©January 2011

One of the most palatable features of the “Law of Supply and Demand” is the intuitive notion that the value of something diminishes when you have too much of it.  This phenomenon is easily illustrated by comparing the unwasteful care focused upon a crab leg at the beginning of an all-you-can-eat crab feed compared with the attention garnered by the last crab leg of the evening.  However, in an era that is likely to be seen by our descendents as the “Information Age,” which began with access to newspapers and now at mid-stream is highlighted by the Internet, Facebook, Google, Yahoo, and cell phones smarter than NASA computers of yesteryear, it is worthwhile to remind ourselves that information, like crab meat, is at risk of being devalued by its shear plenty.

From the perspective of public health, the danger that we lose respect for information is no laughing matter.  One of the largest underground activities of public health in this country is the collection and analysis of data relating to our health.  Without this infrastructure the discovery of epidemics or the identification of risk factors that shorten life expectancy or quality of life would be delayed.  By scrutinizing this data according to stringent statistical rules, the public health system wades through a sea of potential and alleged risks in order to identify those that appear to have a causal relationship to illness and select the ones for which practical mitigating measures are available. In this way, every health care and illness prevention dollar can be spent to the greatest public benefit.  There is enormous responsibility inherent in this mission.

First, it is important that the analysis of data be done objectively.  All of the mysterious tools available to statisticians and epidemiologists – coefficients of variance, confidence intervals, t-scores, etc… – should be applied with consistency.  In accordance with a timeless scientific principle, those collecting the data should have no self-interest or pre-judgment about the conclusions of the ultimate findings, within what is humanly possible.  A positive and productive recommendation cannot justify misrepresentation of the data.

Secondly, the importance of credibility cannot be overemphasized when we are talking about the role of public health in the dissemination of information.  Recognizing what we do not know is equally as important as recognizing what we think we know.  The list of historical examples of science doing a poor job of public education and suffering a lack of public support because of it is striking.  More important, serious and unnecessary outbreaks of illness have resulted from such events.  A few examples follow.

The British Medical Journal recently published a report identifying incriminating evidence that the article published in another English journal in 1998 that fueled the anti-vaccine movement was rife with distorted data, misrepresentations and frank conflicts of interest.  These ethical lapses ultimately led to the revocation of the author’s license to practice medicine, but this has not prevented countless deaths resulting from cases of vaccine-preventable illnesses that may have been, at least in part, a result of this misinformation.

The ongoing debate regarding climate change is another example of science falling victim to passion and dogma on both sides of the debate.  While the data is absolutely convincing that unprecedented changes in certain parameters are occurring within the historical records, the interpretation and dissemination of this information needs to follow scientific guidelines, as free from political or self-centered influence as possible.

The recent release of Healthcare Acquired Infection rates for healthcare facilities throughout California is another example.  It was clear to the experts that the rates of infections due to surgical procedures at various hospitals was reported inconsistently between hospitals, under different criteria, and was largely influenced by the patient mix at various hospitals.  Naturally, hospitals receiving a large number of seriously ill patients and burn victims suffered higher infection rates.  Therefore, to the objections of certain consumer groups but in accordance with objective principles, this data was released by the California Department of Public Health with clear disclaimers.

The responsibility to handle information with great respect, of course, extends to all levels of the community.  Whether in debates involving party politics, health reform, climate change, private agencies or public health, maintaining a sense of humility about the data we wield and showing a healthy skepticism about the data we consume is a duty and skill that deserves our attention, right down to that last crab leg.

©September 2008

Many communities around the United States engage in an annual ritual called a “Health Fair.”  While such events are organized as differently as the communities themselves, they often make certain screening tests available to participants and arrange for counselors to help people make some sense of our so-called “health care system.”  However, one service that is not usually provided at Health Fairs is a physical examination, or “P.E.”  Therefore, it might be worth pondering the value of a physical exam, and taking a moment to consider its place in the preventive services armamentarium.

The United States Preventive Services Task Force (USPSTF) is assigned the task of identifying those preventive services which are recommended for the general public.  Several criteria are used to assess various preventive procedures to see if they make sense.  Such criteria include the prevalence of the illness to be prevented, the effectiveness of the detection method, the disability caused by a preventable condition, the effectiveness of disease treatment once it (or the risk of it) is detected, possible negative consequences of a preventive intervention, and finally the cost of a preventive procedure, test or treatment.  All of these criteria must be used to determine if a particular preventative step should be recommended to the public.

A physical examination requires that the patient bring his/her body to the care givers office.  It also requires that the patient’s body be looked at, touched, moved, probed and scrutinized with fairly primitive lights and lenses.  To do so requires that the patient remove his/her clothing.  Otherwise, a P.E. might be accomplished simply by sending ones laundry and a photograph to the care givers office.  Make a note of this when you are next seen for a routine physical examination.

It is now becoming popular, particularly in rural areas with limited availability of certain specialty physicians, for certain clinics to be conducted via camera, through something called “telemedicine.”  The patient is observed through a video camera and the specialist is also visible on a monitor while the patient is interviewed and visually evaluated.  Psychiatry and Dermatology are specialties for which this system sometimes works fairly well.  However, “telemedicine” is not a satisfactory method of performing a routine P.E.

While asymptomatic discoveries during a P.E. are unusual, they do indeed occur.  Whether it is a new heart murmur, an enlarged liver, a new spot on the skin or a lump that was previously undetected, with enough time in practice virtually every doctor has encountered such instances.  While it is fairly uncommon for these findings to be life saving, it is not rare that these unexpected results enhance the quality of life of the patient.  At the very least, such instances remind the patient that they are connected to the human race.  These are examples of some of the benefits of a regular physical examination.

However, one of the less celebrated benefits of a P.E. is difficult to encapsulate and even more difficult to measure.  This is the moment within the examination room when personal, confidential concerns and troubles that are encountered in every day life are shared.  These generally are items that affect our health, but sometimes include things that we may not even recognize as health concerns.  The treatments provided by the care giver may be nothing more than lending an ear, or answering questions tuned to the individual life of the patient.  However it is this moment during the exam when issues affecting the quality of life can be addressed and reflected.  It is an opportunity that the care giver recognizes as the greatest privilege of his/her profession, and it is an opportunity for the patient that should not be squandered.

The goal of a physical examination will be different, depending upon the age and/or developmental stage of the patient. During infancy, a P.E., traditionally called a “well-child exam,” is focused upon the developmental milestones, immunizations and parental education.  A physical examination during the prepubescent years will raise new questions about relationships and body changes that may have the young persons head spinning.  Young adulthood will touch on many issues that are forming lifelong objectives for the patient.  More than 50% of adult patients will have complaints that revolve around happiness and satisfaction with their lives.  And older patients often teach providers what to tell all the others.

While specific recommendations for a P.E. are not generally agreed upon by all specialty organizations, the following represents a recommended approximate frequency for routine physical exams for the general population based upon the current guidelines of the USPSTF and the California Child Health and Disability Prevention program (CHDP). You should consult your private care giver to determine the frequency of physical examination for your specific needs:

Infancy:  At birth, age 2 weeks, 2 months, 4 months, 6 months, (9months), 12 months, 15 months, 18 months, 2 years

Childhood: At age 3 years, 4-5 years, 6-8 years, 9-12 years, 13-16 years, and 17-20 years

Adult: Every three years between 20-39 years of age

           Every one to three years between 40-64 years of age

Senior: Every year from age 65 and older

©September 2008

There are reasons to believe that our health care system was designed by Dr. Seuss.  It is not as though some feather-tufted creature in striped socks woke up one day and deliberately organized a system with convoluted billing procedures and hopelessly tedious eligibility requirements.  No.  The system is a product of an uncountable series of decisions made by conscientious people – legislators, insurance companies, doctors, nurses, employers, administrators, technicians, investors and (yes) patients – that contributed a galaxy of modifications to a system which was originally fairly straightforward: sick people were provided with care in exchange for money.  So what were the major curves and intersections in the road that brought us to “Whoville?”

In 1900 there was very little protection for people who became ill to help them continue to provide for their families while simultaneously covering the costs of health care.  Granted, at that time there was minimal cost for such things as “Thunderclap Hot Springs Injection: World Famous Remedy for Gonorrhea and Gleet,” but neither was there much benefit to the patient for such snake oil.

It was not entirely a benevolent act when, at the turn of the century, employers developed the novel idea of “disability insurance.”  The idea was to offer your employees some financial assistance when they became ill so they could cover the costs of health care and continue to feed their families…and, of course, return to their factory jobs more quickly.  Diseases such as tuberculosis were widespread and it was to the advantage of employers to have a healthy work force.  This was the foundation for the employer-based health insurance system we have today.

In 1945 an organization called Kaiser Permanente was established to provide not only financial assistance to employees of the Henry J. Kaiser Company, but to actually provide doctors and clinics.  Several similar experiments had been explored in the 1930s, but it was during the construction of the Grand Coulee Dam in Washington that the notion took hold.  This was the beginning of the Health Maintenance Organization, or “HMO.”

Prior to 1965 most care for people without the economic means to pay for their care was provided as a charity, both by hospitals and physicians.  However, there was no way to guarantee to the poor that they would be able to find a source for such services.  Health care was becoming more expensive and effective.  Therefore the Social Security Act was passed and Medicaid (or MediCal in California) and Medicare were born.

Unfortunately, there were few controls to the cost of care to MediCal and Medicare recipients, so that government expenditures went rapidly through the roof.  In 1970 health care represented 7% of the Gross Domestic Product (GDP).  In 1980 that increased to 8.8% of the GDP.  In an effort to enlist the assistance of private industry to control health care costs, the HMO Act was passed in 1973.  It was expected that the insurance industry would be able to more efficiently deliver health care.

Expenses continued to skyrocket.  The Managed Care Act was passed in 1982, extending additional leverage to health insurance programs to control costs.  This provided the recipe for an alphabet soup of organizations who were interested in skimming the cream from the well-financed health care system: PPOs, HMOs, MCOs and others that are not appropriate for a family website.  Unfortunately, by 1990, 12% of the GDP was going into health care and today, in 2008, health care represents 16% of the GDP.  Insurance companies thrive.

It was inevitable in such a system that gaps in health care delivery would occur where providing health care was difficult and unprofitable.  In response to such gaps, legislators developed individual programs to assist people who fell into the chasm.  MediCal and CMSP for the unemployed.  CHDP for well-child care. AIM for pregnant mothers.  FPACT for adolescents needing family planning services.  CDP for women needing mammography and Pap smears, etc…  At last count, there are twenty seven different government-operated programs to delivery health care to those who are not served by the meager generosity of the insurance industry, each public program with it’s own forms, eligibility requirements, administrators, infrastructure, trained staff, computers, and budget.  Welcome to “Whoville.”

It is time for a Universal Health Care system.  The problem is not that the government is somehow intrinsically inefficient, but rather that our current health care model has become obsolete.  A single health care program for all Americans would render the bewildering array of band-aid programs unnecessary, providing more dollars for direct patient care.  Such a step might even simplify the management of a state budget.

In fact, it turns out that the good Dr. Seuss did focus his satirical wit on the health care industry in his book, You’re Only Old Once:  “You are in pretty good shape for the shape you are in!”

©July 2012

People often comment to front line health care providers that they could not imagine becoming desensitized to the sight of blood and gore in the way that doctors and other health care providers seem to become desensitized during training.  But for me, I cannot imagine having the intestinal fortitude that it must take for legislators to escort new legislation through the messy process of becoming law.  No example of this surrealistic process is more apt than the tortuous path that has been foisted upon the Affordable Care Act.  But now it is time for all of us to sponge the wound and take care of the patient.

Obviously, there are many explanations why this landmark health reform was confronted by such a mournful battlefield.  Political diversions from all directions are certainly partly responsible.  The fact that virtually everybody has a personal relationship with health care is another contributing factor.  But there is another contributor which, unlike many of the other issues, we can do something about.  That is a lack of public understanding about the details of the Affordable Care Act itself.  It is perhaps past time that a physical examination of this law needs to be made by every American.

One point is worth mentioning before putting the Affordable Care Act on the examination table.  By searching the internet with “the healthcare law and you,” (or by going to healthcare.gov) you can review the actual text of the law.  You will find that in the legislative version each page has only slightly more words than a fortune cookie.  Thus the entire act comes to 2407 pages.  However, in the “consolidated version,” the act fits just fine on 906 pages.  The first ten pages of the 906 pages of the language of the law will give you a look at the table of contents.  By scanning over these first ten pages you will actually get a pretty good overview of the content of the entire act without being intimidated by the common belief that the law is “too complex to understand.”

The Affordable Care Act consists of ten Titles, each of which is listed in the table of contents broken down into Subtitles and Sections that address different aspects of each Title.  While the language is not designed for every person’s palate unless you are familiar with legislative lingo, the healthcare.gov website offers a more user-friendly way to peruse the contents of the law.

Title I tackles multiple obstacles encountered by people trying to qualify for affordable health insurance.  Measures include a phased-in schedule for eliminating pre-existing conditions as a reason for insurance disqualification, incentives to assure that each person either seeks personal insurance coverage or   contributes to the overall health coverage for the community (AKA “The Mandate”) and extending coverage to youth on their parents insurance plans up to 26 years of age.

Title II Expands and refines the role of safety-net services like Medi-Cal, while Title III addresses efficiency and quality in the healthcare system.  Title III also fills the so-called “doughnut-hole” in coverage for prescription medications in Medicare for seniors.  Title IV provides for an expansion of prevention in our communities and in our health care system to capture savings that until now have been limited to pilot programs.  Title V seeks to bring more qualified and well-trained individuals into the healthcare workforce.  Title VI assures that the public will have access to their own healthcare information and addresses abuses within the system that divert dollars away from actual patient care.  Title VII endeavors to fund new and promising treatments and incorporates discounts that are used in the private healthcare industry that have not been adequately employed to save taxpayer money in public systems.  Title VIII prepares for the cohort of Baby Boomers who will be moving towards senior care in the next few decades by expanding Long Term Care options.  Title IX describes a number of cost saving measures and imposes some requirements upon hospitals that have been enjoying the benefit of tax deductions.  Finally, Title X addresses the needs of Native Americans in keeping with old agreements and cleans up language scattered throughout other portions of the law.

There you have it.  Learn about the new health care law that has withstood judicial review.  Talk about it and express your opinion about the parts you support and the parts you do not.  But please recognize that our patient needs our attention, and it is time that we endeavor to first clearly understand and then contribute to improve the status quo.

December 20, 2017

When I read the recent headline that our nation’s primary public health agency, the Centers for Disease Control and Prevention (CDC), has been “prohibited” from “using seven words in official documents used for next year’s budget,” I found myself stomping around the house in disbelief.

As clarified by the CDC director, the truth of this news is probably less provocative than the face value of that headline.  And yet, the preponderance of evidence points to an ongoing and relentless effort to undermine science and scientific principles by our political leaders.  The proverbial last straw has landed on this camel’s back.

In 1996, a federal budget bill stated that “none of the funds made available for injury prevention and control at the Centers for Disease Control and Prevention may be used to advocate or promote gun control.”

Subsequently, Congress eliminated funding for Gun Violence Prevention Research at the CDC.  Funding declined from $2.6 million in 1996 to zero in 2014, 2015, 2016 and 2017, despite a request for $10 million for each of those four years.

This lack of funding prevented scientific research that may have helped address firearm violence in this country, like a 2009 study of suicide rates in California that was funded by local Tuolumne County dollars to identify that, over the prior decade, for every firearm-related homicide in rural parts of the state, there were approximately four firearm-related suicides.

A disrespect for science can cause politicians to blunder into the realm of pseudo-science in response to public outcry, designing legislation with good intentions but with disastrous results.

In 2001, AB 487 was approved by Governor Davis requiring physicians in California to receive 12 hours of training in pain management because of a perception “that physicians consistently fail to manage their patient’s pain appropriately” in part due to “…undertreatment and undermedication.”

The passage of this bill coincided with the release of new opiate medications by pharmaceutical companies.  The encouragement to prescribe long-acting narcotics provided by AB 487 in conjunction with savvy marketing by pharmaceutical companies helped pave the way to today’s opiate addiction crisis.

Pseudo-science and ideological convictions may even misguide us to oppose sound science.  The trail of scientific discovery is littered with the lives of scientists whose sacrifices have resulted in the eradication of smallpox, travel into space, the control of yellow fever and endless research that has either proven or disproven contemporary theories.

To ignore the practical benefits of new discoveries discounts the sacrifices of these modern explorers.  If such neglect aggravates global climate change or results in a chronically ill child contracting an unnecessary infectious disease in school, it is nothing short of tragic.

Scientists must also bear some of the blame for public skepticism.  Real science is humble.  While scientists are generally superb at describing their fields of expertise, they are often not so good at translating their knowledge to the masses.  Science has unfortunately abdicated marketing to the corporate world that stands to prosper from the sales of products and services that are the fruits of science.

Here in Tuolumne County we are trying to change that.  A program called the Exploratorium of Health Care Careers will visit every public school in the county this year.  It is also active in Calaveras County and will be starting in Merced County this spring.

The program is made possible by an intrepid group of volunteers from many scientific and educational backgrounds who are seeking to introduce local 7th, 8th and 9th graders to the wonders and rewards of careers in science and health care.

But to bring new generations into those fields we must encourage students to ask questions.  They must shed their fear of asking the “wrong” question.  We cannot do that if our leaders prohibit our best scientists from asking certain questions or “using seven words” – or for that matter even one word – in their quest to understand our world better and to improve our lives for tomorrow.

If we accept this kind of scientific censorship we degrade the quality and integrity of our science and lower the expectations of tomorrow’s scientists.

In today’s world, with all its diversity, we need to instill our youth with evidence-based and science-based reasoning, so that tomorrow all of us – from the vulnerable fetus to the transgender community – can benefit from opportunities that represent our entitlement.