Controlling the Costs of Innovation: Let’s Refocus and Remember The Patient

In a controversial study released this week, Tufts University’s Center for the Study of Drug Development estimates that the cost to bring a new drug to market exceeds nearly 2.6 billion dollars.  The study, which was 40% funded by industry has been criticized for over estimating these costs in favor of industry and misrepresenting some cost estimates.  While we will not know fully the extent of the methodology of the study until later in 2015 when it is published in a peer reviewed journal, these preliminary findings were released in advance and have already begun to spur debate.

However, irrespective of these criticisms, I believe that the study does have merit and brings an important issue forward—is the FDA stifling innovation with excessive fees and paperwork?  Are smaller, less well funded researchers/corporations unable to significantly contribute without partnering with big pharma? Who will ultimately bear the increased cost of drug development?

Innovation is what has always made healthcare in the US great–it is what separates us from the rest of the world.  For decades, the US has been able to attract talent from throughout the world and this has resulted in numerous “game changing” breakthroughs in medicine.  Through continued development of new drugs, new technologies and new ways to better treat disease, we are able to improve outcomes and reduce death from preventable disease.  The US has always been a place where others from around the world have come to incubate and grow ideas.  Now, it appears that innovation must come at a substantial cost–the increasing capital required for drug development as well as taxes on medical device companies only serve to squeeze out the “small guys with big ideas” and limit our ability to continue to produce new, more effective therapies and cures.  In addition, these additional costs to the pharmaceutical industry are not simply added to their bottom line–they are pushed on to the healthcare consumer as well as Federally funded healthcare plans.  Ultimately, the taxpayer bears the brunt of the increased cost.

The process of drug development is long and arduous.  Government regulation, politics and greed have served to make it even more difficult.  Physicians in academic medicine, scientists, pharmacologists and leaders in industry have learned to partner and share ideas in order to bring basic science principles from the bench to the bedside—ultimately translating ideas into cures.  Certainly, big pharma is in place to make profits and increase market share.  But as costs increase, many drug makers are putting less and less profit back into research and development.  Growth can become stagnant and new ideas may never reach the bench or bedside.  Federally funded research–such as NIH grants–face big cuts and budgets are often embroiled in political battles.  Legislators use research dollars as bargaining chips and fund projects that appeal only to a particular interest group or a group of favored donors.  We must find a better way to promote medical innovation and reward research.  We must find better ways to choose the most promising projects for funding.  We must be good stewards of the R & D dollar and make every single investment count.

As with most things in medicine, we must always pause and remember to focus on the patient.  Advocating for the patient suffering with disease is the reason most of us became involved in medicine in the first place.  Whether the study from Tufts over-estimates the cost of development or not, it should still serve as a wake up call to us all.  We must work to control the cost of developing new therapies—we must limit excessive taxation, we must promote entrepreneurship and begin to fix the current system of FDA approval for new therapies.  We must separate politics from medicine and streamline processes—eliminate paperwork and promote efficiency–if we are to continue to lead the world in medical innovation.  We must continue to make room for the “small guy with the big ideas”–If we do not–ultimately it will be our patients that suffer in the end.

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An Apple A Day—Changing Medicine Through Technology and Engagement

The practice of medicine and healthcare in general has become an electronic and increasingly mobile interaction. Patients are better informed, more engaged, more connected and have a much greater virtual presence. In fact, according to Pew Research data, the fastest growing demographic on Twitter are those who are in the 45-65 age bracket.   Nearly 50% of all seniors engage online on a daily basis through at least one social media platform and many of these interactions and online engagements occur via mobile devices. Almost 75% of all adults go online within hours of attending a visit with their physician in order to gather more information about their particular medical problem. For healthcare providers—and for patients—the internet and mobile technology presents us all with wonderful opportunities to interact, engage, support and ultimately improve outcomes.

New connected devices and medical applications for mobile devices are on growing exponentially.   The world responded favorably to the latest release of the iPhone 6 and the iOS8 operating system recently released by Apple. The new device has many interesting features but one in particular caught my eye early on. Apple has created a standard package for all iOS 8 devices that is called the Health Kit. This particular application allows a user to track calories, steps taken (similar to a pedometer), flights of stairs climbed and other customizable health related data points. These data can be organized into graphs and charts that allow users to track progress and adjust activity levels to achieve particular goals. More impressively, the device will allow other health related applications to organize data in the Health Kit as well. One of the biggest problems with medial applications in the past is that there has never been an easy place to organize, store, collect and view all of the data together. Moreover, this data is not easily shared with healthcare providers. The Health Kit and Apple may revolutionize this entire process of data collection, retrieval and sharing—Apple has partnered with a major electronic medical record service known as EPIC. Work is underway to allow the Health Kit data and applications to easily interact with the EPIC medical record. This would allow for easy downloads of health data during a face-to-face encounter with healthcare providers. Currently, most major hospitals and healthcare systems are moving to the EPIC platform. The data collected and downloaded at one location would subsequently be available to all providers in the system—portability of data allows for better care and less duplication of effort.

Much has been written about patient engagement and improved outcomes in the medical literature. I can think of no better way to improve engagement than through the use of real time health applications –these allow patients to receive real time feedback—both good and bad—and respond quickly in order to improve their overall health status. I think that this type of technology will only continue to grow. Apple plans to release the Apple Watch in early 2015. I expect that this will also be integrated with Health Kit and allow for the measurement of respiratory rate, heart rate, body temperature and other biologic measurements. As these tools continue to develop and applications grow, healthcare providers as well as patients must be receptive to their use. These technologies have the potential to allow clinicians to better assess patients between office visits and provide more directed and timely changes in therapy. Ultimately I believe these technologies will transform healthcare. As we continue to struggle with healthcare cost containment in the era of healthcare reform, the ability to shift care and routine interaction to mobile platforms may very well prove to be a critical piece of the puzzle.

This is an exciting time in medicine as well as in healthcare technology. Moving forward, I look to a day where biologic sensors collect data, relay data to mobile devices and then transmit information seamlessly to healthcare systems. The healthcare providers are alerted to any abnormalities and electronic responses are generated—those patients requiring timely in person visits can be identified and scheduled, while those that can be handled virtually can be managed quickly and effectively as well. Ultimately, our goal is to better manage disease and improve outcomes. I think that technologies such as the Health Kit and the Apple Watch are giant leaps forward and are just the beginning of a new age of virtual healthcare.

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Heads in the Sand: Obama, the CDC and Claims of Ebola Preparedness

Thousands of people have travelled from West Africa to the US in the last 6 months.  While the CDC and others throughout the Obama administration continue to reassure everyone that the US is 100 percent prepared for an outbreak,  potential cases and exposures continue to surface all across the country.  In Dallas, the first confirmed case of Ebola remains in critical condition.  Even more concerning is the fact that the patient initially presented to the Emergency Room with a fever at Texas Health Presbyterian Hospital (and even though he provided a high risk travel and exposure history) we was sent HOME.  Initially, the hospital blamed the fact that he was sent home with high risk features (his records documented the fact that he had just travelled from Liberia) was that there was a “technical glitch” in the electronic medical record and that physicians were unable to access the data obtained by the triage nurse.  Days later, the hospital rescinded their comments and admitted that the data was there for anyone involved in the case to see but in fact, no one even noted his West Africa travel history and released him from the ER.  These missteps resulted in the potential exposure of nearly 100 contacts AND the isolation of several family members.  But today, the director of the CDC, Dr. Tom Frieden, continues to proclaim on the national media that the US is well prepared and that all local healthcare agencies have policies and procedures in place to avoid major outbreaks and exposures.

Really?  Its Time for the CDC and our administration to get its collective head out of the sand!  

According to the WHO, the number of Ebola cases is expected to continue to rise sharply in the month of October.  The CDC estimates that there may be as many as 1.4million cases before the current outbreak is over.  Others worry that the disease is now so far out of control in West Africa that it will soon become endemic.  Currently, most families in West African countries actually spend nearly 80% of their monthly income on food–now prices are increasing and food is becoming even more scarce.  As West African nations become increasingly economically challenged by the outbreak, it is likely that many will flee the country illegally (and untracked and unscreened)–resulting in further spread of disease and wider contact with individuals from other nations.  The first US case admitted to lying on his immigration forms before fleeing Liberia and would have been considered high risk due to close contact with family members with documented Ebola.  At this point, the CDC and its leadership continue to proclaim that they are “looking at possible actions” to help prevent the entry of Ebola into the US.  However, there are no specific plans in place and no real travel protocols have been established.  US air carriers admit to confusion about what to do and how best to screen passengers.  One particular airline has told its employees to treat all bodily fluids on flights as potentially infectious.

Now certainly, we should not panic.  I agree that the US is better equipped to handle an outbreak of an infectious disease than any other country in the world.  We have state of the art isolation facilities, an abundance of medical resources and the wisdom of many of the worlds’ brightest physicians.   Our advantages in treating any potential Ebola cases in the US are huge—However, we must put policies and procedures in place NOW–not after more cases appear stateside.

What steps can we take to prevent Ebola spreading in the US?  First, we need to make sure the virus does not arrive here–and when it does we must have a plan in place to isolate and contain any potential carriers

 

  1. Initial standardized screening of people travelling from endemic countries must be set into place now.  We must consider travel bans and Pre Flight 21 day quarantines prior to travel to the US in order to ensure that no patients with disease are inadvertently admitted to the US.
  2. Airline personnel must have standard protocols in place should a passenger become sick–isolation equipment and protective gear must be readily available and crews should be provided with specific training designed at protecting themselves as well as other passengers.
  3. Improved education for healthcare providers, emergency department personnel and first responders.  We must put protocols for response in place that are easily implemented when confronted with a suspected case.  Travel history and exposure history must become the first line of defense–we cannot afford to send a high risk patient home again.
  4. Immigration and Passport control should also screen all high risk travelers (from endemic countries) upon entering the US as well.  Those that are considered to pose a risk must be quarantined upon arrival for 21 days.
  5. Private industry resources must be focused on the mass production of vaccines such as ZMAPP and other potentially life saving drugs. While government should play a role in development and deployment, the private sector should be leading the charge in order to avoid the inevitable slow downs associated with government led initiatives.  These drugs should be fast tracked and studied while being put to use in West Africa.  While the science behind their effectiveness is solid thus far, there have not been nearly enough clinical trials and standard safety and efficacy trials put in place.   However, these drugs must be tested in practice in areas of outbreak.  We do not have time to await months to years of clinical trials in healthy subjects.

So, where is our government in all of this?

At present, both the Obama administration and the CDC continue to downplay the threat of Ebola in the US.  I fear that while government rhetoric continues to highlight the absolute preparedness of the US in the case of an outbreak, the reality of Ebola cases in the US (the one documented case thus far was sent home from the Emergency Room with a fever) are quite concerning.  I wonder if we could quickly coordinate an effective response should more cases arise?  The situation in Dallas–while contained now, had the potential to spread to more than 100 people during the initial presentation of the patient.  Today, the President will meet with the director of the CDC.  It is my hope that we will soon put policies in place to protect Americans from the spread of the disease.

We must Act rather than discuss.  We must Prevent rather than respond.

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Should We All Die at 75?: Addressing the “Emanuel Principe” in Obamacare

Ezekiel Emanuel, one of the authors of the Affordable Care Act spoke publicly this week about his own desire to “die at 75” in a article published in the Atlantic.  In his piece, he argues that as he ages, he wishes to stop all preventative medical measures and “let nature take its course” as he approaches the age of 75.  This includes screenings such as colonoscopy as well as taking flu shots for the prevention of communicable illness.  While currently in excellent health, Mr Emanuel believes that while death is a loss–”living too long is also a loss.” He argues that the American obsession with living longer results in a larger number of elderly, disabled citizens.  I take significant issue with this position and fear that this is simply the beginning of a new phase in the ACA debate–the rationing of care. From the outset, many of us in healthcare and scholars of healthcare policy have seen Obamacare as a way to promote the rationing healthcare (particularly for the elderly).  While the administration has vehemently denied these claims throughout the legislative and implementation phases of the new healthcare law, it is particularly revealing that one of the principal architects of the law firmly believes that we should not pay attention to life expectancy statistics beyond the age of 75.  Medical advances have made it increasingly possible for seniors to lead healthy, productive exciting lives well into their 80s.  Now, I certainly am not arguing for providing futile care in the setting of terminal illness but–Why then should government (instead of doctors) now have the right to determine how healthcare resources are utilized and who gets what?  Is it all about age?  Do we value the young more than the more “seasoned” citizens? The US healthcare system, while certainly imperfect, offers some of the greatest technological advances in the world and the most significant thing that has always set US healthcare apart form others has been CHOICE.  With Obamacare in place, we now have less choice in our healthcare and very little improvement in access.  This latest article by Mr Emmanuel is no surprise–he has been clear about his belief in allocating health care dollars away from activities which may extend lifespans for Americans.  While, Mr Emmanuel certainly has the RIGHT to refuse care for himself at a certain age neither he (NOR OBAMA or any GOVERNMENT agent) should be able to determine an “acceptable” life span for each of us. Quality of life and health status can be very subjective and care must remain individualized rather than mandated (or withheld) based on actuarial tables or government rationing of resources. Medicine is all about innovation and the development of new technologies.  Through technology we are able to provide longer, more productive lives for our patients.  Our patients are able to retire from a life of work and enjoy spouses, family and friends–well into their 80s and 90s WITH a quality of life.  In fact one of my favorite “golf buddies” is 80 years old and going strong–He can still shoot in the 80s from time to time and never misses a game. In MEDICINE one size does not fit all.  OBAMACARE wants to force a ONE SIZE FITS ALL healthcare system on all of us and as a physician I find this to be unacceptable.  Just as we must cater therapy to individual patients—when (and how) you die must also be catered to each individual patients needs, desires and beliefs. Chronological age such as 75 may be different for different people AND we must respect individual needs.  Medicine is a clearly a science but in many cases the practice of medicine –particularly when making decisions about end of life issues–makes it more of an ART.  The government has no place in dictating ART.  Government should help to preserve and curate art–not regulate and mandate the way in which medical care is delivered to individual patients based on age. Ultimately, left to its own devices, I believe that the ACA will create rationing of care for Americans and we will have two classes of people–those that are wealthy and can afford private care and can pay cash for it–these can make their own healthcare decisions and decide when enough is enough.  The others–most of us–will be lumped into the disaster that IS obamacare and will have little or no choice in how our healthcare is delivered.  Waiting lists for advanced procedures and denials of advanced care for the elderly will be the standard–Just as Mr Emanuel envisioned it when he crafted the law just a few short years ago.

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Engaging Patients with an Apple and Health Apps: Watches Are No Longer Just for Telling Time

Today patients are increasingly connected.  The fastest growing demographic on Twitter is actually those that are between 45 and 65 years old.  Our patients are becoming better informed and are flocking to the internet and to social media to discuss and learn more about disease.  Prevention of disease is becoming more of a priority in our healthcare system as we begin to adjust to the mandates provided for in the Affordable Care Act and physicians are now expecting patients to take a more active role in their healthcare.  In the last 5 years, the concept of the electronic patient has emerged and is becoming more and more prevalent among mainstream patient populations.  These patients often come to office visits armed with information and data collected on the internet and are very technologically savvy.  They embrace new devices and are eager to track health indicators such as blood sugar, blood pressure and heart rate through easy to use phone applications.

This week, Apple intends to announce a new smartwatch and a group of associated health applications.  These innovations will further allow the electronic patient to become more of a mainstream phenomenon.  However, in order to be effective, physicians and other healthcare providers must embrace these technologies and begin to better understand their utility in all patient populations.  According to the Wall Street Journal, the announcement of the new smartwatch is expected to introduce no less than ten new sensors for monitoring health indicators.  Apple has created a data repository that will allow health related information to be stored (with the user’s permission) and directed to healthcare providers if so desired.  This assimilation and collection of massive amounts of health indicator data may be a significant game changer in the fight against chronic disease.  With many patients, compliance with medication or lifestyle modification plans is a challenge.  Many diseases such as hypertension do not produce immediate ill health effects–rather they accumulate over time.  However, if we can clearly demonstrate to patients the positive responses to interventions on a daily (or even hourly basis) they may be much more likely to comply with prescribed treatment plans.  Glancing at a smartwatch and noting a response to exercise or to a completed dose of medication can be a powerful motivational tool.

What if all of the data is collected simply by wearing a watch?

If we make collection and organization of information simple and user friendly, then important information can be transmitted to a physician who can review the data prior to the next face to face office encounter.  Real time feedback can then be provided to the patient and this may ultimately result in increased engagement and may actually spur change in habits or behaviors that are detrimental to a particular patient’s health.  Moreover, according to the WSJ, the new Apple operating system will include a Health icon that will allow for the development of a dashboard with many health indicators that are easily accessible in one place–lab results, heart rate, blood pressure, weight–even calories consumed and burned in a given time period.  The engaged patient can see what they are doing right, what they are doing wrong and can track improvements in habits rather quickly.  Having the data all in one place will likely increase compliance and improve overall health of the adopters of this technology.

What about security of sensitive personal healthcare data?

As with most new advances in medicine, there are significant concerns about data breaches and compliance with the federal Health Insurance Portability and Accountability Act (HIPAA) regulations.  According to a story in the New York Times, Apple is working with application developers as well as the federal government in order to ensure that any stored or tracked healthcare data will remain secure.  Partnerships with application designers, insurance companies, healthcare systems and physicians will be critical to the success of the new Apple smartwatch.  As these new technologies are rolled out and continue to develop, efforts to secure data will continue to evolve.

The development of new and exciting healthcare technologies and applications will continue to bolster the development and of the growing number of electronic patients.  Ultimately, the Apple smartwatch and other soon to be developed health indicator monitors, trackers and data repositories will only serve to further engage both patients and doctors and, in my opinion, significantly improve our ability to intervene EARLY and prevent the terrible consequences of chronic disease.

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Setting the record straight: New stool DNA test for Colorectal Cancer Screening (A guest Blog by @DrDeborahFisher)

 

A bit about today’s Blog Post…..

Dr Deborah Fisher is a brilliant Gastroenterologist at Duke University Medical Center.  She is also a fantastic wife and mother.  A Twitter fanatic, Dr Fisher has taken to Social Media to promote issues in Gastroenterology.  Today, she writes about a very controversial subject in GI–Does a New stool DNA test Replace Colonoscopy and is the Media Creating Confusion in the Market? 

Setting the record straight: New stool DNA test for Colorectal Cancer Screening (A guest Blog by @DrDeborahFisher) 

An occupational hazard of being married to a rising media star is that when I expressed my concern and exasperation at the misinformation being circulated about a newly FDA-approved colorectal cancer screening test, his response was “write a guest blog for my blog page”. Another occupational hazard is having the local NBC-affiliate news truck parked in front of our house at 9:30 on a random summer evening. But that is for another blog.

For full disclosure, I am a gastroenterologist and much of my research and clinical focus is colorectal cancer screening. Some of my previous comments on the new stool DNA test, Cologuard, have already been published in the New York Times as well as in a previous issue of @MedPageToday. However, I have recently noticed a number of misleading articles in various newspapers across the country and wanted to address these, likely common, misconceptions about the new test.

First, I want to openly acknowledge the positives about Cologuard. The study in the New England Journal of Medicine examining its ability to find a colon or rectal cancer as a one-time test (compared to colonoscopy as the gold standard) was large, well-designed and well-executed. It showed that as a one-time test Cologuard was 92% sensitive for cancer. It also showed that the false positive rate was about 13%.

The problem has arisen in how the study results are being spun in the media. Here are a couple emerging myths to debunk:

  • Cologuard is for patients who absolutely positively want to avoid colonoscopy.

                                                     FALSE

While colonoscopy is the most common test used in the US to screen for colorectal cancer , it is not the only test. It is not even the “best” test. It is the most accurate test for finding cancers and polyps but that is not the same as the “best” because there are clear downsides including cost, risk of complications, access. A screening strategy of using a non-invasive test first can greatly decrease the need for colonoscopy but does not eliminate colonoscopy because Positive Screening Tests Should Be Followed By a COLONOSCOPY. Therefore, a positive stool DNA test needs to be evaluated with colonoscopy or the point and potential value of screening is lost.

The fecal immunochemical test, aka FIT, is also a non-invasive colorectal cancer screening test. It has been around for decades, and in its current form is a widely available test that is included in all the US colorectal cancer screening guidelines

In fact, I will argue that it is a better test for your patient who is not completely against screening but would prefer to avoid colonoscopy if possible because 1) its false positive rate is 5% vs. 13% for Cologuard. Therefore it carries a lower risk of leading to an unnecessary colonoscopy 2) it is currently covered by all insurance carriers

  • Cologuard will increase colorectal cancer screening rates in the US population

                                                       FALSE

Or perhaps a more accurate response might be “We have no idea” since it is a new test and the only people who have used it were in a research study.

On the other hand, we have compelling data that FIT increases screening rates compared to the older guaiac-based fecal tests and among patients who were previously unscreened.

 

  • Cologuard is the best non-invasive test for colorectal cancer screening

                                                       FALSE

And a bit of a trick question because we really do not have a Best Test at this point. Nonetheless, Exact Science is clearly going after the screening market leftover after colonoscopy takes its lion’s share. In addition to my general case for no “best” test, I would argue that Cologuard has not accumulated enough data to knock FIT off its best non-invasive test perch.

Yes, Cologuard had a higher rate of diagnosing cancer in one-time testing compared to a single FIT product in a single study, but

1) Screening is not a one-time test. FIT is meant to be repeated annually (or biennially in most screening programs outside the US). We have no idea if after 2 or 3 rounds of FIT the higher sensitivity (detecting cancer among individuals with cancer) of Cologuard will remain.

2) The interval of annual FIT testing has a wealth of data support vs. no data whatsoever supporting ANY testing interval for stool DNA tests (currently CMS is considering a 3 year interval

3) In a healthy population, it is important to consider harms and the higher rate of false positives leading to colonoscopy could translate into an increased rate of adverse events.

4) FIT is $25 vs. $600 for Cologuard

 

Now, some might say, “hey colonoscopy is the most expensive, risky option out there”. To which I say touché. Perhaps unfortunately, no headlines are claiming any test is better than colonoscopy. That might be another blog. Poor Dr Campbell is creating a social media monster.

Deborah Fisher, MD, MHS

Associate Professor of Medicine

Duke University Department of Medicine

Division of Gastroenterology

@DrDeborahFisher

Photo on 6-16-14 at 2.49 PM #3

Turf Battles and Collateral Damage: Are We Really Putting the Patient First?

Last week, Medpage Today reporter Sarah Wickline Wallan tackled a very controversial issue in medical practice.  In her piece, Ms Wallan explores the ongoing battle between Dermatologists and AHPs (Allied Health Professionals) over the performance of dermatologic procedures.  As independent NPs and PAs begin to bill for more and more procedures (thus potentially talking revenue away from board certified Dermatologists) specialists are beginning to argue that the AHPs are practicing beyond their scope of practice. According to the Journal of the American Medical Association, nearly 5 million dermatological procedures were performed by NPs and PAs last year–this has Dermatologists seeking practice limits–ostensibly to protect “bread and butter” revenue streams from biopsies, skin tag removals and other common office based interventions.

In response to this controversy and the article, I was asked to provide commentary for Med Page Today’s Friday Feedback.  Each week, the editors at MPT discuss a controversial topic and have physicians from all over the country share their feelings on the issue in order to provide readers with a mulit-specialty perspective.  This “Friday Feedback” feature is typically released on the web near the end of the day on Fridays and often spurs a great deal of social media activity and discussion.  Based on reaction to Ms Wallan’s article our topic this past Friday was “Specialty Turf Battles”.  Each respondent was asked to provide commentary on the growing angst between Dermatologists and Allied Health Professionals.    As I began to reflect on the issue itself and its potential impacts on all aspects of medicine, I felt that a complete blog would be a more complete forum to discuss my thoughts.

First of all I want to say that AHPs are essential to providing care in the era of the Affordable Care Act.  NPs and PAs are able to help meet the needs of underserved areas and do a remarkable job complementing the care of the physicians with which they work.  With the rapidly expanded pool of newly insured, as well as the increase in administrative tasks (electronic documentation) assigned to physicians, AHPs must help fill in the gaps and ensure that all patients have access to care.  In my practice we are fortunate to have many well qualified AHPs that assist us in the care of our patients both in the hospital as well as in the office.

We must remember, however, that physicians and AHPs have very different training.  Each professional posses a unique set of skills and each skill set can complement the others.  Many of us in specialty areas spend nearly a decade in post MD training programs and learn how to care for patients through rigorous round the clock shifts during our Residency and Fellowship years.  In addition, we spend countless hours performing specialized procedures over this time and are closely supervised by senior staff.  Most AHPs, in contrast, do not spend time in lengthy residencies and often have limited exposure to specialized procedures.  Turf battles have existed for decades and are certainly not limited to Dermatology–nor or they limited to MDs vs AHPs.  In cardiology in the late 1990s, for instance, we struggled with turf battles with Radiology over the performance of Peripheral Vascular Interventions.  In many areas, these battles resulted in limited availability of specialized staff to patients and a lack of integrated care.  Ultimately, the patients were the ones who suffered.

Fortunately, in the UNC Healthcare system where I work (as well as others across the country) we have taken a very different approach.  After observing inefficiencies and redundancy in the system, several years ago our leadership (under the direction of Dr Cam Patterson) decided to make a change.  The UNC Heart and Vascular Center was created–Vascular surgeons, Cardiologists, Interventional Radiologists, and Cardiothoracic surgeons–all working under one cooperative umbrella.  Patients are now discussed and treated with a multidisciplinary approach–Electrophysiologists and Cardiothoracic surgeons perform hybrid Atrial Fibrillation ablation procedures, Vascular surgeons and Interventional Cardiologists discuss the best way to approach a patient with carotid disease–all working together to produce the BEST outcome for each individual patient.  We have seen patient satisfaction scores improve and we have noted that access to multiple specialty consultations has become much easier to achieve in a timely fashion.  Most importantly, communication among different specialties has significantly improved.

Unfortunately, with the advent of the ACA and decreasing reimbursement I suspect that turf battles will continue.  Financial pressures have become overwhelming for many practices and the days of the Private Practice are limited–more and more groups will continue to “integrate” with large hospital systems in the coming years.  Specialists such as Dermatologists and others will continue to (rightly so) protect procedures that provide a revenue stream in order to remain financially viable.  However, I believe that our time will be better spent by working together to improve efficiency of care, quality of care and integration of care.  NPs and PAs are going to be a critical component to health care delivery as we continue to adapt to the new (and ever changing) ACA mandates.  We must put patients FIRST–turf battles and squabbles amongst healthcare providers will only limit our ability to provide outstanding, efficient care.  Let’s put the most qualified person in the procedure room–and make sure that ultimately patients get exactly what they need.

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