There was some big, big news recently that you probably haven’t heard. After years of legal wrangling, the tobacco industry has not only been found guilty of fraud, conspiracy, and racketeering, but they have been ordered to run television and newspaper ads admitting the truth that they fought so hard to suppress for decades.
Let’s go back to the beginning. It was more than 50 years ago, in 1964, when Luther Terry, the 9th Surgeon General of the United States, issued a landmark report linking smoking to lung cancer and a host of other diseases. Since that time, Big Tobacco lied, deceived, and in every way engaged in a no-holds-barred battle against every attempt to regulate or curtail the sale of tobacco products. In the meantime, tens of millions of U.S. citizens have died prematurely from tobacco use.
In 1999, the Department of Justice took on Philip Morris and other tobacco giants under the Racketeer Influenced and Corrupt Organizations Act (RICO), alleging that the tobacco companies had engaged in a decades-long conspiracy to (1) mislead the public about the risks of smoking; (2) mislead the public about the danger of secondhand smoke; (3) misrepresent the addictiveness of nicotine; (4) manipulate the nicotine delivery of cigarettes; (5) deceptively market cigarettes characterized as “light” or “low tar,” while knowing that those cigarettes were at least as hazardous as full flavored cigarettes; (6) target the youth market; and (7) not produce safer cigarettes.
Seven years later, in 2006, Federal District Court Judge Judy Kessler ruled that Philip Morris and other tobacco companies engaged in fraud, conspiracy and racketeering – all to deliberately deceive the American public about the health risks of smoking and secondhand smoke. Her ruling noted that Big Tobacco had “marketed and sold their lethal product with zeal, with deception, with a single-minded focus on their financial success, and without regard for the human tragedy or social costs that success exacted.” Judge Kessler ordered that these companies admit their guilt publically by running newspaper and television ads detailing their deception.
It took eleven more years – and a lengthy appeal process – for Big Tobacco to finally agree to any sort of public mea culpa about the health effects of smoking and their role in addicting hundreds of millions of people. Their watered-down admissions of guilt (known in legal parlance as “corrective statements”) will appear in about 50 newspapers and for a year on major television networks. One startlingly honest (and obvious) fact that must be publicized is that Altria, R.J. Reynolds Tobacco, Lorillard, and Philip Morris USA intentionally designed cigarettes to make them more addictive.
Think about that. At a time when we rightly are criticizing pharmaceutical companies for how they market pain medications (which actually have a therapeutic use), we still give a pass to the companies that market the most addictive, useless, and deadly product around. At least Big Tobacco now must admit publically that “More people die every year from smoking than from murder, AIDS, suicide, drugs, car crashes, and alcohol combined.”
Other statements you may see are, “Many smokers switch to low tar and light cigarettes rather than quitting because they think low tar and light cigarettes are less harmful. They are not,” and “There is no safe level of exposure to secondhand smoke.” Sadly, we have known all of this for years. No, decades.
These ads started on November 26, but I have yet to see one myself. I wonder if anyone who needs to see them will see them. Major newspapers and even television are not the way our vulnerable youth consume media these days. I am sure Big Tobacco is counting on that.
In the meantime, tobacco sales continue at a brisk pace. A Wall Street Journal article in April of this year noted that revenues for U.S. tobacco companies hit $117 billion in 2016, up from $78 billion in 2001, despite lawsuits, rising taxes and declining smoking rates. Americans spent more than $90 billion on cigarettes in retail stores last year.
Stores that sell tobacco products today are complicit in the very deception that Big Tobacco is guilty of. The retail markup of tobacco products, according to the Wall Street Journal, is 17%, higher than that on groceries. No wonder grocery and convenience store chains put tobacco products front and center in their stores – or even out in front of their stores. Easy money. Dirty money.
The conservative/libertarian argument about supply and demand and “personal choice” is, pardon the pun, smoke and mirrors when people are knowingly addicted to the product in question. Cigarettes are not sugar water. I don’t mind companies making a profit – even obscene profits – as long as it isn’t by addicting us and killing us.
If nothing else comes from this mea culpa – these “corrective statements” – I hope tobacco and related products become so regulated and so taxed that not only is it not possible to become addicted, but it is too expensive for our youth to even consider starting. Nothing short of a world without tobacco will do. Perhaps that is a pipe dream, but our kids are worth it.
Sunday, December 10, 2017
Sunday, November 12, 2017
Why I Shout about Being a Cancer Doctor
A prestigious oncology journal recently published an opinion piece titled, “Why I Keep Quiet about Being a Cancer Doctor.” I was depressed after reading it, because the author self-identified as “someone who deals with the onslaught of disease and despair day in and day out.” If that is his true outlook, no wonder he keeps quiet! He seemed to have difficulty answering the question, “How do you do this every day?” When he managed to reflect poetically about the nuances and minefields of daily practice, it was almost apologetically.
Let me just say, I love being asked what I do. Maybe that’s because I love what I do!
I love my patients, for one thing, and I try hard not fall into the easy trap of judging people based on lifestyle or insurance status. Whether their cancer was self-inflicted or environmental, genetically-linked or totally random, I find there is always something in everyone worthy of compassion and care. Cancer is a journey, and cancer patients need to trust that their physician is committed to going on the journey with them. I do that, honestly, out of respect for the dignity of each individual. It doesn’t hurt that I am constantly aware that my time may come, and I, too, want to be treated with compassion and respect.
I love being a provider of hope. That’s not limited just to hope for cure, as much of a desired goal that may be. Sometimes my most grateful patients have been the ones I have told are dying. They usually knew it, but nobody would talk to them about it (not to mention they were afraid to ask). Giving them hope - of comfort, of peace, of relief of pain - is very gratifying. Their care is no less important than the wonderful cures we prefer to celebrate.
Of course, I love sharing the news of success in oncology. In the more than twenty five years I have been in practice, the cure rate of all cancers combined increased from 50% to 70%. That is a remarkable improvement! Many cancers have 5-year survival rates well above 90%. Last month – Breast Cancer Awareness Month – we celebrated the fact that the breast cancer death rate has dropped 40% over the same period of time.
Yes, the oncologist writer rightly pointed out how demanding (and emotionally exhausting) it can sometimes be to be a cancer doctor. We don’t cure pancreatic cancer often at all. And it is frustrating that the cancer that kills more people than any other – lung cancer – is almost entirely preventable. And we’ve all known that for more than 50 years.
I do tire of dealing with the cancer conspiracy theories that inevitably come up, like, “Drug companies have a cure; they are just keeping it from us.” But rather than ignore or avoid opportunities to both dispel myths and celebrate research triumphs, I relish the chance to advocate not only for my specialty, but for organizations like the American Cancer Society and movements like hospice care, which help us with everything from research, prevention and early detection, treatment support and survivorship, to palliative and end of life care where needed.
Above all, being a physician (and specifically an oncologist) is for me a sacred calling. How can I keep quiet about what I love and am called to do? I can’t suppress talking or writing about my passion any more than a bird can stop chirping in the spring. That’s worth shouting about!
Let me just say, I love being asked what I do. Maybe that’s because I love what I do!
I love my patients, for one thing, and I try hard not fall into the easy trap of judging people based on lifestyle or insurance status. Whether their cancer was self-inflicted or environmental, genetically-linked or totally random, I find there is always something in everyone worthy of compassion and care. Cancer is a journey, and cancer patients need to trust that their physician is committed to going on the journey with them. I do that, honestly, out of respect for the dignity of each individual. It doesn’t hurt that I am constantly aware that my time may come, and I, too, want to be treated with compassion and respect.
I love being a provider of hope. That’s not limited just to hope for cure, as much of a desired goal that may be. Sometimes my most grateful patients have been the ones I have told are dying. They usually knew it, but nobody would talk to them about it (not to mention they were afraid to ask). Giving them hope - of comfort, of peace, of relief of pain - is very gratifying. Their care is no less important than the wonderful cures we prefer to celebrate.
Of course, I love sharing the news of success in oncology. In the more than twenty five years I have been in practice, the cure rate of all cancers combined increased from 50% to 70%. That is a remarkable improvement! Many cancers have 5-year survival rates well above 90%. Last month – Breast Cancer Awareness Month – we celebrated the fact that the breast cancer death rate has dropped 40% over the same period of time.
Yes, the oncologist writer rightly pointed out how demanding (and emotionally exhausting) it can sometimes be to be a cancer doctor. We don’t cure pancreatic cancer often at all. And it is frustrating that the cancer that kills more people than any other – lung cancer – is almost entirely preventable. And we’ve all known that for more than 50 years.
I do tire of dealing with the cancer conspiracy theories that inevitably come up, like, “Drug companies have a cure; they are just keeping it from us.” But rather than ignore or avoid opportunities to both dispel myths and celebrate research triumphs, I relish the chance to advocate not only for my specialty, but for organizations like the American Cancer Society and movements like hospice care, which help us with everything from research, prevention and early detection, treatment support and survivorship, to palliative and end of life care where needed.
Above all, being a physician (and specifically an oncologist) is for me a sacred calling. How can I keep quiet about what I love and am called to do? I can’t suppress talking or writing about my passion any more than a bird can stop chirping in the spring. That’s worth shouting about!
Sunday, October 8, 2017
Palliative Care: Something We All Want
As a hospice physician – in addition to my role as a doctor who treats cancer – much of my focus is on comfort care. Part of my motivation to study medicine stems from my childhood concept of who a physician was and should be: a healer and comforter. The physician of yesteryear came to the bedside to care for and comfort the sick (and yes, the dying). I love that the Latin root for comforter is confortare, meaning, “to strengthen much.” In Christianity, the Holy Spirit is also called the Comforter.
Frankly, all physicians should practice comfort care. We know we aren’t to harm our patients. That obligation not to inflict harm intentionally is the ethical principle of nonmaleficence. It is summed up in the Latin phrase Primum non nocere – First, do no harm. The Hippocratic Oath states, in part, “I will use treatment to help the sick according to my ability and judgment, but never with a view to injury and wrong-doing.” That oath – to help the sick – expresses our obligation to do good (the ethical principle of beneficence). Though the actual oath used in various medical schools has changed over time, the overarching mandate to help the sick – and, at a minimum, not to harm them – is universal.
What does it mean to help the sick? That seems, on the surface, like an obvious question. “To cure, of course!” we would say in the 21st century. But curing disease is a quite modern concept. For most of medical history, comfort care was the primary goal. Modern technology and the emphasis on cure got us advanced cardiac care, open heart surgery, amazing innovations in cancer treatment, and so much more. But by 1980, most people died in the hospital. This was rare just a generation or two prior to that, when nearly everyone died at home (or on the battlefield).
Since 1980, the number of people dying in the hospital has declined somewhat, thanks in part to better end of life care (including hospice care). However, 7 out of 10 Americans still die in a hospital, nursing home or long-term care facility when 7 out of 10 of us say we want to die at home (only 25% of Americans actually do die at home). Utilization of hospice care at the end of life is still woefully low.
But, what about those in the hospital who aren’t expected to die, who want a better, more “comfortable” hospital care experience overall? “Cure sometimes, treat often, comfort always,” is a wonderful mantra attributed to the 19th century tuberculosis physician Dr. Edward Trudeau. This phrase sums up a newer movement in medicine called palliative care.
Palliative care focuses on preventing and relieving suffering and on supporting the best possible quality of life for patients and their families facing any serious illness. To palliate means to relieve – literally, to cloak – with the focus being on symptoms. Symptom management obviously should not be limited to end of life care.
As an example, for an ICU patient suffering from an acute exacerbation of lung disease, probably on a ventilator for a short period of time (but expected to recover), the physician historically has been paying attention to oxygen and carbon dioxide measurements, volumes of air going in and out, the acidity of the blood, and other “numbers” that paint a picture of how the patient is doing. But not how the patient or family is feeling. Shortness of breath? Anxiety? Nausea? Pain? Dealing with prognosis and potential end-of-life decision-making? Social and spiritual support? These are issues that might benefit from a palliative care consult.
Every hospitalization (whether ICU or not) has the potential for needing some degree of palliative, or comfort, care in addition to and alongside the acute medical needs that precipitated the admission in the first place. Often, the treating physician can and should address these needs. Quality metrics such as patient satisfaction, length of stay, and even cost of hospitalization are improved with good symptom management.
And, believe it or not, sometimes patients live longer with good comfort care! In my field of oncology, randomized trials have shown improved quality of life and even improved survival with early use of palliative care. The American Society of Clinical Oncology (ASCO) recommends the integration of palliative care with conventional oncology treatment, and the American Society for Radiation Oncology (ASTRO) has urged early palliative care referral when cure is not expected, even if death is not imminent and treatment still is ongoing.
CHI St. Luke’s Health Memorial in Lufkin will be starting a new palliative care consult service later this fall. A team consisting of a physician, nurse, and social worker all certified in palliative care will be available to consult with and advise physicians on any patient with difficult to manage symptoms, regardless of whether or not the patient has a terminal prognosis.
As we learn more about palliative care, we remember the Golden Rule: “So in everything, do to others what you would have them do to you, for this sums up the Law and the Prophets (Matthew 7:12, NIV).”
Comfort always.
Frankly, all physicians should practice comfort care. We know we aren’t to harm our patients. That obligation not to inflict harm intentionally is the ethical principle of nonmaleficence. It is summed up in the Latin phrase Primum non nocere – First, do no harm. The Hippocratic Oath states, in part, “I will use treatment to help the sick according to my ability and judgment, but never with a view to injury and wrong-doing.” That oath – to help the sick – expresses our obligation to do good (the ethical principle of beneficence). Though the actual oath used in various medical schools has changed over time, the overarching mandate to help the sick – and, at a minimum, not to harm them – is universal.
What does it mean to help the sick? That seems, on the surface, like an obvious question. “To cure, of course!” we would say in the 21st century. But curing disease is a quite modern concept. For most of medical history, comfort care was the primary goal. Modern technology and the emphasis on cure got us advanced cardiac care, open heart surgery, amazing innovations in cancer treatment, and so much more. But by 1980, most people died in the hospital. This was rare just a generation or two prior to that, when nearly everyone died at home (or on the battlefield).
Since 1980, the number of people dying in the hospital has declined somewhat, thanks in part to better end of life care (including hospice care). However, 7 out of 10 Americans still die in a hospital, nursing home or long-term care facility when 7 out of 10 of us say we want to die at home (only 25% of Americans actually do die at home). Utilization of hospice care at the end of life is still woefully low.
But, what about those in the hospital who aren’t expected to die, who want a better, more “comfortable” hospital care experience overall? “Cure sometimes, treat often, comfort always,” is a wonderful mantra attributed to the 19th century tuberculosis physician Dr. Edward Trudeau. This phrase sums up a newer movement in medicine called palliative care.
Palliative care focuses on preventing and relieving suffering and on supporting the best possible quality of life for patients and their families facing any serious illness. To palliate means to relieve – literally, to cloak – with the focus being on symptoms. Symptom management obviously should not be limited to end of life care.
As an example, for an ICU patient suffering from an acute exacerbation of lung disease, probably on a ventilator for a short period of time (but expected to recover), the physician historically has been paying attention to oxygen and carbon dioxide measurements, volumes of air going in and out, the acidity of the blood, and other “numbers” that paint a picture of how the patient is doing. But not how the patient or family is feeling. Shortness of breath? Anxiety? Nausea? Pain? Dealing with prognosis and potential end-of-life decision-making? Social and spiritual support? These are issues that might benefit from a palliative care consult.
Every hospitalization (whether ICU or not) has the potential for needing some degree of palliative, or comfort, care in addition to and alongside the acute medical needs that precipitated the admission in the first place. Often, the treating physician can and should address these needs. Quality metrics such as patient satisfaction, length of stay, and even cost of hospitalization are improved with good symptom management.
And, believe it or not, sometimes patients live longer with good comfort care! In my field of oncology, randomized trials have shown improved quality of life and even improved survival with early use of palliative care. The American Society of Clinical Oncology (ASCO) recommends the integration of palliative care with conventional oncology treatment, and the American Society for Radiation Oncology (ASTRO) has urged early palliative care referral when cure is not expected, even if death is not imminent and treatment still is ongoing.
CHI St. Luke’s Health Memorial in Lufkin will be starting a new palliative care consult service later this fall. A team consisting of a physician, nurse, and social worker all certified in palliative care will be available to consult with and advise physicians on any patient with difficult to manage symptoms, regardless of whether or not the patient has a terminal prognosis.
As we learn more about palliative care, we remember the Golden Rule: “So in everything, do to others what you would have them do to you, for this sums up the Law and the Prophets (Matthew 7:12, NIV).”
Comfort always.
Sunday, September 10, 2017
The Demise of Polite Conversation
When did the art of pleasant conversation and open dialogue end? Every national new item – it seems – sparks vitriol that demands an alignment in one political camp or the other, one race or the other, or one sexual orientation or the other. I am afraid we have lost the ability to exchange ideas, to communicate freely, to learn from one another. To celebrate our differences rather than condemn them. Passionate speech and polite speech are not incompatible.
But I am afraid to speak, for fear my words are misinterpreted. I am afraid to write, lest my writing not encourage the thoughtful conversation I intended, but provoke a hateful backlash. Is it no longer possible to have civil discourse?
I am afraid to laugh, for fear my laughter is misconstrued. Can’t I both laugh at Tina Fay’s Saturday Night Live sheet-caking stunt, for example, as well as at Chad Prather’s “Unapologetically Southern” YouTube videos? At political cartoons of both the Wall Street Journal and the New York Times? Or is humor no longer funny, only hateful? Can’t we laugh at ourselves anymore, at our own hypocrisies? We all have them. I’m afraid we no longer recognize that; we are blinded by our self-interest.
I am afraid of social media. Facebook has unfortunately turned into a forum where, other than the annual birthday wish or mundane vacation photo, posts are filled with inflammatory opinions and commentary-as-fact with the self-righteous, ignorant replies that follow. Mob mentality sets in and people post things they would never say to your face. Hurtful – hateful – things.
Free speech is not the same thing as kind speech, uplifting speech, or frankly, intelligent speech. Nor should honest disagreement be labeled hate speech. Unfortunately, much speech today is designed to shut down the conversation by labeling one’s opponent –are they really an opponent? – a bigot, or by declaring they have no moral standing even to join the conversation. That is coercion, intimidation, and bullying no matter which side is doing it. That makes me very afraid.
I am afraid when I see fellow Christians deciding that following politics is more important than following the Ten Commandments. When they opt for strict party affiliation over and above "Thou shalt love thy neighbour as thyself" (Mark 12:31, KJV). And when they decide it is expedient to legislate hate, discrimination, and economic disparity while ignoring inconvenient moral issues like poverty and healthcare. What happened to being Jesus to those around us?
Rod Dreher, in his timely book The Benedict Option, notes that political victory does not vitiate the vice of hypocrisy. The socially liberal churches are just as guilty of blindly aligning with the Democratic Party as the fundamentalists are with the Republican Party. Could it be that Jesus understood this when he said, “Render therefore unto Caesar the things which are Caesar’s; and unto God the things that are God’s” (Matthew 22:21, KJV)?
I am afraid our clumsy, partisan involvement has resulted in a political environment increasingly hostile to the very real – and very Christian – charitable work of the Church. We must redirect our gaze outside our church walls and into our increasingly diverse and desperate communities. Putting our faith to work on the ground speaks volumes and accomplishes so much more than legislating selective moral conformity.
It often takes a crisis – a disaster? – to bring the country together to work for the common good. Perhaps Hurricane Harvey will accomplish that. It appears to be doing so; I just hope it lasts.
Dreher wrote, "The state will not be able to care for all human needs in the future, especially if the current projections of growing economic inequality prove accurate.” Christians need to rediscover an ethic that marries personal responsibility with intentional charity and corporate love and respect. I fear we may have drifted too far to do so.
But I am afraid not to try.
But I am afraid to speak, for fear my words are misinterpreted. I am afraid to write, lest my writing not encourage the thoughtful conversation I intended, but provoke a hateful backlash. Is it no longer possible to have civil discourse?
I am afraid to laugh, for fear my laughter is misconstrued. Can’t I both laugh at Tina Fay’s Saturday Night Live sheet-caking stunt, for example, as well as at Chad Prather’s “Unapologetically Southern” YouTube videos? At political cartoons of both the Wall Street Journal and the New York Times? Or is humor no longer funny, only hateful? Can’t we laugh at ourselves anymore, at our own hypocrisies? We all have them. I’m afraid we no longer recognize that; we are blinded by our self-interest.
I am afraid of social media. Facebook has unfortunately turned into a forum where, other than the annual birthday wish or mundane vacation photo, posts are filled with inflammatory opinions and commentary-as-fact with the self-righteous, ignorant replies that follow. Mob mentality sets in and people post things they would never say to your face. Hurtful – hateful – things.
Free speech is not the same thing as kind speech, uplifting speech, or frankly, intelligent speech. Nor should honest disagreement be labeled hate speech. Unfortunately, much speech today is designed to shut down the conversation by labeling one’s opponent –are they really an opponent? – a bigot, or by declaring they have no moral standing even to join the conversation. That is coercion, intimidation, and bullying no matter which side is doing it. That makes me very afraid.
I am afraid when I see fellow Christians deciding that following politics is more important than following the Ten Commandments. When they opt for strict party affiliation over and above "Thou shalt love thy neighbour as thyself" (Mark 12:31, KJV). And when they decide it is expedient to legislate hate, discrimination, and economic disparity while ignoring inconvenient moral issues like poverty and healthcare. What happened to being Jesus to those around us?
Rod Dreher, in his timely book The Benedict Option, notes that political victory does not vitiate the vice of hypocrisy. The socially liberal churches are just as guilty of blindly aligning with the Democratic Party as the fundamentalists are with the Republican Party. Could it be that Jesus understood this when he said, “Render therefore unto Caesar the things which are Caesar’s; and unto God the things that are God’s” (Matthew 22:21, KJV)?
I am afraid our clumsy, partisan involvement has resulted in a political environment increasingly hostile to the very real – and very Christian – charitable work of the Church. We must redirect our gaze outside our church walls and into our increasingly diverse and desperate communities. Putting our faith to work on the ground speaks volumes and accomplishes so much more than legislating selective moral conformity.
It often takes a crisis – a disaster? – to bring the country together to work for the common good. Perhaps Hurricane Harvey will accomplish that. It appears to be doing so; I just hope it lasts.
Dreher wrote, "The state will not be able to care for all human needs in the future, especially if the current projections of growing economic inequality prove accurate.” Christians need to rediscover an ethic that marries personal responsibility with intentional charity and corporate love and respect. I fear we may have drifted too far to do so.
But I am afraid not to try.
Sunday, August 13, 2017
Moving the Needle on Health in Angelina County
Back in January, I wrote about the abysmal county health rankings in Deep East Texas and the fact that Angelina County has been named the county with the highest obesity rate in Texas. Almost four out of ten of us aren't merely overweight, we are downright obese. Let’s just admit it; we’re fat. And that fatness is a major factor in the development of high blood pressure, diabetes, heart disease, and many cancers, among other illnesses.
Obesity is a two-edged sword that is both killing us early and costing us a lot in terms of ongoing healthcare expenditures and lost productivity. Smoking is, of course, another huge factor in our high cost of healthcare and poorer health outcomes. We must do better.
The rhetoric on the national stage is all about the skyrocketing cost of health insurance and how to tweak (or get rid of) Obamacare, as if that would solve our healthcare problems. The government can’t do it for us, folks. Regardless of what happens with healthcare reform, we need to collectively get off our fat behinds and take more responsibility for our own health. We need to do this individually, yes, but we also need to work on this as a community.
I mentioned in January the groundwork being laid by the Texas Forest Country Partnership. They hosted a series of strategic planning sessions to set goals for growth across a broad spectrum of our regional economy, from forestry and tourism to manufacturing and healthcare. Part of their healthcare recommendation was to raise our county health rankings in the region.
Since then, the $1 billion Episcopal Health Foundation, whose goal is to improve the health of the 10 million people living throughout the 57-county region served by the Episcopal Diocese of Texas, hosted a community meeting in Nacogdoches specifically to deepen their relationship with organizations working to improve community health in this area. Other foundations have expressed a similar interest.
But let’s be very clear: no foundation or partnership is going to do the work for us. We all have to be involved. The amazing thing about Angelina County is the number of resources we already have, along with the incredible people behind them! These resources need to intentionally focus on both individual and community health and work in a coordinated effort to put the pieces of our health puzzle together.
Hospitals must strengthen community outreach, especially with diabetes, heart disease, stroke, and cancer education. Physicians must expand care for the indigent in our communities. It is our duty. The Angelina County & Cities Health District deserves our full support for the incredible care they already provide, but they can and must do more. That requires funding, whether from grant support, state government, or from within Angelina County. Their primary care outreach is crucial to the health of our county.
Organizations like the American Cancer Society, The Coalition, ADAC, and the Burke Center must expand outreach and education about healthy lifestyles and disease prevention, cancer screening, smoking cessation, and immunizations. Women’s Special Services at CHI St. Luke’s Health Memorial will continue to apply for grants for low income women to get breast and cervical cancer screening.
Lufkin went smoke free years ago and is better off for it. What about other cities? Diboll? Angelina County? Texas? Our state legislators need to use that proposed bathroom bill as toilet paper and instead pass smoke free legislation, which we know will both improve the health of our communities and save taxpayer dollars.
Chamber businesses need to provide or strengthen wellness programs for their employees, encouraging healthier lifestyles, diet, exercise, and smoking cessation. Maybe if people had to climb two flights of stairs to buy their cigarettes rather than drive through a barn or stop at a convenience store, fewer people would smoke. And they’d lose weight while they were at it! Is it just as easy for us to shop for healthy foods as it is tobacco and junk food? How do we encourage and facilitate healthy eating?
Our educational institutions from elementary school through college should have comprehensive, intentional programs to promote health and exercise. It is discouraging when I see employees at both our local hospitals riding the elevator to go up one floor when taking the stairs is much more beneficial.
Active events like the Neches River Rendezvous, Pineywoods Purgatory and Relay for Life are fantastic. What other events can we organize that will involve an even larger and broader swath of people year round? Find a reason to get outside. Participate in a fun run, even if you simply walk a mile or two. A stroll around the zoo can be good exercise and lots of fun. Or, spend an hour or two hiking the trails at Kit McConnico Park. It’ll do your heart and soul good!
City sidewalks have been a great addition in recent years. Use them! Our Parks and Recreation Department has a website with programs and classes as well. Do we have a master plan for parks and recreation activities? If not, maybe we should.
I have a dream of a coordinated community effort where healthy living concepts infuse everything we do. Will Angelina County catch the vision to join in this effort? Lifestyle changes are hard. Nothing happens overnight. Changes in community health are measured over years - decades, even. We cannot get discouraged. Slow, meaningful progress over time will make a difference.
One early step coming up is the Texas Forest Country Partnership Economic Summit November 7-8, 2017 at the Pitser Garrison Convention Center. Included in that Summit will be a Rural Healthcare Symposium. Though it will address more than just Angelina County healthcare, it will be an important venue to discuss and brainstorm together. The Texas Forest Country Partnership should continue to take the lead in bringing groups together, applying for and administering grants, and monitoring progress and effectiveness.
As we plan for a healthy new direction in Angelina County, I encourage everyone to get involved. Be prepared to work! Come up with concrete ideas that you (or your business or organization) are willing to implement. Where philanthropic support is necessary, we will approach local, regional, and national foundations for assistance.
We must become the change we want to see and move the needle on health in Angelina County out of the red zone and into the green. Who’s with me?
Obesity is a two-edged sword that is both killing us early and costing us a lot in terms of ongoing healthcare expenditures and lost productivity. Smoking is, of course, another huge factor in our high cost of healthcare and poorer health outcomes. We must do better.
The rhetoric on the national stage is all about the skyrocketing cost of health insurance and how to tweak (or get rid of) Obamacare, as if that would solve our healthcare problems. The government can’t do it for us, folks. Regardless of what happens with healthcare reform, we need to collectively get off our fat behinds and take more responsibility for our own health. We need to do this individually, yes, but we also need to work on this as a community.
I mentioned in January the groundwork being laid by the Texas Forest Country Partnership. They hosted a series of strategic planning sessions to set goals for growth across a broad spectrum of our regional economy, from forestry and tourism to manufacturing and healthcare. Part of their healthcare recommendation was to raise our county health rankings in the region.
Since then, the $1 billion Episcopal Health Foundation, whose goal is to improve the health of the 10 million people living throughout the 57-county region served by the Episcopal Diocese of Texas, hosted a community meeting in Nacogdoches specifically to deepen their relationship with organizations working to improve community health in this area. Other foundations have expressed a similar interest.
But let’s be very clear: no foundation or partnership is going to do the work for us. We all have to be involved. The amazing thing about Angelina County is the number of resources we already have, along with the incredible people behind them! These resources need to intentionally focus on both individual and community health and work in a coordinated effort to put the pieces of our health puzzle together.
Hospitals must strengthen community outreach, especially with diabetes, heart disease, stroke, and cancer education. Physicians must expand care for the indigent in our communities. It is our duty. The Angelina County & Cities Health District deserves our full support for the incredible care they already provide, but they can and must do more. That requires funding, whether from grant support, state government, or from within Angelina County. Their primary care outreach is crucial to the health of our county.
Organizations like the American Cancer Society, The Coalition, ADAC, and the Burke Center must expand outreach and education about healthy lifestyles and disease prevention, cancer screening, smoking cessation, and immunizations. Women’s Special Services at CHI St. Luke’s Health Memorial will continue to apply for grants for low income women to get breast and cervical cancer screening.
Lufkin went smoke free years ago and is better off for it. What about other cities? Diboll? Angelina County? Texas? Our state legislators need to use that proposed bathroom bill as toilet paper and instead pass smoke free legislation, which we know will both improve the health of our communities and save taxpayer dollars.
Chamber businesses need to provide or strengthen wellness programs for their employees, encouraging healthier lifestyles, diet, exercise, and smoking cessation. Maybe if people had to climb two flights of stairs to buy their cigarettes rather than drive through a barn or stop at a convenience store, fewer people would smoke. And they’d lose weight while they were at it! Is it just as easy for us to shop for healthy foods as it is tobacco and junk food? How do we encourage and facilitate healthy eating?
Our educational institutions from elementary school through college should have comprehensive, intentional programs to promote health and exercise. It is discouraging when I see employees at both our local hospitals riding the elevator to go up one floor when taking the stairs is much more beneficial.
Active events like the Neches River Rendezvous, Pineywoods Purgatory and Relay for Life are fantastic. What other events can we organize that will involve an even larger and broader swath of people year round? Find a reason to get outside. Participate in a fun run, even if you simply walk a mile or two. A stroll around the zoo can be good exercise and lots of fun. Or, spend an hour or two hiking the trails at Kit McConnico Park. It’ll do your heart and soul good!
City sidewalks have been a great addition in recent years. Use them! Our Parks and Recreation Department has a website with programs and classes as well. Do we have a master plan for parks and recreation activities? If not, maybe we should.
I have a dream of a coordinated community effort where healthy living concepts infuse everything we do. Will Angelina County catch the vision to join in this effort? Lifestyle changes are hard. Nothing happens overnight. Changes in community health are measured over years - decades, even. We cannot get discouraged. Slow, meaningful progress over time will make a difference.
One early step coming up is the Texas Forest Country Partnership Economic Summit November 7-8, 2017 at the Pitser Garrison Convention Center. Included in that Summit will be a Rural Healthcare Symposium. Though it will address more than just Angelina County healthcare, it will be an important venue to discuss and brainstorm together. The Texas Forest Country Partnership should continue to take the lead in bringing groups together, applying for and administering grants, and monitoring progress and effectiveness.
As we plan for a healthy new direction in Angelina County, I encourage everyone to get involved. Be prepared to work! Come up with concrete ideas that you (or your business or organization) are willing to implement. Where philanthropic support is necessary, we will approach local, regional, and national foundations for assistance.
We must become the change we want to see and move the needle on health in Angelina County out of the red zone and into the green. Who’s with me?
Sunday, July 9, 2017
The Crockett Hospital’s Painful Demise
June 30, 2017 was a sad day for Crockett, Texas, our neighbor just 47 miles to the west. Little River Healthcare ended its management affiliation with the Houston County Hospital District that Friday, effectively shuttering the Crockett hospital. Nearly 200 employees are affected by the closure.
The simple sign taped on the front door said, “HOSPITAL CLOSED” and directed people to either call 911 in an emergency or to go to Palestine Regional Medical Center, the closest hospital 39 miles away.*
Though this seemed like a sudden event, in many ways it was a slow death over many years. The 49-bed Crockett hospital – most recently known as Timberlands Healthcare, under the management of Little River Healthcare since April 18, 2016 – had danced with several management partners over the last several years. Little River Healthcare didn’t even last 15 months.
Prior to Little River Healthcare, CHC (Community Hospital Corporation) was brought in June 1, 2015 to run the Crockett hospital for an interim period after the hospital’s messy divorce from East Texas Medical Center (ETMC) in Tyler. ETMC ran the hospital for 10 years. ETMC claimed to have invested $27 million in facility and technology upgrades in Crockett, but for a hospital in the 21st century, that was a paltry amount when spread out over 10 years.
So why didn’t Little River Healthcare succeed?
According to published news reports, Little River Healthcare blamed Blue Cross and Blue Shield for not paying $32 million it was owed; BCBS would not comment. Little River stated that when it took over the Crockett hospital, the hospital had been “cash flow negative for a long time,” but that they thought they could turn it around.
It was a helluva lot to turn around. Payroll alone was $1.5 million per month. To keep the hospital running in its current state would have cost $2.7 million per month. The Houston County Hospital District board had already increased property taxes to the max amount and even borrowed money in an attempt to keep the hospital afloat.
LRH Co-Owner Ryan Downton was quoted as saying, “We came to the conclusion the patient volume just isn’t there in the town anymore.” The problem was not volume; it was reimbursement. You can double or triple the number of patients you see, but if you don’t get paid adequately, you are just digging a deeper hole.
Crockett is a dying town. According to the Census Bureau, its population is around 6,500 and shrinking. 39% of the population is living in poverty. Only half of those 16 years of age and older are employed. A mere 17.2% of the population 25 years and older has a bachelor’s degree or higher (and 22.4% don’t even have a high school diploma). 27.4% of the population under the age of 65 has no health insurance. In today’s medical climate, no hospital can survive with this demographic. No hospital district can squeeze enough taxes and reimbursement out of an uneducated, poverty-stricken, unemployed, and under- or un-insured demographic to keep a hospital afloat.
What happened in Crockett is, unfortunately, not unusual. At least 15 rural hospitals have closed across Texas over the last several years. Dozens of counties in Texas have just a single physician – or none at all.
I grieve for Crockett. My brother and his wife live there. I have had the privilege of treating many dear patients from Crockett over the years. We share a compassionate state representative, Trent Ashby, whose rural upbringing cannot be far from his mind in a situation like this. Trent has said he is “committed to working with all of the involved stakeholders to mitigate the loss of existing jobs and help move forward with a plan to increase access to healthcare in our area of the state.” I don’t doubt it one bit. But to be honest, there’s not much he can do. CHI St. Luke’s Health Memorial Lufkin leadership was over in Crockett even before the closing to assist some with employment, but even they can’t come close to softening the impact of nearly 200 jobs lost.
Ultimately, this falls far too heavily on the shoulders of the local Houston County Hospital District board to find a solution. They can’t pull money out of thin air or tax property any higher. And they certainly can’t get paid for healthcare when no insurance coverage or safety net exists. I hope the hospital district board can reassess and reallocate resources to focus on providing comprehensive primary care and prevention services to the citizens of Houston County, at a minimum. They also need to strengthen relationships with surrounding regional hospitals to provide higher level of care services where needed.
Those of us outside Houston County need to open our eyes. Without a much deeper, systemic and national change in how we allocate and pay for healthcare in this country, what just happened in Crockett is going to be replicated in more and more communities around the country. Let’s help Crockett, but don’t think it can’t happen to us.
*Will Johnson, Senior Reporter for the Messenger News in Grapeland, and Caleb Beames with KTRE-TV have done an excellent job reporting on the hospital closure, and I am indebted to them for some of the details and quotes in this column.
The simple sign taped on the front door said, “HOSPITAL CLOSED” and directed people to either call 911 in an emergency or to go to Palestine Regional Medical Center, the closest hospital 39 miles away.*
Though this seemed like a sudden event, in many ways it was a slow death over many years. The 49-bed Crockett hospital – most recently known as Timberlands Healthcare, under the management of Little River Healthcare since April 18, 2016 – had danced with several management partners over the last several years. Little River Healthcare didn’t even last 15 months.
Prior to Little River Healthcare, CHC (Community Hospital Corporation) was brought in June 1, 2015 to run the Crockett hospital for an interim period after the hospital’s messy divorce from East Texas Medical Center (ETMC) in Tyler. ETMC ran the hospital for 10 years. ETMC claimed to have invested $27 million in facility and technology upgrades in Crockett, but for a hospital in the 21st century, that was a paltry amount when spread out over 10 years.
So why didn’t Little River Healthcare succeed?
According to published news reports, Little River Healthcare blamed Blue Cross and Blue Shield for not paying $32 million it was owed; BCBS would not comment. Little River stated that when it took over the Crockett hospital, the hospital had been “cash flow negative for a long time,” but that they thought they could turn it around.
It was a helluva lot to turn around. Payroll alone was $1.5 million per month. To keep the hospital running in its current state would have cost $2.7 million per month. The Houston County Hospital District board had already increased property taxes to the max amount and even borrowed money in an attempt to keep the hospital afloat.
LRH Co-Owner Ryan Downton was quoted as saying, “We came to the conclusion the patient volume just isn’t there in the town anymore.” The problem was not volume; it was reimbursement. You can double or triple the number of patients you see, but if you don’t get paid adequately, you are just digging a deeper hole.
Crockett is a dying town. According to the Census Bureau, its population is around 6,500 and shrinking. 39% of the population is living in poverty. Only half of those 16 years of age and older are employed. A mere 17.2% of the population 25 years and older has a bachelor’s degree or higher (and 22.4% don’t even have a high school diploma). 27.4% of the population under the age of 65 has no health insurance. In today’s medical climate, no hospital can survive with this demographic. No hospital district can squeeze enough taxes and reimbursement out of an uneducated, poverty-stricken, unemployed, and under- or un-insured demographic to keep a hospital afloat.
What happened in Crockett is, unfortunately, not unusual. At least 15 rural hospitals have closed across Texas over the last several years. Dozens of counties in Texas have just a single physician – or none at all.
I grieve for Crockett. My brother and his wife live there. I have had the privilege of treating many dear patients from Crockett over the years. We share a compassionate state representative, Trent Ashby, whose rural upbringing cannot be far from his mind in a situation like this. Trent has said he is “committed to working with all of the involved stakeholders to mitigate the loss of existing jobs and help move forward with a plan to increase access to healthcare in our area of the state.” I don’t doubt it one bit. But to be honest, there’s not much he can do. CHI St. Luke’s Health Memorial Lufkin leadership was over in Crockett even before the closing to assist some with employment, but even they can’t come close to softening the impact of nearly 200 jobs lost.
Ultimately, this falls far too heavily on the shoulders of the local Houston County Hospital District board to find a solution. They can’t pull money out of thin air or tax property any higher. And they certainly can’t get paid for healthcare when no insurance coverage or safety net exists. I hope the hospital district board can reassess and reallocate resources to focus on providing comprehensive primary care and prevention services to the citizens of Houston County, at a minimum. They also need to strengthen relationships with surrounding regional hospitals to provide higher level of care services where needed.
Those of us outside Houston County need to open our eyes. Without a much deeper, systemic and national change in how we allocate and pay for healthcare in this country, what just happened in Crockett is going to be replicated in more and more communities around the country. Let’s help Crockett, but don’t think it can’t happen to us.
*Will Johnson, Senior Reporter for the Messenger News in Grapeland, and Caleb Beames with KTRE-TV have done an excellent job reporting on the hospital closure, and I am indebted to them for some of the details and quotes in this column.
Sunday, June 11, 2017
A Truly Community-Wide Cancer Program
Every three months or so, I chair a meeting at CHI St. Luke’s Health Memorial in Lufkin of the Cancer Committee. As an accredited cancer program through the American College of Surgeons Commission on Cancer (CoC) since 1995, we have many different standards we have to meet dealing with quality of care and services provided. Our Cancer Committee – which is composed of the radiation, chemotherapy, and surgical doctors, radiologists, pathologists, and others (nursing, social work, etc.) involved in cancer care – is charged with maintaining a program that meets or exceeds the CoC standards.
There are around 1,300 CoC-accredited cancer programs in the U.S. This represents about 25% of hospitals. However, accredited facilities treat nearly 70 percent of recently diagnosed U.S. cancer patients annually. A multidisciplinary approach to cancer treatment is a key defining feature of accredited programs. In other words, do your cancer physicians communicate with one another and work together on a plan of care for you. The patient is the center and focus of care.
The benefit to you as a cancer patient is knowing that you are receiving quality and comprehensive care, close to home, with a complete range of state-of-the-art services and equipment. A multidisciplinary team approach ensures you are offered current, national guideline-recommended treatment options, including access to clinical trials if desired. Prevention and early detection programs, cancer education and support services are available. Some of these services are in the Temple Cancer Center (radiation treatment) or the East Texas Hematology and Oncology Clinic (chemotherapy), but others may be in local surgeon’s offices or even in the hospital.
Actual diagnosis and treatment of cancer is just the tip of the iceberg of a comprehensive cancer program. As I chaired our Cancer Committee meeting last week, I heard reports about all the great things we are doing out in the community related to cancer patients. Our community outreach coordinator, Tina Alexander-Sellers, presents cancer prevention and screening information to literally thousands of people each year at health fairs and industry and workplace events, educating our community on getting screening mammograms and Pap smears, smoking cessation, colorectal cancer screening, and even lung cancer screening for smokers at high risk for getting lung cancer.
We got an update from Sharon Shaw on the colorectal cancer screening efforts for under- and un-insured patients through the Angelina County & Cities Health District as part of a state grant in which we participate. Angie Whitley, our nurse over Women’s Special Services, detailed the number of low income women reached for mammograms and Pap smears through our state grant in her area.
Jay Gilchrist, our Vice President of Mission Integration, talked about CHI’s Community Needs Assessment and a new FQHC (Federally Qualified Health Center) branch office to be opened soon in North Lufkin, further expanding the healthcare options for our minority and underserved populations.
We discussed how we can meet a need we have in the community for more and better palliative care, which extends beyond just cancer patients and end-of-life care. Palliative care is focused on providing relief from the symptoms and stress of any serious illness, even while curative or aggressive treatment is being administered. It is a recognition that all patients and families want to maintain or improve quality of life even when dealing with a serious illness, not just when an illness is terminal.
The American Cancer Society representative, Daisy Drinkard, updated us on the impact the ACS is having by reaching patients through our oncologists at the East Texas Hematology and Oncology Clinic and at the Temple Cancer Center as well as through their strong work at the ACS office.
The Temple Cancer Center social worker, Apollonia Ellis, described how she is helping meet the needs of dozens of cancer patients already this year with navigation needs, be it transportation, lodging, or psychosocial and spiritual support. Our nurse practitioner, Kim Burnett, and oncology nurse, Madelene Collier, reviewed programs we recently developed dealing with genetic counseling and testing as well as cancer survivorship.
In addition, patients that are diagnosed and/or treated at CHI St. Luke’s Health Memorial in Lufkin are tracked and followed by our Cancer Registry, which has entered more than sixteen thousand patients since 1990. Our certified tumor registrar, Ginger Strange, can analyze patient data over the years for type of cancer, stage, treatment given as well as results.
As you can see, a comprehensive cancer program is about so much more than “simply” treating cancer patients, as if that alone was simple! Quality, multidisciplinary care includes recognizing and providing solutions for the needs of cancer patients both in and out of the clinic. I am proud of our truly community-oriented cancer program at CHI St. Luke’s Health Memorial in Lufkin. Kudos to all who are a part!
There are around 1,300 CoC-accredited cancer programs in the U.S. This represents about 25% of hospitals. However, accredited facilities treat nearly 70 percent of recently diagnosed U.S. cancer patients annually. A multidisciplinary approach to cancer treatment is a key defining feature of accredited programs. In other words, do your cancer physicians communicate with one another and work together on a plan of care for you. The patient is the center and focus of care.
The benefit to you as a cancer patient is knowing that you are receiving quality and comprehensive care, close to home, with a complete range of state-of-the-art services and equipment. A multidisciplinary team approach ensures you are offered current, national guideline-recommended treatment options, including access to clinical trials if desired. Prevention and early detection programs, cancer education and support services are available. Some of these services are in the Temple Cancer Center (radiation treatment) or the East Texas Hematology and Oncology Clinic (chemotherapy), but others may be in local surgeon’s offices or even in the hospital.
Actual diagnosis and treatment of cancer is just the tip of the iceberg of a comprehensive cancer program. As I chaired our Cancer Committee meeting last week, I heard reports about all the great things we are doing out in the community related to cancer patients. Our community outreach coordinator, Tina Alexander-Sellers, presents cancer prevention and screening information to literally thousands of people each year at health fairs and industry and workplace events, educating our community on getting screening mammograms and Pap smears, smoking cessation, colorectal cancer screening, and even lung cancer screening for smokers at high risk for getting lung cancer.
We got an update from Sharon Shaw on the colorectal cancer screening efforts for under- and un-insured patients through the Angelina County & Cities Health District as part of a state grant in which we participate. Angie Whitley, our nurse over Women’s Special Services, detailed the number of low income women reached for mammograms and Pap smears through our state grant in her area.
Jay Gilchrist, our Vice President of Mission Integration, talked about CHI’s Community Needs Assessment and a new FQHC (Federally Qualified Health Center) branch office to be opened soon in North Lufkin, further expanding the healthcare options for our minority and underserved populations.
We discussed how we can meet a need we have in the community for more and better palliative care, which extends beyond just cancer patients and end-of-life care. Palliative care is focused on providing relief from the symptoms and stress of any serious illness, even while curative or aggressive treatment is being administered. It is a recognition that all patients and families want to maintain or improve quality of life even when dealing with a serious illness, not just when an illness is terminal.
The American Cancer Society representative, Daisy Drinkard, updated us on the impact the ACS is having by reaching patients through our oncologists at the East Texas Hematology and Oncology Clinic and at the Temple Cancer Center as well as through their strong work at the ACS office.
The Temple Cancer Center social worker, Apollonia Ellis, described how she is helping meet the needs of dozens of cancer patients already this year with navigation needs, be it transportation, lodging, or psychosocial and spiritual support. Our nurse practitioner, Kim Burnett, and oncology nurse, Madelene Collier, reviewed programs we recently developed dealing with genetic counseling and testing as well as cancer survivorship.
In addition, patients that are diagnosed and/or treated at CHI St. Luke’s Health Memorial in Lufkin are tracked and followed by our Cancer Registry, which has entered more than sixteen thousand patients since 1990. Our certified tumor registrar, Ginger Strange, can analyze patient data over the years for type of cancer, stage, treatment given as well as results.
As you can see, a comprehensive cancer program is about so much more than “simply” treating cancer patients, as if that alone was simple! Quality, multidisciplinary care includes recognizing and providing solutions for the needs of cancer patients both in and out of the clinic. I am proud of our truly community-oriented cancer program at CHI St. Luke’s Health Memorial in Lufkin. Kudos to all who are a part!
Sunday, May 14, 2017
What I Learned in Medical School That Was Wrong
I recently attended my 30th medical school reunion at Baylor College of Medicine in Houston. It was a grand time of reminiscing and reconnecting with war buddies from the trenches of medical school. Part of our reunion weekend included lectures on current hot topics, such as the absurdity and danger of the anti-vaccine movement. But the lecture most of us were anticipating was on what we were taught in medical school that turned out to be wrong.
The topic itself was quite an admission from one of the most prestigious academic institutions in the world. I mean, everything science tells us is true, factual, indisputable, and remains so forever, right?
One example where the teaching of the time was wrong was peptic ulcer disease. When we started medical school, surgery for ulcers was common. Ulcers were thought to be caused by stress-induced excessive secretion of acid in the stomach. The surgical procedure known as antrectomy (removal of the distal end of the stomach) and vagotomy (cutting the nerves that lead to acid secretion) was performed basically to stop acid production. But this was not a small operation. Patients were often left with really unpleasant gastrointestinal issues such nausea, vomiting after eating, and dumping syndrome (abdominal cramps and diarrhea after eating).
What we now know is that ulcers quite often are caused by a bacterium known as H. pylori, which can be easily treated with an antibiotic – to kill the infection – and antacids. Not only was this revolutionary (and simple), but the medical establishment refused to believe it at first. There were many reasons, but it just didn’t fit what they thought they knew. It was, so they thought, a psychosomatic illness. And bacteria weren’t thought to be able to live in the stomach. The Australian doctor who co-led the discovery was so desperate to prove his theory that he even drank a cocktail of the bacteria to prove his point. History shows he was vindicated. The whole bacteria/ulcer connection was a radical idea at the time. Yet it was right, and the two who discovered it were awarded the Nobel Prize in 2005.
In my own field of oncology, there has been significant progress over the last 30 years. We now cure 70% of cancer patients compared with just 50% a generation ago. It was still a fairly paternalistic time in medicine. You didn’t question what the doctor told you to do. Physicians were taught – wrongly – that we should treat all patients aggressively all the way up to the end of life; otherwise, we would be taking away hope and devastating our patients.
In retrospect, it seems obvious that was a ridiculous and cruel assumption. Informed consent demands honesty. Hope cannot be reduced simply to wanting to live one more day at all cost, especially when ravaged by an incurable disease. What about hope for reconciliation with estranged family members? Hope for a pain and symptom-free death? Hope to die at home surrounded by family and friends, not alone in an ICU? Of course, now we have an entire field of comfort care/palliative medicine – including hospice care – to help with end-of-life symptoms and care.
Another example is less about what we were taught that was wrong than with what we just didn’t know. My class of 1987 started medical school in 1983. The AIDS epidemic was so new at that time that we didn’t even know caused it. The human immunodeficiency virus (HIV) – originally called HTLV-III, or human T-cell leukemia virus – wasn’t even called HIV until 1986. Fear and judgmentalism drove much of the public and academic response to this novel epidemic. We even had a classmate die of AIDS before the identification of the virus was made. These were scary times. With HIV/AIDS, we were living in and experiencing a time when urgent research and rapid discovery were needed to fight a terrible (and terribly misunderstood) disease. Our own fear and prejudice slowed that effort down.
I am curious what we will admit to being wrong about when the current medical school graduates have their thirty year reunion in 2047. Perhaps a brilliant discovery about Alzheimer’s, for example, will turn the medical world upside down. That is an illness where everyone would rejoice in acknowledging what we either got wrong or just didn’t know. Of course, more or unique discoveries in the field of cancer prevention and treatment would be welcome. In any case, we must be willing to admit that we don’t know everything there is to know today, and that we just might be wrong about some things. However, in today’s political climate I am not holding my breath to hear a mea culpa from the scientific community any more than when H. pylori was discovered. Maybe I’m wrong…
Sunday, April 9, 2017
The Grass is Greener in Lufkin!
Sometimes our medical community gets a bad rap. In any community, there can be a tendency to think the grass is always greener somewhere else. This is true whether we talk about education, retail, quality of life, or in my case, medical care.
I have been accused of being critical of our local healthcare community. Perhaps my commentaries on healthcare in general, and the very real problems we all face, have been taken by some to mean I am not supportive of our local healthcare. Nothing could be further from the truth!
Those who work with me know that I strive for excellence in all I do, and I expect the same from those who work with me. I have considered it an honor and a privilege to be part of this medical community for almost 25 years now, and had I not found this community to be welcoming, supportive, and high quality, I would not have stayed.
Think about it. We are a town of barely 35,000 people, and we have access to everything from neonatal intensive care to neurosurgery and open heart surgery. (Oh, and excellent cancer treatment as well!) These services are rarely seen in a town our size, and it happened for a number of reasons.
First of all, we are a destination for healthcare for patients coming from many surrounding counties. That give us an effective population of several hundred thousand - enough to support sophisticated specialties. Second, we have had visionary leadership from key physicians over the years. I won't try to mention all who have made a difference - there are many - but I do want to highlight just a few for what I see as having provided a significant and long lasting contribution to local healthcare.
Anyone's list would include Dr. Ravinder Bachireddy, a world-class cardiologist whose incessant focus on quality brought credibility and excellence to local cardiac care at a time when everyone in the state (indeed, the nation and the world) was headed to Houston. Along the same lines, Dr. Bill Shelton and Dr. Kavitha Pinnamaneni, in their respective radiation and medical oncology fields, made it possible for cancer patients to stay at home for outstanding cancer care, unifying many different physicians and surgeons involved in cancer treatment into a nationally accredited cancer program.
Dr. George Fidone's energy, intensity, vision, and incredible skill has brought pediatric care to virtually every child in the area. Our kids are healthier for it. Neurosurgery, neurology and stroke care are as good here as can be found in big cities, thanks not only to local medical leadership but also to philanthropic support. Robotic surgery has been embraced and mastered by our local surgeons and gynecologists to a far greater extent than our neighbor to the north or, frankly, most communities.
An early family practice pioneer, Dr. Anna Beth Connell led the way early on for women physicians to be not only allowed into the good ole boy network but also respected as colleagues. Women now make up the majority of medical school graduates and are coming to Lufkin in record numbers and in all specialties.
Finally, I cannot even begin to talk about healthcare without considering the incredible support of local foundations, especially the TLL Temple Foundation and the Kurth Foundation. Their contributions can hardly be totaled or their impact measured. We struggle at a national level to figure out how to care for all people, but that burden has been significantly lowered at the local level by the incredible generosity of our foundations. For that, I am eternally grateful.
Sometimes we all need a reminder of how green the grass is right here in Lufkin and Angelina County, and what a privilege it is to have the healthcare community and resources we have. Next time you see a local doctor, nurse, or other healthcare professional, thank them for living and working here!
Sunday, March 12, 2017
What I Would Like to See in Healthcare Reform (Part 2)
Last month, I wrote about the bloated, incredibly
inefficient federal bureaucracy that eats up hundreds of billions of dollars
annually in administrative costs. I mentioned that Obamacare was not, in my
opinion, true healthcare reform and did not address these inefficiencies;
rather, it simply added people to the rolls of a broken system.
In this column, I am not intending to argue for or against
Obamacare or whether we “repeal and replace” or go with “Obamacare Lite”,
whatever that might be. I am simply pointing out areas where I see daily a
burden for both patients and providers. My dream would be for simplification of
much of the process of valuing, coding, and billing for healthcare services.
Whether any of these thoughts are achievable or affordable, I don’t know.
Let’s start with that dreaded hospital bill. Medical billing
is indecipherable. Even patients with advanced degrees can spend hours trying
to interpret the bill they receive for a hospital stay. And that bill is
obscenely higher than what either the hospital or the providers are going to
get paid. What’s ironic is that bill often has no correlation with the actual
cost of the care received or the value that the federal government (or the insurance
company) places on that care. We must simplify how we charge for medical care
and how hospitals and providers get paid. Unfortunately, the only patients who
get stuck with the full, inflated bill are those without insurance – the ones
who can least afford to pay it. That is unethical.
The overall cost of care (and your bill) is determined by
coding every aspect of care, from the Kleenex and bedpan to the heart valve.
For every cancer patient I treat, there are dozens of separate codes submitted
for reimbursement covering all different aspects of planning, designing, QA’ing,
and delivering treatment. I have no doubt that much of that could be combined
into, say, a fixed reimbursement for treating prostate cancer. The problem is,
when the government wants to bundle procedures together, they do it to cut
overall reimbursement immensely. We still do the work; we deserve to get paid.
Why can’t we work out a way to simplify, cut administrative costs, and make it
a win-win both for the providers and the payors?
Along the same lines, consider a simple office visit to the
doctor. The complexity required to determine whether I get paid a level 2 or
level 3 office visit – which reimburse only $25 and $50 – is outrageous. These
so-called Evaluation and Management (E&M) codes – and there are many of
them – are based on four different possible levels of complexity of three
aspects of the patient encounter: history, examination, and medical
decision-making. Take history, for example. The proper level of complexity is determined
by the presence or absence of documentation for four sub-elements: chief
complaint, history of present illness, review of systems, and past, family,
and/or social history. Do you see where I am going with this? Documentation of
these encounters (consultations, follow up office visits) often takes longer
than the encounter itself! And, any "error" in billing is considered
fraud and abuse. It is common to hear patients complain that their doctor never
looked at them, but was always looking at the computer screen. We need to
simplify coding and put physicians back face-to-face with their patients.
Then there is the ever-increasing burden of deductibles and
co-pays. We have such a mishmash of healthcare plans, each with their own
deductibles and co-pays, that it is virtually impossible to keep it all
straight. At the beginning of every year, doctors’ offices and hospitals
cringe. Did a patient change insurance plans, or did their insurance lapse?
What about the deductible for the new year? What about co-pays? More than half
of Americans have less than $1,000 in savings. Deductibles for individuals
enrolled in the lowest-priced Obamacare health plans will average more than
$6,000 in 2017. Can the majority of Americans afford that? Certainly not! This
is an unfair burden both on patients and on providers, who end up providing
that care for free. Why? Most of it gets written off, but only after we spend a
lot of personnel time and effort proving we try to bill for what we can’t
collect in order to avoid the appearance of fraud and abuse. Those patients who
are forced to pay may rack up credit card debt, get sent to a collection
agency, and/or go bankrupt. Some go without the care they need rather than add
to their debt. I truly believe co-pays and deductibles are a vestige of a
bygone era. I would like to see the dollars saved by decreasing the
administrative burden of healthcare go to actually paying hospitals and
providers what they deserve and earn, and do away with co-pays and deductibles.
There should be one price for a procedure or encounter, and that cost should be
paid 100% by insurance.
What about insurance companies? In the best of
circumstances, they pay fairly and quickly. But too often they can and do delay
patient care and prevent patients from getting the care they need in a timely
manner, if at all. They do this through a process called precertification or
prior authorization (read: denial). And sometimes when they do give prior
authorization, they still deny payment. This ought to be illegal. But it
happens without recourse because the state insurance regulations are written in
favor of the insurance companies. We need to loosen the precertification grip
on the practice of medicine, and we need to be able to hold insurance companies
accountable to their agreements. A preauthorization is a contract to pay.
The two hospitals in Lufkin (Woodland Heights Medical Center
and CHI St. Luke’s Health Memorial) have spent tens of millions of dollars on
electronic health records, not to mention what individual and group physician
practices have spent, all mandated by the federal government. To what end? This
was supposed to be about “quality”, but that emperor had no clothes. There is
precious little improvement in communication between providers and hospitals
than before electronic health records. The various doctor’s offices use a
number of different vendors, and each hospital uses their own separate vendor.
None of them share information with each other. I dream of a truly universal
electronic health record language with seamless interconnectivity between
offices and hospitals, but I sure don’t want to live through the incredible
expense, time and effort it would take to get there. But I do dream.
Finally, let’s talk about rights. I have never felt that free
or universal healthcare was a “right”. Hear me out. No one has a
"right" to healthcare without some responsibility. That
responsibility may be in purchasing insurance, but that is not the only way to
contribute. The most glaring, but not the only, example is smoking. Half of long-term
smokers will die of a smoking-related illness. If you smoke, the rest of us are
burdened with some (or all) of your healthcare costs. On average, a pack of
cigarettes in the US costs a smoker $5.51, while the combined medical costs and
productivity losses attributable to each pack are approximately $18.05,
according to researchers. This is where consumption taxes are attractive, but
only if the tax truly goes to help offset the cost of healthcare. How we
balance rights and responsibilities in healthcare is a good subject for a
doctoral dissertation.
As well all hear about and read about proposed healthcare
changes over the next year or two, look for what they are really trying to
change, and ask yourself, are they really improving the system, or are they
just trying to squeeze more people under a broken umbrella? Can they do both?
Let’s hope they try.
Monday, February 27, 2017
Support Raising the Smoking Age to 21
The 85th Texas Legislative Session is in full swing. On
Wednesday, February 15, a bill was filed in the House by Representative (and
physician) John Zerwas (R) to raise the smoking age in Texas to 21 (so-called Tobacco
21, or T21 for short). A companion bill has been filed in the Senate. This is truly
a bipartisan effort and is a great idea. For decades now, the legal drinking
age has been 21. Tobacco kills far more people than alcohol, and almost all long-term
smokers start smoking before they reach the age of 21.
Deep East Texas contains the lowest ranked counties in Texas
for health outcomes, and part of that is due to our higher smoking rates. Nearly
90 percent of adults who smoke started smoking before the age of 18 and nearly
100 percent started by age 26. 18- and 19-year-old smokers are a major supplier
of cigarettes for younger kids, who rely on friends and classmates to buy them.
Raising the smoking age to 21 can help decrease our smoking rates as well as save
tax dollars on future healthcare spending related to tobacco use.
Speaking of tax dollars, annual Texas health care
expenditures directly caused by tobacco use amount to a whopping $8.85 billion,
and we taxpayers bear part of that cost. The State Medicaid program’s total
health spend as a result of tobacco use is $1.96 billion. No, we can’t save all
of that, unfortunately, unless no one smokes. However, Jeffrey Fellows, PhD, in
a Center for Health research report wrote, “Increasing the smoking age to 21
[in Texas] would result in 30,500 fewer smokers after three years, and lead to
$185 million in reduced healthcare expenditures and productivity costs over
five years. Lower cigarette excise tax revenue of $3.4 million would reduce the
5-year net savings; however the state would still generate a net financial
savings of just under $182 million.”
It isn’t just about dollars; it’s about lives, too.
The Institute of Medicine predicts that smoking prevalence
would decline by 12 percent if the national minimum age of sale was raised to
21. One of their models also predicted that raising the national minimum age of
sale to 21 would result in approximately 223,000 fewer premature deaths, 50,000
fewer deaths from lung cancer, and 4.2 million fewer years of life lost for
those individuals born between 2000 and 2019. Smoking kills.
In case you wonder if the tobacco companies think this will
work, here’s a quote from a 1986 Philip Morris report (one of the largest
suppliers of tobacco products worldwide): “Raising the legal minimum age for
cigarette purchaser to 21 could gut our key young adult market (17-20) where we
sell about 25 billion cigarettes and enjoy a 70 percent market share.” To the
tobacco industry, it is always and only about market share and profit.
Raising the smoking age to 21 isn’t the only answer to our
smoking and poor health epidemic. Many cities and even entire states have gone
smoke-free. Texas needs to. Dietary and exercise components of good health also
need to be emphasized. But if we can lessen the number of the next generation
who start to smoke simply by increasing the smoking age of to 21, why wouldn’t
we? That’s right… there is no good answer. For a healthier Texas and Angelina
County, support Tobacco 21.
Sunday, February 12, 2017
What I Would Like to See in Healthcare Reform (Part 1)
I often tell people that if all I had to do was take care of
patients, life would be grand. It is the countless hours of dealing with the
administrative aspects of healthcare that have practically ruined the practice
of medicine for many physicians. You should care; it takes away from our time
with you.
TheHill.com, noted that physicians and their staff spent
over 15 hours per week complying with quality reporting requirements and that
for every hour a physician spends with patients, an additional two hours are
consumed completing administrative tasks related to the visit. This meaningless
(to physicians, anyway) work has costs in both time and money, leads to
burnout, and is increasingly mentioned as the reason for early retirement. I,
for one, found myself daydreaming in a committee meeting the other day and I
calculated that it was 3361 days until my 65th birthday. That's 9 years, 2
months, and 15 days. No, am not planning to retire early, but sometimes I sure
wish I could. Healthcare needs reform.
The average person thought Obamacare WAS healthcare reform.
In reality, Obamacare did nothing to actually improve the healthcare system; it
simply added more people to the rolls. Don't get me wrong. Having more people
insured is not a bad thing. But we need more than just additional enrollees in
a broken system.
After Trump was elected, there was an initial, overly
optimistic assumption that Obamacare was on its last leg. Recent infighting
among policy makers suggests Obamacare may be more like the proverbial cat with
nine lives. I only hope true reform is part of whatever "replacement"
or "repair" Congress and the President come up with.
In particular, let's hope some of that reform will
significantly scale back a bloated, paranoid bureaucracy that sucks hundreds of
billions of dollars out of healthcare that could go to those who actually care
for patients. And, perhaps, some could go back into the taxpayers' pockets.
Back in 2012, Berkshire Hathaway CEO Warren Buffett called
healthcare "the tapeworm of the American economy". To be more
accurate, the federal government is healthcare's tapeworm. In an online article
in Medical Economics last year, Ryan Gamlin, who studies what drives
inefficiency, waste, and harm in U.S. healthcare, found that "as countries
spend a larger percentage of their healthcare dollars on administration (as
opposed to public health, or providing patient care, for example), things get
worse for patients and healthcare providers. High administrative expenditures
seem to be associated with negative experiences of providing and receiving
healthcare." That is a nice way of saying there's a ton of money wasted
going to paper pushers.
Helen Adamopoulos, writing in Becker's Hospital Review in
2014, noted that US hospital administrative costs account for more than 25% of
hospital spending, more than double that of Canada, for example, where
hospitals receive global, lump-sum budgets. In contrast, US hospitals must bill
per patient or DRG (diagnosis-related group), requiring additional clerical and
management workers and specialized IT systems. They also have to negotiate
payment rates with multiple payers with differing billing procedures and
documentation requirements, driving up administrative spending. Not to mention
all the personnel, time, and IT required to satisfy CMS’s (the Centers for
Medicare & Medicaid Services) monstrous appetite for "quality"
and "safety" data, with the ever-present threat of fraud and abuse
hanging over every unintentional misstep.
What should be a simple process of billing for services
provided is a minefield. And anyone who has ever tried to understand a hospital
bill knows it is an impossible task. Aliya Jiwani, writing in BMC Health
Services Research, notes that billing and insurance-related (BIR)
administrative costs in 2012 were estimated to be $471 billion and that fully
80% of this spending, which provides little to no added value to the healthcare
system, could be saved with a simplified financing system. Jiwani predicted
that greater use of deductibles under Obamacare will likely further increase
administrative costs, stating, "Empirical evidence from similar reform in
Massachusetts is not encouraging: exchanges added 4% to health plan costs, and
the reform sharply increased administrative staffing compared with other
states."
A CNBC report of a Health Affairs study tagged the extra
administrative costs of Obamacare at more than a quarter of a trillion dollars,
an average of $1,375 per newly insured person, per year, from 2012 through
2022. The Health Affairs blog authors reported, " The overhead cost equals
a whopping 22.5 percent of the total estimated $2.76 trillion in all federal government
spending for the Affordable Care Act programs during that time."
What do I wish we could be different in our healthcare
system? In March, I will discuss some specific changes that would reduce the
administrative burden on healthcare providers and, in many ways, return us to a
simpler, more direct, and frankly better transaction of healthcare.
Tuesday, January 3, 2017
Resolve to Improve the Health of our Region
January is a time of resolution, and often our New Year resolutions focus on diet and exercise. My friends, we need a city, county, and region resolution to lose weight!
In July, 2016, Sabrina Perry wrote an article for HealthGrove.com – a health data analysis and visualization site – titled, The County with the Highest Obesity Rate in Every State. She repeated the American Medical Association’s contention that obesity is a disease and noted that the World Health Organization considers obesity a global epidemic. I perused the article with interest, looking for the county in Texas that got the dubious honor of being the fattest. Unfortunately, it was our very own Angelina County.
Look around and it is evident. Angelina County has the highest obesity rate in Texas, coming in at 37.5%. That means nearly 4 out of 10 of us aren’t just overweight; we are downright fat. To achieve the dubious distinction of being fat, you have to get to a body mass index (BMI) of over 30. To give you an idea what it takes to qualify as obese, consider a 5’11” male such as myself. My appropriate weight is less than 180 pounds (and probably more like 160 pounds). Any more than that and I am considered overweight. But to be considered obese – which is what 37.5% of Angelina County residents are – I would need to weigh 215 pounds or more. For me, that would be at least 35 pounds overweight, if not more. I routinely see patients with a BMI of 40 or more, which is considered extreme (or morbid) obesity. That would be a whopping 100 pounds overweight for me.
What can we do?
Dan Buettner, author and founder of bluezones.com, has been writing for years about particular geographic pockets around the world where people live longer. According to the website, “Residents of the Blue Zones live in very different parts of the world. Yet they have nine commonalities that lead to longer, healthier, happier lives.” So much of this is what has been preached to us for decades: don’t smoke, eat your vegetables and legumes, exercise, don’t overeat, and drink wine in moderation. On top of this are stress-related factors, having strong family and friend relationships, and spirituality.
It’s not just that we are obese. Our overall health is terrible. The Robert Wood Johnson Foundation ranks population health by county. In Texas, many of the lowest ranked counties are in deep East Texas. Wouldn’t it be great if Lufkin could be known not just for pump jacks and forests, but also for the health of our citizens? This can only work for communities if each of us individually works at it. We have family, friends, and lots of churches. Strengthen those relationships. And, let’s stop smoking, exercise, and eat right!
I recently participated in a set of strategic planning sessions hosted by the Texas Forest Country Partnership called Stronger Economies Together, or SET. The purpose was to set goals for growth across a broad spectrum of our regional economy, from forestry and tourism to manufacturing and healthcare. Our SET healthcare workgroup noted that we have significant work to do if we are going to impact the poor healthcare factors and outcomes the Robert Wood Johnson Foundation identified in the deep East Texas region. We set an ambitious goal simply to raise our overall health ranking from the lowest 20% to the next lowest; in other words, from poor to still below average. But we have to start somewhere.
This will require a multi-year effort working with all aspects of the healthcare and social service community to start to move the dial toward a healthier region. We can do it, but we all need to make – and keep – that that resolution for better health!
In July, 2016, Sabrina Perry wrote an article for HealthGrove.com – a health data analysis and visualization site – titled, The County with the Highest Obesity Rate in Every State. She repeated the American Medical Association’s contention that obesity is a disease and noted that the World Health Organization considers obesity a global epidemic. I perused the article with interest, looking for the county in Texas that got the dubious honor of being the fattest. Unfortunately, it was our very own Angelina County.
Look around and it is evident. Angelina County has the highest obesity rate in Texas, coming in at 37.5%. That means nearly 4 out of 10 of us aren’t just overweight; we are downright fat. To achieve the dubious distinction of being fat, you have to get to a body mass index (BMI) of over 30. To give you an idea what it takes to qualify as obese, consider a 5’11” male such as myself. My appropriate weight is less than 180 pounds (and probably more like 160 pounds). Any more than that and I am considered overweight. But to be considered obese – which is what 37.5% of Angelina County residents are – I would need to weigh 215 pounds or more. For me, that would be at least 35 pounds overweight, if not more. I routinely see patients with a BMI of 40 or more, which is considered extreme (or morbid) obesity. That would be a whopping 100 pounds overweight for me.
What can we do?
Dan Buettner, author and founder of bluezones.com, has been writing for years about particular geographic pockets around the world where people live longer. According to the website, “Residents of the Blue Zones live in very different parts of the world. Yet they have nine commonalities that lead to longer, healthier, happier lives.” So much of this is what has been preached to us for decades: don’t smoke, eat your vegetables and legumes, exercise, don’t overeat, and drink wine in moderation. On top of this are stress-related factors, having strong family and friend relationships, and spirituality.
It’s not just that we are obese. Our overall health is terrible. The Robert Wood Johnson Foundation ranks population health by county. In Texas, many of the lowest ranked counties are in deep East Texas. Wouldn’t it be great if Lufkin could be known not just for pump jacks and forests, but also for the health of our citizens? This can only work for communities if each of us individually works at it. We have family, friends, and lots of churches. Strengthen those relationships. And, let’s stop smoking, exercise, and eat right!
I recently participated in a set of strategic planning sessions hosted by the Texas Forest Country Partnership called Stronger Economies Together, or SET. The purpose was to set goals for growth across a broad spectrum of our regional economy, from forestry and tourism to manufacturing and healthcare. Our SET healthcare workgroup noted that we have significant work to do if we are going to impact the poor healthcare factors and outcomes the Robert Wood Johnson Foundation identified in the deep East Texas region. We set an ambitious goal simply to raise our overall health ranking from the lowest 20% to the next lowest; in other words, from poor to still below average. But we have to start somewhere.
This will require a multi-year effort working with all aspects of the healthcare and social service community to start to move the dial toward a healthier region. We can do it, but we all need to make – and keep – that that resolution for better health!
Subscribe to:
Posts (Atom)