The performance of health care systems interests me greatly, as it is my job to help my local health care system be the best. Recent evidence suggests we are not getting better. In fact, one study suggests the disparity in health outcomes is getting worse. That is, some people benefit more than others from our health care system in the US. The income inequalities translate directly into health outcome inequalities. And racial differences also are getting worse. How can we tolerate a society where we apply our resources so unfairly?
The researchers in this study looked at health outcomes by county in the USA and then looked at race, gender, and socioeconomic class. The results are very disturbing. “If you look at the extremes in 2000, men in the most deprived counties had 10 years’ shorter life expectancy than women in the most affluent counties (71.5 years versus 81.3 years).” The difference between poor black men and affluent white women was more than 14 years (66.9 years vs. 81.1 years).
Of course people with lower incomes have less access to health insurance. I don’t think this is fair or reasonable, but even more disturbing is that among people with health insurance, there are still racial disparities. I cannot help facing the terrible likelihood in all this — that racism persists in health care workers.
There is some hope here. Between 1966 and 1980, disparities in health outcomes actually got better in the US. It’s since 1980 that the gap is widening. What really worries me now is that the economy is in tough shape and government will have trouble finding the resources to do the right thing. What homeowner and voter will support more taxes this year? What politician would suggest it?
But health care needs to be like education- we should all have access to a basic set of benefits. So where do we get the funding? I have a simple idea — we are now spending $5,000 a second in Iraq. We can’t afford to further mortgage our kid’s future, so we better figure out a way to pay as we go. According to forensic psychiatrist Marc Sageman's book Leaderless Jihad: Terror Networks in the Twenty-First Century, our current policy is likely creating more terrorists anyway. We could fund a lot of health care for the uninsured with $5,000 a second.
Why have others write on my blog? The short and sweet answer is: fresh perspectives. I shared with you several journal entries from my friend Michael Polifka’s international medical experiences. I believe this provides an interesting viewpoint on what we do here and helps keep medicine grounded in its core values. I have been on this medical staff for 27 years. I’m a local. Dr. Martin Luloff is an experienced pediatrician who is new to our medical staff. His perspective on our medical staff, our community, and health care in this system is a fresh look. Good leaders should always be asking for input and seeking to learn. I look forward to adding Marty’s point of view to my commentaries.
Flatlander Pediatrician…Reflections of an SVHC Rookie
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Dr. Martin Luloff
SVMC's Newest Pediatrician
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Why does a pediatrician from a successful multiprovider practice in Massachusetts and faculty member at the University of Massachusetts Medical School decide to give up a known quantity and move up to Bennington, Vermont to join Southwestern Vermont Health Care?
That’s a question that I had to answer for myself, my wife and my colleagues. The challenge of starting a new practice from scratch to see if “I still had it” to have the opportunity to live full time in a state that my family has loved for over 20 years.
These were some of the answers, but after my first visit to SVHC the most important answer was to have the opportunity to truly make a difference for a wonderful community and to be able to practice with a group of like minded and excellent physicians and support staff in a hospital dedicated to providing the best care possible at a time of shrinking health care dollars…and after 4 months of practice here, I haven’t had one day when I felt that I made the wrong choice.
In the weeks that follow, I will try to explain why practicing in this environment provides all the rewards both personal and professional that any physician could hope for.
Until next time…Marty Luloff, MD, FAAP
National media coverage of the physician shortage in USA Today on Feb. 26 reinforces the concepts we have been using to enhance recruiting for the past 2 years at SVMC. We have been able to enhance our general surgery supply with several methods, some of which are mentioned in this article.
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Dr. Elizabeth Warner, SVMC's
newest general surgeon.
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We brought solo surgeons together in a group. They worked with the medical staff office to change our recruiting from “Come to town and set up a solo practice; we’ll help you in the first 2 years” to “Come join a hospital based group of general surgeons; we’ll pay you at the national median; we’ll employ you for the long haul to reduce your hassle and improve your security; you’ll have mentorship and support.”
Our recruiting changed dramatically and as of this fall we will have 6 general surgeons — a 50% increase over the 4 we started with. Enhanced recruiting includes: dedicated in house recruiting staff, using local doctors as champions, improved web site with videos of our institution, better data bases, improved direct mail, and improved financial support for doctors with predictable salaries and better loan repayments.
Read my first post on this subject: "Why is it So Difficult to Recruit Doctors to Vermont?"
It’s no secret that the planet is struggling with increasing energy prices. A recent book has me thinking differently about where all this is going. James Howard Kunstler, in his book, The Long Emergency, makes a compelling argument that the world has passed the peak of world oil production and that the future of petroleum extraction from the planet (all kinds) is one of declining supply, and increasing difficulty obtaining the oil, over a very short time frame. He points out the amazing evolutionary phenomenon:
that it took about 270 million years to produce and store all that organic material as petroleum. Excellent scientific research (which he extensively documents) shows that world oil discovery peaked in the 1960s and that world oil production has already reached peak. So if it took about 100 years to get to peak, then we’ve got about another 100 years left — right? Well, sort of. The problem is that the removal of oil, coal, and natural gas from here on out is going to get more and more difficult, and involve going places that are more and more dangerous, both environmentally and politically. We’re seeing that already — increased political unrest, and pressure on increasingly remote and dangerous wilderness.
So here is the human population consuming 270 million years worth of energy in about 200 years — no wonder the planet has exploded with development. The Long Emergency is the long and painful adjustment humans will be making as we run out of this unique transportable form of energy. He makes the case that even if we harness every form of alternative energy — it’s nowhere near enough to replace this incredible evolutionary accident of being able to use so much energy in such a short time. And most of the replacement energy sources are not transportable — so things we are used to now — especially air travel — will get impossibly expensive or unavailable. You can’t fly a plane on electricity from a nuclear power plant.
So his well documented thesis is that we will be forced to rely on less travel and more local resources — essentially returning to a local agrarian society, highly dependent on resources near where we live. The likely form of long distance transport would be train travel, because it works with electricity rather than a portable fluid energy source. This thesis has a big impact on how we decide where to live (what will Arizona look like?), and how we organize community resources to provide for ourselves locally.
In 1987, I designed and built a 3000 square foot post and beam passive solar house here in Manchester, Vt. We heated the house and the domestic water with solar energy. The only extra heat source for the house was 2 cords of wood a winter (about $250). It was warm and cozy. No oil, no gas, modest use of electricity (but not for heat). New England can do this — we have the technology. We also have the agricultural base to support ourselves locally, if we preserve it. We have a history of community focused culture — town meeting, local schools, farmer’s market, self sufficiency.
And the connection to the community hospital? Well, it’s another very local and very important resource. If we’re traveling less, we’ll need it more. Our community hospitals must sustain their infrastructure to be there for us. They also will need to be more integrated with a primary care health delivery system that is more robust than we have now as care moves more to the outpatient setting. We have all these elements in our local system.
Read the book, it may change how you make choices about how you use energy, and where you live, and what community resources we invest in to be ready for this inevitable change.
Our hospital staff holds monthly reviews of mortality and the care of patients at the end of life. For those deaths that so clearly come at the end of a long chronic illness, we ask ourselves how we could have done better. Over and over we see a pattern of shared denial — both patients and their caregivers seem to ignore the signs that life is slipping away. Why?
Well, human nature for one. We all thrive on hope. We humans, especially in Western societies, seem to think death is optional. We don’t like to face it, think about it, or plan for it. And medical professionals are trained to always look for the treatment we have missed, the breakthrough that will pull someone back from the brink. We have all experienced amazing recoveries in a few patients, so we tend to constantly strive to find that for everyone — it’s what our patients expect from us. It’s the thrill that we trained for — finding the cause of the symptom, zapping it with a drug or a surgical procedure or a radiation beam, and returning the person to full function.
However, there is good evidence that this optimism and constant search for another treatment make us lousy prognosticators. We typically overestimate a person’s life expectancy at the end of life. [There are plenty of egregious examples of the other error, but in aggregate we overestimate]. We hate to give in, we want to transmit hope.
And the sad reality is that the ‘silver bullet’ is really uncommon. Most of us will die of the gradual loss of functions associated with one or more chronic diseases. It’s not a hidden mysterious rare tumor that can be zapped into oblivion as often as it’s the accumulation of functional loss from diabetes, heart disease, chronic lung disease, or a common cancer we’ve had for a long time and is now back again. These chronic illnesses take away function in a stepwise fashion, and offer many tragic but welcome opportunities to discuss what an individual wants, and what a doctor can offer. Too often, these conversations don’t take place.
They are tough conversations — they are sad. Doctors assume patients notice their declining function and will ‘speak up’ when they have had enough. Patients can get used to declining function, and often assume that doctors can return them to previous levels of function after their disease acts up. This is actually uncommon.
Each of us defines the quality of life we want or will accept. And our thinking may evolve when we develop a severe illness. Care is ALWAYS centered on the patient’s choice. That choice, however, needs to be informed by the best medical facts available. And those facts need discussion before facing an urgent medical intervention.
As I have evolved my thinking about all this, I find that these discussions are easier each time. Patients usually welcome the opportunity to talk. I never know where the conversation will go, but for me, ‘taking care of someone’ means more than the right drug or surgical referral. It means helping people recognize futile care, and giving them a chance to think through what they want. Giving them a chance to cry about the unfairness of it all, to listen to those they love, even to ask for another medical opinion. It means really listening — and then following the direction the patient wants. That means sometimes doing more than I would have wanted to or sometimes stopping treatment before I am ready.
The reward is so clear, however, a deeper trust between doctor and patient. And for many at the end of life — the gift of the opportunity to make the choice to be at home, and stay there, with good plans for managing symptoms, and in the environment they want — around loved ones. That reward is the motivation for doctors and patients to find a way to speak up.