The Valley’s health problems are well-documented. John Capitman, executive director of the Central Valley Health Policy Institute, called its scores on the nation’s 10 leading health indicators (e.g., obesity and smoking rates and air quality) “a sad story.” The region meets national standards in only a couple areas, one of which is physical activity, thanks to its many farm laborers. But 40 percent of its adults are overweight or obese, while the national standard is around 15 percent.

These health problems are also deeply ingrained. When, asked moderator and KQED health reporter Sarah Varney, was the area at its healthiest? Capitman said that even in the 1970s the Valley performed worse than California and the nation, “but a little bit less worse.”

Sarah Reyes, the California Endowment’s Central Valley program manager, argued that the problems are bigger today only because the population is higher. “We have always been worse off than other parts of California,” she said, pointing to high poverty rates, a large immigrant population, and the region’s poor air quality.

However, said Capitman, certain demographics–insured and educated white men, for example–are healthier than the state or national averages. The problem lies in disparities that aren’t being addressed by our current healthcare system.

That system hasn’t changed since the 1970s, explained San Joaquin Valley Rehabilitation CEO Edward C. Palacios, and as a result people don’t know where or when to get healthcare. As a hospital administrator, he said, “We can deliver care and education to the people who access us, but how do we go out to educate others?”

The Central Valley’s large undocumented population is particularly challenging to reach. Many illegal immigrants rely on emergency-room treatment–the most costly option but also the only one that’s guaranteed by federal law, since ERs are prohibited from turning anyone away. We’re hiding from this issue, said Capitman, and even though the Affordable Care Act has the potential to insure a million more people in the region, it won’t help undocumented patients.

Even when organizations have aimed education efforts at the region’s lower-income residents, they’ve struggled to succeed. Reyes said that lecturing people about exercise hasn’t worked in the past, but the California Endowment has had success with increasing people’s access to it. It has sponsored boot camps with local boxing champion Jenifer Alcorn at Fresno’s public parks that are drawing large crowds on the weekends.

Hospitals are taking a similar approach. “We’re going beyond the hospital walls and finding out where the community resources are and trying to make those connections,” said Palacios. It doesn’t stop at finding someone a wheelchair, he said. We also need to make sure the patient is going home to a place with wheelchair access.

Education and access go hand in hand, said the panelists. Capitman has found that young mothers don’t take advantage of prenatal care because they find it “culturally inconsiderate and downright insulting.” Warning these women that they can expect to be insulted–and also why prenatal care is helpful and what they can demand from the system–goes a long way.

When it comes to getting people to eat healthier, said Reyes, the presumption is that building a grocery store in a neighborhood that’s a food desert is enough to solve the problem. But grocery stores are front-loaded with junk food, and many people don’t know how to prepare fresh fruits and vegetables. The California Endowment is working on storefront conversions to move junk food to the back and healthier options to the front, while Fresno County’s Economic Opportunities Commission is sending dietitians into grocery stores with mothers.

“The challenge and the opportunity is to take advantage of how we access people,” said Palacios. We can take advantage of cell phone and smartphone use to reach people, he said–or Facebook, added Reyes.

But Capitman believes that the problem lies still deeper–and isn’t limited to the Central Valley. “It’s about getting a shift in our cultural conversation,” he said. The Central Valley’s failing health “is just a symptom of a larger process where we’re allowing communities to fail.”

In the question-and-answer session, audience members asked the panel what’s next on the education and policy fronts. What’s the tipping point in convincing the masses that healthcare change is needed?

Palacios thinks that many movements are working independently and instead need to share their work with one another. Reyes said that people should start by admitting that there’s a problem that goes beyond personal responsibility. “The tipping point comes when folks realize it’s not a level playing field,” she said.

Can California move ahead if the federal healthcare reform law changes? Yes, agreed the panelists. Long before the Affordable Care Act came to the federal level, said Reyes, California was already working on reform.

Watch full video here.
See more photos here.
Read expert opinions on how to improve the health of the Central Valley without increasing government spending here.

*Photos by Dalton Runberg.

The post The Central Valley Is Fine If You Don’t Eat, Breathe, Or Get Sick appeared first on Zócalo Public Square.

Moderator Michelle Levander, director of the California Endowment Health Journalism fellowships, opened the discussion by presenting some bleak statistics about the inequalities of healthcare in the Central Valley. In the region’s poorer zip codes, the rate of premature death is double that of its higher-income zip codes. And the range in life expectancy from poorer to wealthier areas is as wide as 21 years. “These are really issues of a shared destiny,” said Levander.

Dr. Marcia Sablan’s patients at her clinic in rural Firebaugh–50 miles from Fresno–deal with transportation issues and specialist shortages on a daily basis. Take “a common, everyday care of gallbladder disease,” said Sablan. A patient with private insurance will have his or her gallbladder removed in a week or two. Someone with Medi-Cal will have the procedure in a few months, after a few trips back and forth to Fresno (which winds up costing about $100 per trip). And someone without insurance, who has to see the doctor at the local safety-net clinic, won’t get an appointment for “months and months.”

Gallbladder disease isn’t usually fatal, but Sablan frequently sees patients whose lives are put at greater risk as a result of delays in treatment of such problems. One, a 30-year-old woman, learned she was pregnant just before a sarcoma was discovered growing on her leg. She died after spending two months waiting to be transferred to a hospital that could treat her while she was pregnant. “I’m ashamed of our medical care situation,” said Sablan. No one can say she would have been saved elsewhere, “but at least she would have had a chance.”

San Joaquin Valley-based community health reporter Rebecca Plevin has found that transportation is “a huge issue” for the doctors and patients she meets, from a pregnant woman who had to take an hour-long ambulance ride after her contractions started to school nurses who report students who are unable to get the glasses they need. “There are clinics that will bring in specialists to avoid patients traveling,” said Plevin, “but it’s still a big barrier.” And although there is a strong network of local clinics and many access points to healthcare, it’s often difficult for patients to get to where they need to go–and to be able to afford to take off work for appointments.

Policy changes are also affecting healthcare in the region. For example, the Healthy Kids Program–a children’s insurance program intended for children who didn’t qualify for state-funded healthcare programs due to immigration status and family income–lost its funding last year. Sablan pointed to a stopgap in the form of Medi-Cal’s gateway program for children without immunization or physicals–but it only covers children for a month.

Herrmann Spetzler, the CEO of Open Door Community Health Centers in northern California’s Humboldt and Del Norte counties, offered one possible solution: telemedicine. It’s “a tool for getting over the mountains and getting that care that we need, or that connection to urban areas where the centers of excellence are always going to be,” he said. Telemedicine connects his clinics to doctors at UCSF and UC Davis, among other places. In the case of an eight-year-old girl with an undiagnosed seizure disorder, her caretaker, her local pediatrician, and two specialists in Los Angeles and Phoenix were able to analyze her condition together thanks to the technology.

“We are all over the state, because no longer is the geography an issue,” said Spetzler, who thinks that telemedicine is the future of rural healthcare. “It’s an economic development opportunity that this next generation of medical providers will have at their fingertips.” He added, “We can focus totally on the woe of how poor the distribution of healthcare resources is between rural and urban [communities]. Or we can look at what opportunities we have to go ahead and use modern technology.”

Technology also helps address the perennial problem of recruiting doctors to rural areas, said Spetzler. His clinics have one infectious disease doctor, but she meets regularly via telemedicine with three other rural doctors–who can even be on call to relieve her while she’s on vacation.

Pipeline programs are addressing this issue in the San Joaquin Valley, said Plevin. One is the Doctors Academy, which tries to increase interest among middle and high school students in joining the medical professions, encouraging them to go on to study medicine in college and beyond–and to return to the Valley. UC Merced and UC Davis also have a new program that studies the needs of the area and trains students to work there, while UCSF Fresno brings students to the Valley for their residency. The idea is to “train doctors who will be familiar with the needs of the Valley and who will want to stay here and practice here,” she said.

These programs are the answer, and our hope for the future, added Sablan.

Watch full video here.
See more photos here.
Read more stories from rural doctors here.

*Photos by Esteban Cortez

The post Last Doctor For 50 Miles appeared first on Zócalo Public Square.

“The cowboy mythology suffuses many of the views about the doctor, and for the doctor, it suffuses many of our views about ourselves,” he said. Cowboys, Lawrence explained, are independent, brave, resourceful loners. Almost irascible. Think House, MD.

The audience at the Harmony Gold Theater on Sunset Boulevard listened attentively. Lawrence soon wove together these analogies, his personal anecdotes and diverse experiences within the health care system–both managerial and political–to illuminate a trend toward medical team collaborations.

Medical knowledge is growing at an astonishing rate. In 1950, there were about ten to twelve physician specialties, and today there are well over 120, Lawrence enumerated. (When his own 88-year-old mother fell and needed medical help, he followed her through the system for thirty days and counted at least 10 different primary physicians, 50 nurses and over 100 health care providers who tended to her needs and made decisions about her care.)

These numbers add up to a hard truth: the cowboy can’t keep up with the complexities of modern medicine. “We have models of the autonomous physician coming against modern medicine…but is the primary care physician obsolete?” Lawrence asked, before giving a resounding No.

“The patient needs a mechanism for bringing the care together,” said Lawrence. “That’s a critical role as well as trying to understand what the presenting symptoms are.”

Unfortunately, the primary-care physician is endangered, particularly when it comes to serving an aging and more diverse, non-Anglo community. Fewer and fewer medical students are choosing primary care over better-paying specialties. “It’s a situation that’s going to be aggravated over the next ten to fifteen years at least,” explained Lawrence.

The good news is that a number of new models are emerging. “My hunch is that what we’ll see over the next decade or so are variations of these models,” he said.

One of these models is the “concierge medicine model.” That’s when wealthier subsets of the population simply pay a premium to buy direct access to primary care physicians. Lawrence doesn’t see this model as a long-term viable option, particularly because it removes primary-care doctors from an already depleted general pool.

The model Lawrence views as most promising involves physicians forming groups and teams. There is great evidence of success from collaborative work among primary care and secondary care physicians, particularly surrounding chronic diseases like asthma.

Still, the team model must work out a number of specifics, like how to reward a team of caretakers, rather than just one specialist, for high performance results. Payment for piece work, he said, is “antithetical to collaboration.”

Technology will also keep finding new ways to come to our aid. Codifying our health issues and simplifying the process through the use of IT shows incredible promise, said Lawrence, eliminating the need for a professional intermediary and significantly cutting back on health care costs in an unsustainable system. Technology aids triage, navigation, management, screening for preclinical disease, and wellness.

The progress of these newer models is largely determined by how much patients are willing to trust in something new. “Most of us still want our own doctor,” said Lawrence. “We still want the cowboy.”

During the question and answer section of the evening, Lawrence had the chance to opine about the health care bill.

“I supported it, I’m glad it passed, I believe it is the right move for the country. We’re paying for the people who don’t have health insurance in the dumbest way possible right now,” he said, expressing frustration at how information has been twisted. We already pay for hospital visits through our taxes, Lawrence noted, adding that constraints on insurance companies were “long overdue.” He predicted that children’s care and mental health care would show dramatic improvement under the bill.

“If you don’t like government in health care, you probably should have gone to another country in 1965. This is not socialized medicine all of a sudden,” he quipped.

As far as general government involvement goes, Lawrence supports it in broad strokes but with reservations. “My biggest fear with the healthcare legislation…was that it would freeze innovation,” he said.

In any case, President Obama, said Lawrence, could have done a better job discussing the actual care part of the legislation, rather than focus on insurance companies. “I have friends that are trying to change that conversation in the White House.”

Lawrence concluded by returning to cowboys versus teamwork in medicine. In the end, he noted, even the cowboys join a corral.

See event photos here.
Watch full video here.
Read a discussion on technology and the future of medicine here.

*Photos by Aaron Salcido.

The post Mama, Don’t Let Your Babies Grow Up to Be Cowboy Doctors appeared first on Zócalo Public Square.

Sometimes yes–and sometimes yes and good riddance

Technology will not render the physician’s profession obsolete. Technology will, however, render obsolete the notion that there are things that only doctors can do, as advances like molecular diagnostics and clinical decision-support software continue to enhance the capabilities of other individuals–including patients–to manage increasingly sophisticated levels of care in more convenient and affordable settings. But our health care system, like any other sector, will always need experts on the cutting edge, and doctors will constantly seek out new and complicated medical problems that demand their skill and attention. On the other hand, individually, there indeed will be doctors that are made obsolete by technology; in particular, those that make futile attempts to defend their turf and who refuse to adapt to a changing competitive environment. As Harvard Medical School’s Dr. Warner Slack famously professed, “Any doctor who can be replaced by a computer should be.”

Dr. Jason Hwang is an internal medicine physician and executive director of healthcare at Innosight Institute.

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Not obsolete–just different

Technology won’t make doctors obsolete, but it will require them to change in order to provide the best care to their patients. Those that don’t learn to make effective use of these tools may be unable to provide the care patients expect.

The core of what primary care physicians do is diagnose, treat, and coordinate with other clinicians and service providers. Computers can’t diagnose, or do it badly, because they bet on the most likely diagnosis. They can get it right only 90 or 95 percent of the time, and that’s not good enough.

On the other hand, while well-trained physicians can bring more sophistication to the process of diagnosis, using that training requires keeping all the possible causes of the presenting symptoms in mind, all the information needed from the history, physical and basic lab tests to assess each cause, and a systematic way of assessing each possible cause using the data from the history, physical and tests. This is beyond the capacity of the human mind, House notwithstanding. With the right computerized tools, however, collecting the right information and analyzing against all known causes of the patient’s symptoms might become routine. Computers are not ordinarily used in this manner today, but models of how they might be are already in use.

For some conditions, treatment is straightforward. There’s one way to proceed. For others, treatment choices can be complex, and decisions must draw on past experience (does the patient have an allergy to a specific drug, for example) and patient preferences. Computers can assist in making better treatment decisions by making relevant sections of the patient’s history known and by serving as a platform for educating patients and sharing the experience of other patients so treatment choices are well-informed. The expansion of electronic health records may make the integration of patient’s history easier. While there are examples of effective use of computers to improve patient decision-making, this area is still in its infancy.

The most widespread use of computers today is in coordinating care. Orders for tests and prescriptions can be sent electronically and clinicians can communicate electronically and share information. The principal obstacles to more widespread use of these methods are lack of training, cost, limited numbers of user-friendly apps, and payment systems that don’t support this type of coordination. All these can be changed.

Computers and new monitoring technology offer the prospect of routine monitoring of patients away from the physician’s office or hospital, distant diagnosis using monitoring and video technology, and real-time consultation with specialists and other experts. Here, too, changing payment to allow the routine use of such technologies will be critical to their adoption.

Dr. Jack Needleman is professor of health services at UCLA School of Public Health. His research focuses on the impact of changing markets and public policy on quality and access to care.

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Obsolete? Puh-leaze.

No way. The primary care physician will still be the critical point of care for the patient. Technology helps, but it cannot replace the doctor when it comes to managing complex chronic illnesses, which more and more Americans are developing as we age (“old parts wear out”) and as we continue with behaviors of overeating, leading sedentary lifestyles (the two leading to obesity), suffering chronic stress, and (among 20 percent of us) smoking. Coordinating the care of these patients is critical for quality, safety and control of expenditures.

We are blessed with enormous innovation and creativity in the medical arena. There is an ongoing revolution as a result of genomics; a promise for the future in stem cells for regenerative medicine; multiple new vaccines on the drawing boards not only for infections but also for chronic illnesses such as atherosclerosis, Alzheimer’s and cancer; multiple new medical devices that are smaller and smaller yet more powerful (witness pacemakers for heart failure, stents and now catheter-based technologies to replace or repair damaged heart valves (wow!); imaging devices that show internal anatomy better than an artist can with a dissection plus imaging devices that can increasingly observe metabolic changes in real time.

These technologic advances are creating five medical megatrends: personalized or custom-tailored medicine; better preventive care; an expanding ability to repair, restore or replace damaged tissues or organs; digital information available anytime, anyplace; and much safer and higher-quality care.

Sounds great–and it is. But the use of these technologies all revolve around the primary care physician, who knows his or her patient and family well, can make the correct choices (in consultation with the patient), and can then direct or coordinate the patient’s care as he moves through various specialists, testing and procedures. This is especially critical for the increasing number of patients with one or more chronic illness such as heart failure, diabetes or cancer who will need a team of care givers, multiple specialists, many diagnostic tests, a myriad of drugs and frequent procedures over many years. These are all potentially expensive and should be used only as truly necessary so as to improve the quality of the patient’s care without excessive expense. It is only a well educated, well trained and committed physician who can do this level of coordination.

Two posts at the Harvard Business Review web site tackle this issue in more detail: 1, 2

Dr. Stephen C. Schimpff is an internist, professor of medicine and public policy, former CEO of the University of Maryland Medical Center and consults for the U.S. Army, medical startups and Fortune 500 companies. He is the author of The Future of Medicine – Megatrends in Healthcare.

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Nope–but with computers helping out, your doc will become awesome

One of the very first ‘expert systems’ was designed at Stanford University and designed to mimic an expert in infectious diseases. It was called Mycin. When given the right information about a patient’s symptoms, physical findings and lab tests, Mycin performed very well when compared to human doctors. Designed in the 1970’s, it was a rule-driven system, where the available data was run through a set of preprogrammed rules to arrive at a conclusion.

Today’s versions of expert systems have become familiar to us as we interact with commercial systems–like Amazon, Netflix and the Apple’s iTunes “Genius”–which recommend books, movies and music to us based on our prior purchases and those like us in their massive customer databases. So-called pattern-detection systems are also used to detect credit card fraud and stock trends.

These newer systems rely on ‘smart’ algorithms and the availability of electronic data in large enough quantities that we can reliably identify patterns that predict which books we’d like, anomalous credit card use or medical conditions of interest. These are data-driven pattern recognition systems, and they’re likely to have a dramatic influence on medical care by helping us diagnose patients, identify patients at risk for bad outcomes like readmission, and determine which medical practice patterns are the most effective and cost-efficient. In fact, IBM’s Jeopardy-playing supercomputer, Watson, will soon begin to work on health care information to do just this.

Electronic tools are proliferating rapidly in medical care. New electronic medical record and order entry systems allow us to collect data in machine analyzable formats, making data analysis much easier and more immediate. Surgical robots and telemedicine are possible only because of technological advances. New medical buildings will have sensors built into the walls to detect patient movement and track providers.

But while all of this might suggest that the doctor will soon become obsolete, that is not the case. As in other highly automated industries, like aviation, manufacturing and finance, the best medical care in the future will rely on a marriage of human and mechanical capabilities where each complements the other, making the whole greater than the sum of the parts.

Dr. C. William Hanson is professor of anesthesiology and critical care and chief medical information officer at the University of Pennsylvania Health System. He is also the author of the book Smart Medicine.

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Yes, in theory–but in practice we love nice, caring doctors

I could give you great advice about choosing a physician.

I don’t necessarily take it myself.

I understand our country needs to shake loose from the fragmented, disorganized, expensive, proceduralist-oriented, fee-for-service health care system. We need primary-care-focused systems in which we reward doctors for working together to coordinate our care, not just for prescribing more and more stuff. Technology will be important. But it’s a tool, not an end in itself.

I would tell you to find a doctor who is part of a larger health care organization–a medical home in the making, a budding ACO, a multi-specialty physician group. Find someone who is excited, not frightened, by coming changes in health care .

I would recommend a physician who has installed and mastered health information technology, not only to streamline paperwork but also to understand, monitor and coordinate health. Health IT is not a panacea, but it sure would be nice to have all those records and MRIs in one place–and have that place not be a dusty shelf in my bedroom closet.

Yet both of my docs are solo practitioners without health IT. I chose the primary care doctor when I moved to D.C. in 1994 by looking on a list–paper back then–for a female physician near a Metro stop who had gone to a good med school. I found my OB/GYN through a friend.

I stuck with my primary care doctor after she had found a minor thyroid problem and I asked whether fixing it would mean I wasn’t going to be tired anymore. She asked how old my son–then six–was. “You’ll be tired for 12 more years,” she replied.

I stayed with my OB–even after she stopped taking insurance–because she saved the life of my second son during a high-risk and utterly miserable pregnancy.

I assume both of these physicians will, over time, migrate to more technology, and both will adapt to change. In the meantime, they provide me with something that a machine can’t provide and that our system needs more of. They listen. And they care.

Joanne Kenen is a journalist and author who has covered health policy in and out of Congress since 1994. She was the senior writer for New America Foundation’s Health Policy program from 2007 through 2010.

*Photo courtesy of a.drian.

The post So Long, Doc appeared first on Zócalo Public Square.

So what’s a patient to do? You may not like the answer, but at least it’s simple: become your own doctor. I don’t mean you should go to medical school, of course. Nor do I mean you should panic–Google your itchy tongue (more on that later). But you do need to take on a new set of tasks.

Let’s look at the three things adult primary care doctors–also known as GPs (general practitioners), or general internists–do best. The first is to offer “episodic care,” meaning the sort of medical attention you get when you come down with something and head over to the doctor’s office. The second is to offer preventive care, helping you to head things off before they become a big problem. And the third is to monitor and treat continuing problems like diabetes or high blood pressure.

These are all essential services, and we’ll miss them when they’re gone. But here’s the best way to keep them–sort of–going.

First, when you get sick, use a walk-in clinic. These are usually called “urgent care centers,” and they’re often open 16 hours a day, perhaps located in a mall or pharmacy. So if your stomach is hurting like crazy, go consult your yellow pages or Google “urgent care” services in your city. In fact, do it before you eat that suspicious-looking soufflé and get too compromised to make good decisions. Check out the walk-in clinics nearby, write down the info, and put it on your refrigerator, so you have it ready. Here’s what you should not do: go to an emergency room with anything other than a true emergency, like a life-threatening problem. Misusing the ER is an incredible waste of time and money.

Second, start taking the lead in your own preventive care. The good news is that the resources are out there, and this wasn’t the case even as recently as five years ago. The best place to go is the website of the US Preventive Services Task Force. This is an entity that was created precisely to allow patients (and physicians) to have the most up-to-date and scientifically supported information on prevention. The recommendations come from non-governmental, non-biased experts, and there are strict rules in place intended to prevent personal biases–and especially monetary biases–from influencing the advice that’s offered.

If your research into preventive care reveals that you’re in need of some screening service, you can refer yourself directly to a facility that will take care of what you need. For example, go to a radiology center for a mammogram, go to a gastroenterologist for a colonoscopy, or go to a cardiologist for a treadmill. Then hit the urgent care center for blood tests, x-rays, immunizations, or other referrals. Keep a copy of all tests in your personal health record (for more information on this point, see my article on preventing medical miscommunications).

Third, if you’ve got chronic problems that require regular attention, start going to specialists for them. Studies show that primary care doctors do neither better nor worse than specialists when it comes to management of long-term problems such as diabetes, so it’s reasonable for you to seek long-term care with specialists, who will still be plentiful, rather than primary care doctors, who may be as rare as giant pandas.

In sum, being your own primary care provider, while not necessarily the most desirable burden to take on, can be a manageable task if you do a little planning and know where to go.

Now, a lot of these suggestions rely heavily on Internet use. That’s perfectly fine. But what’s not fine is frantically Googling your symptoms and coming up with half-cocked diagnoses. Before you know it, you’ll be suffering from smallpox, typhoid, and rabies. Instead, recognize that the worst-case scenario (my sore throat could be cancer!) is not even remotely likely, and stick to sites that offer reputable information. The websites of the American Academy of Family Physicians and the American College of Physicians are excellent and open to the public. Catch a free ride with them.

Meanwhile, current primary care providers can do a lot to help adjust to the new shortage. Every primary care physician should have a website, even if it just has updates on epidemics, downloadable forms, and basic information about the practice. This would save a lot of time in the office. Also, primary care doctors should eliminate hospital care from their regular work. Traditionally, doctors pay bedside visits to any patients of theirs who are hospitalized, in order to provide continuity in the patient’s care. But the emergence of hospital generalists called “hospitalists”–along with more enhanced communication systems–has largely replaced this need. While it’s nice for the patient in the hospital, it’s a huge and inefficient drain on a doctor’s time.

Primary care providers should also partner with urgent care centers and send all their same-day, sick patients there. This way, they stay on schedule, and their sick patients are seen right away, when it’s most convenient for the sick person.

Docs who do these things will have more patients, better informed patients, and restful nights.

Certainly, the shortage of family doctors is going to be a problem, but it also creates opportunities for both patients and physicians to improve existing healthcare outcomes, provided we take the initiative. As for finding a substitute for the deeper sense of reassurance that comes from spending real time with another human being devoted to your health–well, that we haven’t yet figured out.

Ken Murray, MD is Clinical Assistant Professor of Family Medicine at USC.

*Photo courtesy of daveparker.

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