The Coming Harm

Posting this here, because I don't think my local newspaper will actually publish it.

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To the Editor;

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to repeal the ACA was political bluster, and that now that Americans are seeing benefits from the law, it could not be repealed.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.

Sources:

http://familiesusa.org/product/defending-health-care-2017-what-stake-virginia

http://www.politico.com/story/2016/12/obamacare-republicans-repeal-replace-232025

http://www.vox.com/science-and-health/2016/12/13/13848794/kentucky-obamacare-trump

Join and support the National Physicians Alliance

I 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.

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 ACA began providing health access to millions of Americans in the context of better care and lower costs.

NPA focuses on service, integrity, and advocacy, and is guided by principles 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 social determinants of health such as the environment, available educational opportunities, housing, transportation, etc.

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 24 million Americans risk losing insurance. Women's access to reproductive health care risks being severely limited. Medicaid expansion would be rolled back as part of the repeal of the ACA, but the Medicaid program could be fundamentally restructured and lead to more coverage losses. Even Medicare, a program which has bedrock support, might be changed dramatically (information here).

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.

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.

Join us. Membership is free: http://action.npalliance.org/o/1021/content_item/signup.

Support us. Your support allows us to carry out key advocacy work without restrictions from outside funders: https://org.salsalabs.com/o/1021/donate_page/contribute-to-npa.

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.

Aquí estaré, por lo que vale

Amanecí 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.

Me encontré gravemente equivocado.

Y lo siento. Lamento mi parte en esta decisión. Yo voté en contra de Trump, pero temo que quizás no hice suficiente para oponerlo.

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.

Y quizás abandoné el trabajo que era necesario. Y quizás mis esfuerzos no eran suficiente.

Y ahora temo los daños que vienen. El odio y el prejuicio abierto con cual las comunidades por cual me he dedicado serán atacados.

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.

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.

Privilege and purpose

"Start where you are. Use what you have. Do what you can."--Arthur Ashe

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.

In 2009, the Affordable Care Act (ACA) was an idea, which became a proposal, which eventually became a law. A law that increased access to health insurance for millions of Americans and especially in communities of color and drastically reduced the numbers of children without insurance. 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.

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 speak out against the influence of politics on the doctor/patient relationship, and that we address gun violence as the public health issue that it is.

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.

I found myself waking up today asking if all these changes had been worth it.

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.

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?

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.

They will undo eight years of progress, all in the interest of protecting white privilege, and white male privilege to be precise.

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.

A Presidential Visit

Last 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.

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.

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.

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.

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 Richmond Memorial Health Foundation and another from the Virginia Health Care Foundation--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.

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.

Taking 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.

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 Virginia Academy of Family Physicians and had learned about the National Physicians Alliance.

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.

I have seen increasingly frequent discussions on the importance of primary care and family medicine, and have become a more-active member of the Society of Teachers of Family Medicine, 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.

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.

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.

I finally authored an article that was published. The article focuses on the benefit of an interprofessional service learning activity focused on providing care to Richmond's Latino community.

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.

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.

I will try to be less of a stranger heading forward, and appreciate those who might come along.

Extending the Mission: Family Medicine and Global Health

(Initially written for the Society of Teachers of Family Medicine Foundation's newsletter, The Wire)

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.

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.

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:

• 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.
• 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.
• 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.
• 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.

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.