Archive for the ‘Transformation of Health Care’ Category

Transforming Health Care

Saturday, August 3rd, 2013

By Don McCormick

The underlying causes of bad health care and its high cost will not be fixed in the United States by adjustments to the current system. It will also not be fixed in other countries in which quality of care is higher and the cost of care is lower. Converting the system in the United States to a universal single payer plan, as has been done in many other countries, appears to control costs relative to the our system, but it does not assure the quality of care that is possible at the current level of knowledge in medicine and surgery. In saying that, I assume the depth of knowledge in Science and Medicine is less than it will be and far less than is needed to overcome most diseases and injuries. When we look back at famous physicians in the United States, such as Benjamin Rush, we know that his understanding of the way the body worked and the medicines it needed were without merit and mostly harmful. Hubris and fame in that ”Age of Enlightenment” made what Rush thought he had done the opposite of what he had intended. What we are doing today, driven by those same vices, will, in hindsight, be no less disappointing. This is compounded by economic systems that are nonsensical and socially structured science that is exclusionary. Too many negative factors dominate and exert their forces on the practice and use of medicine to allow adjustments and course corrections to work in fixing the problems. We must begin with humility, with positive acts, and with clear thoughts to bring our power to bear on activities that heal and cure our sicknesses and injuries. That power is always there in knowledge and truth to be taught from the bottom up by those having a higher level of awareness sharing and helping to raise the awareness of every person with whom they live and work.

Thus, we begin with cooperation between patients and physicians in places where they can interact easily and peacefully. While the present condition of the medical care system is in a crisis based on deaths and injuries caused by medical and hospital care, we cannot proceed as if we were in a disaster syndrome. Patients and physicians cannot continue to interact as though the theater were not on fire and they were only spectators doing their own things in their own ways. There is in the “universal conscience” a plan of peaceful engagement in which cooperation in selected communities can begin.

The people in each community are to be enlisted into a cooperative, the physicians that serve them are to be recruited, and the facilities in which care will be delivered are to be made safe and accessible. The economic structure that will support the cooperative is that of mutual support in a private club that has more abundant services and resources and is in a place where care is comprehensive. Patient education will underpin the cooperative to the extent that the knowledge and expertise of the physicians and nurses spreads to the medical assistants and community health workers and patients. The understanding of the people will grow enough so that preventive care and chronic care can be done by the patients and their families.
Insurance, whether it is called Platinum, Gold, Silver, or Bronze does not necessarily result in access to good health care. It just makes the people who deliver health care, regardless of quality or need, able to earn a living wage and much more. It may also help the patient avoid loss of savings and income, but it will not heal anyone and it will not teach anyone and it will not stem mortality and morbidity rates that are caused by attempted medical care.

Suppose that you and the people around you just walked away from the current system. How many people would be needed to assure that the group had access to people with sufficient knowledge and skill to be healthier than in their present conditions? Assuming it were a competition and the knowledge and skills were the same as represented in all of the classes of medical training. Further, suppose that you had to pay these people so that their social status was not lessened by your group. The number of patients needed as members would be large. You would have to support about fifty physicians, a hundred nurses, and two hundred other kinds of medical workers. Support at that level would require about ten thousand families who were at peace, who were willing to help each other, and who could see value in education and cooperation and who were not trapped in a system of patronage and dependency. This can’t be organized in a war zone and it can’t be done by force.

Oddly, we may not need all of the many different kind of skills represented in the medical care industry. The better educated the patients become the fewer advisors they need. So, as the system progresses the demand for physicians lessens and their capacity to treat patients increases. This is unlikely to transform society and even be noticed by the establishment, but it will transform health care for its participants and it will be less expensive and it will extend and save lives.

A 93 Year Old Woman, The Paid Care Giver, and The Hospital Emergency Room

Friday, June 14th, 2013

“No more than can be expected in our money driven system”

Vera lives in an assisted living facility. She has almost no short term memory, but her blood pressure, respiration, blood tests, and general health are normal. In the past she has had fainting spells about once or twice a year since she was a young woman. The doctors think it is caused by a sudden drop in blood pressure. They are probably right. After a fainting episode she recovers in about five minutes and feels normal again. When she is with family members they know what is happening and that she will be back to normal in a few minute. When she is with “professional” care givers and because of her age and that she is in an assisted living facility the response to her fainting is to call 911.

In the last year this 911 response has happened twice by two difference nurse’s aides. The result has been both expensive for Medicare and Vera. The care has also been uncomfortable and risky. The desire to “first do no harm” seems to be canceled by the “please protect me from a mistake.” So, the EMT comes and says, “my, my, this could be a heart attack,” and they take Vera to the Emergency Room at Kingwood Hospital in Houston, Texas. While she was in transit, the nurse’s aide called the family and told them about the fainting episode and the 911 call. The son went to the hospital to meet his mother and arrived shortly after they had put her into an ER room. A nurse had put a needle into her arm in case they wanted to give her an IV or to take blood samples. He had also done an EKG and had put leads on her chest connected to a heart and blood pressure monitor and an oxygen sensor on her finger. It was 65 degrees in the room so he gave her a thin but heated blanket to help her adjust to the cold.

The ER doctor came in, asked Vera how she felt to which she responded that she guessed she had a heart attack, but that she felt fine. He asked why she thought she had had a heart attached and she said that is what she had been told by the EMT. He told her that was not the case, but that she could have had a drop in blood pressure that caused her to faint. He then said that she probably should not have been sent to the ER, however he would run some blood tests and do some Xrays to confirm that she was as she said she felt. The son asked about the X ray and the doctor responded that if he was concerned about the radiation it was no worse than being in the sunshine for a few minutes. The son then asked what kind of X ray and the doctors responded that it was a CT Scan and the son said, “No, you’re not going to do that. A CT Scan was not an X ray, but many X rays and was like being about a mile from the explosion of an atomic boom.” The doctor then said, “You have the right to reject care” and he left the room.

The nurse then drew about eight tubes of blood and told Vera that if she needed anything to just push the nurse call button. Two hours later the nurse came back into room and took a urine sample to test for a possible infection in the bladder. The urine was taken, not donated, and Vera was not even asked if she could provide the sample. She was coherent and cooperative, but with Vera at age 93 maybe the young nurse was making some assumptions about old people and whether they could urinate at will.

Five hours passed in the very cold room. No one checked on Vera and she did not push the call button.

She had no water, there was no IV, there was no food. She had a bowel movement and had urinated in the diaper they put on her after the urine extraction. The doctor returned to room with the lab and chest X ray results and said she was OK, but he was going to keep her overnight for observation, because he was a very conservative ER doctor. The son said, “No. I’m taking her to my home,” to which the doctor replied, “Okay, that’s fine.”

The nurse then brought in about ten pages of documents to sign saying they were not responsible for anything and then brought a wheelchair, loaded Vera into it and took her to the son’s car which was brought to the ER doorway. The Nurse had not cleaned her up nor had he removed all of the sticky tabs from the EKG and the Monitor leads. The son drove her home, cleaned her, bathed her, put her into a warm bath to soak, dressed her in her night clothes, fed her and let her rest in a warm bed until morning. She was up and around walking on her own the next morning. No harm was done, but the idea that it was to be avoided seemed never to cross the minds of the care takers, nurses and doctor.

The ER had at least thirty rooms and about about ten people were in rooms. There were at least twenty-five people working in the ER and at any given moment twenty of them were sitting in front of a computer screen doing something. As far as I could tell no nurse, technician, or doctor touched a patient or talked with them for more that a minute. It was the closest thing to a game room that I have seen.

Advocacy For Improvement In Community Health

Friday, June 14th, 2013

By Don McCormick

There is a short story called The Lottery that is a metaphor for our local community health care system. In this story members of a small town assign death by stoning to a randomly chosen citizen. The game becomes accepted annual tradition in the town. Although the townspeople appear saddened at losing their family members and neighbors, they never question the morality of a game that gambles with human life.

Our community health system in which sales, profits, convenience, and productivity are placed above healthcare seems like this fictional short story. Patients and health professionals suffer under the system because they are powerless to change what is seen as the destructive health habits of individuals.

We know that improvements in our healthcare system stem from a broader understanding of the economic, social, and environmental factors that determine health. We can change the system by working in our own communities to identify and challenge policies that have profound effects on individual health.  For example, there is evidence that social determinants of health, such as poverty, lack of education and school nutrition have a greater influence on health than individual risk behaviors.   Considering this, it may be possible with knowledgeable leadership to eliminate some health risks altogether and to generally improve health care and reduce its cost.

Physicians can play a significant role in disease prevention by establishing themselves in particular communities, both their office and their residence, and by teaching a group of patients to be community health workers and organizers. Based on that kind of educational and organizational activity the clinic can become a cooperative that would grow to the size needed to support the physician and deliver primary health care to 1,500 patients.

Those of us who know about the health care problems and the potential solutions need to add our voices and labor to this cause: The Organization of Local Patient/Physician Cooperatives. From what we already know we can identify ways that physicians and patients can become involved in influencing community health policy. We can identify and describe the local economic, social, and environmental determinants of health relevant to the area we want to develop. By organizing physicians and patients around community health issues such as tobacco control, air pollution, food policy, or advertising to children, we can become a voice for change and influence the public policy that influences health. By teaching health care to selected patients who live in the community they will be enabled to organize their families, friends and neighbors to join the cooperative and establish the clinic. These trained patients will make up a health committee that will:

  1. Make the neighborhood secure so the physician and nurse can work freely and comfortably in the area.
  2. Accompany the physician or nurse on rounds to patient homes to show support and give confidence to the provider and the patient.
  3. Help collect and record all of the demographic and medical data.
  4. Promote “comprehensive community medicine.”
  5. Promote a culture of wellness.
  6. Analyze data and identify major ailments in the patient population.
  7. Help to fix the problems that are identified using the prescription of the primary care physician.
  8. Make the work real and the people involved accountable.

The teaching and organizing activities precede any delivery and financing systems for health care services. Once a primary care physician is in place and the community health worker team has been trained and deployed the patient membership can be built in such a way that the physician and the team know every patient on a first name basis and the medical problems that these patients need help in solving. In that process the social determinants of health care in the community will be well understood by the physician and the cooperative members so that root causes of bad health can be systematically addressed.

In a community with a population of about 50,000 people we should establish ten primary care practices on this model and over a period of two years enroll 1,500 patients into each coop clinic. If there is an average of 3 people in each household then we could expect 500 household memberships. Each community health care worker would be responsible for 50 households. That number is about the limit of personal contacts an individual can manage. Most of the time this kind of medical care and relationship building work is best done by women between the ages of 40 and 60, but there are exceptions.

Ultimately this development will allow the cooperatives to achieve goals and objectives not possible in the traditional healthcare systems. These are those goals:

  1. Put preventive care first.
  2. Train health providers to promote comprehensive integration of family health care in community life.
  3. Increase the number of physicians per patient in the population until it is 1 for every 150 patients instead of 1 for 417 patients as it is now in the United States.
  4. Reduce the cost of drugs by every means possible and introduce herbal medicines to provide alternatives to patients that cannot afford patent medicines.
  5. Place physicians in communities with the greatest needs.
  6. Raise the awareness of public health issues to lower mortality and morbidity rates
  7. Have physicians live among the poor to learn first-hand the sources of their illnesses.
  8. Increase primary care and improve specialist skills by making primary care their starting base.
  9. Start with “comprehensive general medicine” in neighborhood clinics and then form “basic health teams.”
  10. A team is a physician and a nurse and the volunteer health committee of ten patient members (the physician trained community health workers) assisted by a specialist team at the diagnostic clinics or specialty hospitals.
  11. The local team serves 1,500 patients ( about 500 households ). Specialty groups at diagnostic clinics can serve patients from 20 of these teams.
  12. The physician lives in the neighborhood and serves and is available 24/7.
  13. The physician and the nurse treat patients both in the clinic and in the patient’s home.
  14. These providers get all of the vital medical information and record it in the Electronic Medical Records system.
  15. The health committee members and the providers teach preventive care to every patient member.
  16. Each specialty diagnostic serves from 20,000 to 40,000 patients.
  17. Teams are thorough and attentive to each patient and know them all personally.
  18. The patients that are hospitalized are accompanied to the hospital by his or her primary care physician and the physician consults with the specialty team members that will care for the patient while he or she is hospitalized.
  19. Every specialist is also able to do primary care because they did that before becoming a specialist.
  20. Medicine in this setting is a science that is integrated with “real life” processes and is aligned with the quantum physics now assumed to be the truth about our world and universe.
  21. Identification of problems and interactive learning are used to increase cognitive independence.
  22. Epidemiology and Public Health are emphasized.

This common sense system and its goals cannot be defeated by adversity because it is a continuous process of overcoming problems that are far more complex and closer to the values of each person in the community than any general opposition that will arise because of pride or greed.

Within this network of cooperatives we can create a local university without walls to bring everyone that is interested into a fuller understanding of their role in the health care system, from patients, to health committee members, to nurses, to technicians, to sports trainers, to primary care physicians and to specialists.