Back To Basics in Healthcare:  Barbershops, High Blood Pressure and Better Outcomes

Kevin R. Campbell, MD, FACC

CEO PaceMate

We spend more money per capita in the United States on Healthcare as a percentage of GDP (Gross Domestic Product) than any other industrialized nation in the world. Yet our clinical outcomes are no better than the average (and worse than many countries that spend far less than we do).  Our system is far more complex than others, much more expensive and often difficult to access.  Many patients struggle to engage and partner with a healthcare provider and the logistics of attending a visit with a physician can be difficult for the working poor, those with families and others with multiple obligations and roles to play in the family.

This past week at the American College of Cardiology Annual Scientific Sessions, one of the most important clinical trials in decades was presented.  The trial did not involve a new expensive drug or a new expensive test or surgery.  It simply examined how outcomes improved when patients were engaged around a particular chronic disease on their own turf.

In the study, researchers from Cedars Sinai in Los Angeles found that if they  counseled patients and actually had pharmacists take medicines to black males in their local barbershops, that they had a much more significant reduction in blood pressure as compared to those who did not receive the same service.  Published in the New England Journal of Medicine, the trial involved over 300 African American patients who were entered into one of two study groups–either an intensive counseling and treatment program with pharmacists (conducted at the local barbershop) or a second group that received lifestyle modification encouragement (such as seeing their doctor regularly) by the barbers on duty.   Upon completion of the study, a huge difference in blood pressure reduction was seen between the groups with 65% of the men in the pharmacist led group meeting blood pressure guidelines as compared to only 11% in the control group.  The significance of this study is compounded by data from the American Heart Association that makes it clear that black males have a disproportionately high risk for high blood pressure related complications such as heart attack and stroke.  We also know that medication compliance in hypertension among black males is much lower as compared to other demographics.  Moreover, black males are far too underrepresented in clinical trials in hypertension.
Why Is This Trial So Impactful?

Blood pressure is the silent killer.  Treatment of blood pressure should be individualized and requires a commitment from both doctor and patient.  Our healthcare system often makes it difficult for patients to bond with their providers.  Doctor’s offices can be intimidating places and many Americans do not feel comfortable going to a traditional medical setting.  By coming to the men in an environment where they are comfortable—such as a barbershop—healthcare providers can make a bigger impact.  In addition, when men are treated in a local environment with their friends, they are more likely to feel a sense of accountability for compliance.  Most significantly, however, this trial shows us that we can spend far less money and realize a significant impact when it comes to the treatment of very common diseases such as high blood pressure.  Doctors and patients MUST get back to basics when it comes to healthcare.  Making a connection and developing a relationship is vital to success.  Rather than expecting patients to come to a healthcare facility, we must work to provide more convenient touch points—such as telemedicine, mobile health and….barbershops.

What is Next?

This study should serve as a wake-up call to doctors, patients, politicians and those that determine how healthcare is delivered in the United States.  We must focus more on the patient—take medicine where they are—we should NOT always force patients to come to big healthcare systems.  WE must make sure that physicians are encouraged to reach out to patients and not confined to a clinic or hospital.  It is vital that we spend the time to better understand our patients–why they feel more comfortable in certain settings.  One size does not fit all–cultural differences, socio-economic status, and personal beliefs can have a great impact on who benefits to treatment in a particular environment and by a particular provider.  Most importantly, this study proves that it does not take expensive tests, expensive medicines or therapies to make an enormous IMPACT.  It is time to step back and put patients first—if that means going to a Barbershop to deliver care—then that is what we MUST do.

Unknown.jpeg

 

Trump, Sanjay Gupta and The “Goldwater Rule” :The Fallout From the President’s Latest Health Report

Kevin R. Campbell, MD, FACC

CEO, PaceMate

This past week, President Trump’s physician released his first full medical evaluation as President.  What has in the past been a routine event with a few questions asked in the daily White House press briefing turned into a 90-minute circus with physician journalists such as Dr. Sanjay Gupta of CNN making sweeping diagnoses from afar.  A basic tenet of the practice of medicine is that in order to make a diagnosis you must establish a doctor-patient relationship and have seen and examined the patient.  In fact, prescribing medications or making diagnoses without an interaction with a patient violates the rules of most state and local medical boards throughout the United States.  Why then does the press (and even Physicians who are active in the media) insist on making uninformed and misinformed medical diagnoses when it comes to President Trump?

The mainstream media has used the President’s annual physical report as another tool for furthering a particular political agenda.  While I certainly do not agree with all of Mr. Trump’s policies, behaviors and decisions, I do not think that perturbing the facts associated with his health and making sweeping, broad statements about his health status are an appropriate means for political gain.  In fact, it serves to only demonstrate the desperation seen among Democrats and liberals throughout the country.

What did the President’s Yearly Physical Reveal About his Cardiovascular Health?

President Trump underwent an extensive evaluation by the White House physician (who, of note, was appointed by President Obama) and this included a history, a physical exam and several diagnostic tests.  The results of the exam and all of the tests have been made public and I have personally read through the entire document—but that does not mean I am qualified to make any diagnosis—I have never seen the patient and personally evaluated him.  Sir William Osler, one of the founders of modern medicine often said “if you listen to the patient long enough they will tell you what they have”—emphasizing the importance of the history and physical exam in making a diagnosis.

Mr Trump appears to have mild obesity (his BMI or body mass index is 30.1 and above 30 is considered to be obese).  He also has an elevated total cholesterol at 223 and a LDL (bad cholesterol) of 129.  Current guidelines suggest that we should use a total cholesterol of 200 and an LDL of less than 100 as a treatment goal.  Mr Trump also underwent extensive cardiovascular testing including a stress echocardiogram (ultrasound of the heart) which showed an absolutely normal result—no evidence of blockages, normal heart structures and chamber sizes and normal valves.

Sanjay Gupta’s Diagnosis from Afar

Minutes after the White House press briefing where all of Mr. Trump’s health data were made public and available to the press, Dr. Gupta stated on LIVE television that “President Trump has heart disease”.  In reality, heart disease is a complex diagnosis that relies on the consideration of risk factors—such as male sex, high blood pressure, high cholesterol, diabetes, obesity, family history and others—just to name a few.  In the case of President Trump, he does have risk factors for heart disease including the fact that he is a man and that he has high cholesterol.  However, he had a normal stress echocardiogram test—a test that evaluates the presence of any significant heart artery blockages and his cholesterol is being appropriately treated.  As mentioned above, the President is slightly overweight and needs to watch his diet and exercise more.  Technically, Dr Gupta is right—ALL of us have some amount of heart disease as evidenced by “fatty streaks” in our aorta even as children.  A fatty streak is the first sign of atherosclerotic disease and has been seen in very young children.  However, Dr. Gupta, who is a neurosurgeon by training and has no experience as a cardiologist, seems to have based the entirety of his comments on the result of a Calcium Score.  A calcium score is a test where a CT scan is done to determine if there is calcium in the coronary (Heart) arteries.  Some studies have indicated that an elevated calcium score can be predictive of the presence of coronary artery disease (blockages in the heart arteries).  According to many researchers, there is a paucity of randomized controlled prospective clinical trials about the accuracy and effectiveness of a calcium score in the prediction of heart disease.  There are data that do provide correlation but the widespread use of calcium scores in the evaluation of coronary artery disease has not yet been seen among US cardiologists.  In addition, calcium scores can be a useful tool to motivate patients and physicians to treat and modify risk factors for heart disease.  Calcium scores have also been shown to help with predictive models BUT are not diagnostic.  So, I would suggest that Dr Gupta, rather than making a sweeping statement such as “Donald Trump has heart disease” would be far more accurate by qualifying his remarks and reference the data concerning a calcium score rather than sensationalizing the President’s health during a package for CNN.

What is the Goldwater Rule?

The Goldwater rule was adopted by psychiatrists in 1973 after an incident in 1964 during the Presidential election in which a media outlet (Fact magazine) published a survey of thousands of psychiatrists in which they were asked if Barry Goldwater was psychologically fit to be President.  The Goldwater rule prohibits psychiatrists from offering an opinion about a patient they have never met or personally evaluated.  In many ways, the comments from Dr. Gupta and others are eerily similar to those made by the psychiatrists who never actually interviewed Mr. Goldwater.  For psychiatrists, this principle remains part of the American Psychiatric Association’s code of ethics even today (Section 7.3).  As physicians, we are to taught to assimilate the available data—through taking a patient history, performing a physical exam and evaluating laboratory data—in order to come up with a comprehensive diagnosis and treatment plan.  Making diagnoses without incorporating all data and actually examining the patient personally is simply irresponsible.  This not only applies to psychiatrists but should apply to ALL physicians specialties—even those of us who report in the media.

Is the President Healthy?

Bottom line, President Trump is healthy for a man his age.  If the President were my patient I would tell him the following:  You has risk factors for heart disease that must be modified—high cholesterol and obesity.

Currently, he is being treated for his cholesterol and his medications are being adjusted appropriately.  He does need to focus on making better dietary choices and he should lose some weight.  He must incorporate exercise into his daily routine and should have routine check ups to follow his progress.

5a5f8e341a095.image.jpg

(Image via screenshot from MikeSheltonCartoons.com)

 

The CDC Bans Words “Science Based” and “Evidence Based”: Is this 2017 or 1984 and the Thought Police?

“The thought police would get him just the same. He had committed–would have committed, even if he had never set pen to paper–the essential crime that contained all others in itself. Thoughtcrime, they called it. Thoughtcrime was not a thing that could be concealed forever. You might dodge successfully for a while, even for years, but sooner or later they were bound to get you.”
– George Orwell, 1984, Book 1, Chapter 1

This week’s announcement in the Washington Post that the CDC has banned certain words in budget documents elicited outrage throughout the scientific community.  Science and innovation is dependent on the ability of researchers to ask novel questions and push the limits of current thinking.  Creativity, free expression and stoking controversy are an important part of the research process.  In Orwell’s 1984, censorship was the basis of the society and the Thought Police were a feared government agency.  It now appears that the current administration has enlisted Orwellian principles in the American scientific community.  If this is type of censorship is allowed to grow and expand, all of us will suffer—and patients and advancements in Medicine will suffer the most.

Banning Words and Thoughts

According to the Washington Post report, the following words have been banned in all budget communications at the CDC:

Fetus

Transgender

Diversity

Evidence Based

Vulnerable

Science Based

Entitlement

My first reaction to this report was disbelief.  REALLY? There is no way this could happen in modern America….We have come so far in the way we address questions in medicine and respond to public health issues.  From Zika to flu shots—from issues surrounding the treatment of transgender people to ways in which we can better serve underserved populations—science is blind and researchers should be dedicated to improving patient outcomes irrespective of political rhetoric.

However, after the publication of the repot in the Post, the division of Health and Human Services pushed back quickly and argued that the CDC and HHS remains committed to the use of scientific evidence to guide their recommendations for health policy.  Other Federal spokespeople have admitted that the reason for the “banned words” was to help expedite the budgeting process in Congress.  By avoiding certain words in budgetary documents, the agency leadership felt that it would be easier to get their budgetary requests through a Republican-controlled Congress.

For me, none of this really holds water.  Censorship—either direct or indirect—has no place in a government agency dedicated to science and the advancement and development of public health related policy.  As a Duke trained cardiologist, I have always been taught that the BEST way to treat patients is to use the best available scientific evidence from randomized controlled clinical trials (RCTs) in conjunction with clinical judgement to diagnoses and treat my patients.  Politics and censorship has never played a role in the way in which I practice medicine.

How Censorship Can Affect Science?

If allowed, censorship can stifle new advancements in Medicine.  Imagine a world in which Jonas Salk was not allowed to develop a Polio vaccine—or a world in which researchers were not allowed to develop a treatment for the AIDS virus—hundreds of thousands of people all over the world would suffer and die.  Much of our research funding comes from government agencies such as the National Institute of Health (NIH) and public health policy is also set by multiple government agencies including the FDA and the CDC.  IF we allow censorship, then the grant approval process and funding of research projects may be politically motivated.

It’s Time for Action

Politics has no place in science.  Science is neither Republican or Democrat—science is HUMAN and transcends race, gender and religion.  Science is all about passion, compassion, drive and innovation.  Science brings people together—politics divide us.  While HHS has now pushed back at the Washington Post report, the seeds of censorship in medicine have been planted.  As physicians, researchers, scientists and patients we cannot allow this type of behavior to be swept under the carpet.  All of us have a responsibility to express our outrage—reach out to your representatives in Congress today.  As for me, I will be in Washington DC this week to express mine on behalf of all physician scientists and patients.  For my colleagues in Medicine I implore you all:  Continue to innovate—continue to ask the hard questions—continue to think independently—Let’s all stay a step ahead of the “Thought Police” in our nation’s capital.

77041_0.jpg

 

 

 

 

 

 

CVS, Aetna and REM: It’s The End Of The {Healthcare} World As We Know it

This week, it was announced that two of the largest players in the American healthcare market have agreed to merge in a deal worth nearly 70 billion dollars.  This merger represents a departure from the traditional way in which doctors, patients, insurers and pharmacists have interacted for decades.  In the past, insurers and pharmacies have existed in separate silos.  As I discussed in a recent Op Ed, this old system was far from perfect.  Pharmacy benefit managers (PBMs) have taken advantage of patients, doctors and drug manufacturers and have served to raise the cost of medicines through demanding kickbacks known as “rebates”.  As bad as PBMs have been for healthcare, this new merger may actually be WORSE.  Now, mergers such as the CVS/Aetna deal will essentially bring the “Soprano-like” PBMs in house.  In addition, in the last several years, CVS has ventured into the healthcare provider market as well—staffing primary care “clinics” with pharmacists and nurse practitioners in retail stores (note the glaring absences of physicians in the CVS care model).  While CVS argues that the combination of a health insurance company and a pharmacy (that provides primary care services) will streamline patient care and lower costs, I believe it is likely to do just the opposite.

What IS the Likely  Impact of the Insurance Company/Pharmacy/Clinical Services Mega Store on Healthcare?

If this merger is allowed to proceed, all players (except for the mega CVS/Aetna conglomerate) in the US healthcare system will suffer negative consequences.

  1. Diminished Choice

Currently, many patients have limited access to drugs due to the role in which PBMs play in negotiating prices and determining what is on “formulary”.  This less than transparent process basically involves a system of bids from manufacturers where the highest bidder (for a rebate that is pocketed by the PBM) wins the preferred formulary status.  In addition, the PBMs can require patients to deal with a process of “step therapy” where they are forced to use less expensive (and potentially less effective drugs) than originally prescribed by their physician prior to being allowed to take the intended therapy.  If this acquisition is allowed to proceed, we will see even less choice.  Now, an insurer (who is motivated financially to prohibit access to more expensive therapies) will be partnered with a pharmacy who can potentially decide to only stock certain medications.  Price fixing may become the norm—if you are an Aetna customer, you may be only allowed to purchase your medications from CVS—even if there are cheaper options for you elsewhere.

  1. Rising Costs

When there is less competition, the consumer always suffers.  If we allow CVS and Aetna to merge, we are likely to see costs rise.  Healthcare consumers will not be allowed to shop around for less costly purchasing options.  I foresee a system where Aetna is able to dictate that ALL covered medications must be purchased from CVS.  If

  1. The Demise of the Doctor Patient Relationship

Medicine is defined by the way in which doctors and patients interact.  Trust is built over years of interactions—not in a minute clinic.  By removing the physician from the healthcare equation (as this merger is likely to do), patients will no longer be able to bond with a provider who can help them make difficult healthcare choices as they age.  Minute clinic staff tends to be more transient that physicians that work in long standing practices and medical groups.  While minute clinics can certainly be a great way to triage and treat simple, common primary care issues such as colds and flu, it is not a great venue for long term care of chronic disease.  Highly trained physicians who have completed between 3 and 10 years of Residency and Fellowship training AFTER the completion of their medical degrees are better equipped to make difficult diagnoses and manage complex diseases over time.  As a for profit entity, CVS is focused on cost containment—and Nurse Practitioners are far cheaper staff than board certified physicians.  In an ideal world, NPs and physicians work together and co-manage patients as each professional brings a unique perspective and a unique skill set to the clinical arena.

  1. Poorer Outcomes

When we focus purely on the economics of healthcare rather than evidence based medicine for therapy choice, outcomes will most certainly be less favorable.  If the CVS/Aetna merger is allowed to proceed, I expect all clinical decisions by CVS minute clinic staff will be based on treatment protocols and algorithms that are developed to contain cost.  Let’s be realistic—CVS and Aetna are in this to make money for their executives and their stockholders—the patient is really not their top priority.  Care delivered only by a Nurse Practitioner in a minute clinic is not the same as the care delivered by a Residency and/or Fellowship trained physician in a continuity clinic.

Ultimately, it is my hope that regulatory bodies in Washington DC will recognize this planned acquisition for what it is—an assault on the way in which medicine is practiced in the United States.  We continue to allow for profit corporations to dominate the decision making when it comes to healthcare policy.  WE must act to change this paradigm and PUT PATIENTS FIRST.  As Michael Stipe of the rock band R.E.M. wrote in his song, “world serves its own needs , don’t mis-serve your own needs”  If we do not act, this merger will be the first of many and will likely be “The End of  The {Healthcare} World As We Know It”

rem-its-the-end-of-the-world-as-we-know-it-and-i-feel-fine-1991-3.jpg

 

 

 

The “Sopranos” of The Pharmaceutical Industry: Pharmacy Benefit Managers (PBMs) and How THEY Drive Costs UP.

Kevin R. Campbell, MD, FACC

CEO, PaceMate

Today, the New York Times reported that drug companies, insurers and pharmacies may “team up” to create effective monopolies.  Company executives argue that this would be better for patients and would improve care and outcomes—however, nothing could be further than the truth.  These conglomerates would further limit access and drive up costs.

Many patients and physicians have found frustration when attempting to prescribe a particular medication for a particular condition.  Often only certain drugs are “on formulary” (which means they are on contract) at a particular institution.  In the world of drug prices and availability, pharmacy benefit managers or PBMs serve as intermediaries between health plans, manufacturers and pharmacies.  PBMs are companies—such as Express Scripts, CVS CareMark and others–that are hired by health care plans and tasked with determine what drugs are available in a certain plan and which covered patients have access.  According to Forbes, Express Scripts, the leader in PBM market share generated 101 billion dollars in 2015.

How The PBM Mafia Works

Most PBM decision makers have absolutely NO medical training and have no idea how or why a particular therapy works.  They are simply there to manage cost—AND to fatten their own wallets during the process.  For every drug transaction, PBMs receive BOTH a reimbursement fee as well as an administrative fee.  In addition, when PBMs place a particular drug on formulary, they receive rebates and more fees from manufacturers which are NOT passed on to the consumer.  PBMs operate in a world with little oversight and even less transparency.  In other words, PBMs are middle men who are paid on both sides of the transaction—similar to the way in which Tony Soprano and his Captains ran their garbage business in New Jersey.

PBMs claim to drive down costs in healthcare by negotiating discounts, managing formularies to obtain rebates, encouraging generics and non specialty medications as well as increasing the use of their own mail order pharmacies.  In reality, however, PBMs actually drive costs up by using their “middle man” position to increase their own profits.  They work to negotiate contracts with drug manufacturers, health plans and pharmacies that maximize THEIR profits at expense of patients and physicians.  PBMs rely on a shady business maneuver known as “spread pricing”—which is the difference between what PBM charges a health plan for a certain drug and what it reimburses a pharmacy for dispensing it.  The PBM, in turn, is able to increase its margins as neither the health plan or pharmacy has any idea what the other is paid.  PBMs have a great deal of power to determine how YOU, the patient, is treated by your physician through determining tiers of drugs, formularies and preferred drugs.  One would think that efficacy, safety and actual DATA would determine which drugs get “preferred” status—but in the PBM world, its all about which drugs pay the best REBATES.  (Sound familiar? Remember Tony Soprano and all of the bribery, intimidation and other misdeeds? Similar to Tony’s “businesses”, every year, there is a bidding war among manufacturers and the company with the largest rebate (chunk of money to be paid to the PBM) always gets the preferred tier.

How Does This Affect Doctors and Patients?

Once a formulary is set, PBMs work to make it difficult to deviate from its tiers of offerings.  This can have a substantial impact on the doctor-patient relationship and can impact the way patients are treated.  For example, most PBMs put “step edits” in place in order to force physicians and patients to go through a series of preferred drugs prior to getting the drug that the physician originally intended for the patient.  This can result in unwanted side effects and significant delays in treatment.  If a PBM decides to switch to another drug mid year (which is almost always due to a more profitable contract with a different manufacturer), patients are forced to give up a stable therapy for a non-medical reason.  This can lead to disruption in therapy and negative patient outcomes.  The PBM system often stifles innovation as it makes it much harder for new drugs and biosimilar drugs to enter the market.  This can also lead to a non-acceptable lag in getting new therapies to the patients who need them most.  Ultimately, the PBM system and rebates related to PBM profits incentivizes higher drug prices—the higher the list price, the higher the rebate to the PBM.

What Can Be Done?

First of all, we must shed light on the activities of the PBMs and expose them for the mobsters that they are.  We must educate the public, patients, physicians and our legislators in Washington.  While healthcare reform seems unlikely at this time, Congress could act to limit the power and price gouging associated with PBM activities.  Transparency must be mandated—we should all be able to see the flow of cash between manufacturers, PBMs and pharmacies and identify areas of abuse.  In addition, transparency would allow prescribers to see exactly what each prescription really does cost.  Most importantly, we must allow doctors to use the drugs that are best indicated for their patients based on scientific data—NOT based on what generates the most profit for PBM executives.

Acknowledgments:  I would like to thank Dr. Madelaine Feldman–a practicing rheumatologist in New Orleans, Louisiana and leader in the fight against PBMs for her assistance in researching this particular piece.

Unknown.jpeg

(photo via screenshot, HBO, The Sopranos)

 

 

 

 

 

 

Calling A Code Blue on the US Healthcare Reform Initiative:  My Visit to Capitol Hill

Kevin R. Campbell, MD, FACC

 

In the past month, I made yet another trip to Washington DC in order to make the case for meaningful healthcare reform.  While Congress continues to play partisan politics, patients and doctors continue to suffer. According to the Mayo Clinic, physician burnout is at an all-time high with nearly 50% of all US physicians reporting experiencing the symptoms of burnout in the last 3 years.  The Journal of the American Medical Association (JAMA) reported in 2015 that 30% of young physicians had symptoms of depression or suicidal ideations.  In fact, Suicide accounts for 26% of deaths in physicians ages 25-39 as compared to 11% of deaths in individuals of the same age in the general population.  Physicians are leaving practice at an alarming rate, with a shortage of over 100K physicians expected in the next decade. For patients, frustrations continue to mount.  Rising premiums, diminished choice (only one choice in nearly 23% of counties in the US and only 1 or 2 choices in 41%), and limited access have patients scrambling for their basic healthcare needs.  Medicaid expansion has not happened in over 1/3 of the States and many are left uninsured—millions more are underinsured.  Medicine continues to focus on the treatment of disease rather than on prevention. Patients are not getting proven screening therapies and many cannot afford necessary medication due to rising costs.   Clearly, something MUST be done.  Healthcare in the US is on the verge of a major collapse—poor care, poor access and likely physician shortages are looming.

Dr. Campbell Goes to Washington

I began making phone calls about a month before my visit in order to set up meetings with key Congressional influencers and leaders.  I was able to secure a few meetings and set off for DC.  On arrival on Capitol Hill, I was amazed by the general lack of interest in the healthcare debate (other than when cameras are rolling for the mainstream media).  On the day I entered the Rayburn Building (which houses most of the House of Representatives offices), there was a long line of people and politicians were buzzing around in the hallways—all due to more hearings on Russia and our election as well as President Trump’s tax proposal announcement—almost no one was interested in discussing healthcare.  I was able to secure meetings with a few Congressional offices and staff, including the Deputy Whip, Patrick McHenry from North Carolina.  I was able to meet with Congressman McHenry’s team and spent nearly an hour going over issues with healthcare.  They listened, took notes, and promised to follow up in the coming weeks.  They seemed truly interested and empathized with the plight of patients throughout the United States.  I also met with staff from Vern Buchanan’s (R-Florida) office and shared more of my concerns. Mr Buchannan sits on the Ways and Means Committee and is influential in discussions concerning healthcare expenditures and funding of healthcare related programs.   Interestingly, both of the Congressional staffs that I met with seemed genuinely surprised about my report of the “real” state of healthcare, particularly when I discussed issues of billing, reimbursement for physicians and the cost of drugs and medical devices.  I really think that many of our Congressmen and women are not adequately informed about healthcare related issues because they do not have to deal with the system in the same way that doctors and the average American patient have to on a daily basis.

Healthcare and Congress, On Life Support

I really believe that there is little hope for saving the US healthcare system during the next 4 years.  After more than 7 years of criticizing the ACA and campaigning on promises to repeal and replace, the Republicans have little to offer.  One would think that during the two Obama terms, the Republicans could have been working on a viable replacement plan—but clearly they have not.  In Medicine, we are always taught to be prepared, to be able to be flexible, and respond to unforeseen circumstances.  We meticulously plan our treatment, or surgical approach and our next steps.  Congress, after winning majorities in both Houses and also taking the White House, has shown a lack of preparation to actually govern—particularly when it comes to healthcare.  The Democrats, always simply satisfied with the status quo, refuse to admit that Obamacare is not viable in the long term and have not put forward ANY plans to address its failings.  Most of their energy has been put in to thwarting any legislation put forward by the opposition.  The Republicans, due to bitter infighting within the party, have crafted piecemeal replacement plans that are likely to show no real improvement—in short, these plans simply “rearrange deck chairs on the Titanic”.

What MUST Happen Now?

In the hospital, when a CODE BLUE is called, all available staff rush to the bedside of a patient who is in distress.  In most cases this means the initiation of CPR of cardio pulmonary resuscitation and any necessary heroic measures are employed in order to save the patient’s life. Any indecision or any delay in treatment can result in death for the patient.  However, if the CODE team works in concert, with a single goal (of saving the patient’s life), comes together quickly and effectively, a positive outcome is far more likely.   It is now time to call a CODE BLUE on healthcare in Washington DC.  We must demand that both Houses of Congress focus on real, meaningful healthcare reform.  Any delay, much like with a patient who is in distress, will lead to disaster and ultimately, death.  Not only for healthcare as we know it, but ultiamtely for doctors and patients as well.

 

Lessons Learned from The South Pacific: Implications for US Healthcare

Kevin R. Campbell, MD, FACC

For the last several weeks I have been working as a medical volunteer on a remote island off the coast of Fiji called Batiki.  Home to 234 natives, Batiki has no running water, and no electricity (other than solar generated power).  The inhabitants are subsistence fishermen and farmers and are filled with joy and a real sense of community.  While on the island, I found extremely high rates of high blood pressure and moderate rates of type 2 diabetes, but overall, I found a very happy and healthy indigenous population.  Previous research has shown that the South Pacific islands have the second highest rates of type 2 diabetes in the world–but there were fewer cases on Batiki than I expected.  My time on Batiki has led me to reflect on the beauty and passion of its people and how we, as Americans, can learn so much from them when it comes to living a happy and healthy life…

 

Island Map_1.jpg

(Image with permission, courtesy of Sea Mercy)

Life on Batiki: Back to Basics

I traveled to the South Pacific as the medical director of a charitable organization known as Sea Mercy.  This organization was formed by businessman Richard Hackett as a way to respond to the devastation caused by tropical cyclones over the last several years.  Many islanders lost everything—homes, families, possessions and many still struggle to survive. Yet they are incredibly resilient and continue to enjoy the simple lives that they have

During my time on the island, I was fortunate enough to spend two weeks living with the villagers in Mua (one of four villages on Batiki) as a guest in the home of the island Chief.  I was able to learn a great deal about the culture and values of the Fijians and I gained a great deal of insight into what really makes us healthy—its not always expensive healthcare plans and pricey name brand medications.  In the case of the villagers of Batiki, much of what makes them healthy is their ability to do so much with so little.  They live off of the land around them and they do not seek care for routine aches and pains.  It was not uncommon for me to see patients in my makeshift clinic that were suffering from orthopedic injuries for months or years.  Many had sprains, healed bone breaks and old cuts—but all continued to work and play.

In addition, the focus on family and community—on supporting one another—seems to result in an increased emphasis on group activities and family meals.  For example, almost every night, the men of the village—both young and old—played rugby games for hours.  The girls played a game called “net ball” and also enjoyed volleyball.  The children loved to swim and run up and down the beach.  Dinners are family events and everyone gathers around a tablecloth placed on the floor to eat together.  While the meals are NOT well balanced—far too carbohydrate heavy and lacking in proteins and vegetables—they are family events.

In the clinic on Batiki, a government paid nurse provides healthcare services for the entire island (four villages) with very limited supplies.  She has no running water or power in the clinic and has a variable stock of diabetes medications, Blood pressure medications, anti inflammatory medications and vaccines.  Due to cultural stigma with seeing a doctor or nurse, it is often difficult to get villagers to come to the clinic and many diseases go undiagnosed and untreated.  In order to overcome this when I was on the island, I made house calls to protect patient privacy.  Rather than use imaging tools and expensive tests, I made complex diagnoses such as Lupus, Neurofibromatosis and others, simply by history and physical examination.  I spent more time talking to patients and their families and did not spend any time imputing data into a medical record or filling out billing forms.  The focus was on the PATIENT.  Imperical treatment and follow up helped confirm most diagnosis and also resulted in a refinement of a patient’s therapy.  In the US, we are far too obsessed on testing and often forget about the power of the patient interaction.

IMG_9863.JPG

(Batiki nurses station–photo courtesy of Dr Kevin Campbell)

So, What Can We Learn from Healthcare on Batiki?

One of the founders of modern medicine, Sir William Osler once said that “if you listen to the patient long enough, he will tell you what he has”.  This has been proven to be very true over the years and has been the basis for the doctor patient relationship for decades in the US healthcare system.  Unfortunately, we no longer value the doctor-patient relationship in the US.  Those that mandate the way in which healthcare is delivered (not doctors, mind you), value billing and coding documentation via electronic medical records far more than they value the time a physician spends with a patient connecting on an interpersonal and very human level.  On Batiki, healthcare is both more complicated and actually a lot simpler, all at the same time.  While resources are scarce and you must carefully choose when to use antibiotics or other drugs that are common in the US (and in short supply there), you also are not weighed down by bureaucratic paperwork, rules and regulations.  The patient is the focus of the interaction, not the computer.  There are no practice or hospital administrators—only a team of nurses and doctors who want to get a job done.  On the island, medicine returns to its purest form—listening to symptoms, observing the patient and making a best guess as to the diagnosis based on available data.  Patients heed the advice of the physician and actually WANT to follow the treatment plan.  They do not come in to the clinic as the “worried well” or looking for pain medications—they seek care for problems that they cannot manage any other way.  Both doctors and patients benefit from every single interaction because each and every interaction is unique and unrushed.  Doctors are not stressed due to unmanageable patient volumes and patients are not upset at wait times.  Everyone is happy to be alive and everyone is working towards a common goal—better health and a happy life.  Those in power in Washington DC could learn a lot about healthcare from my friends in Batiki.  Rather than catering to special interests and allowing costs to spiral out of control, focus on what matters most—THE WELLNESS of the PATIENT and the PREVENTION of disease.  If we shift gears and change our paradigm, we all be better for it.  I expect that healthcare costs will stabilize and that outcomes may even improve.  Currently we spend more money per capita on healthcare than any other industrialized nation yet our outcomes are not nearly the best in the world—so, in my mind, something has to change.  I think we must look to the far away parts of the world for guidance.

How Has Batiki Changed Me?

After my experience on the island, I am forever changed—I like to believe that I am now a better physician, a better person as well as a better husband and father.  My brothers on the island of Batiki have taught me many valuable lessons—most importantly, I have learned to live in the moment and to appreciate the little things in life.  I am grateful for many things that I once took for granted—a warm shower, a soft bed, a healthy meal and time spent with family and friends.  For now, it is my hope that my “Batiki transformation” will allow me to do a better job advocating for my patients and will allow me to  inspire others to continue to fight for a better healthcare system in the US today.

IMG_0042.JPG

(Photo of Batiki, Courtesy Dr Kevin Campbell)