In repsonse to my last two blog posts, a number of readers responded that women, not just people of color, experience bias and disrespect in the health care system. This brought to mind a study done over 20 years ago by a brilliant colleague of mine, Dr. Jonathan N. Tobin. His 1987 Study published in the July 1 issue of the Annals of Internal Medicine (Volume 107, pp 19-25) revealed that there was substantial "Sex Bias in Considering Coronary Bypass Surgery".
The abstract of that study reads in part:
" In a study of 390 patients consecutively referred for nuclear exercise testing, abnormal results found in 31% of the women and in 64% of the men affected physicians' decisions to recommend catheterization in men only; 4% of the women with abnormal radionuclide scans were referred for catheterization compared with 40% of the men (p < 0.001). This 10:1 ratio was independent of age."
Gender bias, racial bias, bias against obese individuals, bias against those who speak a language other than English - all affect the care that patients recieve in the health care system. And they have secondary effects as well - as some of the commentors on my previous blogs pointed out - they make one loathe to go to the doctor at all. And with no medical visit, the odds are that people neglect needed preventive care and comprehensive care for chronic conditions. Can this problem be helped through training? Perhaps. But we have a very long way to go. And tragically - for decades since the Tobin article was published, there is little evidence that we have made any substantial progress.
Saturday, July 25, 2009
Wednesday, July 22, 2009
CNN Report on Aparthied in Medical Care in New York City - a follow-up note
(The message below was posted on Anderson Cooper's blog in response to many comments recieved about the show that aired on July 20 on AC360. It is scheduled to air again on Saturday July 25 on Dr. Sanjay Gupta's House Calls)
My name is Dr Neil Calman and I was the physician interviewed by Dr. Gupta for the segment on racism in medical care. For those of you who may have missed it you can see it by clicking on the link below:
http://www.youtube.com/watch?v=8j51CYlSFRQ
First, I would like to express my appreciation to CNN, Anderson Cooper, Dr. Sanjay Gupta and his senior producer Caleb Hellerman for a thoughtful and accurate portrayal of the difficulties people of color in New York (and certainly in other parts of the country) have in obtaining good medical care. This report was the result of an investigation of the named hospitals in New York City done more than a year ago and which formed the basis of a complaint to the New York State Attorney General.
I also sincerely appreciate the many comments on CNN’s blog from patients – many of whom were not Black - who were also misdiagnosed, mistreated or otherwise received inadequate care and concern for their medical problems. These stories require our attention as American’s receive grossly inadequate care while our country spends 2 to 3 times more per person than some other countries that achieve far better outcomes and whose residents live longer and healthier lives. That is why we need health reform and need it now. It also speaks to the need for more primary care physicians – so every person in America that wants one, can have an ongoing, supportive relationship with one main provider who cares for almost all their medical needs and advocates for them when they need to see a specialist or when they need specialized care or a special procedure.
I want to address the issue that being Black is not what the CNN story was about but rather was the same story that could be told by poor or uninsured white people as well. Telling the story of only a few Black ministers in the Bronx was not meant to suggest that the problem was exclusively one faced by people of color. The people interviewed were just examples of over 100 phone calls made and recorded by our researchers who looked at how people were sorted into different models of care in New York City based upon the type of insurance they have. In New York City, because of the predominance of Blacks and Latinos among the uninsured and those on Medicaid, sorting people of color into systems with less well trained providers, no continuity of care, no emergency call systems and no communication back to the patients primary care provider – all contribute to the inadequate medical care that many receive and contribute to the poorer health outcomes Blacks experience.
Some people say that its all about education – or poverty – or lack of insurance. In fact, imagine that each of these things – education, financial well-being and good insurance coverage – are all things people need to get the best medical care. And also imagine – what hundreds of published studies have shown – that race, independent of all these other factors, is a predictor of poorer health care processes and poorer outcomes. If you imagine this, then you can understand that the question is not which of these factors is more important – but how many strikes do you have against you when you seek medical care. Race is one factor and being Black or Latino is one strike. Being poorly educated is another strike – especially when that means a poor understanding of the diseases that are important in your own preventive care plan, your family’s health or the diseases most prevalent in your community. Lack of financial means may create a situation where you put off, sometimes indefinitely, needed preventive care measures or put off buying the prescription drug not covered by your health plan. And being uninsured is a fourth strike as it is the greatest predictor of bad health outcomes.
Racism in health care is a common experience of people of color so let’s stop saying that race does not matter. We know it does. It is one very important factor in why people get bad medical care. . So is poor education, poverty and lack of insurance.
Our health care system needs to do better. We need to fight racism in medicine wherever it occurs and that is what the CNN story is about. We also need to get health reform passed now! That will largely fix the insurance issue. We need many more primary care physicians so everyone can have a trusted physician they know over time and who will care for all their basic medical needs. And we need a better campaign to educate all America about the importance of preventive care, good care for their chronic illnesses and about the health behaviors that can help them lead healthier and longer lives.
As President Obama points out – this is not a debate over politics. Everyone knows we need to fix our very broken health care system. Everyone has a horror story to tell somewhere in their personal experience or the experience of their friends or family. We have to do better than this and we can.
My name is Dr Neil Calman and I was the physician interviewed by Dr. Gupta for the segment on racism in medical care. For those of you who may have missed it you can see it by clicking on the link below:
http://www.youtube.com/watch?v=8j51CYlSFRQ
First, I would like to express my appreciation to CNN, Anderson Cooper, Dr. Sanjay Gupta and his senior producer Caleb Hellerman for a thoughtful and accurate portrayal of the difficulties people of color in New York (and certainly in other parts of the country) have in obtaining good medical care. This report was the result of an investigation of the named hospitals in New York City done more than a year ago and which formed the basis of a complaint to the New York State Attorney General.
I also sincerely appreciate the many comments on CNN’s blog from patients – many of whom were not Black - who were also misdiagnosed, mistreated or otherwise received inadequate care and concern for their medical problems. These stories require our attention as American’s receive grossly inadequate care while our country spends 2 to 3 times more per person than some other countries that achieve far better outcomes and whose residents live longer and healthier lives. That is why we need health reform and need it now. It also speaks to the need for more primary care physicians – so every person in America that wants one, can have an ongoing, supportive relationship with one main provider who cares for almost all their medical needs and advocates for them when they need to see a specialist or when they need specialized care or a special procedure.
I want to address the issue that being Black is not what the CNN story was about but rather was the same story that could be told by poor or uninsured white people as well. Telling the story of only a few Black ministers in the Bronx was not meant to suggest that the problem was exclusively one faced by people of color. The people interviewed were just examples of over 100 phone calls made and recorded by our researchers who looked at how people were sorted into different models of care in New York City based upon the type of insurance they have. In New York City, because of the predominance of Blacks and Latinos among the uninsured and those on Medicaid, sorting people of color into systems with less well trained providers, no continuity of care, no emergency call systems and no communication back to the patients primary care provider – all contribute to the inadequate medical care that many receive and contribute to the poorer health outcomes Blacks experience.
Some people say that its all about education – or poverty – or lack of insurance. In fact, imagine that each of these things – education, financial well-being and good insurance coverage – are all things people need to get the best medical care. And also imagine – what hundreds of published studies have shown – that race, independent of all these other factors, is a predictor of poorer health care processes and poorer outcomes. If you imagine this, then you can understand that the question is not which of these factors is more important – but how many strikes do you have against you when you seek medical care. Race is one factor and being Black or Latino is one strike. Being poorly educated is another strike – especially when that means a poor understanding of the diseases that are important in your own preventive care plan, your family’s health or the diseases most prevalent in your community. Lack of financial means may create a situation where you put off, sometimes indefinitely, needed preventive care measures or put off buying the prescription drug not covered by your health plan. And being uninsured is a fourth strike as it is the greatest predictor of bad health outcomes.
Racism in health care is a common experience of people of color so let’s stop saying that race does not matter. We know it does. It is one very important factor in why people get bad medical care. . So is poor education, poverty and lack of insurance.
Our health care system needs to do better. We need to fight racism in medicine wherever it occurs and that is what the CNN story is about. We also need to get health reform passed now! That will largely fix the insurance issue. We need many more primary care physicians so everyone can have a trusted physician they know over time and who will care for all their basic medical needs. And we need a better campaign to educate all America about the importance of preventive care, good care for their chronic illnesses and about the health behaviors that can help them lead healthier and longer lives.
As President Obama points out – this is not a debate over politics. Everyone knows we need to fix our very broken health care system. Everyone has a horror story to tell somewhere in their personal experience or the experience of their friends or family. We have to do better than this and we can.
Saturday, July 18, 2009
CNN AC360 Dr. Sanjay Gupta Covers our Attorney General Complaint Re: Dsicrimination in NYC Hospitals
Bronx Health REACH Attorney General Complaint to be featured on CNN's AC 360
Segments Produced by Dr. Sanjay Gupta – Monday July 20
10pm-12midnight [1]
Monday night, July 20, 2009, on CNN’s Anderson Cooper 360, Dr. Sanjay Gupta will be airing a two-part segment on racial discrimination that results from separate and unequal care provided by private teaching hospitals in New York City. Since 2005, Bronx Health REACH has shown, through its research efforts, that in many institutions in NYC, people covered by Medicaid and those who are uninsured are routinely treated in separate hospital-based facilities and by different providers than those who have private insurance. Furthermore, inadequate after-hours coverage, absent communication back to referring providers, and limited appointment availability all create disparities in care and lead to worse health outcomes. Because 16 times as many African-Americans and Latinos in the Bronx are covered by Medicaid or are uninsured compared to Whites, this creates de facto discrimination based upon race, a practice that is both immoral and illegal.
As you may remember, in June 2008, Bronx Health REACH, a coalition of community-based, faith-based and other organizations led by the Institute for Family Health, filed a civil rights complaint with the Office of the Attorney General of New York State. This complaint and the allegations contained in it were prepared and filed on behalf of Bronx Health REACH by New York Lawyers for the Public Interest (NYLPI).
Through multiple visits to New York accompanied by his producer and film crews, Dr. Gupta has interviewed faith leaders, patients, and REACH staff to bring this issue to light. The REACH Coalition has been working in the Bronx for nearly a decade to reduce racial and ethnic disparities in health outcomes for patients with diabetes and heart disease. Our hope is that national exposure of this issue will help end these practices in New York City and will make sure that equality in health services becomes part of our Nation’s health reform agenda.
REACH began its investigation of the out-patient referral practices of three hospitals named in the complaint - Montefiore, NY Presbyterian, and Mt. Sinai – after hearing multiple stories shared by patients in the coalition’s member organizations, as well as learning the experiences of primary care providers seeking to obtain out-patient specialty care for their patients. In consultation with researchers from New York University, hundreds of scripted phone calls were made and recorded over a period of months to the physician referral lines of the named institutions. In addition, REACH obtained the recorded testimony of a number of patients who experienced this discriminatory care and suffered because of it.
Our research findings show systematic channeling of patients into different care systems based upon their type of insurance – or lack thereof. As documented in our complaint and other findings over the years, it is commonplace for New York’s voluntary teaching hospitals to separate patients at the point of entry to their outpatient practices into two systems of care: their clinics and their faculty practices. Worse yet, while the faculty practices function the way we would all want to get care—with good continuity, reports sent back to the primary care providers, after-hours call by the group’s doctors, and access to the best that New York medical care has to offer—the clinics offer patients a rotating group of residents and fellows with little or no continuity of care; provide no communication with the primary care providers who referred their patients there for care; and often refer patients to the Emergency Room if they have questions or problems after-hours. Given this difference in care systems, differences in outcome should come as no surprise.
I know you all believe we can do better than this. We must do better, particularly as we promote the concept of medical homes for patients throughout New York State, and health reform at the national level. The vast sums of money that the State and Federal government put into health care for those who receive Medicaid and the uninsured obligate us to do better. In fact, recent increases in Medicaid out-patient rates mean that hospitals are now, in many instances, getting paid more by the State than private insurance is paying for their covered patients – and getting inferior care.
For far too long the health care system has blamed patients for their own poor outcomes, pointing to their delays in seeking care, their inadequate follow-up with appointments and their lack of compliance with treatment. The experience of the more than 100 primary care providers at the Institute for Family Health, and the experience of the members of the organizations of the Bronx Health REACH coalition tell a different story. New York’s voluntary teaching hospitals have created clinic systems that are difficult to negotiate, that provide care that patients quickly realize is not the best the institution has to offer, and that severely jeopardize their health and their lives. While these factors alone do not explain the 7 to 8 year decrease in life expectancy that Blacks and Latinos experience in the U.S., nor the increase in hospitalizations for conditions that are treatable in office settings and the excess morbidity and mortality suffered by people of color for almost every disease studied, we must change those aspects of our health care system that contribute to these tragic and disparate outcomes.
Filing a complaint with the Attorney General was a last resort to fix a problem I have been addressing on behalf of Bronx REACH and the Institute for nearly a decade. I have met personally with leadership from a number of voluntary teaching institutions in New York City, have presented findings of our studies at dozens of professional meetings, have had multiple discussions with the Greater New York Hospital Association leadership, and have discussed this issue with the former Commissioner and senior staff of the NYS Department of Health on multiple occasions over the years. In 2005, we published a report Separate and Unequal: Medical Apartheid in New York City, which received substantial press coverage and resulted in a number of public responses from voluntary hospitals. In private discussions, many agree that systems should be changed, but there has been no motivating force to stimulate this change.
I expect that the institutions named will once again be highly critical of the complaint and the CNN report, and will defend their practices in the same ways they have previously. First they will claim that faculty practices are not part of the institution but are merely affiliated private practices. This argument is both spurious and irrelevant. Personnel who are paid by the hospital and staff their physician referral lines, facilities that are licensed to the hospital, and systems that the hospital has established are sending people down different paths of care based upon their insurance status.
Next they will claim that billing requirements make it essential that clinics are run separately. This is also not true. Nothing prohibits privately insured patients from being seen in a hospital licensed out-patient facility, and doing so would not jeopardize private insurance payments in any way.
Finally, some will claim that they will be unable to attract patients from the suburbs and from outside the country if the services they offer must be integrated with the care of clinic patients. This is perhaps the most disturbing rationale of all. I invite leadership of these institutions to come to our Institute practices where corporate executives, patients referred from our homeless centers for follow-up, and a broad cross-section of New York comes for care, sit in the same waiting room and all have access to the best care we have to offer. As health care providers we, of all people, need to demonstrate a commitment to ending discrimination based on insurance status with the disparate impact it has on racial and ethnic minorities.
Traditions and long-standing systems do not die easily, but this one can and must. We have encountered a number of departments at each of the institutions where department leadership—either for moral or practical reasons—have decided to integrate the care of all patients into the same system. Hospital leadership should take note of these successful models in their own institutions and adopt their practices broadly and completely. Nothing less than that will provide our patients with the care they deserve and nothing less than that will help to eliminate the disparities in care that continue to exist in our institutions.
Please make time to watch Anderson Cooper 360 on Monday night, and share your thoughts with us by commenting on this blog. Please join me in encouraging our colleagues in voluntary teaching hospitals across New York City to address this longstanding injustice and inequity in care.
---------
[1] As with all news broadcasts, changing current events may necessitate changing the broadcast date or time of these segments
Segments Produced by Dr. Sanjay Gupta – Monday July 20
10pm-12midnight [1]
Monday night, July 20, 2009, on CNN’s Anderson Cooper 360, Dr. Sanjay Gupta will be airing a two-part segment on racial discrimination that results from separate and unequal care provided by private teaching hospitals in New York City. Since 2005, Bronx Health REACH has shown, through its research efforts, that in many institutions in NYC, people covered by Medicaid and those who are uninsured are routinely treated in separate hospital-based facilities and by different providers than those who have private insurance. Furthermore, inadequate after-hours coverage, absent communication back to referring providers, and limited appointment availability all create disparities in care and lead to worse health outcomes. Because 16 times as many African-Americans and Latinos in the Bronx are covered by Medicaid or are uninsured compared to Whites, this creates de facto discrimination based upon race, a practice that is both immoral and illegal.
As you may remember, in June 2008, Bronx Health REACH, a coalition of community-based, faith-based and other organizations led by the Institute for Family Health, filed a civil rights complaint with the Office of the Attorney General of New York State. This complaint and the allegations contained in it were prepared and filed on behalf of Bronx Health REACH by New York Lawyers for the Public Interest (NYLPI).
Through multiple visits to New York accompanied by his producer and film crews, Dr. Gupta has interviewed faith leaders, patients, and REACH staff to bring this issue to light. The REACH Coalition has been working in the Bronx for nearly a decade to reduce racial and ethnic disparities in health outcomes for patients with diabetes and heart disease. Our hope is that national exposure of this issue will help end these practices in New York City and will make sure that equality in health services becomes part of our Nation’s health reform agenda.
REACH began its investigation of the out-patient referral practices of three hospitals named in the complaint - Montefiore, NY Presbyterian, and Mt. Sinai – after hearing multiple stories shared by patients in the coalition’s member organizations, as well as learning the experiences of primary care providers seeking to obtain out-patient specialty care for their patients. In consultation with researchers from New York University, hundreds of scripted phone calls were made and recorded over a period of months to the physician referral lines of the named institutions. In addition, REACH obtained the recorded testimony of a number of patients who experienced this discriminatory care and suffered because of it.
Our research findings show systematic channeling of patients into different care systems based upon their type of insurance – or lack thereof. As documented in our complaint and other findings over the years, it is commonplace for New York’s voluntary teaching hospitals to separate patients at the point of entry to their outpatient practices into two systems of care: their clinics and their faculty practices. Worse yet, while the faculty practices function the way we would all want to get care—with good continuity, reports sent back to the primary care providers, after-hours call by the group’s doctors, and access to the best that New York medical care has to offer—the clinics offer patients a rotating group of residents and fellows with little or no continuity of care; provide no communication with the primary care providers who referred their patients there for care; and often refer patients to the Emergency Room if they have questions or problems after-hours. Given this difference in care systems, differences in outcome should come as no surprise.
I know you all believe we can do better than this. We must do better, particularly as we promote the concept of medical homes for patients throughout New York State, and health reform at the national level. The vast sums of money that the State and Federal government put into health care for those who receive Medicaid and the uninsured obligate us to do better. In fact, recent increases in Medicaid out-patient rates mean that hospitals are now, in many instances, getting paid more by the State than private insurance is paying for their covered patients – and getting inferior care.
For far too long the health care system has blamed patients for their own poor outcomes, pointing to their delays in seeking care, their inadequate follow-up with appointments and their lack of compliance with treatment. The experience of the more than 100 primary care providers at the Institute for Family Health, and the experience of the members of the organizations of the Bronx Health REACH coalition tell a different story. New York’s voluntary teaching hospitals have created clinic systems that are difficult to negotiate, that provide care that patients quickly realize is not the best the institution has to offer, and that severely jeopardize their health and their lives. While these factors alone do not explain the 7 to 8 year decrease in life expectancy that Blacks and Latinos experience in the U.S., nor the increase in hospitalizations for conditions that are treatable in office settings and the excess morbidity and mortality suffered by people of color for almost every disease studied, we must change those aspects of our health care system that contribute to these tragic and disparate outcomes.
Filing a complaint with the Attorney General was a last resort to fix a problem I have been addressing on behalf of Bronx REACH and the Institute for nearly a decade. I have met personally with leadership from a number of voluntary teaching institutions in New York City, have presented findings of our studies at dozens of professional meetings, have had multiple discussions with the Greater New York Hospital Association leadership, and have discussed this issue with the former Commissioner and senior staff of the NYS Department of Health on multiple occasions over the years. In 2005, we published a report Separate and Unequal: Medical Apartheid in New York City, which received substantial press coverage and resulted in a number of public responses from voluntary hospitals. In private discussions, many agree that systems should be changed, but there has been no motivating force to stimulate this change.
I expect that the institutions named will once again be highly critical of the complaint and the CNN report, and will defend their practices in the same ways they have previously. First they will claim that faculty practices are not part of the institution but are merely affiliated private practices. This argument is both spurious and irrelevant. Personnel who are paid by the hospital and staff their physician referral lines, facilities that are licensed to the hospital, and systems that the hospital has established are sending people down different paths of care based upon their insurance status.
Next they will claim that billing requirements make it essential that clinics are run separately. This is also not true. Nothing prohibits privately insured patients from being seen in a hospital licensed out-patient facility, and doing so would not jeopardize private insurance payments in any way.
Finally, some will claim that they will be unable to attract patients from the suburbs and from outside the country if the services they offer must be integrated with the care of clinic patients. This is perhaps the most disturbing rationale of all. I invite leadership of these institutions to come to our Institute practices where corporate executives, patients referred from our homeless centers for follow-up, and a broad cross-section of New York comes for care, sit in the same waiting room and all have access to the best care we have to offer. As health care providers we, of all people, need to demonstrate a commitment to ending discrimination based on insurance status with the disparate impact it has on racial and ethnic minorities.
Traditions and long-standing systems do not die easily, but this one can and must. We have encountered a number of departments at each of the institutions where department leadership—either for moral or practical reasons—have decided to integrate the care of all patients into the same system. Hospital leadership should take note of these successful models in their own institutions and adopt their practices broadly and completely. Nothing less than that will provide our patients with the care they deserve and nothing less than that will help to eliminate the disparities in care that continue to exist in our institutions.
Please make time to watch Anderson Cooper 360 on Monday night, and share your thoughts with us by commenting on this blog. Please join me in encouraging our colleagues in voluntary teaching hospitals across New York City to address this longstanding injustice and inequity in care.
---------
[1] As with all news broadcasts, changing current events may necessitate changing the broadcast date or time of these segments
Wednesday, April 29, 2009
Who will Represent America’s Poor as We Move Toward Health Reform?
Both the Administration and the Congress have been gearing up for health reform for many months. There are some good signs that both branches of government are taking health reform seriously. The President has spoken out on many occasions on the need for health care reform which includes a transition toward electronic health records on an accelerated timeline. Congressional committees have held a number of hearings and discussions. But the voices of our most underserved populations and those who serve them directly have largely been absent. This must change because poor people in our country, the uninsured, and people of color are sicker and die disproportionately because of lack of access to care and differences in the quality of care when it is given. Many in our most vulnerable communities use the emergency room as their only source of primary care because they have no health insurance, speak languages other than English or lack access to adequate preventive and primary care services.
As a result, those most at risk experience poorer health outcomes for almost every chronic condition studied and for most surgical procedures. This is the definition of health disparities and why our nation experiences the high cost of treating them. As our nation becomes even more of an ethnic melting pot, these disparities will only get worse if we don’t get health reform right this time around. By 2050 nearly one in two Americans will be persons of color – folks who experience higher levels of chronic disease, shorter life spans, less health insurance and generally poorer health due to lower participation in health insurance plans and less access to care.
But where are these voices in the current health care debate? Both the Administration and the Congress hear regularly from a chorus of organized representatives from the health care industry as they should. But the voices of those most affected by health disparities and the voices of those providers, hospitals and insurers who are most knowledgeable and most involved in their care are largely missing from the current national debate. A recent Senate panel on health care reform included some of the most distinguished names in the health care community. Unfortunately these panels did not include a single representative from underserved communities or those who serve them. If we are to truly reform health care in this nation, this must change.
This Administration and our Congress must enact measures that implement coverage and access for those who cannot now afford health coverage while paying attention to the worsening shortage of primary care providers in our nation’s poorest urban and rural communities. The use of electronic health records and health information technology must also focus on the maximizing the affects of these changes in underserved communities.
As the Administration and the Congress move toward health reform, they must widen the net of the communities and their representatives to whom they are talking. In the establishment of the Health Information Technology Committee of the Department of Health and Human Services, a designated seat was established for "An expert in the health of vulnerable populations". I am pleased to have been appointed by the Administration to that position and look forward to input from my colleagues from a broad spectrum of safety net provider organizations and from community and faith-based organizations to help bring the voice of America's most medically underserved folks into the critical discussions concerning the widespread deployment of HIT. What an exciting time this is and what a great responsibility we have to get it right!
As a result, those most at risk experience poorer health outcomes for almost every chronic condition studied and for most surgical procedures. This is the definition of health disparities and why our nation experiences the high cost of treating them. As our nation becomes even more of an ethnic melting pot, these disparities will only get worse if we don’t get health reform right this time around. By 2050 nearly one in two Americans will be persons of color – folks who experience higher levels of chronic disease, shorter life spans, less health insurance and generally poorer health due to lower participation in health insurance plans and less access to care.
But where are these voices in the current health care debate? Both the Administration and the Congress hear regularly from a chorus of organized representatives from the health care industry as they should. But the voices of those most affected by health disparities and the voices of those providers, hospitals and insurers who are most knowledgeable and most involved in their care are largely missing from the current national debate. A recent Senate panel on health care reform included some of the most distinguished names in the health care community. Unfortunately these panels did not include a single representative from underserved communities or those who serve them. If we are to truly reform health care in this nation, this must change.
This Administration and our Congress must enact measures that implement coverage and access for those who cannot now afford health coverage while paying attention to the worsening shortage of primary care providers in our nation’s poorest urban and rural communities. The use of electronic health records and health information technology must also focus on the maximizing the affects of these changes in underserved communities.
As the Administration and the Congress move toward health reform, they must widen the net of the communities and their representatives to whom they are talking. In the establishment of the Health Information Technology Committee of the Department of Health and Human Services, a designated seat was established for "An expert in the health of vulnerable populations". I am pleased to have been appointed by the Administration to that position and look forward to input from my colleagues from a broad spectrum of safety net provider organizations and from community and faith-based organizations to help bring the voice of America's most medically underserved folks into the critical discussions concerning the widespread deployment of HIT. What an exciting time this is and what a great responsibility we have to get it right!
Monday, December 1, 2008
In Memory of Steven B. Tamarin MD - a Great Physician and a Great Friend
I am deeply saddened to relay to you news of the death of Steven B Tamarin MD, a personal friend, a great physician and one of the founders of Family Medicine in New York City. Steve died unexpectedly in his sleep while visiting his cousin in Massachusetts. His loss is a tragedy for all who knew him and loved him as I did. While others sought his advice as their physician, I was the beneficiary of decades of close friendship with this incredible person. Steve could sit quietly and with uncanny attentiveness when you broached him with a personal problem as a friend. His listening skills were impeccable. Yet he spoke out vociferously about issues that moved him.
Steve was an outspoken advocate for women’s rights, an ardent supporter of the Tipitapa project in Nicaragua where he visited and worked many times over the years – as well as being one of the smartest and most dedicated physicians I have ever met. He read medical journals like they were novels that he couldn’t put down – enthralled at every new study that provided insight into the workings of the human body in health and disease. One could not spend even a single dinner with Steve without him being called on his cell phone by his patients – many of whom he had cared for over decades. His patients adored him and many travelled great distances to see him after moving away from the Upper West Side where he practiced. Steve always ran late and appointments meant little to him. He was dedicated to enjoying every patient encounter himself and gave his patients whatever time they needed to share their concerns with him.
Over a decade ago Steve became a member of the Institute for Family Health's Board of Directors and as the only physician on our Board, was depended upon to challenge our clinical protocols when needed and provide advice on issues of medical controversy. He was also a past president of the New York State Academy of Family Physicians – a position he held with distinction and one of which he was most proud. He continued to be involved in the Academy on a local level, bringing politically important issues to the forefront at all times.
Steve's own spirit was sustained by music. I was often the beneficiary of his incredible music collection as he burned compilations of his favorite blues songs for me on CDs and would share his eclectic musical selections proudly. While we were both on the Board of the New York State Academy of Family Physicians we took dozens of trips by car to Binghampton NY where their headquarters was located and braved many a snowstorm together across Route 17. We both loved those trips, brought CDs from our collections and sang out loud half way across NY State. I am sure that all who were close to him have their own stories of settings where Steve was so outwardly exuberant that an unknowing observer would think him insane.
One special evening he invited me to hear a particular Cuban pianist about whom Steve had encyclopedic knowledge and about whom I knew nothing. We went to a very classy jazz club somewhere in Manhattan where people were dressed to kill and where the staff were dressed in tuxedos. We were seated a few rows from the piano which was lit romantically and the crowd applauded enthusiastically after a long wait when the performer entered the spotlight. Steve could hardly contain his enthusiasm. As the first number began the crowd fell silent. Not 30 seconds into the first piece Steve could no longer contain himself. He was so excited he jumped out of his seat, threw his arms in the air and yelled "you go man! - play that thing!" While the crowd was appalled, the pianist nodded his head and smiled at Steve - obviously flattered and embarrassed. I recovered a few minutes later and crawled out from under the table.
I can't get the picture of Steve skiing out of my mind. We spent many a winter weekend at his parent's home in the Berkshires where we would sneak away to Brody Mountain during the day to ski. Steve had the best snowplow I had ever seen. Not to be mistaken for a real skier he always wore a long winter coat that went down to his knees and would snowplow down the steepest slopes at breathtaking speed his arm waving his ski poles wildly in the air and often yelling enthusiastically about what a fantastic day it was. In the evenings we would sit by his parent's twenty foot high fireplace in their Berkshire get-away and play guitar together - or debate the implications of the latest medical findings. It is time that I will always cherish.
Steve was one of the first of the new generation of Family Physicians in Manhattan. Along with the late John Falencki, they forged the path that many of us followed. We are forever indebted to them for their foresight and courage.
Steve will be sorely missed by his family, his patients, his friends and his colleagues. Whenever we parted - whether I was driving him home from a Board meeting or after spending the New Years weekend we would hug. Either he or I would say "I love you, man." and the other would reply, "I love you too." Life doesn't bring us many friends like that.
I am heartbroken to lose him.
Steve was an outspoken advocate for women’s rights, an ardent supporter of the Tipitapa project in Nicaragua where he visited and worked many times over the years – as well as being one of the smartest and most dedicated physicians I have ever met. He read medical journals like they were novels that he couldn’t put down – enthralled at every new study that provided insight into the workings of the human body in health and disease. One could not spend even a single dinner with Steve without him being called on his cell phone by his patients – many of whom he had cared for over decades. His patients adored him and many travelled great distances to see him after moving away from the Upper West Side where he practiced. Steve always ran late and appointments meant little to him. He was dedicated to enjoying every patient encounter himself and gave his patients whatever time they needed to share their concerns with him.
Over a decade ago Steve became a member of the Institute for Family Health's Board of Directors and as the only physician on our Board, was depended upon to challenge our clinical protocols when needed and provide advice on issues of medical controversy. He was also a past president of the New York State Academy of Family Physicians – a position he held with distinction and one of which he was most proud. He continued to be involved in the Academy on a local level, bringing politically important issues to the forefront at all times.
Steve's own spirit was sustained by music. I was often the beneficiary of his incredible music collection as he burned compilations of his favorite blues songs for me on CDs and would share his eclectic musical selections proudly. While we were both on the Board of the New York State Academy of Family Physicians we took dozens of trips by car to Binghampton NY where their headquarters was located and braved many a snowstorm together across Route 17. We both loved those trips, brought CDs from our collections and sang out loud half way across NY State. I am sure that all who were close to him have their own stories of settings where Steve was so outwardly exuberant that an unknowing observer would think him insane.
One special evening he invited me to hear a particular Cuban pianist about whom Steve had encyclopedic knowledge and about whom I knew nothing. We went to a very classy jazz club somewhere in Manhattan where people were dressed to kill and where the staff were dressed in tuxedos. We were seated a few rows from the piano which was lit romantically and the crowd applauded enthusiastically after a long wait when the performer entered the spotlight. Steve could hardly contain his enthusiasm. As the first number began the crowd fell silent. Not 30 seconds into the first piece Steve could no longer contain himself. He was so excited he jumped out of his seat, threw his arms in the air and yelled "you go man! - play that thing!" While the crowd was appalled, the pianist nodded his head and smiled at Steve - obviously flattered and embarrassed. I recovered a few minutes later and crawled out from under the table.
I can't get the picture of Steve skiing out of my mind. We spent many a winter weekend at his parent's home in the Berkshires where we would sneak away to Brody Mountain during the day to ski. Steve had the best snowplow I had ever seen. Not to be mistaken for a real skier he always wore a long winter coat that went down to his knees and would snowplow down the steepest slopes at breathtaking speed his arm waving his ski poles wildly in the air and often yelling enthusiastically about what a fantastic day it was. In the evenings we would sit by his parent's twenty foot high fireplace in their Berkshire get-away and play guitar together - or debate the implications of the latest medical findings. It is time that I will always cherish.
Steve was one of the first of the new generation of Family Physicians in Manhattan. Along with the late John Falencki, they forged the path that many of us followed. We are forever indebted to them for their foresight and courage.
Steve will be sorely missed by his family, his patients, his friends and his colleagues. Whenever we parted - whether I was driving him home from a Board meeting or after spending the New Years weekend we would hug. Either he or I would say "I love you, man." and the other would reply, "I love you too." Life doesn't bring us many friends like that.
I am heartbroken to lose him.
Friday, August 29, 2008
Medical Apartheid In NYC Voluntary Hospitals
On June 9, 2008 a complaint was filed with the Attorney General of New York State, Andrew Cuomo, by Bronx Health Reach, a coalition of faith based and community based organizations with health and human services providers. The complaint describes descrimation against people who are convered by Medicaid and the uninsured when they seek out-patient medical care in New York City's Voluntary Hospitals.
See July 18, 2009 Blog post for more detailed information.
See July 18, 2009 Blog post for more detailed information.
Saturday, February 16, 2008
Teaching Our Doctors and Our EHR to Speak English (and other languages)
Mary Sampson waited in Exam Room D for her bimonthly blood pressure and blood sugar check. She was a relatively new patient in my practice who I had only been seeing for a few months. Upbeat and proud of the great control she maintains of her hypertension and diabetes she always greets me with a hug and a smile and asks about my family before I even get a chance to ask about her. Her eyes were red today and she had been crying. “I am so worried”, she said. I cancelled my last two appointments because I couldn’t face the bad news. She held out an envelope for me to take it. It was a letter from me, and I was mystified by her reaction. Had I sent her a letter with bad news and forgotten it? I took the envelope from her hand and pulled the letter out to read it aloud. Mary sat with her eyes closed and her hands clenched together.
“What is wrong?” I asked her.
“Just tell me what I need to do, OK?” She replied.
I looked at the page I remembered spitting out of our electronic health record one evening at home. It was the letter I send all my patients after I receive lab results, diagnostic test results or consult reports. This one was formatted to report on normal mammography results.
I read it our loud.
“Dear Ms Sampson,
I am writing to report that your recent MAMMOGRAPHY WAS NEGATIVE. You should schedule your next exam in approximately 1 year. If you have any questions or concerns please feel free to call me at the office or on my cell phone.
Sincerely,
Neil Calman MD.”
“What do I do now?” she asked again.
“You wait and get another exam in about one year”.
“But what about the Negative test now?”
“Negative is normal!” I exclaimed. “Did you think it meant you had a problem?
Mary was speechless. Tears flooded down her cheeks. I stood up to hug her and repeated “I am so sorry”, over and over again. She slowly regained her composure after leaving a pile of damp tissues on my desk.
“I never got a letter from a doctor before, she said. I looked at it quickly and saw the word ‘Negative’ and I thought I had cancer. I have been so worried the past two months I didn’t even want to show the letter to my husband. He doesn’t know anything about this. He has a bad heart and I thought this would kill him.”
“Mary,” I said reassuringly. “Everything is perfect.”
Unintended consequences of progress, you might call it. But as with many seemingly trivial mishaps in the course of primary care practice, there are important messages contained within.
In 2002, as President of the Institute For Family Health, I led the implementation of EPIC (Verona, WI) one of the Nation’s most sophisticated and highly rated (KLAS Market Intelligence) health information technology programs in our network of thirteen community health centers in the Bronx and Manhattan, New York. Contrary to many horror stories in the health information technology literature, the 90 physicians, social workers, nurse practitioners and family medicine residents who work at the Institute welcomed this development heartily and immediately put some of its most powerful tools to work. Through training classes, on line instructional sessions and individual mentoring, in a few months we were almost completely paperless.
One of the most exciting parts of implementing electronic health records is how they help our communication with patients - at least most of time.
Restructuring Workflows to Incorporate the EHR
Prior to the implementation of the EHR we had done everything we were all taught to do to keep patients separated from their medical record and the information it contains. We kept charts outside the exam room door so patients could not look at them while they waited. We wrote in a complicated professional style with abbreviations that often were ambiguous and were sometimes not even understood by our colleagues when they covered for our patients and tried to use our notes. Many of us had handwriting that resembled hieroglyphics except that no historian had been successful in providing a book to assist in their translation.
Whose record is it anyway? Few patients go through the formal processes we put in place for them to examine their own records. Times have changed. Patients want to know so much more about their health and the Internet has provided limitless opportunities to access information on any health care issue of interest. Physicians have come to realize how extensively our patients’ lifestyle choices determine our ability to influence their health outcomes. Our relationship with our patients must become one in which we, as their doctors, serve them. They must have ownership of their health information, understand their health care needs in health and disease and understand how to obtain optimal care for themselves and their families.
We viewed the EHR as a tool to bridge the information gap with our patients and made many decisions in the setup process to enhance this.
We specifically rejected the option of portable wireless touchpad computers as they have screens which are visible only to the provider, and are often held cradled in the provider’s arm, preserving the secrecy of the paper charts they replaced. Even though not all patients choose to look at the monitors, the availability they offer creates a bridge of trust and improves the provider-patient relationship.
We chose to redesign the encounter to put the review of prior information in the context of the current day’s encounter, and use this as an opportunity to involve the patient in his or her own care.
Providers enter the exam room unprepared by prior review of the patient’s record. Their review of the record and any activity since the previous encounter is done in collaboration with the patient. Looking at the computer screen together, the provider might say, “Let’s look over the note I wrote on the last visit to make sure we have followed up on all your issues.” Then, “Now let’s go over all the reports that have come in since your last visit ... two consult reports and your blood test results.” Rather than being insulted by this, patients are immediately drawn into reviewing their own records with their provider at their side, where a discussion of the results and necessary follow-up are facilitated. Copies are printed for the patient to keep at home with their medical records.
But there is a flaw in our system, a serious one which must be addressed and that flaw is that health care professionals do no speak English the way other people do. We write funny and speak about patients in an unnatural way.
“The patient did not comply with my diet instructions.”
“The patient appears in no acute distress.”
“ This is a 34 year old Hispanic woman who appears to be her stated age.”
When I started going over my previous notes with my patients I realized how ridiculous these notes were. People were genuinely confused. Most were too polite to comment but some turned away from the computer and simply blanked over as I read the medical history, exam findings and plans from the past visit. I started imagining what my patients were thinking as they translated my writings into common English.
“head – normocephalic” (Is that better than just plain ‘normal’)
“lungs clear to auscultation” (I don’t remember anyone named ‘auscultation’ listening to my lungs)
“reflexes 2+ bilaterally” (Is that 2 a good score – shouldn’t they be a 10?)
“thyroid not palpable” (Nobody ever told me I didn’t have a thyroid gland. I wonder if I need one?)
“Babinskis down” (I never even knew I had a Babinski. Shouldn’t they it be up?)
I was also amazed at how many times we qualify what the patient tells us like we are always suspicious that they are lying to us.
“The patient denies having sexual intercourse for the past 6 months”
Even referring to our patients as “the patient” itself is a ridiculous was of depersonalizing the medical encounter.
Printers in Every Exam Room Promote Patient Education and Involvement
Another example of the critical decisions that need to be made in the set-up of hardware is the location of printers. We decided to install printers in every examination room so that information could be produced for patients as part of the entire encounter process. This not only improved the patient flow in the center, but made the vast resources of the EHR instantly available to both the patient and the provider. It also insured the confidentiality of patient information, eliminating the possibility of a document being picked up off a central printer and inadvertently handed to the wrong patient.
At the start of the encounter, while reviewing lab results and returned consult reports, the provider can print copies for their patients on the spot. The workflow used by most providers next involves a review of the nurse’s notes and the vital signs taken when preparing the patient to see the provider. Vital signs, as well as all lab values, can be trended, graphed and printed for patients. The most common use of this function is the printing of progress charts of weight or blood pressure, graphing patients’ improvements (or lack thereof!)
It is well known that patients frequently do not take all the medications they were prescribed.[i] The EHR permits providers to review the list of current medications the patient should be taking, and print a summary for them as well. Prescriptions are printed in the exam room, as are requests for labs and specialty consultations. All of these documents become part of a package of health information that the patient can take with them and keep as part of their personal health records.
Patients Leave the Center with a Full Report of Their Encounter and Follow-up Recommendations
Studies of patients leaving their doctor’s office indicate that they rarely have a complete understanding of what was done and what they are supposed to do next.[ii] To combat this, the Institute designed an “After-visit Summary” that contains patient-friendly headings and a printout of all issues discussed in the day’s encounter. The summary includes patient identifying information, a list of their measured vital signs, the chief issues as told to the nurse, the provider note, a complete problem list, a summary of active medications, any new orders written for the patient, including consultations, imaging studies, lab tests, and immunizations or medications administered in the center. Providers who use this feature regularly in our practice report that their patients remind them to print the After-Visit Summary if they forget to do so at the end of an encounter.
Reading the Afer-visit summaries is another issue altogether. Aside from the obvious problems of providers using medical terms that patients do not, for the most part, understand there is the additional issue of abbreviations that are totally meaningless to those who have not studied medicine. Some would say we made great strides in developing list of “approved abbreviations” to avoid clinical error s and improve doctor to doctor and doctor to nurse communication but we have not even begun the journey of translating these abbreviations into English – another frontier altogether.
When I type PND into our computer I get “PND” on the screen. When I type “.PND” the computer spells out Paroxysmal Nocturnal Dyspnea. But that is programmable. What I want to do is tell the computer that “.PND” should be written as shortness of breath at night when lying down”. Better yet, if the patient’s primary language is Spanish and is so designated in the EHR, “.PND” should be translated to “falta los respiraciones por la noche cuando esta acuestado.” In that manner we will truly be improving communication with our patients – both in the exam room and when we share our written summaries with them to take home.
Lab Results
The mysteries of laboratory reporting have also puzzled my patients since giving them copies of their labs to take home or sending them in follow-up letters. Scientists have standardized many lab results in International units or mg/dl (milligrams per deciliter) measures. Imagine telling a patient though that a change from a creatinine (a kidney function test) from 1.5 to 1.8 is highly critical but a change in BUN (blood urea nitrogen – another kidney function test) from 20 to 28 is nothing to worry about. None of this makes any sense to people not educated in medicine or laboratory science. And all of this is fine until we start to try to draw patients into their own care and setting their own goals. Rather than telling folks that keeping all their values at 50 is the goal and that the safe range is from 40 to 60 for all values – we tell them to keep their HgbA1c (glycosylated hemoglobin – a test of diabetes control) below 7.0, their LDL (low density lipoprotein or “bad cholesterol”) below 130 (or 100 if they are diabetic), their HDL (high density lipoprotein or “good cholesterol” ) above 45, their hematocrit (red blood count) above 35, and so on. Not only don’t the values make sense but their normal ranges are not standardized between tests nor between different labs running the same test using different methods.
What does all this mean.
We need to transfer health information back to patients – a job that will require a major transformation of the way we use medical language and even the units of measurement we use.
It is essential that we do this. A patient making six ½ hour visits each year to my office spends 3 hours out of 8760 or .03% of their life that year in my office. The rest of the time they need access to their health information to keep them informed of what they need to do and to keep them motivated to stay focused on the health care issues that are important to their continued well-being.
[i] Safran DG, Neuman, P, Schoen C, Prescription Drug Coverage and Seniors: Findings from a 2003 National Survey, Health Affairs Web Exclusive, 19 April 2005; W152-W166. Available at Health Affairs.org (accessed 6/8/05).
[ii] Lukoschek P, Fazzari M, Marantz P, “Patient and physician factors predict patients’ comprehension of health information, Patient Education Counseling, 50(2):201-210.
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