The Last Word

by Robert Bunata, MD – Publications Committee Interim Chair

This piece was originally published in the September/October issue of the Tarrant County Physician. You can read find the full magazine here.


After our first year of college, my little group of high school friends had a summer reunion.  Ed was pursuing literature and publishing, Steve accounting, and Roger a business degree.  We had the following conversation after Roger said, “I have a great idea. You be the doctor and I’ll run the business.”

To that I replied, “Why would I do that?  I’ve watched my father and mother run their business just fine for years. I think I can do it myself with a little help and I’d have control like my dad.” 

“But with smart business practices you could make more money and I’d handle the stress of the paperwork.”

“Granted,” I said, “I might make more money, but that’s not what I want. I want freedom, control, and to do what I’ll be trained for, to take care of patients.  I want to make sure my business runs like I want. And, besides, I’d have to pay your salary as well as mine, meaning I’d have to take home less or charge the patients more.” At that time I failed to add: “Besides, Roger, if I approach my patients with a bill collector they would think I was only interested in making money and not in them.”  

Over the next decade or two, due to the mix of new health insurance companies, specialization, technical development, and lots of greed, medical costs got out of hand and the specter of Roger came back in the form of big business and managed care.  

About 25 years ago, as our autonomy was being eroded, I wrote an article for The Physician advocating that doctors stand up for their rights.  I went so far as to recommend we form a union even though it was illegal.  But I did not have a plan or even an idea of what to actually do.  Business and politics won and they set the agenda for the practice of medicine, and we followed like sheep to the slaughter—literally to the slaughter in the form of burn-out, depression, retirement, and suicide.  

“We should admit that we gave up control of our profession too easily, and let politicians and businesspeople define who we are.”

Two recent articles I read express the same exasperation. Richard Byyny, MD, and George E. Thibault, MD, have recently published a monograph entitled, “Burnout and resilience in our profession.”1 Since I am unable to paraphrase the article satisfactorily, I will quote the part I found most interesting, shortening where possible. 

Our current problems with burnout were anticipated by sociologists who posed that bureaucratic and professional forms of organizing work are fundamentally antagonistic. Medical schools do not yet prepare graduates as practitioners who can best resist the bureaucratic and market forces shaping health care and the care of the patient. 

Physicians experience conflict between what they …should do, and what they have been educated and socialized to do. They have been professionalized for acquiescence, docility, and orthodoxy. They are taught to be more like sheep than cats—ultra-obedient following the rules. They are not taught to be cats—independent activists – … advocating for medical values.

We have prepared physicians to follow the rules; however, whose rules? The rules generated by … (our own) … profession?  Or the rules generated by the organization with different values and objectives?

As a result, physicians see professionalism more about conformity. This creates a conflict in the current health care system and organizations. Physicians seem to be perverting core principles of the profession to a just-follow-the-rules … practice of medical professionalism. We are essentially responsible for the problems we now encounter, especially when the care of the patient is often not the focus.

We need cats who will resist conformity in service of extra-professional forces. The mission … (should be) about saving health care for patients and society and enabling (us) … to care for patients and not experience burnout.

That article was sitting in my mind when I came across another— “After the storm”—by Siddhartha Mukherjee, MD, subtitled, “The pandemic has revealed dire flaws in American medicine. Can we fix them?”2 Mukherjee is an oncologist who won a Pulitzer Prize for his book, The Emperor of All Maladies: A Biography of Cancer. He says he wrote this article to use this tragedy to improve American medicine.  First he discusses the points of failures in the organization and implementation of the medical distribution system, and the tendency to buy the cheapest foreign products (masks, gowns, pharmaceuticals), shunning our local providers. He especially criticizes the underfunding of medical research and public health.   

Then he reaches the most interesting part of the article, an anecdotal story about how he contacted doctors in different parts of the country on Twitter and Facebook to share ideas on treating COVID-19 patients.  In their informal transmissions they shared minute by minute discussions like the cause and treatment of thrombi, or how to best position patients to breathe. That improvised social media exchange drew his attention to the fact our balky, billion-dollar electronic medical record (EMR) system doesn’t provide a medical, but rather a financial database.   

These articles tell us that we need some housekeeping, some specific and some general changes.  By “we” I must emphasize that means every doctor, not just a few with an interest in politics.  This involves not just every doctor’s practice or earnings, but our whole life.  If we don’t work together and improve this, burnout will spread like COVID-19.   

There are many things that need improvement (to my mind too, especially the underfunding of medical research), but I’d like to look at two specific changes to consider.  

The first specific change is improving our EMR system to make it more medically useful. Mukherjee’s anecdote tells our story.  If we compare our EMR to the system in Taiwan— which may or may not be fair given such factors as their size and homogeneity—their electronic health records system made a swift targeted response to COVID-19 possible.3 Although the system was not designed to stop a pandemic, it was nimble enough to be reoriented toward one. The government merged the health card database with information from immigration and customs to send physicians alerts about patients at higher risk for having COVID-19 based on their travel records.  

While the U.S. has come a long way with its use of electronic records, thanks in part to the financial incentives built into the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, the sharing of data—so called interoperability between different electronic health record vendors—has lagged. It’s expensive, but shoring up the U.S.’s digital health infrastructure will help improve routine care while empowering us to better respond to future infectious disease outbreaks.4,5,6 

Next specific change, the topic of EOBs, is one of my pet peeves.  Whenever I get an EOB for services I’ve received, the doctor’s charge is high compared to the payment received.  This is especially obvious dealing with Medicare EOBs with approved payments from Medicare being about a third of what the doctor charges.  When physicians see an EOB, we think how we’re being underpaid, but many patients have told me they think it shows the doctor is overcharging.  When I see this, I think this is exactly what “Roger” would have done, and it paints a bad image of doctors.  It makes us look like we’re only interested in making money and not in them.

As you can imagine, the list of improvements we could make can go on forever. But the point is we have to work together to improve the practice of medicine and the lives of doctors. 

Now for the general changes to consider. They are more vague and difficult to enumerate.  In my opinion, we should admit that we gave up control of our profession too easily, and let politicians and businesspeople define who we are. For instance, we should stop ridiculous requirements like having our payments reduced if a patient doesn’t take his medicine. We should take back what is rightfully ours—control of our profession, our practices, and our lives.  A big part of burnout is the feeling of not being in control; the best way to feel like we’re in control is to actually be in control. While I don’t have a detailed plan to do this, identifying the objective is a start. This should be a prime issue on the agenda of the AMA, AOA, TMA, TOMA, and of every doctor.  

Another general change concerns professionalism.  We all know what professionalism means on an individual level: put the patient’s interests ahead of our self-interests. We have all done that at one time or another—missed a Thanksgiving dinner or a child’s soccer game.  But what does professionalism look like on a national level?  What does it mean to put the nation’s patients’ interests ahead of our collective own?  While I have a few ideas I would rather not reveal them now. I am asking each of you to consider the question and write a letter to the editor or send an email with your observations and ideas. You can email us at editor@tcms.org, or mail us at 555 Hemphill St, Fort Worth, 76104.

References
1. http://alphaomegaalpha.org/medprof2015.html

2. After the storm. New Yorker, May 4, 2020

3. https://www.healthit.gov/topic/laws-regulation-and-policy/health-it-legislation

4. https://www.healthit.gov/topic/laws-regulation-and-policy/health-it-legislation

Tarrant County COVID-19 Activity – 10/29/20

COVID-19 Positive cases: 66,110*

COVID-19 related deaths: 734

Recovered COVID-19 cases: 52,544

Data from Tarrant County Public Heath’s (TCPH) report of COVID-19 activity in Tarrant County, updated Thursday, October 29, 2020. Find more COVID-19 information from TCPH here.

*These data are provisional and are subject to change at any time.

Deaths and recovered cases are included in total COVID-19 positive cases.

Tarrant County COVID-19 Activity – 10/27/20

COVID-19 Positive cases: 64,727*

COVID-19 related deaths: 723

Recovered COVID-19 cases: 51,635

Data from Tarrant County Public Heath’s (TCPH) report of COVID-19 activity in Tarrant County, updated Tuesday, October 27, 2020. Find more COVID-19 information from TCPH here.

*These data are provisional and are subject to change at any time.

Deaths and recovered cases are included in total COVID-19 positive cases.

There is Some Good News, Too

by Tilden Childs, MD – TCMS President

This piece was originally published in the September/October issue of the Tarrant County Physician. You can read find the full magazine here.


by Tilden Childs, MD – TCMS President

When I was perusing the Wall Street Journal the other day, I ran across an article by one of my favorite writers, Daniel Henninger. He started his article with the following observation, “On Tuesday the New York City sky was clear, blue and filled with sunshine. That’s it for this week’s good news.”  His article was not about COVID-19, but it prompted me to think that yes, there is some good news on COVID-19.

As I suspected early on, the COVID-19 pandemic is not going to be a short-term phenomenon with a “V” shaped medical recovery for the country, unlike the stock market (well at least some stocks). However, some recent developments do appear to be positive and hope for some return to normalcy has not been extinguished. The re-opening of the U.S. economy has been progressing, which is good, but unfortunately the infection rates have also increased. Parts of Texas, particularly in the Valley, are suffering. However, the mantra of “wear a mask or face covering, wash your hands frequently, and maintain physical distancing” seems to be working when rigorously applied. Even President Trump is taking the situation more seriously and now supports the wearing of a mask or facial covering.

The mortality rate from COVID-19 may be lower than was initially thought, but this is a complicated issue. As explained in an article in Nature: “Researchers use a metric called infection fatality rate (IFR) to calculate how deadly a new disease is. It is the proportion of infected people who will die as a result, including those who don’t get tested or show symptoms.” “The IFR is one of the important numbers alongside the herd immunity threshold and has implications for the scale of an epidemic and how seriously we should take a new disease,” says Robert Verity, an epidemiologist at Imperial College London. “Calculating an accurate IFR is challenging in the midst of any outbreak because it relies on knowing the total number of people infected—not just those who are confirmed through testing. But the fatality rate is especially difficult to pin down for COVID-19, the disease caused by the SARS-CoV-2 virus,” says Timothy Russell, a mathematical epidemiologist at the London School of Hygiene and Tropical Medicine. “That’s partly because there are many people with mild or no symptoms, whose infection has gone undetected, and also because the time between infection and death can be as long as two months.”1

Some potential reasons for the apparent recent decrease in the mortality rate were discussed in an article in The Atlantic: “COVID-19 Cases Are Rising, So Why Are Deaths Flatlining?”2

  1. Deaths lag cases—and that might explain almost everything.
  2. Expanded testing finds more cases, milder cases, and earlier cases.
  3. The typical COVID-19 patient is getting younger.
  4. Hospitalized patients are dying less frequently, even without a home-run treatment.
  5. Summer might be helping—but only a little bit.

Let’s hope that #1 above is not correct! I would like to believe that the evolution of our understanding of the virus and the disease it causes, including a better appreciation for its variable severity and multi-organ involvement, has and will continue to result in more and better treatment options which are at least in part improving mortality and morbidity outcomes.

“This is really good news as it now appears that herd immunity may be the key to successfully mitigating the current crisis and controlling the SARS CoV-2 virus.”

Progress on developing a vaccine(s) is moving forward at an accelerated pace. This is the result of  the National Institutes of Health and the Foundation for the NIH (FNIH) forming the Accelerating COVID-19 Therapeutic Interventions and Vaccines (ACTIV) partnership with the goal of developing “a collaborative framework for prioritizing vaccine and drug candidates, streamlining clinical trials, coordinating regulatory processes and/or leveraging assets among all partners to rapidly respond to the COVID-19 and future pandemics.”3 This represents an unprecedented cooperative alliance between government agencies and private industry to expedite the development of vaccine(s) as well as begin production of potentially successful vaccines in advance of final approval of the vaccine(s). At the time of writing this article, Phase III trials are about to begin for at least one of the vaccines under development. Availability of a vaccine(s) may be as early as late 2020 or early 2021.

This is really good news as it now appears that herd immunity may be the key to successfully mitigating the current crisis and controlling the SARS CoV-2 virus. Recent evidence suggests that immunity following infection is time limited and that significant long-term morbidity is believed to occur after recovery from the acute COVID-19 infection phase. This means that herd immunity generated by vaccinations rather than by community infections looks to be the key to getting the crisis under control and reducing the mortality rate and the long-term sequelae of community acquired infections.

I hope this Good News gives you reason to Keep up the fight and Keep the faith.

Thank you and stay safe!

References
1. https://www.nature.com/articles/d41586-020-01738-2

2. https://www.theatlantic.com/ideas/archive/2020/07/why-covid-death-rate-down/613945/

3. https://www.nih.gov/news-events/news-releases/nih-launch-public-private-partnership-speed-covid-19-vaccine-treatment-options

Tarrant County COVID-19 Activity – 10/26/20

COVID-19 Positive cases: 64,290*

COVID-19 related deaths: 719

Recovered COVID-19 cases: 51,363

Data from Tarrant County Public Heath’s (TCPH) report of COVID-19 activity in Tarrant County, updated Monday, October 26, 2020. Find more COVID-19 information from TCPH here.

These data are provisional and are subject to change at any time.

Deaths and recovered cases are included in total COVID-19 positive cases.

Tarrant County COVID-19 Activity – 10/23/20


COVID-19 Positive cases: 62,375*

COVID-19 related deaths: 713

Recovered COVID-19 cases: 50,328

Data from Tarrant County Public Heath’s (TCPH) report of COVID-19 activity in Tarrant County, updated Friday, October 23, 2020. Find more COVID-19 information from TCPH here.

These data are provisional and are subject to change at any time.

Deaths and recovered cases are included in total COVID-19 positive cases.

Thank You, Telemedicine

By Susan Bailey, MD – AMA President

This piece was originally published in the September/October issue of the Tarrant County Physician. You can read find the full magazine here.

It happened twice in the same morning.

I saw two women for checkups that morning—their stories were so similar.  Both older but not elderly, living alone, physically impaired needing a walker or motorized scooter, and always very crabby at their appointments.  A litany of chronic non-specific complaints—fatigue, aching, headachey, etc.  Honestly, I was not looking forward to their visits. They never seemed satisfied, and I never felt like I had helped them much.  When I saw them both on the schedule that morning, I confess that I grimaced a bit.  

But their telemedicine visits were just the opposite of their usual in-person visits.  They both were happy, smiling, and relaxed.   The conversations were easy and their questions were few.  I anticipated much COVID-19 anxiety but found little; they were used to staying at home and hadn’t had to change their way of life much.  They both just needed refills—I would have liked to have done a physical exam, but I really didn’t need to.  

At the end of the morning, I wondered to myself what was different, and then it hit me.  They didn’t have to physically come to see me, which so many of us take for granted but for them was likely a physically draining, frustrating, expensive, humiliating, and even painful experience. Wow. Was I humbled.  

Telemedicine is a gift to some of our patients, such as parents stuck without childcare who have to bring multiple children along with them, people who lack reliable transportation, or elderly people who don’t like driving anymore but are embarrassed to ask for a ride. It can help someone two hours away who just needs a refill or a patient who can’t afford to miss work.  I could go on and on; I’ve seen cases like every example I’ve given and I’m sure many of you have, too.

The coronavirus pandemic has added a new layer of urgency to the implementation of telemedicine.  Physical distancing and shutdowns have made it extremely difficult, if not impossible, to see our patients safely face to face (especially when PPE is still hard to find).  Telemedicine enables routine care to continue without the risk of exposure to the virus.  It keeps medical offices safe and in business.  

The AMA, along with many other organizations, has been developing telemedicine policy and recommendations for years.  The AMA House of Delegates approved a report from the Council on Medical Services laying out principles for coverage and payment in June 2014.  

An AMA survey in 2016 showed that 15 percent of physicians worked in a practice that utilized telemedicine in some way.1 But a far smaller percentage of actual patient encounters were done via telemedicine. 

When COVID-19 struck and communities were shutting down all over the country, the telemedicine guidelines, reimbursement policies, and the work we had already done with CMS helped the organization be ready with their new guidelines for coverage and payment, which were initially released on March 17, 2020.  

AMA had been working with the Physicians Foundation, the Texas Medical Association, the Florida Medical Association, and the Massachusetts Medical Society to create the Telehealth Initiative to provide a wide array of assistance for physicians to implement telemedicine in their practices.2  The launch of the program was not scheduled until later in the year but instead was moved up to March 19, 2020, just two days after the CMS announcement.  

Virtually every medical society in the country now has guidance available for physicians on using telemedicine. 

However, the current telemedicine coverage and payment program will only stay in effect as long as there is a national emergency, which has now been extended to the end of October 2020.  Of course, we all know that COVID-19 will not be gone then, so AMA is working with state and specialty societies to lobby Congress for permanent solutions.  

I believe that every specialty will develop its own guidelines for the appropriate use of telemedicine going forward, and every practice will utilize telemedicine to some degree.  

The genie is out of the bottle. Let’s hope it stays that way. We deserve to be compensated fairly for services regardless of location, and our patients deserve the ease of access.   

References
1. https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2018.05077

2. https://www.ama-assn.org/press-center/press-releases/ama-supports-telehealth-initiative-improve-health-care-access

COVID-19 Deadlines for Doctors

Originally published on the Texas Medical Association website.

The following deadlines and extensions are in effect during the COVID-19 pandemic.

Through Oct. 23

Several Medicaid and Children’s Health Insurance Program(CHIP) flexibilities, including paying for Texas Health Steps (THSteps) medical checkups via telemedicine and CHIP copay waivers expired. 

Through Oct. 31

Cigna is extending certain cost-share waivers for COVID-19 screening, testing, and treatment, including telehealth screening.

Through Dec. 31

Texas-regulated insurers must continue to pay for telemedicine services, including mental health visits, at the same rate as in-person visits. The extension was part of an emergency rule that was set to expire Sept. 12.

  1. Aetna is extending coverage for commercial telemedicine service, including audio-only visits. Cost share waivers expired Aug. 4.
  2. Blue Cross Blue Shield of Texas is extending certain cost-sharing and telemedicine waivers for state-regulated, fully insured HMO and PPO members and Medicare members. 
  3. Cigna is extending telemedicine waivers.

To help you understand all of the changes to telemedicine during the pandemic, the Texas Medical Association has published up-to-date information for each type of payer.

Stay up to date with the latest news, resources, and government guidance on the coronavirus outbreak by visiting TMA’s COVID-19 Resource Center regularly.

Tarrant County COVID-19 Activity – 10/18/20

COVID-19 Positive cases: 59,274*

COVID-19 related deaths: 703

Recovered COVID-19 cases: 48,688

Data from Tarrant County Public Heath’s (TCPH) report of COVID-19 activity in Tarrant County, updated Sunday, October 18, 2020. Find more COVID-19 information from TCPH here.

These data are provisional and are subject to change at any time.

Deaths and recovered cases are included in total COVID-19 positive cases.

Tarrant County COVID-19 Activity – 10/16/20

COVID-19 Positive cases: 58,053*

COVID-19 related deaths: 699

Recovered COVID-19 cases: 48,108

Data from Tarrant County Public Heath’s (TCPH) report of COVID-19 activity in Tarrant County, updated Friday, October 16, 2020. Find more COVID-19 information from TCPH here.

These data are provisional and are subject to change at any time.

Deaths and recovered cases are included in total COVID-19 positive cases.