Thursday, July 18, 2013

The Strength To Accomplish Incredible Things

Illnesses, like cancer, can be devastating but hope springs eternal and love and caring can be healing no matter what the final outcome. Fortunately in this family crisis, the outcome was incredibly positive in many ways and led to the strength to accomplish incredible things. My posts are usually my own work. But I am posting this very beautiful and positive story sent by a husband turned caregiver. 

“Lessons Learned through Caregiving

In August of 2005, my family changed forever. Our daughter, Lily, was born, and my wife Heather and I could not have been more excited to be new parents. However, three months later, our lives changed again. On that day, Heather was diagnosed with malignant pleural mesothelioma, and I got a new, unexpected job. I became a caregiver for a cancer patient. Instead of dealing with the chaos of the holiday season as planned, we began to deal with a new type of chaos – fighting cancer.

My life as a caregiver began as soon as Heather was diagnosed. Completely overwhelmed, shocked and unable to make any decisions, Heather looked at me for help. I knew I had to be there for her as best I could, and I made the first essential decision, that of where Heather would receive treatment. We were given several options, but one in particular stood out.  It was Dr David Sugarbaker, a mesothelioma specialist in Boston, known for his work with patients with my wife’s type of cancer. I told our local doctor to get us to Boston. 

I had to cut my hours in my full-time job, and Heather left her job. Instead of working my 9-5, I turned into a full time caregiver. I scheduled our trips and drove to doctors’ appointments. I was also still a full-time dad, caring for three month old Lily.

Life became a challenge. Everything was turned upside down, and I was often uncertain and worried. My to-do list turned into a whirlwind of overwhelming emotions, and I couldn’t just give up. I let myself surrender to the bad days, but I never gave up hope. Although I often felt helpless, I knew I had to stay strong for Heather. The support we received made me feel hopeful. People we didn’t even know were offering all kinds of help, giving us less to be anxious about. That outpouring of support helped keep me sane.

All of our hard work, perseverance, and refusal to give up paid off. After surgery and multiple treatments for mesothelioma, Heather beat the odds as this short video demonstrates and defeated this awful disease, a rare feat accomplished by far too few. After seven years, she is still cancer free, and has been able to see Lily grow into a beautiful young lady. 

I have since been able to balance the tasks of going back to school while raising a family. Being a caregiver and standing by my wife through cancer gave me the strength and the courage to pursue this dream of mine, two years after Heather’s diagnosis.  The stress and time management skills that I learned helped me to succeed and graduate with high honors.  I was even given the great privilege of speaking at graduation. During my graduation speech, I shared the greatest lesson that I learned as a caregiver to someone with cancer. I told the audience that within each of us is the strength to accomplish incredible things, as long as we never give up hope, and always keep fighting for the ones we love.”  

Cameron Von St James, July 17, 2013

Saturday, July 6, 2013

The Coming Disruptive and Transformational Changes in Health Care Delivery

There will be some very disruptive and some transformational changes in the way health care is delivered, not as a result of reform, but as a result of the drivers of change described previously. They included an aging population, an obese society, shortages of doctors, and emerging consumerism, among others.                       

I interviewed in depth about 150 medical leaders from across the United States to collect information and then distilled it down to a few key observations for my book “The Future of Health Care Delivery - Why It Must change And How It Will Affect You.”. 

As a result of those previously discussed drivers of change, here is some what we can expect to occur in the coming years. 

First, there will be many more patients needing substantial levels of medical care. These won’t be just any patients but two specific groups that are growing rapidly. Americans are aging. “Old parts wear out” and there are impairments in vision, hearing, mobility, bone strength, dentition and cognition that become more prevalent with age. And of course our society has many adverse lifestyles such as consuming too much of a non-nutritious diet, being sedentary, being chronically stressed and 20% still smoke. These all lead to chronic illnesses like diabetes type II, heart failure, cancer, chronic lung and kidney disease, etc. So there will many more individuals with chronic illnesses. The especially sad thing is that many of these individuals will be moderately young as a result of obesity since one third are overweight and another one third are frankly obese. (And now that the AMA has specifically listed obesity as a disease rather than just a predisposer to disease, then the number of Americans with chronic illnesses jumps dramatically.) This increase in chronic diseases and the impairments of aging will have huge impacts on care delivery.           

Of course, more and more care is and can be done out of hospital. But with many more patients in need of care for serious chronic illnesses, there will be a need for more high tech hospital beds, ICUs, ORs, and interventional radiology. This is different than the mantra of recent decades which proclaimed that there are too many hospitals and too many beds. Now it is the just the reverse. This too is a big change. 

But building new hospitals or new wings or renovations costs a lot of money. So does technology such as the electronic medical record, new CT or MRI scanners, and the needed technology for the operating rooms or radiation therapy equipment. To garner the required money, hospitals will need to access the capital markets. What will smaller hospitals do that have less ability to enter the credit markets? Merge with larger systems to get access to capital. So there will be more and more smaller hospitals merging into larger systems. Indeed there will be few stand alone community hospitals in the coming years. This is quite a disruptive change. 

There is already a shortage of primary care physicians and this will undoubted accelerate since few are entering primary care today after medical school and training.  In part to compensate, there will be greater use of NPs and PAs, especially in primary care. Notwithstanding the debate as to whether NPs can serve as well as MDs in primary care, they can be very effective and allow the MD to do what he or she is best at doing. Together they can create an excellent team.  

Primary care doctors are caught in a catch 22. They are in a non sustainable business model. Reimbursements from insurers have stayed level for years but office and other expenses have gone up each year. So in order to keep their personal income at least flat, they need to “make it up in volume” by seeing more patients. This means no longer visiting their patients in the hospital and in the ER. Instead they wait for the hospitalist or the ER doctor to call with reports. And they shorten the time with each patient so they can see 24 to 25 patients or even more each day.  

But seeing this many patients means they cannot give comprehensive preventive care  and cannot adequately coordinate the care of their patients with chronic illnesses – two of the key things a PCP should be doing for optimum quality care. It is the absence of time – time to listen, time to prevent, time to coordinate and time to just think – that is the critical issue. 

There are at least two approaches PCPs are taking to counter this dilemma. One is to no longer accept insurance and rather expect patients to pay a reasonable fee at each visit. Pay at the door. It cuts out a lot of haggling with the insurer and means they can spend more time with the patient. Importantly, it recreates a normal, typical professional-client relationship since the patient, not the insurer, is paying the doctor directly.  But this is certainly a disruptive change to not accept your insurance! It is like going back a few decades.   

Another approach gaining rapid popularity is to switch to retainer based practices, sometimes called concierge or boutique practices. The basic concept is to limit one’s practice to 500 patients rather than the typical 2000 or more. This means more time per patient. So in return for a fixed fee of about $1500-2000 per year the PCP agrees to be available by cell phone 24/7 and by email. He or she will see you in the office within 24 hours of a call. You get as much time as needed for the problem at hand. And the PCP will visit you in the hospital, the ER or the nursing home – maybe even do a house call.

The result is better quality. But there is more. Since the doctor now has the time – the patient now gets much more preventive care attention. And if a patient has a chronic illness, the PCP will take the very real time needed to coordinate that care. This will mean much better care from the specialists and will avoid unnecessary tests, scans and procedures. Better care at less expense.  – One more very disruptive and I would say transformational change occurring in medical care delivery.


Praise for Dr Schimpff

The craft of science writing requires skills that are arguably the most underestimated and misunderstood in the media world. Dumbing down all too often gets mistaken for clarity. Showmanship frequently masks a poor presentation of scientific issues. Factoids are paraded in lieu of ideas. Answers are marketed at the expense of searching questions. By contrast, Steve Schimpff provides a fine combination of enlightenment and reading satisfaction. As a medical scientist he brings his readers encyclopedic knowledge of his subject. As a teacher and as a medical ambassador to other disciplines he's learned how to explain medical breakthroughs without unnecessary jargon. As an advisor to policymakers he's acquired the knack of cutting directly to the practical effects, showing how advances in medical science affect the big lifestyle and economic questions that concern us all. But Schimpff's greatest strength as a writer is that he's a physician through and through, caring above all for the person. His engaging conversational style, insights and fascinating treasury of cutting-edge information leave both lay readers and medical professionals turning his pages. In his hands the impact of new medical technologies and discoveries becomes an engrossing story about what lies ahead for us in the 21st century: as healthy people, as patients of all ages, as children, as parents, as taxpayers, as both consumers and providers of health services. There can be few greater stories than the adventure of what awaits our minds, bodies, budgets, lifespans and societies as new technologies change our world. Schimpff tells it with passion, vision, sweep, intelligence and an urgency that none of us can ignore.

-- N.J. Slabbert, science writer, co-author of Innovation, The Key to Prosperity: Technology & America's Role in the 21st Century Global Economy (with Aris Melissaratos, director of technology enterprise at the John Hopkins University).