The value of mentorship

I 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.

    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.

    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.

    I am honored to consider Gus a mentor, a colleague, and a friend.  I was glad when he received the Medical Society of Virginia Foundation's 2013 Salute to Service Award for Service to the Profession.  You can hear some of Gus's story in his own words here.  I could not imagine a better recipient, or a better role model.

Some thoughts on healing

Late last year, I led a session for our MS1 students in which we discussed the idea of healing.  We used this article 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.

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.

Healing is made more difficult because of what people heal from.  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.

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.

What is the Value of the Doctor/Patient Relationship?

(In response to Abraham Verghese's TED talk)

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.

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.

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. 

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.

Relationships are critically important, and so are patients' expectations and experiences.  In the case of research around the placebo effect 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?

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.

A 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.

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.

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.

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.

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.

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.

Hopefully, you will see more on this blog soon.  Thanks to all those who might have been bearing with me.

What 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.

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:

• Ensuring safe, accessible, affordable healthcare for all.
• 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).
• Emphasizing evidence-based medicine and good stewardship of our patients' and our nations' resources.
• Encourage civic engagement as part of medical practice.

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.

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.

I hope you will join me in supporting NPA. Physicians: please consider becoming a supporting member of NPA. Everyone else: please consider making a tax-deductible organization to support this organization's great work.

Please support Medicaid expansion in Virginia

I am writing to ask Virginia's General Assembly to expand Medicaid in Virginia. 

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.

I would like to provide a few examples as to why this expansion is so important:

• Medicaid expansion in other states has been associated with reduced mortality: http://www.nejm.org/doi/full/10.1056/NEJMsa1202099
• 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): http://www.nejm.org/doi/full/10.1056/NEJMp1108222
• Medicaid expansion will cost Virginia less, both in the short and the long term: http://www.thecommonwealthinstitute.org/2013/02/01/revised-medicaid-expansion-still-saves-money-in-virginias-budget/ and http://www.timesdispatch.com/news/state-regional/government-politics/medicaid-expansion-would-save-initially-va-official-says/article_e379990f-75b1-5fc0-9931-241fa922c4fb.html
• 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.

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.

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.

I believe the way forward is clear: expand Medicaid as called for in the ACA. 

Sincerely,

Mark Ryan, MD, FAAFP

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If you are a Virginia voter, you can click here to find your state Senator and Delegate.

Why physician groups support the Affordable Care Act

(Originally posted on the National Physicians Alliance blog November 4, 2012)

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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.

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 guiding principles 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 broken covenant 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.

As a result of NPA's determination to ensure equitable and affordable healthcare for all Americans, 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.

How does the ACA protect patients?

The ACA provides important benefits for ALL Americans: The ACA provides multiple benefits for the middle class.  Considering the major role that healthcare costs play in personal bankruptcies (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 the health benefits of having health insurance (PDF).  Adult children will now be able to stay on parents' insurance policies until they are 26 years old, thereby enhancing their ability to access health insurance 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.

The ACA promotes fairness and equality in medical care: The ACA reverses one of the most egregious facts of healthcare insurance in the US: the fact that a person's gender was the basis for charging women more for health insurance than men.  This difference exists only because a woman was a woman, and is not due to specific coverage (PDF) such as for pregnancy or maternity care.  The ACA will also target national healthcare inequalities by strengthening the nation's community health centers, increasing the number of physicians working in medically underserved areas by increasing National Health Service Corps scholarships.  Finally, the ACA begins to address our national need for more primary care physicians and move towards a healthcare workforce that is accessible to all.

The ACA protects patients from insurance company abuses:  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 already gone into effect for children 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.  Insurance companies are required to spend 80-85% of members' premiums on providing benefits to those members, 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 ACA provides greater governmental scrutiny of unreasonable insurance rate hikes, 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.

The NPA is not the only physician organization to support the ACA.  The law is also supported by the American Medical Association, the American Academy of Pediatrics, the American Academy of Family Physicians, the American College of Physicians, the American Congress of Obstetricians and Gynecologists, the Association of American Medical Colleges, and the American Osteopathic Association.

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.