Posted by & filed under Noah's Notes.

Although America’s health care system is often touted as “the best in the world” that is demonstrably untrue. A recent study published in Health Affairs magazine, however, indicates that we are a world leaders in one area of healthcare: inequality.

The difference between rich and poor as it pertains to access to care and health outcomes is dramatic in the US, and is among the most stark in the entire world.  In fact, in comparing 32 rich and middle class countries only Chile and Portugal were worse.  Some findings from the study, between 2011 and 2013:

  • 38% of people in households making less than $22,500 a year reported being in poor or fair health.
  • 12% of people in households making more than $47,700 a year reported being in poor or fair health.
  • 1 in 5 people in the lower 1/3 of income earners skipped medical treatments due to cost (only the Phillipines was worse than the US).
  • 1 in 25 people in the upper 1/3 of income earners skipped medical treatments due to cost.

Most alarmingly to me, 2/3 of Americans are aware that there are many Americans who do not have access to needed care, but only 54% of people believe that this disparity is unfair.  That indicates a very significant apathy toward the plight of the less fortunate in this country, and may reflect the US approach of attaching health care coverage to employment, and our bias about the unemployed or underpaid.

It’s important to note that this study was conducted before many of the Affordable Care Act policies were implemented, and US studies after that implementation indicated some promising trends, especially in states where Medicaid was expanded.  However, The American Health Care Act, proposed by Congress, would result in 23 million people in the US and 117,000 in Maine losing healthcare coverage and would remove many of the policies which expanded access to care.  That is certain to worsen disparities between the rich and poor.  The question is, does that matter to the American people?

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One of the biggest safety concerns across healthcare settings is diagnostic error, and unfortunately diagnostic error is relatively common.

It accounts for 17% of preventable errors in hospitalized patients and one autopsy study conducted over 40 years indicates that 9% of patients had important medical conditions that went undetected.  There are multiple factors which contribute to diagnostic error, flaws in the way we communicate and work together, lab and other diagnostic test errors, various members of the healthcare team working in isolation from each other (“silo effect”), and time pressure.

But our natural human tendencies and their influence on the manner in which we arrive at a diagnosis can also lead to errors.  Those of us responsible for making a diagnosis and creating a treatment plan have to obtain and process information like symptoms, duration of illness, physical exam findings, environment, past medical history, current clinical circumstance and individual patient characteristics, then identify a potential or “provisional” diagnosis which adequately explains all of this information and which will inform additional testing and treatment.  And it turns out that we have a tendency to develop mental short cuts or “rules of thumb” to arrive at those conclusions.  In the lingo of cognitive psychology those shortcuts are called heuristics, and we are especially prone to using heuristics when the presenting symptoms are common.  The Patient Safety Network recently listed some common areas of concern, referred to as cognitive bias, in our use of heuristics.  They include:

  • Availability heuristic – the diagnosis applied to a current patient is unduly influenced by experience with past cases, especially if the diagnostician had a positive or negative emotional experience with those cases
  • Anchoring heuristic – relying too heavily on initial impressions, sometimes developed before even talking to the patient (based on chief complaint, initial vital signs and labs, past experiences with the patient)
  • Framing effect – undue impact of subtle cues and collateral information (for example, staff tells you that patient always exaggerates their symptoms)
  • Blind obedience – giving exaggerated deference to a specialist’s opinion, or relying heavily on a test result

As you might imagine there is a growing body of literature on this topic and much to be learned.  But there are some strategies for mitigating the impact of cognitive bias.  These include regular feedback on performance and open discussion of diagnostic errors when they are identified, more autopsies (these used to be much more common and were important learning opportunities – unfortunately this is unlikely to occur), and the development and use of evidence based decision support software.  The creation of teams of clinicians who care for patients will also be an important improvement.  But right now each of us involved in the care of our patients can reflect on our own processes for diagnosing, how our team functions and where we can work to limit the negative impacts of cognitive bias.

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Congress has now released the American Health Care Act (AHCA), their proposal for replacing the Affordable Care Act (ACA), or what is commonly referred to as Obamacare.

There are some very important distinctions and in order to be informed about policy that impacts all of our lives and it’s helpful to be explicit about the most critical of those differences. So based on a summary that appeared in the New York Times here they are:

Individual mandate:

This is the requirement under the ACA that if you can afford it you must obtain health insurance. This helps to ensure that healthier people are in the market so the costs for those with more disease are less than they would be otherwise.  It is very similar to the requirement to have car insurance.  It makes the entire system sustainable. AHCA eliminates the individual mandate, but if you have insurance and lose it for any reason, you could pay a 30% premium penalty to re-obtain insurance.

Employer mandate:

The ACA requires that larger companies provide affordable insurance with a standard benefit set. AHCA repeals this requirement, which means more employed people may lose health insurance (and be subject to that 30% penalty noted above if they wish to purchase insurance on the individual market.

Subsidies for out of pocket expenses:

Under the ACA there is a federal tax credit for middle-income people to help offset the costs of co-payments and deductibles.  Under AHCA this is repealed.

Premium subsidies:

The ACA provides tax credits to middle-income people to help cover the cost of premiums.  AHCA  re-distributes these credits based on age, rather than income, so younger people and wealthier people will do better, and costs to poorer and older people would go up.  AHCA also expands the kinds of plans that would qualify for subsidy, including more “bare bone” plans that might appeal to young healthy people.

Medicaid expansion:

Under the ACA 31 states have expanded Medicaid coverage.  AHCA would allow that to continue until 2020 when coverage would effectively be gradually reduced for new people covered by Medicaid and those who go off and back on to Medicaid (a very common phenomenon as people on the margins gain and lose employment).  Federal funding per enrollee would be capped at 2016 levels, which would ultimately require reducing the number of people covered as medical inflation has its effect.

Health Savings Account:

The ACA allows an individual to place $3400 and a family to place $6750 a year into a tax free Health Savings Account.  AHCA would increase those amounts to at least $6500 and $13,100 respectively.  A good deal if you have that kind of flexibility with your income.

Increased charges for older people:

The ACA allows the oldest purchasers to be charged 3 times as much as the youngest.  AHCA would increase that to a factor of 5.

Pre-existing conditions:

The ACA prohibits discrimination against people with pre-existing conditions.  AHCA does as well, but that will be difficult to sustain without a mandate for coverage because the costs per enrollee will increase.

Both the ACA and AHCA require essential health benefits and prohibit annual and lifetime limits on coverage.


If you would like to learn more about what this might mean for you I recommend the Kaiser Family Foundation calculator, which compares your costs under each plan, should you have to buy insurance on the individual market.  It can be found here:

Posted by & filed under Noah's Notes.

On January 30, 1 week after his inauguration, President Trump issued sweeping Executive Orders which, among other things, blocked the entry of citizens from 7 predominantly Muslim countries for 90 days, barred all refugee entry for 120 days and indefinitely barred refugees from Syria.

The response to this action has been dramatic and plays itself out on our TV screens, on social media and in our everyday conversations.  Many medical professional organizations have issued formal statements and as a member of the American Academy of Family Physicians for over 30 years I am especially proud of the AAFP’s response.  In his letter to President Trump, AAFP President Dr. John Meigs, Jr. points out that 20% of our 125,000 members and 25% of our FP residents are international medical graduates, that like the rest of the country, we benefit from the talent and energy that these good people bring to our shared work, and that the full engagement of the talents, expertise and diversity of everyone in the healthcare community strengthens all of us and leads to better health outcomes.

The American Academy of Pediatrics issued a statement reaffirming their commitment to protecting the health and well-being of all children regardless of where they or their parents were born, and stated that the Executive Orders “are harmful to immigrant children and families throughout our country.  Many of the children who will be affected are the victims of unspeakable violence and trauma.  Children do not immigrate, they flee.”  And the American College of Physicians issued a statement emphasizing their commitment to non-discrimination and stated that “it is already clear to us that the Executive Order is resulting in discrimination based on religion against physicians and medical students from the designated countries…”.

The Executive Leadership of PCHC strongly and unequivocally affirms PCHC’s commitment to non-discrimination, to the value of each and every one of our employees, and to service to all members of our communities, and we embrace our explicitly stated value of respect,  by promoting diversity as a strength, both to PCHC and to our community at large.

  • EMHS and St. Joseph Healthcare leadership have issued similar statements for their staffs.
  • Graduates of foreign medical schools make up 25% of the US physician workforce.
  • Nurses, researchers, technicians and other healthcare workers are also impacted.
  • Those who have visas may feel threatened, reluctant to travel or targeted.
  • Bangor has physicians from 26 countries providing care for our community, and many are from countries impacted by the immigration ban.

It seems like an appropriate moment to share a blog which I wrote over a year ago, entitled “Pay Back”:

I want to pay back Muslims for what they’ve done. I mean it. Their actions have impacted my life profoundly and I am compelled to act. I cannot stay quiet any longer, or refrain from doing what I must. I need to get even.  It’s a long list.

For the Muslims who taught me and helped to mold me as a physician, I will pay you back by being the best mentor and educator that I can be.

For the Muslims who shared in the care of my patients, and helped to improve my skill and knowledge in providing that care, I will pay you back by always trying to improve in my craft, and imparting the same lessons to willing colleagues.

For the Muslims who helped to teach me about their tradition, I will pay you back by helping others understand.

For the Muslims who wrote books that have inspired me and added depth to my thinking, I will pay you back by sharing your ideas and your works.

And for the Muslims who have been my friends, and have shown me their warm, embracing hospitality and unending support and encouragement, you know who you are. I’m coming after you…and I want a hug.

Posted by & filed under Noah's Notes.

On November 17 The U.S. Surgeon General, Dr. Vivek H. Murthy released the first ever Surgeon General’s report addressing substance abuse and addiction.

Entitled “Facing Addiction in America” this remarkable 500 page document summarizes all that we know about this disease and its treatment and creates a hopeful roadmap for the future. As General Murthy points out:

  • 21 million Americans have a substance use disorder (for the vast majority it is alcohol)
  • 66 million people report binge drinking each year
  • 88,000 people die each year from complications of alcohol
  • 47,000 die from complications of drug use.

The total annual cost of all of this, including lost productivity, criminal justice and treatment is $442 billion. These ought to be compelling arguments for policy makers, healthcare systems, public health organizations, caregivers, and education systems to act. And the combined and collaborative effort of all of these sectors is exactly what the report repeatedly and convincingly recommends.

Dr. Murthy explains and emphasizes the neuro-biologic basis of substance use disorders (also known as addiction), highlights evidence based preventive education for all age groups, summarizes the evidence supporting effective treatment for Opioid Use Disorder and stresses the need for integration of screening for, and the diagnosis and treatment of use disorders in all health care settings. His vision for the future includes:

  • Reframing substance use disorders in a public health context, rather than a criminal justice context (although he acknowledges the effectiveness and supports the use of modest law enforcement interventions, such as the positive impact of OUI laws in decreasing deaths from drunk driving)
  • Expanding access to evidence based treatment
  • Implementation of broad prevention programs
  • Full integration of substance abuse/substance use disorder treatment services within the rest of healthcare
  • Coordination and implementation of laws requiring equal coverage for mental health and substance abuse under the Affordable Care Act (this may be threatened if the new administration repeals or retracts the ACA)
  • Ongoing research to guide the public health approach in the future

The Surgeon General’s recommendations for healthcare delivery systems include:

  • Promotion of primary prevention through safe prescribing practices
  • Effective and evidence based treatment of chronic pain
  • Use of important adjunctive tools like the Prescription Monitoring Program (where prescribers can see all controlled substances prescriptions a patient has received)
  • Evidence based treatment for substance use disorder
  • Integration of mental and behavioral health services with primary care
  • Payment reform to support these changes
  • Full use of Health Information Technology, including not just the electronic health record and disease registries, but innovations like computer based education and treatment and mobile apps

The collaboration of legislators and the administration, public policy leaders, health systems, mental and behavioral health providers, law enforcement and educators from across the state will allow us to continue to address this most important public health challenge of our time.

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The overproduction of stomach acid and our sensitivity to it is one of the most common reasons people visit a doctor’s office.  Of course, many lifestyle choices contribute to that as well (overeating, obesity, smoking, alcohol use, to name a few).

Drugs that suppress acid production have been blockbusters for a long time.  In 1990 the first Proton Pump Inhibitor (PPI), Prilosec, was approved for use for the treatment of ulcers, acid reflux and esophagitis.  PPIs are now the 3rd largest pharmaceutical seller, accounting for 113 million prescriptions in 2012, and $14 billion of revenue for their makers.  When they were first marketed PPIs were promoted as having very few adverse effects, and that has largely been true for short term use.  But with the addition of 5 other PPIs (Prevacid, Dexilant, Nexium, Protonix, and Aciphex) and long term experience with the use of these drugs, we now know that there are some very serious risks of harmful effects.  We also know that longer use, higher doses and advancing age further accelerate these risks.  The risks include:

  • Hip fracture and fractures of the wrist and spine – This risk is even higher if you have diabetes or kidney disease.
  • Heart Disease – In addition to causing an overall 21% increase risk of heart attack, PPIs reduce the effectiveness of a very important heart medication called Plavix (clopidogrel).  Certain PPIs, like Protonix, increase the risk of heart attack by 80%!
  • Iron deficiency – this occurs because suppressing acid interferes with the absorption of iron.
  • Clostridium Difficile infection – this is an increasingly common cause of severe and sometimes life threatening diarrhea.  It turns out that the acid in our stomach kills the bacteria that cause this disease.
  • Pneumonia – again, acid kills bacteria, and when those bacteria can live in the gut it increases our risk of lung infection.
  • Stroke – just this month a new study has been released indicating a 21% increase in the risk of stroke from PPIs.
  • Kidney failure – a study in April indicated a 96% increase in the risk of kidney failure from these medications.

Startlingly, it is estimated that 70% of people taking PPIs are using them for a non-approved indication.  In addition, if you have been taking a PPI for a long time and you stop it, there may be a rebound over-production of acid, causing worsening symptoms and making it more difficult to stop.

What can be done?

  • If you have been on a PPI for more than a year, and most especially if you are over age 50 or have other chronic diseases, talk to your doctor about other treatment options.  It makes sense to try to get off the PPI if your doctor, NP or PA thinks it is safe.
  • If you have acid symptoms, lifestyle adjustment is the best treatment.  Stop smoking, reduce or eliminate alcohol, avoid food that triggers symptoms, lose weight, exercise, don’t overeat and get adequate sleep.
  • For symptoms that occur less than once a week consider old standbys like liquid antacids.
  • H2 blockers like Zantac (ranitidine) are likely less risky if a prescription is necessary.

Posted by & filed under Noah's Notes.

Doctors, nurse practitioners and physician assistants who work as primary care providers have always been busy and through much of the history of modern medicine, that busy-ness was balanced by a high level of job satisfaction, well above average compensation, and a position of esteem in society.

But over the past decade that balance has been lost.  Health care providers, while still well respected, have lost some esteem from those we serve.  Compensation remains very good, but salaries for primary care specialties (family medicine, pediatrics and internal medicine) are among the lowest for physicians.   And now over 50% of family doctors suffer from burnout (loss of energy and empathy).  This is becoming a work force crisis and a lamentable loss for many of us who feel called to this work.  What went wrong?  One important clue is to look at how we spend our work time.

New research recently published in the Annals of Internal Medicine reveal  that our primary care workdays have become distorted.  Basically, for every hour primary care providers (PCPs) spend in face-to-face time with patients, they spend 2 hours working in documentation tasks, paperwork and work in the electronic health record (EHR).  This is how it breaks down for each day that we work providing primary care:

  • We spend 27% of our time in exam rooms, with patients.
  • We spend 49% of our time working on deskwork and documentation the EHR.
  • While we are actually in the exam room, we only spend 53% of our time talking with and examining the patient.  The rest of our time is spent working on documentation and other tasks.  So that really means that only about 14% of our time each day is spent directly interacting with our patients.

In addition to these very serious challenges we know that many PCPs also spend time at home completing their documentation each day.  This unrelenting time pressure, time spent doing work that we do not enjoy and time lost from that which motivates us and is a key source of resiliency (taking care of our patients) is at the root of our challenge in primary care.

As we work to transform the way we deliver primary care there is no doubt that PCPs will need to spend more time developing and managing treatment plans for our patients, and leading a team that helps to ensure that the panel of patients for whom we are responsible are staying as well as possible, and that new role will mean less traditional face-to-face time with patients.  But we will still spend most of our day caring for patients in our offices, and we must work to find sustainable models that allow us to be more present for our patients and to gain back our time to care for them in a way that improves outcomes, improves our patients’ experience of care, and once again becomes a source of energy and resiliency for those of us providing that care, by fulfilling the very motivation that drives us to do this important work.

Some examples from the study:

  • Physicians (this was the only group that was studied in this research) with dictation support averaged 31% face-to-face time, compared to the average of 27%.
  • Physicians with a documentation assistant (scribe) averaged 44% face-to-face time with patients.
  • Those with no documentation support averaged only 23% face-to-face time with patients.

Obviously these resources cost money and building and spreading a model that provides this kind of support must be done carefully and responsibly.  There may also be other areas which help to address our time imbalance, such as coding support and increasing clinical support staff.  What is clear is that we must attend to this challenge and work together to find impactful and sustainable solutions, so that we have an engaged and energized primary care work force to serve our patients in the future.

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Hepatitis C is a very important cause of liver disease and damage in the US and across the world.

Once infected, 80% of people will develop chronic infection and 20% of those will develop cirrhosis, and the risk of developing cancer of the liver is also increased.  75% of those who develop cirrhosis will die from the disease if left untreated.  Over 185 million people around the world are infected with Hepatitis C and 350,000 people a year die from it.  In the US it is estimated that 2.7 million people are chronically infected and the annual cost of treatment and lost work is estimated at $6.5 billion.  What is more alarming is that the number is expected to grow, and the majority of people infected with the virus have never been tested and are unaware that they have the disease.

There are a number of reasons why it is vital that people with Hepatitis C infection are identified and offered treatment:

  • Although treatment in the past was aimed at containing the disease and delaying progression, newer treatments can now reliably cure the disease.
  • Until recently there was a complicated protocol for determining who should be treated. New guidelines released by the Infectious Disease Society of America now recommend that virtually everyone with Hepatitis C should be treated.
  • Because the virus is spread through blood and body fluids, knowledge of infection can help protect sexual partners of those who are infected.
  • Treatment of the disease helps to reduce unintentional spread through blood exposure.
  • Those who are known to be infected can be counseled to eliminate other liver toxins, like alcohol and acetaminophen.
  • Those who are infected should receive vaccinations for hepatitis A and B.

Not everyone needs to be tested for infection with Hepatitis C, but those who should be tested include:

  • All people born between 1945 and 1965 due to a higher prevalence of the disease in this age group (this is a one-time test)
  • Current or former injection drug users, including those who injected only once many years ago
  • Recipients of clotting factor transfusions made before 1987
  • Recipients of blood transfusions or organ transplants before July 1992
  • Hemodialysis patients
  • Persons with known exposures to HCV, such as
    • health care workers after needle-sticks involving Hepatitis C positive blood
    • recipients of blood or organs from a donor who tested Hepatitis C positive
    • people with HIV infection
    • children born to Hepatitis C positive mothers

All of this will require that we who work in primary care to develop reliable systems to identify and test those at risk for Hepatitis C and that treatment systems are in place so that every infected person can be offered treatment aimed at curing the disease.

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Over the past 20 years the rate of teenage pregnancy has steadily declined, and with that trend the rates of pregnancy termination have declined as well.

This is a success largely fueled by the availability of contraception and improved patient education. Yet the U.S still has a teen pregnancy rate 7 times higher than that of most developed countries. There are 2.8 million unintended pregnancies in the U.S. each year, including 430,000 in young women aged 15 to 19 and 124,000 in those aged 15 to 17. We know that teen pregnancy is associated with delays in prenatal care, increased fetal exposure to alcohol and tobacco, poorer health outcomes for the newborn and negative impact on social and economic outcomes for the mother.

How can this be happening in an age in which we have highly effective contraception? The answer is in the actual effectiveness of these methods when used in real life settings. Take a look at the table below. For every hundred women using a particular technique for 10 years, it shows how many will have an unintended pregnancy:

Unplanned Pregnancy/100 Women over 10 Year Period

  • ⚪ Condoms: 86/100
  • ⚪ Pill or patch: 61/100
  • ⚪ Depo-progesterone (shot): 46/100
  • ✔️ Copper IUD: 8/100
  • ✔️ Hormonal IUD: 2/100
  • ✔️ Hormonal implant: 1/100

Most people are startled to learn, for instance, that birth control pills have a 10 year failure rate of 61%. Of course if the pill is taken properly and if no medications are prescribed which may interfere with it, its effectiveness is vastly better. But in real life things happen.
IUDs and implants are called Long Acting Reversible Contraception, or LARC, and have a much higher rate of success in preventing unplanned pregnancy. In addition the Affordable Care Act requires that all forms of contraception must be covered by insurance, without cost to the patient. Yet less than 5% of women choose LARC as their contraception method. There are several reasons for this; studies have shown that notwithstanding the ACA requirements for coverage many insurers do not properly cover all of the costs of LARC, which can be as much as $1000 (for the IUD or implant plus costs of insertion). Few primary care practices stock an inventory of LARC (due to costs) and delays in obtaining it result in lower rates of use. And many providers were incorrectly taught that LARC should not be used in teenagers or in women who have never been pregnant.
A large study carried out over 5 years has shown that with good patient education, same day availability and no cost to the patient 72% of adolescents will choose LARC, and that the use of LARC results in significantly decreased costs associated with pregnancy and significant decreases in the rates of pre-term birth. It should be no surprise that the CDC states that all clinicians should offer the full range of contraceptive services to patients who wish to delay or prevent pregnancy.

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Last month I reviewed the recommendations of the Prevention and Harm Reduction task force of the US Attorney’s Maine Opiate Collaborative.  This month I will share the recommendations of the Law Enforcement task force of the collaborative, which was made up of representatives of law enforcement agencies spanning the state.

And let me preface this by saying that in my interactions discussing this issue with law enforcement people, I have been struck by how knowledgeable, compassionate and innovative they are in working to address this challenge in an effective manner.  The recommendations are as follows:

  1. Train all existing and new law enforcement personnel on the science of substance use disorders. This is fundamental to an effective approach and, I think, shows tremendous insight on the part of the task force.  By the way, the same could be said for medical personnel and for policy makers.  The task force goes into some detail on how to accomplish this objective.
  2. Identify, investigate and prosecute the most dangerous drug traffickers. Hard to argue this point, and while we recognize the disease of substance use disorder, those who take advantage of the current prevalence of that disease to market drugs illegally ought to be held criminally responsible.  The task force recommends statewide intelligence sharing, implementation of software designed to meet some of this need, record sharing, information sharing, outreach from drug intelligence officers to local law enforcement and improved collaboration as strategies for advancing this goal.
  3. Support and encourage effective law enforcement pre-charge diversion programs. This refers to the need for a treatment and recovery resource in each prosecutorial district so that people arrested on drug charges could be referred for treatment of their substance use disorder.  They also recommend tracking data so that the effectiveness of these interventions can be monitored.
  4. Increase statewide access to effective problem solving courts. This includes the recommendation to seek state and federal funding to support facilities, case managers, judges, prosecutors, and treatment providers.
  5. Provide treatment for county jail inmates with substance use disorders and provide case management services for re-entry into the community. This is critical in order to stop the cycle of addiction, arrest, detoxification, release and relapse.  In addition, the 48 hours after release from jail is the time of highest risk for fatal drug overdose.  If a person with substance use disorder is established in a treatment program and, most importantly, if the treatment can continue seamlessly as they transition out of jail, we can break that cycle and help people enter long term recovery.

Next month, the recommendations of the Treatment and Recovery Task Force.