suficiente.<br />
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Y ahora temo los daños que vienen. El odio y el prejuicio abierto con cual las comunidades por cual me he dedicado serán atacados.<br />
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Estoy en este momento averiguando como mejor puedo acompañar esta gente y mís comunidades. Y estoy preparandome para el trabajo e las luchas que vienen para protejer sus derechos, su salud, y su dignidad.<br />
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Esta no es mi lucha: yo tengo el privilegio de ser un hombre, americano, médico. El riesgo en esta lucha no es mia: my privilegio y mi posición me protegen. Lo menos que yo puedo hacer es pararme al lado de ellos, de aprender de ellos como crear una comunidad y un país generoso, abierto a todos, dejando nadie atras. Y aquí estaré, por lo que vale, mientras que nos preparamos para el futuro.RichmondDochttp://www.blogger.com/profile/17928931511086527042noreply@blogger.com0tag:blogger.com,1999:blog-3831362075230684289.post-3882422913772074702016-11-09T23:45:00.000-05:002016-11-10T09:20:52.817-05:00Privilege and purpose<span class="_c24 _50f4"> "Start where you are. Use what you have. Do what you can."--Arthur Ashe</span> <br />
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When I started this blog, some years back, I did so out of a desire to have a voice, to be an advocate for change I thought would make a difference. In the last few years, as my work roles shifted and my obligations stretched into evenings and weekends, I lost the rhythm of blogging. And, if I am honest, I lost the urgency and drive, and my focus.<br />
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In 2009, the Affordable Care Act (ACA) was an idea, which became a proposal, which eventually became a law. A law that <a href="https://www.blogger.com/blogger.g?blogID=3831362075230684289#editor/target=post;postID=388242291377207470" target="_blank">increased access to health insurance for millions of Americans</a> and especially in <a href="http://www.commonwealthfund.org/publications/blog/2016/aug/latinos-blacks-major-gains-under-aca" target="_blank">communities of color</a> and <a href="http://www.realclearhealth.com/articles/2016/11/01/looking_for_some_good_aca_news_health_reform_medicaid_and_chip_drive_sharpest_decline_in_child_uninsured_rate_on_record_110214.html" target="_blank">drastically reduced the numbers of children without insurance</a>. It survived reviews by the Supreme Court, and dozens of votes for its repeal. Under its coverage, insurance companies extended coverage to adult children on their parents' plans, ended the practice of denying health insurance to those Americans with preexisting conditions, and ensured that health insurance companies would spend money on providing health insurance coverage, not just on their own profits. Americans were seeing real benefits from the law, and while not perfect, it was doing its job.<br />
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With the urgency to push for healthcare reform and accessible coverage for all, my attention wandered to other issues, which I feel are also terribly important: ensuring medical practice is free of industry influence, that we practice good stewardship and avoid over-treatment, that we <a href="http://npalliance.org/blog/2015/10/14/new-report-politics-exam-room/" target="_blank">speak out against the influence of politics on the doctor/patient relationship</a>, and that we address gun violence as the public health issue that it is.<br />
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I also found my role moving away from the clinic. I became medical director of a program focused on training medical students with a commitment to provide care in medically underserved communities after they completed their training. I became the director of a course focused on teaching students about the interactions of patients, physicians and society at large. And I valued these roles, and learned new skills, and moved away from the clinic: down to just two sessions a week.<br />
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I found myself waking up today asking if all these changes had been worth it.<br />
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In the past few years in Richmond, I have tried to become more aware of my own privilege, and the struggles and obstacles faced by others. I am a white, cis-gendered, heterosexual, married, US-born male physician. I am the very picture of "privilege". I have not faced discrimination, and I carry with me opportunities and status that I have not earned, that I assumed as a part of the culture in which we live. I have tried to recognize this, and have tried to learn about and be a partner to those who do not have this privilege.<br />
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And this is why I woke up today reassessing so many things. Has the clinical work I have done made a difference in the community? Are two sessions a week in clinic enough to be a resource to my patients and to my community? Has my focus on teaching and my non-clinical work taken me away from the people I aim to help?<br />
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The results of this election have served to reinforce my privilege. The President-Elect and his supporters have attacked people of color, women, immigrants, Muslims, and members of the LGTBQ community. They oppose a women's right to free reproductive choice. They have control of the Congress and may appoint a number of Supreme Court justices over the course of their term.<br />
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They will undo eight years of progress, all in the interest of protecting white privilege, and white male privilege to be precise.<br />
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So: as I gather my thoughts and figure out a way forward, I will try and use this space for the purpose for which it was created: to raise my voice outside of my office and the classroom, and to join the voices of so many others rising tonight in pain, and fear, and anger at the harm which is coming. This is not my fight: the privilege I have protects me. The least I can do, then, is to accompany, support, and stand alongside those for whom this fight is personal and high stakes. I can work to understand their worries and learn about their hopes and how we can make our society more just and inclusive, and I can try to be an ally. And I can prepare myself for the work ahead.RichmondDochttp://www.blogger.com/profile/17928931511086527042noreply@blogger.com0tag:blogger.com,1999:blog-3831362075230684289.post-11997757503303483972015-09-13T22:08:00.003-04:002015-09-13T22:09:59.110-04:00A Presidential VisitLast week, our university's President came for a visit to our office. So far as I know, this was the first time that any of our university's Presidents have been to the office, at least since the opening ceremony 20 years ago. The President was accompanied by a number of high-level officials from our health system.<br />
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Our office is located in South Richmond, Virginia. The neighborhood that surrounds us was, when the practice opened, mostly made up of low-income African-American residents. Starting in 2000, Richmond's Latino community started to grow, and this growth has been largely centered in South Richmond. Richmond's largest single housing community is just about 1/2-1 mile from our office: about 1,000 townhomes, now estimated at 80-85% Latino. This change in the demographics of Richmond has been sudden (from about 5,000 Hispanic residents in the city to over 20,000 in 15 years), and I believe that this is going to be a permanent shift for the city.<br />
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The Latino community is a young community, composed of young and growing families. In our office, 25-30% of our patient visits are for pediatric patients (under 18), and 70% of our these patients are Spanish-speaking. Meanwhile, the low-income African-American community has not left--many of our adults are uninsured (between 50-60% of our adult visits 18-64 are uninsured--recall that Virginia has opted not to expand Medicaid). The office also has a high mental health comorbidity among our patients: in one survey, 44% of our patients had moderate/severe ratings of anxiety and/or depression, and only one-half were receiving active care. We also have a high proportion of patients who are dealing with chronic pain and/or substance abuse.<br />
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Many of these patients have little access to needed healthcare services. We are able to provide much of their healthcare, but we lack the capacity and contacts to allow for full-service behavioral health care (e.g. including counseling, not just medications). Our adult uninsured patients lack access to dental care. Our Spanish-speaking children and families face a landscape in Richmond nearly devoid of Spanish-speaking behavioral health providers: an increasing problem given the fact that increasing numbers of Latino kids are now entering school...and running into learning problems and facing behavioral issues.<br />
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I shared with our President how exciting it is, then, for us to be working to fill these gaps in care. We have physicians who are in the office, and working with this sometimes challenging patient population, by choice. We have been awarded two grants--one from the <a href="http://rmhfoundation.org/what-we-do/responsive-grant-making/responsive-grant-making-awards-by-year.aspx" target="_blank">Richmond Memorial Health Foundation</a> and another from the <a href="http://www.vhcf.org/2015/07/28/vhcf-awards-1-6-million-in-grants-to-help-uninsured/" target="_blank">Virginia Health Care Foundation</a>--to provide in-office behavioral health services in collaboration with our Department of Psychology. Even better: the RMHF grant specifically targets services to the Latino families. The VHCF will provide us with one-day-a-week coverage from a psychiatric nurse practitioner to better help adults with chronic or severe mental illness. Now that the office renovations are completed, we can also look to resume our tele-psychiatry collaboration with our system's Child and Adolescent Psychiatry service.<br />
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I am very glad that we were able to discuss and share these initiatives with our President and with our healthcare leadership. Admittedly, these may be small steps in the greater healthcare landscape in Richmond, but they are important steps, and it is important to have supportive leadership helping push this forward.<br />
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<img alt="Embedded image permalink" src="https://pbs.twimg.com/media/COfAKDUWUAAweDu.jpg" style="width: 100%;" />RichmondDochttp://www.blogger.com/profile/17928931511086527042noreply@blogger.com3tag:blogger.com,1999:blog-3831362075230684289.post-39403910804810260122015-09-07T16:39:00.000-04:002015-09-07T16:39:00.629-04:00Taking stock: where does the time go?Looking at the blog, it is hard to believe that it has been nearly one and one-half years since I updated or posted anything here. Frankly, even as I write this, I am not even sure what will follow this post: blogging does not come easily for me, and other time commitments do not easily allow me to focus on the blog.<br />
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It is also interesting to think about where we are since the blog started. When I first started blogging regularly, I was working as a full-time clinician at a safety net clinic here in Richmond, Virginia. I was pushing for healthcare reform, and advocating for the legislation that eventually became the ACA. I was also a board member of the <a href="http://vafp.org/" target="_blank">Virginia Academy of Family Physicians</a> and had learned about the <a href="http://npalliance.org/" target="_blank">National Physicians Alliance</a>.<br />
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From 2009 to 2014, we saw the ACA become law and now survive two Supreme Court challenges while its reforms became increasingly ingrained in Americans' daily life. We have experienced a paradigm shift in that the presumption is now that all Americans will have access to health insurance, and through health insurance access to health care. Though it is clear that there is still work to be done--and perhaps more significant reforms to come--the truth is that most Americans will no longer be excluded from the system...at least in states that have chosen to expand Medicaid.<br />
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I have seen increasingly frequent discussions on the importance of primary care and family medicine, and have become a more-active member of the <a href="http://www.stfm.org/" target="_blank">Society of Teachers of Family Medicine</a>, including serving on STFM's Communications Committee as we work to train future generations of family physicians and family medicine educators. I have also seen that a flawed approach to paying for medical care and primary care is still in place, despite the evident need for change.<br />
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I have joined the leadership of NPA as the Vice-President of Communications, and have worked with the organization's leadership to continue to encourage the implementation of the ACA while increasingly focusing on other areas of importance: bringing attention to the issues around gun violence and promoting a focus on gun violence as a public health issue, addressing the influence of big PhRMA and the medical industry device on medical practice, and encouraging physicians and patients to work together together to make good decisions that benefit patients and that conserve valuable resources and prevent harm and over-treatment.<br />
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I have moved into a leadership role teaching medical students both in a specialized honors program for medical students focused on working with medically underserved communities after completing their training, and leading a curriculum focused on the humanistic, ethical and holistic care.<br />
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I finally authored an article that was <a href="http://www.tandfonline.com/doi/abs/10.3109/13561820.2015.1020360#.Ve3uvM7ugYd" target="_blank">published</a>. The article focuses on the benefit of an interprofessional service learning activity focused on providing care to Richmond's Latino community.<br />
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Finally, I became medical director at the office I joined in 2007. I took on this role in December, and have spent the past 8 months working through the challenges that have presented themselves and looking to enhance care for our patients.<br />
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So: I am going to try and pick this up again, but I am not sure where it is headed. It will probably still be an advocacy blog--as there is still much work to be done related to the ACA, and I am still committed to the work NPA is doing--but I will admit that my focus is much closer these days. Being in a leadership role in a safety net clinic has provided the opportunity for me to help make our healthcare system more responsive and accessible for everyone, and to provide holistic care for patients who have serious needs. I hope that I will be able to use the blog to describe what we have been doing in the office, what impact it has, and how we are looking to continue enhance and improve our patients' health.<br />
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I will try to be less of a stranger heading forward, and appreciate those who might come along.RichmondDochttp://www.blogger.com/profile/17928931511086527042noreply@blogger.com0tag:blogger.com,1999:blog-3831362075230684289.post-36750577913441993542014-03-30T11:18:00.002-04:002014-03-30T11:18:24.392-04:00Extending the Mission: Family Medicine and Global Health(Initially written for the <a href="https://www.stfm.org/Foundation" target="_blank">Society of Teachers of Family Medicine Foundation</a>'s newsletter, <a href="http://stfm.createsend1.com/t/ViewEmail/j/05011A0C55DDC6C7/23DD8D1B420F91EED9767B6002735221" target="_blank"><i>The Wire</i></a>) <br />
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I was born in the Dominican Republic, but only lived there for a few months. As a child, I lived 10 of my first 16 years in Latin America: four in Venezuela, four in Argentina, and two in Panama. After graduating from the VCU School of Medicine in 2000 and completing my Family Medicine residency in Blackstone, Virginia in 2003, I joined my first international medical trip: from my experiences growing up and my interest in returning to Latin America as an adult, the opportunity to work overseas as a physician—in a profession focused on service and on providing care for those in need—was exciting, and the experience was fulfilling. I recall waking on the first day for clinic, seeing the rugged hills of rural Honduras stretching to the highway, and seeing our patients lining up for care, having arrived on foot, by horse, or by shared vehicle. I recall my anxiety and excitement over the nature of medical care in this setting: no x-rays, no labs beyond urinalysis or pregnancy test, no specialists or specialized diagnostic equipment. We took care of patients by taking a good history and completing a careful physical exam: the H&P, our clinical judgment, and help from colleagues were our only resources. As just-graduated resident, this was thrilling and validating: thrilling because I had to rely on my skills, and validating because my Family Medicine training from a rural residency program allowed me to provide the care these patients needed.<br />
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Since that first trip, I have since led 14 medical trips to Santo Domingo, the capital of the Dominican Republic. The first trip was set up in 2005 alongside undergraduates from the College of William and Mary, my undergraduate alma mater. This trip was what I would now consider a “duffle bag medicine” project--we had put little thought into how we would fit into the local health care system, and we had little consideration of sustainability or our long-term impact. After that trip, we refocused and regrouped, and returned to the Dominican Republic with a long-term commitment to provide medical care and work to improve community health in a sustainable manner. I have continued to lead medical trips to the Dominican Republic since then, in collaboration with the Dominican Aid Society of Virginia (DASV), William & Mary’s Student Organization for Medical Outreach and Sustainability (SOMOS), and VCU’s HOMBRE organizations. We now travel to the DR twice a year, and we provide direct medical care and work with the community to address underlying challenges to health and wellness.<br />
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These medical trips are still highlights of my year. Despite being a lot of work to organize, I return from these trips renewed and reinvigorated by practicing medicine without regard to CPT or ICD-9 codes, billing sheets, required documentation, etc. On these trips, medicine is reduced again to its essential components: the dyad of patient and physician, within the setting of the patient’s family and community. Beyond the personal value, though, I believe that participating in global health projects extends the mission of family medicine to communities overseas and to medical school and residency trainees who travel with us as part of our team. The way I see it, global health work aligns with the following key components of the specialty of Family Medicine:<br /><br />
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<li>Thoughtful and appropriate medical care: we provide care for acute illnesses and chronic disease, we deal with mental health issues and preventive check-ups, and we help identify patients who can be cared for in our outreach clinic and those who need formal care and follow-up within the local healthcare system.</li>
<li>Community development and social determinants of health: as explained in the bio-psycho-social model of care that is at the center of Family Medicine, illness and disease do not exist in a patient in isolation. Rather, health, illness, and disease exist in the context of the patient’s surroundings as well as their own individual risk factors. On these trips, as physicians and healthcare providers provide direct healthcare, SOMOS and other team members work with the community to identify the community’s healthcare priorities and develop community-drive, sustainable solutions.</li>
<li>Teaching: whether we are teaching our patients or our trainees, teaching is at the core of what we do in Family Medicine. Each of the medical trips to the Dominican Republic incorporates trainees at multiple levels: undergraduate pre-med students, medical students in the pre-clinical and clinical years, medical residents, pharmacy students, and pharmacy residents. These trainees have experiences that resemble my first trip to Honduras: cast loose from technology and readily available resources, they learn to listen to patients, to focus on the clinical setting, and to work through difficult situations with limited resources. These experiences stand to make them better physicians and providers in the future.</li>
<li>Research and scholarship: in the process of providing clinical care and working on community development projects, we have the availability to engage in research and scholarship that will improve our ability to provide medical care for acute and chronic illnesses in the community as well as better understand the organization of the community itself. Our experiences can inform others, and we readily share our knowledge with others doing similar work.</li>
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In closing, global health projects are both well within the scope of practice of Family Medicine, and are aligned with our specialty’s goals and vision. At the practical level, Family Medicine residents and physicians are ideal members of global health trips: with our community focus, our scope of practice and our whole-person orientation, Family Medicine physicians can take on any role on these trips without regard to patients’ age or gender: no accommodations and no restrictions needed. The alignment of the project’s needs and Family Medicine physicians’ abilities is notable, and it makes leading and participating on these trips rewarding and renewing, and continues to validate my choice to enter Family Medicine 13 years ago.<br />RichmondDochttp://www.blogger.com/profile/17928931511086527042noreply@blogger.com3tag:blogger.com,1999:blog-3831362075230684289.post-3758003980627358582014-03-16T16:32:00.001-04:002014-03-16T18:49:22.550-04:00The value of mentorshipI entered medical school in 1996 with a vague interest in primary care. During my M1 year, I focused more on my studies than on my career path, and sought to spend time with my wife (having just been married a month before medical school). My M1 Foundations of Clinical Medicine (FCM) community preceptor placement was in a family medicine office in South Richmond, but I received little hands-on experience, and it did not help clarify my path.<br />
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Everything changed in my M2 year. As part of our school’s rural interest group, I had met Dr. Augustine (Gus) Lewis, who had taken on his father’s practice in rural Aylett, Virginia, and I was matched to his office for my M2 FCM placement. Dr. Lewis was a family physician committed to his community and patients, and they were committed to him. He knew patients by name, and he knew many of their families and stories. He focused on patients’ needs, and took their social situation into account when recommending care. He had a comprehensive, whole-person focus.<br />
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As a teacher and physician, Dr. Lewis was generous with his time and knowledge, and engaged me as an active learner. He also could have chosen to practice anywhere, and chose rural Virginia. I realized that one could be an up-to-date, knowledgeable, patient-focused, community-oriented physician in rural Virginia. His example became a guide for me during my own training and career, and I am glad to consider him a colleague and friend.<br />
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I am honored to consider Gus a mentor, a colleague, and a friend. I was glad when he received the <a href="http://foundation.msv.org/Foundation/Leadership/Salute-to-Service/2013-Salute-to-Service-Winners.aspx" target="_blank">Medical Society of Virginia Foundation's 2013 Salute to Service Award for Service to the Profession</a>. You can hear some of Gus's story in his own words <a href="https://www.youtube.com/watch?v=rlVbN_gtays" target="_blank">here</a>. I could not imagine a better recipient, or a better role model. <br />
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<br />RichmondDochttp://www.blogger.com/profile/17928931511086527042noreply@blogger.com0tag:blogger.com,1999:blog-3831362075230684289.post-59477106533465729852014-02-23T23:41:00.002-05:002014-02-23T23:41:35.516-05:00Some thoughts on healingLate last year, I led a session for our MS1 students in which we discussed the idea of healing. We used <a href="http://www.annfammed.org/content/3/3/255.full" target="_blank">this article</a> as a jumping off point in the discussion. The article goes through a process of defining healing, but the core concept is that of healing as a transcending of suffering.<br />
<br />
Healing is a complicated issue. Not everyone heals the same way, at the same pace, or to the same level. Healing can be fast or slow, complete or incomplete and it can be very hard to recognize how to heal. The traumas and the stresses that people face can be so severe that it might be difficult to identify the best way forward, and to determine what steps need to be taken. Sometimes these steps might be harmful, might create problems of their own. Sometimes when in the depth of a crisis we strike out, or we lapse too far inwards. The hope is that we can find some way to move past those harmful actions and find a true way forward--even if that way is diminished.<br /><br />Healing is made more difficult because of what people heal <i>from</i>. If they are healing from a physical suffering, an emotional injury, a loss of control or some loss of wholeness, they will heal differently. Until we can accurately identify the source of the suffering, then the path to healing will be extremely difficult.<br /><br />I think this is an important reason why people seek medical care as part of their healing. Sometimes we can help, with medications, or surgery, or some other treatment. Often times, our role in healing is simply our presence helping patients and families through the difficult times, advising and treating where we can, and bearing witness and sharing in the process. The assurance that someone will be there to care and to help may be an important step in peoples' healing. RichmondDochttp://www.blogger.com/profile/17928931511086527042noreply@blogger.com0tag:blogger.com,1999:blog-3831362075230684289.post-21683319355471258072014-02-17T12:00:00.000-05:002014-02-17T12:00:01.580-05:00What is the Value of the Doctor/Patient Relationship?(In response to <a href="http://www.ted.com/talks/abraham_verghese_a_doctor_s_touch.html" target="_blank">Abraham Verghese's TED talk</a>) <br />
<br />
Verghese's talk centers on the process of the physical exam, but I think the central themes are that of ritual and connection. In the healing relationship that physicians (should?) attempt to develop with our patients, the ritual and roles of healer and patient--those who are present to aid and to care and those that are seeking assistance and caring--enhance the physician's presence to beyond a source of a prescription or a recommendation for a treatment. Instead, the ritual helps establish a connection between the two parties, and the connection enhances the benefit of any recommended treatment be it medication prescriptions, physical therapy, or counseling. If a great deal of illness is suffering, then it is the trust between patients and physicians that helps the dyad seek to overcome that suffering.<br /><br />I have long held tight to the concept of the "therapeutic use of self", that as healers we can use our presence to be an important part of helping patients heal in some form. Verghese's closing--that physicians will not abandon our patients, that we will see them through whatever trial--beautifully summarizes this idea.<br /><br />Unfortunately, we are in a situation in healthcare where it is very difficult to live up to Verghese's ideal. I certainly cannot give 1 hr for a patient to tell me their history, and then another 1 hr visit just for the physical. Our office gives us 20 minutes for each visit (whether a new or an established visit), and this is generous: many other offices give 10-15 minutes. I can try to approximate Verghese's approach by taking advantage of the continuity of care primary care offers: I can see patients back repeatedly, and even if I cannot gather all this information at once or develop the desired connection as quickly, I can still work to gain my patient's trust and to preserve the healing relationship heading forward. <br /><br />In a healthcare system that rewards productivity, physicians will be pushed to be productive. Often this means seeing more patients, ordering more tests, sending for more studies…and often times the therapeutic use of self is left aside in the hustle.<br /><br />Relationships are critically important, and so are patients' expectations and experiences. In the case of research around the <a href="http://online.wsj.com/news/articles/SB10001424052970204720204577128873886471982" target="_blank">placebo effect</a> it appears that how much benefit a patient receives from certain interventions depends on their experiences. If we as physicians are caring, kind, patient, and truly interested, might we enhance this benefit?<br /><br />I believe the issue at hand is that we have a healthcare "system" that is not a system, and that does not really care about "health". If we cared about health, we would emphasize the importance of the doctor/patient interaction, we would give the time needed to allow this relationship to develop and be supported, and we would find a better way to value the work being done.RichmondDochttp://www.blogger.com/profile/17928931511086527042noreply@blogger.com0tag:blogger.com,1999:blog-3831362075230684289.post-49726568514592863152014-02-16T20:27:00.000-05:002014-02-16T20:29:15.973-05:00A Change in Course (and, hopefully, a renewal)Looking back at this blog, I am embarrassed at how long it has been since I have updated it. Life has gotten so busy that I hardly ever think to jot down any thoughts here, even if I should have some thought I think worth sharing.<br />
<br />
Now that the ACA has been protected by the Supreme Court, by a Presidential election, and by a finally effective roll-out, I don't feel that I need to tout the law's benefits as loudly as I have been...and I appreciate those of you who have stuck through me during all this time.<br />
<br />
I am hoping to bring this blog back to its original intent: to speak about medicine, and healing, and the challenges and rewards of working with medically-underserved communities.<br />
<br />
In the past year, I have also become increasingly interested in the intersection of evidence-based medicine and patient-centered care. I suspect that some of those thoughts will come into discussion on this blog. <br />
<br />
Since my last post I have been teaching more. I am teaching students in our school's honors program that prepares students to work with medically-underserved communities after they complete their training, and I am teaching the entire medical school class about the important elements of the doctor/patient relationship. I hope that my increased engagement there will renew my energy and desire to share ideas here.<br />
<br />
I am also helping teach a "Medicine and Literature" course on our undergraduate campus. As part of that class, we have an active discussion board. In order to get this blog back online, and to avoid doing the double work that would quickly end this attempt to restart things, I will start by cross-posting some of my thoughts from that discussion here.<br />
<br />
Hopefully, you will see more on this blog soon. Thanks to all those who might have been bearing with me.RichmondDochttp://www.blogger.com/profile/17928931511086527042noreply@blogger.com0tag:blogger.com,1999:blog-3831362075230684289.post-20985354190151135342013-06-23T16:41:00.000-04:002013-06-23T16:46:56.093-04:00What does it mean to be a physician?When I graduated college and entered medical school, I had a strong
vision of what it meant to be a physician. To me, being a doctor was a
service career. It was not a way to make money, but a way to make a
difference. This vision was strengthened and fine-tuned over the course
of my medical school training as I interacted with mentors who shared
this understanding of a medical career. Physicians must be capable of
providing medical care to their patients, but the role should be much
greater than that: community service, leadership, education, and
professionalism are intrinsic to my definition of what it means to be a
physician.<br />
<br />
When I learned about National Physicians Alliance in 2009, I was
thrilled. Although I was already a member of my specialty
organizations, I had not found an organization that fully embraced my
(and NPA's) vision of medicine. Other organizations may have included
some these elements in their definitions, but I had not seen another
organization focus so precisely on these areas:
<br />
<ul>
<li>Ensuring safe, accessible, affordable healthcare for all.
</li>
<li>Focusing on integrity and trust in medicine, and avoiding and
eliminating conflicts of interest in medicine (including interactions
with medical device manufacturers and pharmaceutical companies).</li>
<li>Emphasizing evidence-based medicine and good stewardship of our patients' and our nations' resources.
</li>
<li>
Encourage civic engagement as part of medical practice.
</li>
</ul>
A career in medicine is a vocation, and a trust, and physicians
must focus on the big picture if we are to give our patients and our
communities proper care. We need to be active advocates to address
social determinants of health, and we need to be leaders in targeting
large-scale problems that impact our nations' health.<br />
<br />
I believe that there is a role for trade groups (specialty
organizations) in medicine. However, my membership in NPA speaks to a
different set of interests and beliefs: it is more expansive and more
inclusive, and more energizing. I am proud to be on the organization's
Board of Directors.<br />
<br />
I hope you will join me in supporting NPA. Physicians: please
consider <a href="http://salsa.democracyinaction.org/o/1021/content_item/signup" target="_blank">becoming a supporting member of NPA</a>.
Everyone else: please consider <a href="https://salsa.democracyinaction.org/o/1021/my/donate.jsp?supporter_my_donate_page_KEY=2476" target="_blank">making a tax-deductible organization to support this organization's great work</a>.RichmondDochttp://www.blogger.com/profile/17928931511086527042noreply@blogger.com0tag:blogger.com,1999:blog-3831362075230684289.post-77645866376506479882013-02-03T16:55:00.002-05:002013-02-03T17:01:40.298-05:00Please support Medicaid expansion in Virginia<div id="yui_3_7_2_26_1359337308080_49">
<br class="yui-cursor" id="yui_3_7_2_26_1359337308080_57" /></div>
<div id="yui_3_7_2_23_1359337308080_93" style="background-color: transparent; color: black; font-family: times new roman,new york,times,serif; font-size: 16px; font-style: normal;">
<span id="yui_3_7_2_23_1359337308080_61">I am writing to ask Virginia's General Assembly to expand Medicaid in Virginia. </span></div>
<div id="yui_3_7_2_23_1359337308080_103" style="background-color: transparent; color: black; font-family: times new roman,new york,times,serif; font-size: 16px; font-style: normal;">
<br />
<span id="yui_3_7_2_23_1359337308080_61"></span></div>
<div id="yui_3_7_2_23_1359337308080_108" style="background-color: transparent; color: black; font-family: times new roman,new york,times,serif; font-size: 16px; font-style: normal;">
<span id="yui_3_7_2_23_1359337308080_61">As
a family physician in Richmond, working with some of the Commonwealth's
poorest and most-marginalized citizens, I believe that the expansion of
Medicaid coverage up to 133% of the Federal Poverty Level (as called
for in the Affordable Care Act) is critical to the health of our
citizens, and to the state's economy.</span></div>
<div id="yui_3_7_2_23_1359337308080_154" style="background-color: transparent; color: black; font-family: times new roman,new york,times,serif; font-size: 16px; font-style: normal;">
<br />
<span id="yui_3_7_2_23_1359337308080_61"></span></div>
<div id="yui_3_7_2_23_1359337308080_157" style="background-color: transparent; color: black; font-family: times new roman,new york,times,serif; font-size: 16px; font-style: normal;">
<span id="yui_3_7_2_23_1359337308080_61">I would like to provide a few examples as to why this expansion is so important:</span></div>
<ul id="yui_3_7_2_23_1359337308080_182">
<li id="yui_3_7_2_23_1359337308080_181"><span id="yui_3_7_2_23_1359337308080_61">Medicaid
expansion in other states has been associated with reduced mortality:
<a href="http://www.nejm.org/doi/full/10.1056/NEJMsa1202099">http://www.nejm.org/doi/full/10.1056/NEJMsa1202099</a></span></li>
<li id="yui_3_7_2_23_1359337308080_181"><span id="yui_3_7_2_23_1359337308080_61">In
Oregon, access to Medicaid was associated with improved healthcare
outcomes (though at the cost of increased costs early on--presumably as
patients took advantage of newly available coverage):
<a href="http://www.nejm.org/doi/full/10.1056/NEJMp1108222">http://www.nejm.org/doi/full/10.1056/NEJMp1108222</a></span></li>
<li id="yui_3_7_2_23_1359337308080_181"><span id="yui_3_7_2_23_1359337308080_61">Medicaid
expansion will cost Virginia less, both in the short and the long term:
<a href="http://www.thecommonwealthinstitute.org/2013/02/01/revised-medicaid-expansion-still-saves-money-in-virginias-budget/">http://www.thecommonwealthinstitute.org/2013/02/01/revised-medicaid-expansion-still-saves-money-in-virginias-budget/</a>
and
<a href="http://www.timesdispatch.com/news/state-regional/government-politics/medicaid-expansion-would-save-initially-va-official-says/article_e379990f-75b1-5fc0-9931-241fa922c4fb.html">http://www.timesdispatch.com/news/state-regional/government-politics/medicaid-expansion-would-save-initially-va-official-says/article_e379990f-75b1-5fc0-9931-241fa922c4fb.html</a></span></li>
<li id="yui_3_7_2_23_1359337308080_181"><span id="yui_3_7_2_23_1359337308080_61">Finally,
it is critical to note that the ACA reduces funding to hospitals that
treat a disproportionate share of uninsured patients. These so-called
DISH funds are being eliminated under the ACA because the cost of caring
for these patients was expected to be covered by the law's Medicaid
expansion. At this point, there
is no mechanism in place to account for reduction in DISH funds under
the ACA. This combination of events not only puts hospitals at
significant risk, but also threatens to increase all commercial
insurance costs to all Virginians--individuals and employers as
hospitals face shortfalls from the increase in uncompensated care and
passes those costs along to all insured Virginians. It is also worth
noting that, at least at VCU, DISH funds help cover not just in-hospital
care but also the VCC program that provides community-based primary
care for uninsured patients, meaning that these patients will lose
access to preventive and primary care services.</span></li>
</ul>
<div id="yui_3_7_2_23_1359337308080_347" style="background-color: transparent; color: black; font-family: times new roman,new york,times,serif; font-size: 16px; font-style: normal;">
Given
that it is very difficult for adults to currently qualify for Medicaid
in Virginia, many receive care through volunteer services and through
free clinics. These programs do excellent work, but I believe many are
already running at or near capacity and would struggle to take on
additional patients should the safety net unravel any further. The
ACA's health insurance marketplaces (exchanges) do not benefit anyone
under 100% FPL, meaning that a failure to expand Medicaid ensures our
poorest citizens will left out of our current system.</div>
<div id="yui_3_7_2_23_1359337308080_419" style="background-color: transparent; color: black; font-family: times new roman,new york,times,serif; font-size: 16px; font-style: normal;">
<br id="yui_3_7_2_23_1359337308080_424" /></div>
<div id="yui_3_7_2_23_1359337308080_421" style="background-color: transparent; color: black; font-family: times new roman,new york,times,serif; font-size: 16px; font-style: normal;">
Expanding
Medicaid in Virginia holds the potential to provide better patient
outcomes, and to save money. Failing to expand Medicaid access
threatens a financial crisis to healthcare providers, hospitals, and
anyone who is insured--and I have not heard of ANY action in the General
Assembly or from the Governor that would address this potential crisis.</div>
<div id="yui_3_7_2_23_1359337308080_472" style="background-color: transparent; color: black; font-family: times new roman,new york,times,serif; font-size: 16px; font-style: normal;">
<br id="yui_3_7_2_23_1359337308080_477" /></div>
<div id="yui_3_7_2_23_1359337308080_474" style="background-color: transparent; color: black; font-family: times new roman,new york,times,serif; font-size: 16px; font-style: normal;">
I believe the way forward is clear: expand Medicaid as called for in the ACA. </div>
<div id="yui_3_7_2_23_1359337308080_516" style="background-color: transparent; color: black; font-family: times new roman,new york,times,serif; font-size: 16px; font-style: normal;">
<br id="yui_3_7_2_23_1359337308080_523" /></div>
<div id="yui_3_7_2_23_1359337308080_520" style="background-color: transparent; color: black; font-family: times new roman,new york,times,serif; font-size: 16px; font-style: normal;">
Sincerely,</div>
<div id="yui_3_7_2_23_1359337308080_525" style="background-color: transparent; color: black; font-family: times new roman,new york,times,serif; font-size: 16px; font-style: normal;">
<br id="yui_3_7_2_23_1359337308080_530" /></div>
<div id="yui_3_7_2_23_1359337308080_527" style="background-color: transparent; color: black; font-family: times new roman,new york,times,serif; font-size: 16px; font-style: normal;">
Mark Ryan, MD, FAAFP</div>
<br />
---------- <br />
<br />
If you are a Virginia voter, you can click <a href="http://conview.state.va.us/whosmy.nsf/VGAMain?openform" target="_blank">here</a> to find your state Senator and Delegate. RichmondDochttp://www.blogger.com/profile/17928931511086527042noreply@blogger.com0tag:blogger.com,1999:blog-3831362075230684289.post-58174608029107830822012-11-04T18:10:00.003-05:002012-11-04T18:10:37.011-05:00Why physician groups support the Affordable Care Act(Originally posted on the <a href="http://npalliance.org/blog/2012/11/04/why-physician-groups-support-the-affordable-care-act/" target="_blank">National Physicians Alliance blog</a> November 4, 2012) <br />
<br />
--------------------<br />
<br />
Physicians must care about our patients. In every decision we make
and each action we take, the health and wellness of our patients and our
communities must be at the center of what we do. The Affordable Care
Act (ACA) will make your healthcare better.<br />
<br />
Our organization--the National Physicians Alliance (NPA)--was formed
in 2005 and is committed to advancing the core values of the medical
profession: service, integrity, and advocacy. The organization has key <a _mce_href="http://npalliance.org/about/guiding-principles/" href="http://npalliance.org/about/guiding-principles/">guiding principles </a>that
focus on putting our patients health and wellness above all other
concerns. NPA's advocacy has emphasized the need to ensure patient
protection and to repair the <a _mce_href="http://npalliance.org/broken_covenant.html" href="http://npalliance.org/broken_covenant.html">broken covenant </a>that
our nation's healthcare system must benefit all Americans. Our
commitment and our obligation to care for our patients is limited by
many factors: insurance company policies that restrict the care we can
provide, health disparities that persist despite individual efforts to
address them, and a lack of insurance that limits access to health
insurance and healthcare.<br />
<br />
As a result of NPA's determination to <a _mce_href="http://npalliance.org/equitable-affordable-health-care-for-all/" href="http://npalliance.org/equitable-affordable-health-care-for-all/">ensure equitable and affordable healthcare for all Americans</a>,
the organization has worked to secure the passage of the ACA and to
advocate for its full implementation. In keeping with NPA's guiding
principles, our support of the ACA has been focused on the benefits the
law provides to patients as well as its protection of the doctor-patient
relationship we hold as a sacred responsibility as professionals.<br />
<br />
How does the ACA protect patients?<br />
<br />
<strong>The ACA provides important benefits for ALL Americans</strong>: The ACA provides multiple benefits for the middle class. Considering <a _mce_href="http://www.washingtonpost.com/wp-srv/politics/documents/american_journal_of_medicine_09.pdf" href="http://www.washingtonpost.com/wp-srv/politics/documents/american_journal_of_medicine_09.pdf" target="_blank">the major role that healthcare costs play in personal bankruptcies</a>
(PDF), it is clear that ensuring the affordability of healthcare
provides a crucial protection for middle class Americans. Affordable
insurance--made more so by government support to help lower income
families and changes in insurance enrollment that are predicted to
reduce the cost for all--will allow most Americans to see <a _mce_href="http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&ved=0CEAQFjAA&url=http%3A%2F%2Fwww.mathematica-mpr.com%2Fpublications%2FPDFs%2Fhealth%2Freformhealthcare_IB1.pdf&ei=T_uVULHDO6qV0QHmqoCgDg&usg=AFQjCNGcFFMa8JwgygXXyGU8XPGqOOVewQ" href="http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&ved=0CEAQFjAA&url=http%3A%2F%2Fwww.mathematica-mpr.com%2Fpublications%2FPDFs%2Fhealth%2Freformhealthcare_IB1.pdf&ei=T_uVULHDO6qV0QHmqoCgDg&usg=AFQjCNGcFFMa8JwgygXXyGU8XPGqOOVewQ" target="_blank">the health benefits of having health insurance</a>
(PDF). Adult children will now be able to stay on parents' insurance
policies until they are 26 years old, thereby enhancing their ability to
<a _mce_href="http://aspe.hhs.gov/health/reports/2012/YoungAdultsbyGroup/ib.shtml" href="http://aspe.hhs.gov/health/reports/2012/YoungAdultsbyGroup/ib.shtml" target="_blank">access health insurance</a>
while in school and starting out in the workforce. Coupled with
reforms that will remove limits on annual and lifetime coverage benefits
for patients, Americans will be better protected as they look to move
into the middle class and secure a better future for themselves and
their families. In addition, preventive care services including
vaccines, pap smears, colonoscopies, and other necessary services will
be made available to Americans without requiring co-pays, making them
more available than ever before.<br />
<br />
<strong>The ACA promotes fairness and equality in medical care</strong>: The ACA reverses one of the most egregious facts of healthcare insurance in the US: the fact that a <a _mce_href="http://www.blogher.com/do-women-pay-more-health-insurance-men" href="http://www.blogher.com/do-women-pay-more-health-insurance-men" target="_blank">person's gender was the basis for charging women more for health insurance than men</a>. This difference exists only because a woman was a woman, and is <a _mce_href="http://www.nwlc.org/sites/default/files/pdfs/nwlc_2012_turningtofairness_report.pdf" href="http://www.nwlc.org/sites/default/files/pdfs/nwlc_2012_turningtofairness_report.pdf" target="_blank">not due to specific coverage</a> (PDF) such as for pregnancy or maternity care. The <a _mce_href="http://www.healthcare.gov/news/factsheets/2010/07/health-disparities.html" href="http://www.healthcare.gov/news/factsheets/2010/07/health-disparities.html" target="_blank">ACA will also target national healthcare inequalities</a>
by strengthening the nation's community health centers, increasing the
number of physicians working in medically underserved areas by <a _mce_href="http://healthreformgps.org/resources/aca-funds-to-support-national-health-service-corps/" href="http://healthreformgps.org/resources/aca-funds-to-support-national-health-service-corps/" target="_blank">increasing National Health Service Corps scholarships</a>. Finally, the ACA begins to <a _mce_href="http://www.healthreform.gov/newsroom/primarycareworkforce.html/" href="http://www.healthreform.gov/newsroom/primarycareworkforce.html/" target="_blank">address our national need for more primary care physicians</a> and move towards a healthcare workforce that is accessible to all.<br />
<br />
<strong>The ACA protects patients from insurance company abuses</strong>:
Thanks to the ACA, insurance companies will have less control over
patients' healthcare. Insurers will be required to offer insurance to
everyone regardless of whether or not they have a preexisting medical
condition--a benefit that has <a _mce_href="www.healthcare.gov/law/features/rights/childrens-pre-existing-conditions/index.html" href="http://npalliance.org/wp-admin/www.healthcare.gov/law/features/rights/childrens-pre-existing-conditions/index.html" target="_blank">already gone into effect for children</a>
and is planned to go into effect for adults in 2014. The ACA prevents
insurance companies from setting arbitrary limits to patients' lifetime
health insurance benefits, and as of 2014 will eliminate annual limits
to care. <a _mce_href="http://www.forbes.com/sites/carolynmcclanahan/2012/05/15/what-is-a-medical-loss-ratio-the-check-will-be-in-the-mail/" href="http://www.forbes.com/sites/carolynmcclanahan/2012/05/15/what-is-a-medical-loss-ratio-the-check-will-be-in-the-mail/" target="_blank">Insurance companies are required to spend 80-85% of members' premiums on providing benefits to those members</a>,
as opposed to using that money for administrative costs or executive
salaries. The ACA bans the practice of rescissions, in which insurance
companies would seek reasons to retroactively cancel members' insurance
coverage once those members became ill and most needed the protection.
The <a _mce_href="http://www.hhs.gov/news/press/2012pres/01/20120112a.html" href="http://www.hhs.gov/news/press/2012pres/01/20120112a.html" target="_blank">ACA provides greater governmental scrutiny of unreasonable insurance rate hikes</a>,
helping insure that Americans are not being harmed by insurers
willfully increasing policy costs without reason or justification.
Finally, by establishing health insurance marketplaces (or exchanges),
the ACA will require all insurers to show the purchasers of their
products--our patients--that the companies are effective and responsive
to their customers' needs or they will risk patients finding coverage
elsewhere. This should increase transparency and provide greater
benefits to patients who will be able to vote with their feet and leave
ineffective companies to look for better options.<br />
<br />
The NPA is not the only physician organization to support the ACA. The law is also supported by the <a _mce_href="http://www.ama-assn.org/ama/pub/news/letters-editor/2012-07-06-wsj-ama-support-of-affordable-care-act.page" href="http://www.ama-assn.org/ama/pub/news/letters-editor/2012-07-06-wsj-ama-support-of-affordable-care-act.page" target="_blank">American Medical Association</a>, the <a _mce_href="http://www.aap.org/en-us/about-the-aap/aap-press-room/pages/At-Supreme-Court-AAP-Highlights-Benefits-of-Affordable-Care-Act.aspx?nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR%3a+No+local+token" href="http://www.aap.org/en-us/about-the-aap/aap-press-room/pages/At-Supreme-Court-AAP-Highlights-Benefits-of-Affordable-Care-Act.aspx?nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR%3a+No+local+token" target="_blank">American Academy of Pediatrics</a>, the <a _mce_href="http://www.aafp.org/online/en/home/policy/federal/issues/reform/ppaca.html" href="http://www.aafp.org/online/en/home/policy/federal/issues/reform/ppaca.html" target="_blank">American Academy of Family Physicians</a>, the <a _mce_href="http://www.acponline.org/pressroom/aca.htm" href="http://www.acponline.org/pressroom/aca.htm" target="_blank">American College of Physicians</a>, the<a _mce_href="http://www.acog.org/About_ACOG/News_Room/News_Releases/2012/ACOG_President_Applauds_Supreme_Court_Ruling" href="http://www.acog.org/About_ACOG/News_Room/News_Releases/2012/ACOG_President_Applauds_Supreme_Court_Ruling" target="_blank"> American Congress of Obstetricians and Gynecologists</a>, the <a _mce_href="https://www.aamc.org/newsroom/newsreleases/295714/120628.html" href="https://www.aamc.org/newsroom/newsreleases/295714/120628.html" target="_blank">Association of American Medical Colleges</a>, and the <a _mce_href="http://www.osteopathic.org/inside-aoa/news-and-publications/media-center/2011-news-releases/Pages/1-17-2011-affordable-care-act-statement.aspx" href="http://www.osteopathic.org/inside-aoa/news-and-publications/media-center/2011-news-releases/Pages/1-17-2011-affordable-care-act-statement.aspx" target="_blank">American Osteopathic Association</a>.<br />
<br />
The reasons all of these physician groups support the ACA is simple.
As physicians, the law's reforms allow us to provide better care for
our patients--without being limited by insurance regulations or lack of
access to health insurance. The ACA removes important barriers to care,
and lets us get back to the core focus of our profession: the covenant
to do whatever we can to improve our patients' health and wellness.RichmondDochttp://www.blogger.com/profile/17928931511086527042noreply@blogger.com1tag:blogger.com,1999:blog-3831362075230684289.post-49411600750456609122012-10-28T14:46:00.001-04:002012-10-28T14:46:14.520-04:00Partnering with communities: why and how?To enhance the impact medicine can have in addressing healthcare disparities, it is often necessary to work outside of the clinical space. One-on-one clinical care is critically important for the individual, but can only address the individual's need at that point in time. Although this is the core of medicine--the doctor/patient relationship--it is not sufficient to address broader issues.<br />
<br />
I believe that physicians' roles in leadership and community focus require us to look beyond the clinic to bring necessary change. At the minimum, I believe that physicians need to be advocates for necessary change: at the organizational and/or at the political level, we must be pushing for policies that will improve the health of our communities.<br />
<br />
At the same time, it can often very valuable to develop partnerships in the community itself. However one defines community, the community's members will have a strong sense of the community's strengths, needs, and challenges. However, in many cases forming a productive and effective relationship with underserved communities can be challenging. Many times, these communities may feel isolated and marginalized. In some cases, they may actively distrust medical institutions based on past experiences.<br />
<br />
Every community is unique, and effective community partnerships will all differ in some way. However, there are some general themes that can guide the process in developing community partnerships:<br />
<br />
<ul>
<li>Demonstrate genuine commitment</li>
<li>Have a long time horizon--things will move slower than you would prefer</li>
<li>Assess the communities needs and values, and respect them</li>
<li>Expect challenges and strife: pre-empt them if you can, address them when needed</li>
<li>Understand that all decisions carry political consequences</li>
<li>Good intentions are dangerous things: consider the ethics of your intervention<br /> Identify and engage the community's leadership (official and unofficial)</li>
<li>Inspiration and interest on our part can help generate an idea, but need community guidance for any intervention</li>
<li>Listen, think, talk...then act</li>
<li>Tolerate of uncertainty</li>
<li>Know that communities are heterogeneous, even if there are not any apparent differences on the surface</li>
<li>Align incentives: look for space where your interests/motivations/rewards align with the community's</li>
</ul>
By approaching a community guided by these principles, the resulting partnerships will be more robust, more beneficial, and more respectful. RichmondDochttp://www.blogger.com/profile/17928931511086527042noreply@blogger.com1tag:blogger.com,1999:blog-3831362075230684289.post-47194539905803937732012-07-18T09:48:00.000-04:002012-07-18T09:48:27.751-04:00If it is a problem, why don't you have a solution?First published on the <a href="http://occupyhealthcare.net/2012/07/if-it-is-a-problem-why-dont-you-have-a-solution/" target="_blank">OccupyHealthcare blog</a><span id="goog_1904330400"></span><span id="goog_1904330401"></span>, July 18 2012.<br />
<br />
--------------------<br />
<br />
Just about three weeks ago, the Supreme Court ruled that the Patient
Protection and Affordable Care Act (ACA) was constitutional in its
requirement that all Americans have health insurance. However, the
court also decided that the ACA's expansion of Medicaid eligibility and
coverage could not be forced upon the states. States could opt to
expand Medicaid as the law required, but those states that choose not to
expand would not face the loss of their current Medicaid funding.
Already,<a data-mce-href="http://thehill.com/blogs/healthwatch/health-reform-implementation/236033-fifteen-governors-reject-or-leaning-against-expanded-medicaid-program" href="http://thehill.com/blogs/healthwatch/health-reform-implementation/236033-fifteen-governors-reject-or-leaning-against-expanded-medicaid-program" target="_blank"> a number of Governors have declared their opposition to this Medicaid expansion</a>.<br />
<br />
The
ACA's expansion of Medicaid is an important part of the law's efforts
to expand coverage and healthcare access to most Americans. The law
would require the <a data-mce-href="http://www.forbes.com/sites/bernardkrooks/2012/07/10/medicaid-expansion-under-the-affordable-care-act-what-happens-when-states-refuse-to-enlarge-this-coverage-to-its-residents/" href="http://www.forbes.com/sites/bernardkrooks/2012/07/10/medicaid-expansion-under-the-affordable-care-act-what-happens-when-states-refuse-to-enlarge-this-coverage-to-its-residents/" target="_blank">expansion of Medicaid</a>
to cover individuals up to 133% of the Federal poverty level. The
Federal government will pay 100% of this expansion for the first three
years, a level of support that gradually lowers to 90% over the next
five years. It is expected that, as designed, the ACA's Medicaid
expansion would provide coverage to 17 million Americans. The law's new
health insurance exchanges, that facilitate individuals' purchase of
health insurance and provides subsidies for those with incomes between
133% and 400% Federal poverty level, would account for the rest of the
ACA's increase in health insurance coverage.<br />
<br />
Late last week, the <a data-mce-href="http://rgppc.com/medicaid-and-exchange-letter-2/" href="http://rgppc.com/medicaid-and-exchange-letter-2/" target="_blank">Republican Governors Association (RGA) sent the Obama Administration a letter</a>
outlining their concerns about the proposed Medicaid expansion and the
ACA's health insurance exchanges. The letter, signed by Virginia
Governor Bob McDonnell, has one particularly notable passage:<br />
<a data-mce-href="http://occupyhealthcare.net/wp-content/uploads/2012/07/JPEG-RGA-Letter.jpg" href="http://occupyhealthcare.net/wp-content/uploads/2012/07/JPEG-RGA-Letter.jpg"><img alt="" class="aligncenter size-full wp-image-2660" data-mce-src="http://occupyhealthcare.net/wp-content/uploads/2012/07/JPEG-RGA-Letter.jpg" height="63" src="http://occupyhealthcare.net/wp-content/uploads/2012/07/JPEG-RGA-Letter.jpg" title="JPEG RGA Letter" width="400" /></a><br />
The
reason this passage struck me is because of its chutzpah. The RGA's
own members are those who will make the decisions for their states as to
whether or not the state will expand Medicaid coverage. However, if
the state chooses not to, it is somehow the fault of the Administration
for not having come up with an alternative plan. The letter purports to
show concern for those low-income Americans who would have been covered
by the Medicaid expansion (if not for the Governors' decisions to
reject it), and expects the federal government to provide a means of
coverage for these low-income individuals.<br />
<br />
Of course, the ACA does
provide a means for low-income people to access health insurance: it
expands Medicaid. The RGA's letter is absurd, essentially saying: "If
we reject the remedy you have developed to cover low-income Americans,
you must come up with an alternative." This is even more striking if
one reviews the underlying reasons why the states might reject the
Medicaid expansion: they claim it is a violation of states' rights. If
the states are worried about expansion of federal power, how is asking
the Federal government for an answer to a state's own rate of uninsured
individuals in any way logical? If anything, the states should be
fixing this problem themselves <i>if</i> they were following their
argument to its logical conclusion. Instead of asking for Federal help,
the states should have already addressed this issue.<br />
<br />
The states
that have already rejected the ACA's Medicaid expansion include Texas
and Florida. Both states are among those with the <a data-mce-href="http://www.gallup.com/poll/153053/texas-widens-gap-states-percentage-uninsured.aspx" href="http://www.gallup.com/poll/153053/texas-widens-gap-states-percentage-uninsured.aspx" target="_blank">highest rates of uninsured</a>.<br />
<br />
<a data-mce-href="http://occupyhealthcare.net/wp-content/uploads/2012/07/Uninsured.jpg" href="http://occupyhealthcare.net/wp-content/uploads/2012/07/Uninsured.jpg"><img alt="" class="aligncenter size-medium wp-image-2659" data-mce-src="http://occupyhealthcare.net/wp-content/uploads/2012/07/Uninsured-232x300.jpg" height="300" src="http://occupyhealthcare.net/wp-content/uploads/2012/07/Uninsured-232x300.jpg" title="Uninsured" width="232" /></a><br />
<br />
Mississippi
is second on this list, and is also considering rejecting the Medicaid
expansion. The states whose residents would gain the most in terms of
access to health insurance are those who are fighting this increase in
access. These three states also have Republican governors, who have not
come up with a better plan to improve access to insurance as of yet.
If Republican governors truly thought that low-income Americans' access
to health insurance was a problem, they have had ample time to come up
with a solution...and they have not done so.<br />
<br />
<a data-mce-href="http://www.nejm.org/doi/full/10.1056/NEJMp1108222" href="http://www.nejm.org/doi/full/10.1056/NEJMp1108222" target="_blank">Medicaid coverage improves health outcomes</a>,
with the trade-off of an initial cost increase (possibly as those who
have been insured finally access care). With the Federal government
covering 100% of the initial expansion, they (not the states) would be
paying for these up-front costs. Given that Medicaid is more
cost-effective than private insurers (point 7 on <a data-mce-href="http://www.kaiserhealthnews.org/stories/2009/july/01/medicaid-true-or-false.aspx" href="http://www.kaiserhealthnews.org/stories/2009/july/01/medicaid-true-or-false.aspx" target="_blank">this list</a>), expanding access to health insurance via a program that is both cost-effective and beneficial is a smart move. Meanwhile, <a data-mce-href="http://www.commonwealthfund.org/Publications/In-the-Literature/2003/Jun/The-Costs-and-Consequences-of-Being-Uninsured.aspx" href="http://www.commonwealthfund.org/Publications/In-the-Literature/2003/Jun/The-Costs-and-Consequences-of-Being-Uninsured.aspx" target="_blank">we know that being uninsured is bad for one's health</a>.<br />
<br />
Thanks
to the ACA, we now have the tools to expand health insurance--and
health care--to 30 million more Americans. Those who decry the law's
reforms have, for the most part, failed to act in their own states and
have failed to present a viable alternative. If the ACA's opponents
thought the<a data-mce-href="http://www.politico.com/blogs/politico-live/2012/07/mitch-mcconnell-uninsured-not-the-issue-127814.html" href="http://www.politico.com/blogs/politico-live/2012/07/mitch-mcconnell-uninsured-not-the-issue-127814.html" target="_blank"> issues of heath insurance and access to health care were a problem</a>,
they would have acted long ago. It is time for them to stop
obstructing this important step forward to improve Americans' health.RichmondDochttp://www.blogger.com/profile/17928931511086527042noreply@blogger.com0tag:blogger.com,1999:blog-3831362075230684289.post-77472456217881947492012-06-29T07:59:00.003-04:002012-06-29T07:59:28.484-04:00The healthcare aftermath of June 28, 2012: What we protected, what is missing, and what we still need to do(Originally posted on the <a href="http://occupyhealthcare.net/2012/06/the-healthcare-aftermath-of-june-28-2012-what-we-protected-what-is-missing-and-what-we-still-need-to-do/" target="_blank">OccupyHealthcare blog</a> June 28, 2012)<br />
<br />
--------------------<br />
<br />
Yesterday, the Supreme Court upheld the constitutionality of the Patient Protection and Affordable Care Act (PPACA). After nearly 2 1/2 years of partisan misinformation, the Court has established the law's legitimacy.<br /><br />This is an enormous step forward. The PPACA incorporates many patient protections that will reduce the profit-centered influence of for-profit insurance companies on American's healthcare. Once the law is fully implemented in 2014, insurers will no longer be able to deny insurance coverage to any American even if they have pre-exisiting medical illnesses and will no longer be able to place yearly or lifetime limits on members' benefits. Insurance companies will be required to spend 80-85% of the money members pay in premiums on providing benefits to members as opposed to salaries and administrative costs. Young adults will be able to stay on parents' insurance plans until they turn 26--meaning that they can keep necessary insurance coverage as they finish their educations or start their careers. Federal subsidies will make insurance affordable for Americans who are not offered insurance through their jobs and cannot afford to purchase it on their own. Private insurers have called the shots for too long, and restricted access to necessary care for Americans who could not afford it or who were already ill. These days are now coming to an end.<br /><br />The PPACA also addresses key needs in our healthcare system. It will strengthen our primary care workforce and our community health centers. It will encourage research that is both patient-centered and evidence-based, to help patients and physicians make informed decisions about the best approaches to individuals' care. The PPACA also makes preventive care available for all without co-pays, allowing healthcare providers to detect and treat (or even prevent) chronic disease before they cause permanent harm. The law will increase Medicaid access and will strengthen Medicare. Finally, the PPACA includes programs to explore new ways of providing (and paying for) healthcare services that are more effective, more coordinated, and less expensive.<br /><br />All of these are critical patient protections and healthcare system reforms. The protections will allow us to make sure that healthcare is available with less interference on the part of insurance companies and reforms the most egregious insurance company practices. The reforms will allow us to start to move our healthcare system away from one providers are paid more for doing more care and towards a system that provides better care. These are significant steps, and reforms that the Supreme Court has now endorsed and guaranteed so long as the Affordable Care Act is in effect.<br /><br />However, the law is an incomplete step forward. It still leaves a number of Americans lacking health insurance, and explicitly prevents many immigrants from accessing care. The PPACA supports private, for-profit insurance companies with public money in the form of subsidies to help low-income Americans pay for insurance. There were still be fragmented care as patients will still move between private and public insurances or between private insurers. There is little in the law to address the high and increasing costs of pharmaceuticals and medical devices. By building upon the flawed structure of individual private insurance companies, the PPACA cannot offer the savings inherent in single-payer systems where administrative costs are lowered, coverage and access are assured to all. The political environment in Washington, DC would not allow for such a significant move as a single-payer system. In fact, the law barely survived in its current form. This does not mean that we should rest on our laurels: even with the PPACA's reforms there will be much more work to do.<br /><br />We must monitor how the PPACA is enacted, and we must avoid its reforms being co-opted or weakened by special interests and the law's stubborn opponents. Where the law does not meet its intended results, we must revise it to ensure that it will. We must identify those who do not benefit from the law as written and work to find ways to extend the law's benefits to all. We must continue to speak about the law's benefits and make sure that our friends, families, and colleagues understand how very important this law is.<br /><br />We must be vigilant heading forward. Although the PPACA is constitutional, congressional opponents can continue their attempts to repeal and defund the law. Rest assured that, if they are able to, they will do just that. The House is already planning a repeal vote on July 11. Under the PPACA, the economic and human costs of allowing millions of Americans to go without health care are finally being addressed. We cannot afford to take any steps backwards: there is still a long road ahead.RichmondDochttp://www.blogger.com/profile/17928931511086527042noreply@blogger.com0tag:blogger.com,1999:blog-3831362075230684289.post-83506722074435753072012-06-25T10:54:00.000-04:002012-06-25T10:54:09.708-04:00Global Health and Underserved Communities: Challenges and Rewards<div id="yui_3_2_0_20_1339683796232186">
<span id="yui_3_2_0_20_133968379623266">From May 29 to June 9, I traveled on a medical relief trip to the Dominican Republic. Below is the text of an e-mail I sent the team, which I include here because I believe it states my position on the challenges and rewards that one can attain for working with underserved communities in the US and overseas.</span><br />
<span id="yui_3_2_0_20_133968379623266"><br /></span><br />
<span id="yui_3_2_0_20_133968379623266">--------------------</span><br />
<br />
<span id="yui_3_2_0_20_133968379623266">I
wanted to send this note to thank everyone for their hard work and for
making the trip successful. For those new to global health projects
such as this, I realize it is a difficult adjustment to make: the long
hours, the constant work, the uncertainty around schedules and plans,
and the constant feel that we should, somehow, be doing more than we
are. The recognition that the need is greater than our ability to
respond to it, and how we can come to terms with that without
necessarily accepting it, and how we can use our resources and skills to
do our part in helping the patients we work with. <br />
</span></div>
<div id="yui_3_2_0_20_1339683796232397">
<span id="yui_3_2_0_20_133968379623266"><br />
</span></div>
<div id="yui_3_2_0_20_1339683796232398">
<span id="yui_3_2_0_20_133968379623266">This
is a heavy task: in healthcare, we all would like to think that we can
make big differences through our profession, when the humbling truth is
that often the best we can do is to be a small part of a larger
process. I believe we are obligated to help our patients to the extend
of their needs and to the best of our abilities, but this means that
there will always be someone who we could not reach, or for whom our
skills were not sufficient. <br />
</span></div>
<div id="yui_3_2_0_20_1339683796232399">
<span id="yui_3_2_0_20_133968379623266"><br />
</span></div>
<div id="yui_3_2_0_20_1339683796232400">
<span id="yui_3_2_0_20_133968379623266">This
is not a comfortable place to be, whether in the US or overseas. I
think working in developing nations makes this gap between resources and
needs more evident, but as you continue your training in Richmond you
will start to notice more and more examples of the mismatch between what
people need and what we can offer. </span></div>
<div id="yui_3_2_0_20_1339683796232401">
<br />
<span id="yui_3_2_0_20_133968379623266"></span></div>
<div id="yui_3_2_0_20_1339683796232402">
<span id="yui_3_2_0_20_133968379623266">The
best approach to help as many people as possible is to determine where
you can have an impact, and to work as a team to get the most out of
what we have. We chose to put a lot of focus on diabetes and high blood
pressure because, as medical and pharmacy professionals, this is where
our greatest skill set lies. However, our summer clinical work fits
into the larger picture of our ongoing community development work in the
Dominican Republic: work that aims to address sanitation, flooding, and
other broad social determinants of health. The fact that our ongoing
commitment to the community leverages our skills and matches them to
with community development project allows us to address health on many
more levels than if these two initiatives were separate. We may have
only done a small part, but it is a small part of a greater whole.</span></div>
<div id="yui_3_2_0_20_1339683796232655">
<br />
<span id="yui_3_2_0_20_133968379623266"></span></div>
<div id="yui_3_2_0_20_1339683796232656">
<span id="yui_3_2_0_20_133968379623266">At
the same time, our part was not especially small. In the community, we
provided healthcare to nearly 500 people: people who would have lacked
care if we were not present. For some, this involved treating blood
pressure and other chronic illness. For some, this involved parasite
medications and vitamins to enhance nutrition. For some this involved
coming to get medications to use if problems such as back pain or
stomach pain developed in the future. However, I was taught that the role of a healer is to </span>"cure
sometimes, relieve often, comfort always" and, as with that as a
guiding principle, I believe that there is value in doing our best to
care for everyone regardless of the objective severity of their illness.</div>
<div id="yui_3_2_0_20_1339683796232793">
<br /></div>
<div id="yui_3_2_0_20_1339683796232794">
It would have been impossible to
have seen the over 600 patients (when both clinical sites are added up)
without teamwork, collaboration, and a unified sense of mission.
Despite the challenges noted above, you responded brilliantly. Whether
working registration, vitals, pharmacy or seeing patient, everyone
willingly stepped forward to do what needed to be done to make sure that
we met our commitments to our patients and to each other.</div>
<div id="yui_3_2_0_20_1339683796232847">
<br /></div>
<div id="yui_3_2_0_20_1339683796232848">
For all of this, I thank each and
every one of you for being part of this exceptional team. I look
forward to working with some (many? all?) of you again in the future.</div>RichmondDochttp://www.blogger.com/profile/17928931511086527042noreply@blogger.com0tag:blogger.com,1999:blog-3831362075230684289.post-15601149791905170332012-06-24T14:48:00.002-04:002012-06-24T15:28:11.329-04:00#MedRead (part 3): Non-fiction books: Health policy, healthcare reform, and healthcare redesignRecently, I made a request on Twitter for suggestions for books that
medical students should read. These suggestions could be books of any
sort: fiction, non-fiction, clinically-focused, etc. I was hoping to
get suggestions for books that made a meaningful impact on people. I'll
be posting the lists in a series of blog posts.<br />
<br />
In each case, I've linked the book title to its <a href="http://powells.com/">Powells.com</a>
listing...mainly because I didn't want to link to larger sites such as
Amazon. In practice, I would strongly advise looking for these books at
the library (to test them out--use <a href="http://www.worldcat.org/" target="_blank">this site</a> to find the books at a library near you) or at your local independent bookstore (such as <a href="http://www.chopsueybooks.com/" target="_blank">Chop Suey Books</a>,
in Richmond). Remember that if you're local bookseller doesn't carry
these titles, they can probably order them for you--and they'll keep
your money local.<br />
<br />
Alternately, if you wish to support
the authors directly, feel free to see if you can purchase the book you
are interested in from the author's own website.<br />
<br />
This is the third installment, focused on health policy, healthcare reform, and healthcare redesign. The first installment is <a href="http://richmonddoc.blogspot.com/2012/03/medreads-part-1-non-fiction-books.html" target="_blank">here</a>, and the second is <a href="http://richmonddoc.blogspot.com/2012/03/medread-part-2-non-fiction-books.html" target="_blank">here</a>.<br />
<br />
<a href="http://www.powells.com/biblio/95-9780520931473-0" target="_blank">Pathologies of Power</a> – Paul Farmer<br />
<br />
<a href="http://www.powells.com/biblio/17-9781586489342-1" target="_blank">Landmark: The Inside Story of America's New Health Care Law, and What It Means For Us All</a> – Washington Post Staff<br />
<br />
<a href="http://www.powells.com/biblio/62-9780071770521-1" target="_blank">Understanding Health Policy</a> -- Bodenheimer and Grumbach<br />
<br />
<a href="http://www.powells.com/biblio/2-9780465079353-9" target="_blank">The Social Transformation of American Medicine</a> – Paul Starr<br />
<br />
<a href="http://www.powells.com/biblio/1-9780773532540-3" target="_blank">The Last Well Person: How To Stay Well Despite The Health-Care System</a> – Nortin Hadler <br />
<br />
<a href="http://www.powells.com/biblio/62-9780375760945-0" target="_blank">The Truth About the Drug Companies: How They Deceive Us and What to Do about It</a> – Marcia Angell<br />
<br />
<a href="http://www.powells.com/biblio/1-9781560258568-8" target="_blank">Selling Sickness: How the World's Biggest Pharmaceutical Companies Are Turning Us All Into Patients</a> – Ray Moynihan<br />
<br />
<a href="http://www.powells.com/biblio/1-9781582345796-4" target="_blank">Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer</a> – Shannon Brownlee<br />
<br />
<a href="http://www.powells.com/biblio/2-9780061344763-0" target="_blank">Overdosed America: The Broken Promise of American Medicine</a> – John Abramson<br />
<br />
<a href="http://www.powells.com/biblio/1-9780465025503-1" target="_blank">Creative Destruction of Medicine: How the Digital Revolution will Create Better Healthcare</a> – Eric Topol<br />
<br />
<a href="http://www.powells.com/biblio/65-9780743264761-2" target="_blank">Time To Die : How American Hospitals Shape the End of Life</a> – Sharon Kaufman<br />
<br />
<a href="http://www.amazon.com/Let-record-show-Medical-malpractice/dp/0966545419" target="_blank">Let the Record Show: Medical Malpractice, the Lawsuit Nobody Wins</a> – J. Kelley Avery<br />
<br />
<a href="http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics.page" target="_blank">AMA Code of Medical Ethics</a><br />
<br />
<a href="http://www.powells.com/biblio/1-9780060765330-6" target="_blank">Money Driven Medicine: The Real Reason Healthcare Costs so Much</a> – Maggie Mahar<br />
<br />
<a href="http://www.powells.com/biblio/61-9781439816141-0" target="_blank">Health Care Will Not Reform Itself: A User's Guide to Refocusing and Reforming American Health Care</a> – George C. Halvorson<br />
<br />
<a href="http://www.powells.com/biblio/62-9780787962203-1" target="_blank">Through the Patients’ Eyes: Understanding and Promoting Patient-Centered Care</a> – Margaret Gerteis<br />
<br />
<a href="http://www.powells.com/biblio/61-9780387209784-1" target="_blank">Caring for the Country: Family Doctors in Small Rural Towns</a> – Howard Rabinowitz<br />
<br />
<a href="http://www.infibeam.com/Books/info/Lorraine-M-Wright/Beliefs-and-Families-A-Model-for-Healing/0465023177.html#newUsedBooks" target="_blank">Beliefs and Families: A Model for Healing Illness</a> – Lorraine M. Wright, Wendy Watson, and Janice M. Bell<br />
<br />
<a href="http://www.powells.com/biblio/61-9780195300048-2" target="_blank">On the Take: How Medicine's Complicity with Big Business Can Endanger Your Health </a>– Jerome P. Kassirer<br />
<br />
<a href="http://www.powells.com/biblio/66-9781780660004-0" target="_blank">The Patient Paradox: Why Sexed Up Medicine Is Bad for Your Health</a> – Margaret Mccartney (A more-detailed description can be found <a href="http://www.pinterandmartin.com/the-patient-paradox" target="_blank">here</a>.)<br />
<br />
If you have read these books (or if you recommended them), please use
the comments below to provide us with some thoughts on why the book
mattered to you.RichmondDochttp://www.blogger.com/profile/17928931511086527042noreply@blogger.com0tag:blogger.com,1999:blog-3831362075230684289.post-51929765768744077262012-06-12T10:17:00.000-04:002012-06-12T10:17:00.138-04:00ACA triggers insurer reforms...but the law is still necessary.(First published on the <a href="http://npalliance.org/blog/2012/06/12/aca-triggers-insurer-reforms-but-the-law-is-still-necessary/" target="_blank">National Physicians Alliance blog, June 12 2012</a>)<br />
--------------------<br />
<br />
Yesterday, three major insurers announced that they would keep in place major insurance reforms introduced in the Patient Protection and Affordable Care Act (ACA), regardless of how the Supreme Court decides regarding the law's constitutionality.
<br />
<br />
<a href="http://www.newsmax.com/US/insurers-keep-obamacare-reforms/2012/06/11/id/441937">UnitedHealth, Aetna, and Humana all announced</a> that they would continue allowing children under age 26 to remain on parents' health insurance plans, allow independent appeals of insurance decisions, and cover certain preventive services.<br />
<br />
Although this move by these for-profit insurers appears to be a good thing, there are two important considerations to remember. The first is that none of these insurers have agreed to issue insurance plans regardless of pre-existing conditions. If an individual with prior medical problems applies for insurance from these organizations, the insurers can still deny coverage. This would no longer be possible once the ACA is fully implemented. Therefore, the law is still critically important to make sure that <i>all</i> Americans will have access to health insurance coverage.<br />
<br />
The second consideration is that the ACA was the catalyst for insurers to change their practices. For-profit insurers have been around for a long time, and had plenty of opportunity to implement these reforms on their own. However, none did until the ACA was passed and signed into law. The provisions that the insurers plan to keep in place are the law's most popular provisions, but they were not established by the insurers in a vacuum. The ACA put these reforms in place, the public realized that they were beneficial, and now the insurers have decided to reform their practices accordingly. If not for the ACA, I deeply doubt we would have seen any sort of insurance reforms of this sort. In fact, when the law was being developed, insurers <i>defended</i> their rights to rescind patients' coverage. The ACA deserves full credit for forcing insurers to enact these important patient protection reforms.<br />
<br />
Despite the fact that insurers have belatedly agreed to support these patient protections, the law is still critically important:
<br />
<ul>
<li>Not all insurers have agreed to sustain these important reforms. Blue Cross/Blue Shield, Wellpoint, and Cigna are hedging their bets until the Supreme Court's decision is known and declined to make any commitments in response to yesterday's announcements from UnitedHealth, Aetna and Humana. Considering the size of these insurers, this would place many Americans at risk of losing insurance coverage if the ACA's protections were lost.</li>
<li>The ACA provides subsidies for Americans who cannot afford to pay for private insurance out-of-pocket. These subsidies make health insurance, which is otherwise prohibitively expensive for many Americans, affordable and available. Without the ACA, the insurers could claim to make their coverage available to many in the sense that it is technically available, but could price it at a level that places it out of reach.</li>
<li>One of the major ways that the ACA will expand insurance coverage is by expanding Medicaid. This will provide access to health insurance for millions of low-income Americans, something that these actions by the insurance companies will not affect.</li>
<li>The ACA requires private insurers to spend 80-85% of the money they receive in premium payments on providing health care services (instead of using this money for administrative costs, salaries, etc). This is known as the medical loss ratio (MLR). The ACA's MLR requirements will mean that the money individuals pay to ensure they have insurance coverage will actually be used to provide insurance benefits. None of the insurance companies have pledged to maintain this ratio heading forward should the ACA be overturned.</li>
</ul>
Although it is good to see insurers pledging to keep important patient-centered reforms in place, it is necessary to put this in context. The insurers are agreeing only to keep in place the ACA's most popular reforms and reform some of their most egregious practices. They are <i>not</i> pledging to make their products less expensive (or more affordable) to the average American, they are <i>not</i> agreeing to offer coverage to all Americans regardless of pre-existing medical conditions, they are <i>not</i> agreeing to follow the ACA's MLR guidelines. Finally, not all insurers have agreed to continue the new practices required by the ACA.<br />
<br />
The ACA has forced insurers to make some meaningful changes in how they practice--changes the insurers had given no indication they would enact on their own. This shows the law's power and effectiveness: thanks to the ACA, millions of Americans will have more robust insurance coverage, regardless of the Supreme Court's decision. However, what the private insurers have omitted from their promises to extend the ACA's benefits shows why we still need this important piece of healthcare reform: it is a critical step to ensure affordable and accessible healthcare insurance for all.RichmondDochttp://www.blogger.com/profile/17928931511086527042noreply@blogger.com0tag:blogger.com,1999:blog-3831362075230684289.post-72350552587354863192012-04-29T21:53:00.000-04:002012-04-29T21:53:54.337-04:00The Cost Depends on the Value(Initially <a href="http://occupyhealthcare.net/2012/04/the-cost-depends-on-the-value/" target="_blank">published April 27, 2012 on the OccupyHealthcare blog</a>.)<br />
<br />
-------------------- <br />
<br />
Last week, <a href="http://www.medscape.com/features/slideshow/compensation/2012/public#">Medscape released the results of their 2011 survey of physician compensation</a>:<br />
<img alt="" class="alignright" height="272" src="http://img.medscape.com/pi/features/slideshow-slide/compensation/2012/public/fig2.jpg" width="400" /><br />
<br />
I share this post here to point out the discrepancy in physicians' average salaries based on their specialties. In particular, I would like to highlight that the three lowest-paid specialties are the three primary care specialties: pediatrics, family medicine, and general internal medicine.<br />
<br />
This post is not written to argue that physicians must be paid more. I would submit that if physicians cannot live on $150,000 then we might be doing something wrong...and we are unlikely to get much sympathy from the average person.<br />
<br />
Rather, my intent is to note how <a href="http://www.aafp.org/online/en/home/publications/news/news-now/government-medicine/20110112feescheduleltr.html" target="_blank">undervalued</a> primary care services are in our current system of healthcare delivery and payment. Primary care physicians--the physicians who provide <a href="http://www.commonwealthfund.org/usr_doc/Starfield_Milbank.pdf" target="_blank">comprehensive care, who provide preventive care, who coordinate care</a>--are paid less than all other medical specialists. Radiology and anesthesiology make nearly twice what primary care doctors do; dermatology and anesthesiology make nearly 175% of the average primary care physician.<br />
<br />
This is not to say that these medical specialists do not have important roles in providing medical care; however, should a physician who views x-rays and imaging studies be valued at twice the level of the physicians who keep our children well, who monitor their development and intervene if necessary, and who ensure children are fully vaccinated? Should a physician who deals with skin problems be paid at nearly twice the level of a physician who can deal with many of the same skin problems...while also addressing patients' diabetes, blood pressure, heart disease, and mental illness?<br />
<br />
The cost of any given service or item depends on its value. Precious metals are expensive because we value them greatly. Luxury cars are expensive because they are highly valued in our culture. Primary care physicians in the US are paid less than all other specialists, and cost less per physician than all other specialists...indicating that the primary care specialties are valued less than other medical specialties.<br />
<br />
We have previously noted the <a href="http://occupyhealthcare.net/2012/02/on-the-shoulders-of-giants/" target="_blank">importance of primary care to a high-functioning, efficient, and effective healthcare system</a>. Despite the key role primary care should be playing, however, the chart above shows that primary care is not valued at a commensurate level.<br />
<br />
Unless <a href="http://occupyhealthcare.net/2011/12/the-primary-care-challenge-and-solution/" target="_blank">we value primary care</a>, and redesign our healthcare delivery and payment systems to reflect this, then we will continue to have a healthcare system that under-performs even as healthcare<a href="http://www.kaiseredu.org/Issue-Modules/US-Health-Care-Costs/Background-Brief.aspx" target="_blank"> costs continue to increase</a>. The cost depends on the value: so long as we do not value primary care, then costs will rise even as outcomes do not improve.<br />
<br />
This situation is untenable, and must change. We must demand a healthcare system that values those services and specialties that reduce costs. We must enhance primary care's role in our system in order to improve our system's performance. If we change what type of medical care our system values, then we can truly affect cost.RichmondDochttp://www.blogger.com/profile/17928931511086527042noreply@blogger.com0tag:blogger.com,1999:blog-3831362075230684289.post-55186543554815217082012-03-13T09:00:00.000-04:002012-03-13T09:00:08.399-04:00Setting the Stage for the ACA's Second Anniversary(First published on the <a href="http://npalliance.org/?p=4576" target="_blank">National Physicians Alliance blog</a> March 13, 2012)<br />
<br />
--------------------<br />
<br />
In one week, the Patient Protection and Affordable Care Act (PPACA,
or ACA for short) will attain its second anniversary. In preparation
for the media attention this milestone will attract, it is necessary to
set the stage regarding the ACA's achievements and popularity.<br />
<br />
First, a review of what the reforms already in place as a result of the ACA: <a _mce_href="http://www.commonwealthfund.org/Health-Reform/Health-Reform-Resource.aspx" href="http://www.commonwealthfund.org/Health-Reform/Health-Reform-Resource.aspx">this timeline</a> provides a good summary, as does <a _mce_href="http://www.healthcare.gov/law/timeline/index.html" href="http://www.healthcare.gov/law/timeline/index.html">this timeline</a>. A review of these timelines shows that the ACA has already led to the following changes:<br />
<ul>
<li>Young adults can stay on parents' insurance policies until age 26.</li>
<li>People with preexisting medical conditions who have been uninsured
for at least 6 months can access care via Preexisting Condition
Insurance Plans.</li>
<li>Insurance companies can no longer rescind patients insurance, and have eliminated lifetime caps on insurance benefits.</li>
<li>Children can no longer be denied medical care due to preexisting medical conditions.</li>
<li>Seniors have received discounts and rebates on their medication costs via Medicare Part D.</li>
<li>Patients can receive many preventive care services without paying co-pays.</li>
<li>Funding has been increased for community health centers and for the National Health Service Corps.</li>
<li>Increased targeting of healthcare fraud.</li>
<li>Insurance companies will be held accountable for unreasonable
premium rate increases, and are being required to spend at least 80-85%
of the premiums they receive on providing necessary medical services to
beneficiaries.</li>
</ul>
These are among the <a _mce_href="http://www.kff.org/kaiserpolls/upload/8259-F.pdf" href="http://www.kff.org/kaiserpolls/upload/8259-F.pdf" target="_blank">ACA's reforms that are favored by individuals on both sides of the political spectrum</a>
(pdf link). Even before the ACA's major reforms become active in 2014,
the law is already improving the status of healthcare in America.<br />
<br />
It can be anticipated that there will be a great deal of critical
commentary about how the ACA represents a governmental overreach and
that Americans resent this supposed power grab. However, in the most
recent <a href="http://www.kff.org/kaiserpolls/8281.cfm" target="_blank">Kaiser Family Foundation Health Tracking poll</a> (pdf), 35% of Americans
would like to see the law <i>expanded</i>, while 19% would like to see
the law kept in its current form. When 54% of the nation would like to
leave the law as is or expand its reforms, it is hard to argue that
most Americans oppose the ACA in the way that the law's opponents would
have us believe: they might highlight that 72% of Americans oppose
keeping the ACA in its current form, but 1/2 of that number <i>want the law expanded</i>.
This underlines the disingenuous nature of the claims made against the
ACA: the law's opponents highlight those bits of data that can be
presented as supporting their claims, but conveniently omit the details
that undercut their claims.<br />
<br />
<a _mce_href="http://www.politico.com/news/stories/0112/71967.html" href="http://www.politico.com/news/stories/0112/71967.html" target="_blank">Opponents of the ACA also have chosen not to propose any replacement for the law any time soon</a>,
despite the fact that the House of Representatives actually voted to
repeal the law in 2011. While the Republican Party delays action, <a _mce_href="http://www.npr.org/blogs/health/2012/03/07/148171728/1-in-3-americans-is-having-a-hard-time-paying-medical-bills?ft=1&f=1128&sc=tw" href="http://www.npr.org/blogs/health/2012/03/07/148171728/1-in-3-americans-is-having-a-hard-time-paying-medical-bills?ft=1&f=1128&sc=tw" target="_blank">1/3 of Americans are struggling to pay their medical bills</a>.
This statistic illustrates the reasons that the ACA's reforms were so
badly needed: Americans cannot easily afford necessary medical care.
The law will address this directly as the health benefits exchanges come
online in 2014, but the reforms noted above stand to improve this
statistic.<br />
<br />
We will certainly hear more and more reasons that the ACA was
unconstitutional, especially as the Supreme Court will be hearing
arguments on the law's constitutionality the week following the law's
anniversary. One of the major arguments against the ACA focuses on the
law's mandate that individuals purchase health insurance or face paying a
penalty. <a _mce_href="http://www.thenation.com/article/166672/why-obamas-healthcare-law-constitutional" href="http://www.thenation.com/article/166672/why-obamas-healthcare-law-constitutional" target="_blank">This article</a> nicely encapsulates arguments as to how and why the ACA and its individual mandate are both constitutional and necessary.<br />
<br />
This is where we stand: the ACA is already benefiting Americans, many
of whom are in favor of the law's reforms or who would have preferred
more expansive reforms. The need for reform is clearly evident, and the
ACA's opponents have not proposed any meaningful answer to the current
crisis in healthcare access and affordability. Despite the law's
opponents' fervent claims and beliefs, the law's constitutionality can
be supported in a number of ways.<br />
<br />
If you support the ACA's healthcare reforms, get ready, be vocal, and stand tall. The week of March 19-23, 2012 promises to be quite active.RichmondDochttp://www.blogger.com/profile/17928931511086527042noreply@blogger.com0tag:blogger.com,1999:blog-3831362075230684289.post-23804471134002039132012-03-11T17:13:00.002-04:002012-03-11T18:48:25.096-04:00Poverty in Richmond, Virginia: We Have Our Work Cut Out For UsToday, I attended the first part of a <a href="http://www.richmondfriendsmtg.org/Lists/Events/DispForm.aspx?ID=178&Source=http%3A%2F%2Fwww.richmondfriendsmtg.org%2Fdefault.aspx" target="_blank">three part series of presentations focused on the nature of poverty in Richmond, Virginia</a>. Today's presentation was focused on a review of the data; the next will discuss the history that led to this situation, and the final presentation will discuss suggested interventions that might address this issue. The nature of poverty in the city is especially notable because concentrated poverty compounds desperation and leads to hopelessness and alienation. The presentations are based on <a href="http://www.styleweekly.com/richmond/richmond-professor-stumps-for-the-destitute/Content?oid=1494995" target="_blank">the work of Dr. John Moeser</a>, of the University of Richmond's Bonner Center for Civic Engagement.<br />
<br />
The data is focused on the Richmond Planning District. In 2010, the poverty level for a family of 4 was a yearly income under $22,314. In Richmond City, the rate of those living in poverty increased from 22.1% to 25.8% 2009-2010. Poverty rates rose 18.2%-25.8% 2000-2010. Poverty in the city is at an historical high since 1970. Just as important is the fact that the proportion of those living in poverty in surrounding counties increased from 2000 to 2010 by 94% in Henrico and 71% in Chesterfield. 46% of those in poverty in the Richmond area live in the city; 54% of the region's poor now live in the suburbs. This shift in poverty in the Richmond area reflects a national trend of increasing poverty in suburbs. <br />
<br />
There is also a significant level of wealth inequity in the region. In Richmond City, the wealthiest census tract has an average income 17x greater than the poorest. Wealthiest census tract in central VA has an average income 21x the poorest. Despite this great difference between the riches and poorest residents in the city, there is very little physical distance: there are only 3 1/2 miles separating the wealthiest census tract in the city (Windsor Farms) and the poorest (Gilpin Court).<br />
<br />
Further details regarding <i>who</i> is poor in Richmond is also striking. Currently, 38% of children in Richmond City live in poverty; this is double the rate from 1990. If one looks at poverty by race, it is notable that 48% of the poor are black. However, the % of all whites and Hispanic community living in poverty have increased. In particular, the % Hispanic community living in poverty increased from 8%-23.5% from 1990-2009. [Editorial note: I think this might represent the fact that the Hispanic community has nearly doubled throughout the Richmond metro area in the last 10 years; many of these newly-arrived individuals and families earn annual incomes below the poverty level.]<br />
<br />
Most poor whites live in the suburbs (69%) in suburbs; 61% of all black poor live in the city. Asian and Latino poverty is largely suburban. Overall, Hispanic and black poverty are typically higher density, whether in city or in suburbs; while white poverty less concentrated. More than 20% of the population living in poverty in Richmond City is concentrated in south and east Richmond. 5 census tracts in the city have more than 50% of their residents living in poverty; Gilpin Court has 69% of its residents living in below the poverty line. Concentrated poverty in the City of Richmond is largely found east of Chamberlayne Ave, and on both sides Jefferson Davis Highway south of the river. These areas of concentrated poverty align with the locations of public housing developments. There is no concentrated public housing in counties, but concentrated poverty in the city spills over from the city to the older inner ring of suburbs. There are some census tracts in the city where poverty rates declined, and older housing stock is renovated via gentrification. At the same time, there are some census tracts that have increased in the % of their residents living under the poverty line. Overall, "South Richmond is the city's new East End" with increasingly concentrated poverty. This shift appears to be largely related to increased Hispanic poverty.<br />
<br />
For anyone who believes (as I do) that <a href="http://richmonddoc.blogspot.com/2011/11/why-social-determinants-of-health.html" target="_blank">the social determinants of health matter</a>, then this information is striking and relevant. Improving communities' and individuals' health will require more than disease-focused outreach and prevention programs. We will need to refocus on affecting and influencing public policy in such a way as to take health, education, income, etc. into account whenever policy decisions are made. This is less immediate, and perhaps less gratifying, then working one-on-one with patients...but it is equally (or, perhaps, even more) important work. Physicians need to involve ourselves in discussions about policy changes and we need to hold our elected leaders accountable for making decisions that will improve the health status of all people--both by improving healthcare, and by including healthcare considerations when discussion <i>all</i> policy issues.RichmondDochttp://www.blogger.com/profile/17928931511086527042noreply@blogger.com0tag:blogger.com,1999:blog-3831362075230684289.post-32180123616195405662012-03-11T08:30:00.000-04:002012-06-24T14:46:46.892-04:00#MedRead (part 2) Non-fiction books: Patient narratives, culture, society, and science<style>
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<br />
This is the second in a series of blog posts that will list books recommended for medical students as a result my asking for suggestions on Facebook and Twitter. This second installment (<a href="http://richmonddoc.blogspot.com/2012/03/medreads-part-1-non-fiction-books.html" target="_blank">the first installment can be read here</a>) focuses on society, patient narratives, science, and culture.<br />
<br />
In each case, I've linked the book title to its <a href="http://powells.com/">Powells.com</a>
listing...mainly because I didn't want to link to larger sites such as
Amazon. In practice, I would strongly advise looking for these books at
the library (to test them out--use <a href="http://www.worldcat.org/" target="_blank">this site</a> to find the books at a library near you) or at your local independent bookstore (such as <a href="http://www.chopsueybooks.com/" target="_blank">Chop Suey Books</a>,
in Richmond). Remember that if you're local bookseller doesn't carry
these titles, they can probably order them for you--and they'll keep
your money local.<br />
<br />
Alternately, if you wish to support
the authors directly, feel free to see if you can purchase the book you
are interested in from the author's own website.<br />
<div class="MsoNormal" style="margin-left: 0.25in;">
<br /></div>
<a href="http://www.powells.com/biblio/1-9780684872988-4" target="_blank">Grand Pursuit: The Story of Economic Genius</a> – Sylvia Nasar<br />
<br />
<a href="http://www.powells.com/biblio/1-9780374525644-85" target="_blank">The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures</a> – Anne Fadiman<br />
<br />
<a href="http://www.powells.com/biblio/1-9780312241353-9" target="_blank">And the Band Played On: Politics, People, and the AIDS Epidemic</a> – Randy Shilts<br />
<br />
<a href="http://www.powells.com/biblio/2-9781586481216-3" target="_blank">A Question of Intent: A Great American Battle with a Deadly Industry</a> – David Kessler<br />
<br />
<a href="http://www.powells.com/biblio/61-9780300135749-2" target="_blank">Medicine and Human Welfare</a> – Henry Sigerist<br />
<br />
<a href="http://www.powells.com/biblio/62-9789562915717-0" target="_blank">Guerrilla Warfare</a> – Ernesto Guevara<br />
<br />
<a href="http://www.powells.com/biblio/1-9780802716750-8" target="_blank">28 Stories of AIDS in Africa</a> – Stephanie Nolen<br />
<br />
<a href="http://www.powells.com/biblio/2-9781400078431-19" target="_blank">The Year of Magical Thinking</a> – Joan Didion<br />
<br />
<a href="http://www.powells.com/biblio/2-9780060569662-7" target="_blank">Autobiography of a Face</a> – Lucy Grealy<br />
<br />
<a href="http://www.powells.com/biblio/1-9780312626686-1" target="_blank">Nickle and Dimed</a> – Barbara Ehrenreich<br />
<br />
<a href="http://www.powells.com/biblio/1-9780802150837-25" target="_blank">Wretched of the Earth</a> – Frantz Fanon<br />
<br />
<a href="http://www.powells.com/biblio/2-9780826412768-11" target="_blank">Pedagogy of the Oppressed</a> – Paulo Friere<br />
<br />
Anything by Emily Martin: A good start might be <a href="http://www.powells.com/biblio/62-9780691141060-1" target="_blank">Bipolar Expeditions: Mania and Depression in American Culture</a><br />
<br />
<a href="http://www.powells.com/biblio/18-9781400052189-0" target="_blank">Immortal Life of Henrietta Lacks</a> – Rebecca Skloot<br />
<br />
<a href="http://www.powells.com/biblio/62-9780807001219-0" target="_blank">The Match: "Savior Siblings" and one Family's Battle to Heal Their Daughter</a> – Beth Whitehouse<br />
<br />
<a href="http://www.powells.com/biblio/1-9780767915472-0" target="_blank">Medial Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present</a> – Harriet Washington<br />
<br />
<a href="http://www.powells.com/biblio/1-9781594482694-12" target="_blank">The Ghost Map: The Story of London’s Most Terrifying Epidemic—and how it Changed Science, Cities, and the Modern World</a> – Steven Johnson<br />
<br />
<a href="http://www.powells.com/biblio/7-9780375506161-8" target="_blank">Mountains Beyond Mountains</a> – Tracy Kidder<br />
<br />
<a href="http://www.powells.com/biblio/61-9780465037780-0" target="_blank">Treatment Kind and Fair: Letters to a Young Doctor</a> – Perry Klass<br />
<br />
<a href="http://www.powells.com/biblio/2-9780060929596-8" target="_blank">As Nature Made Him: The Boy who was Raised as a Girl</a> – John Colapinto<br />
<br />
Anything by Richard Feynman: <a href="http://www.powells.com/biblio/2-9780393320923-2" target="_blank">What Do You Care What Other People Think? Further Adventures of Curious Character</a> seems a good start.<br />
<br />
<a href="http://www.powells.com/biblio/95-9781439107751-0" target="_blank">A Whole New Life: An Illness and a Healing</a> – Reynolds Price<br />
<br />
<a href="http://www.powells.com/biblio/7-9780226001395-3" target="_blank">Mama Might Be Better Off Dead: The Failure of Health Care in Urban America</a> – Laurie Kaye Abraham<br />
<br />
<a href="http://www.powells.com/biblio/1-9780395488973-14" target="_blank">Let Us Now Praise Famous Men</a> – James Agee and Walker Evans<br />
<br />
<a href="http://www.powells.com/biblio/9780061733215" target="_blank">Broke, USA: From Pawnshops to Poverty, Inc – How the Working Poor Became Big Business</a> – Gary Rivlin<br />
<br />
<a href="http://www.powells.com/biblio/62-9780927534819-2" target="_blank">Barefoot Heart: Stories of a Migrant Child</a> – Elva Treviño Hart<br />
<br />
<a href="http://www.powells.com/biblio/1-9781439102817-4" target="_blank">Still Alice</a> – Lisa Genova<br />
<br /><a href="http://www.powells.com/biblio/1-9780307387097-2" target="_blank">Half the Sky: Turning Oppression into Opportunity for Women Worldwide</a> – Nicholas Kristof and Sheryl WuDunn <br />
<br />
If you have read these books (or if you recommended them), please use
the comments below to provide us with some thoughts on why the book
mattered to you.<br />
<div class="MsoListParagraph" style="mso-list: l0 level1 lfo1; text-indent: -.25in;">
<br /></div>RichmondDochttp://www.blogger.com/profile/17928931511086527042noreply@blogger.com2tag:blogger.com,1999:blog-3831362075230684289.post-45221584093744144042012-03-04T20:18:00.000-05:002012-06-24T14:56:51.182-04:00#MedRead (part 1) Non-fiction books: Physician Narratives, Medical Practice, and IllnessesRecently, I made a request on Twitter for suggestions for books that medical students should read. These suggestions could be books of any sort: fiction, non-fiction, clinically-focused, etc. I was hoping to get suggestions for books that made a meaningful impact on people. I'll be posting the lists in a series of blog posts.<br />
<br />
In each case, I've linked the book title to its <a href="http://powells.com/">Powells.com</a> listing...mainly because I didn't want to link to larger sites such as Amazon. In practice, I would strongly advise looking for these books at the library (to test them out--use <a href="http://www.worldcat.org/" target="_blank">this site</a> to find the books at a library near you) or at your local independent bookstore (such as <a href="http://www.chopsueybooks.com/" target="_blank">Chop Suey Books</a>, in Richmond). Remember that if you're local bookseller doesn't carry these titles, they can probably order them for you--and they'll keep your money local.<br />
<br />
Alternately, if you wish to support the authors directly, feel free to see if you can purchase the book you are interested in from the author's own website.<br />
<br />
The first group includes books that focus on medical practice, physicians' narratives, and the medical aspects of disease:<br />
<br />
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<br />
<a href="http://www.powells.com/biblio/1-9780767922470-2" target="_blank">Every Patient Tells a Story: Medical Mysteries and the Art of Diagnosis</a><style>
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<span style="font-family: "Times New Roman"; font-size: 12pt;">–
Lisa Sanders</span>
<br />
<br />
<a href="http://www.powells.com/biblio/2-9780547053646-2" target="_blank"> How Doctors Think</a> – Jerome Groopman<br />
<br />
<a href="http://www.powells.com/biblio/68-9780330523622-1" target="_blank">The Man Who Mistook his Wife for a Ha</a>t – Oliver Sacks<br />
<br />
<a href="http://www.powells.com/biblio/2-9780679742449-2" target="_blank">How We Die: Reflections on Life's Final Chapter</a> – Sherwin Nuland<br />
<br />
<a href="http://www.powells.com/biblio/61-9781583222614-1" target="_blank">The Case of Doctor Sachs</a> – Martin Winckler<br />
<br />
<a href="http://www.powells.com/biblio/2-9781581510331-0" target="_blank">House Calls</a> – Thomas Stern, MD<br />
<br />
Anything by Atul Gawande: <a href="http://www.powells.com/biblio/17-9780312421700-21" target="_blank">Complications</a>, <a href="http://www.powells.com/biblio/2-9780312427658-15" target="_blank">Better</a>, and <a href="http://www.powells.com/biblio/2-9780312430009-2" target="_blank">The Checklist Manifesto</a>.<br />
<br />
<a href="http://www.powells.com/biblio/61-9780472031979-2" target="_blank">White Coat, Clenched Fist</a> – Fitzhugh Mullan<br />
<br />
<a href="http://www.powells.com/biblio/2-9780679752929-9" target="_blank">My Own Country</a> – Abraham Verghese<br />
<br />
<a href="http://www.powells.com/biblio/2-9780071407991-1" target="_blank">Of Spirits and Madness</a> – Paul Linde<br />
<br />
<a href="http://www.powells.com/biblio/1-9780679737261-10" target="_blank">A Fortunate Man</a> – John Berger <br />
<br />
<a href="http://www.powells.com/biblio/17-9780140250916-15" target="_blank">The Coming Plague</a> – Laurie Garrett<br />
<br />
<a href="http://www.powells.com/biblio/2-9780786884407-1" target="_blank">Betrayal of Trust</a> – Laurie Garrett<br />
<br />
<a href="http://www.powells.com/biblio/1-9780807001264-0" target="_blank">Medicine in Translation: Journeys with my Patients</a> – Danielle Ofri<br />
<br />
<a href="http://www.powells.com/biblio/61-9780809074013-0" target="_blank">Not All of Us are Saints: A Doctor’s Journey with the Poor</a> – David Hilfiker<br />
<br />
<a href="http://www.powells.com/biblio/1-9780060509057-11" target="_blank">Travels</a> – Michael Crichton <br />
<br />
<a href="http://www.powells.com/biblio/2-9781876175702-2" target="_blank">The Motorcycle Diaries</a> – Ernesto Che Guevara<br />
<br />
<a href="http://www.powells.com/biblio/17-9780143036494-8" target="_blank">The Great Influenza</a> – John Barry<br />
<br />
<a href="http://www.powells.com/biblio/7-9780307275370-1" target="_blank">Final Exam: A Surgeon's Reflection on Mortality</a> – Pauline Chen<br />
<br />
<a href="http://www.powells.com/biblio/1-9780140243277-5" target="_blank">The Youngest Science: Notes of a Medicine-Watcher</a> – Lewis Thomas <br />
<br />
<a href="http://www.medicalarchives.jhmi.edu/osler/aeqtable.htm" target="_blank">Aequanimitas</a> – Sir William Osler<br />
<br />
<a href="http://www.powells.com/biblio/62-9780807061442-0" target="_blank">White Coat, Black Hat: Adventures on the Dark Side of Medicine</a> – Carl Elliott<br />
<br />
<a href="http://www.powells.com/biblio/2-9781439170915-10" target="_blank">The Emperor of All Maladies: A Biography of Cance </a>– Siddhartha Mukherjee<br />
<br />
<a href="http://www.powells.com/biblio/1-9781400082131-7" target="_blank">The Demon Under the Microscope: From Battlefield Hospitals to Nazi Labs, One Doctor's Heroic Search for the World's First Miracle Drug</a> – Thomas Hager<br />
<br />
<a href="http://www.amazon.com/blind-mans-marathon-Steven-Hatch/dp/1595940383" target="_blank">Blind Man's Marathon </a>– Steven Hatch<br />
<br />
If you have read these books (or if you recommended them), please use the comments below to provide us with some thoughts on why the book mattered to you.<br />
<br />
<div class="MsoListParagraph" style="text-indent: -0.25in;">
<br /></div>RichmondDochttp://www.blogger.com/profile/17928931511086527042noreply@blogger.com4