As many industries and individuals are struggling publicly with burnout, a new study from the European Journal of Preventative Cardiology links the “burnout syndrome” with atrial fibrillation (afib). The findings are both interesting and valuable. In general, the public benefits from anything that can raise awareness of heart disease, because early intervention directly impacts improved patient outcomes.
However, headlines that describe afib as a “deadly irregular heartbeat” go too far in the name of public awareness. The truth is, afib is not a sudden killer like a heart attack, cardiac arrest, or stroke. While afib is undeniably serious, it can often be identified in advance and managed with evaluation and treatment.
Afib is a very common arrhythmia that has numerous risk factors, including hypertension, diabetes, obesity, and sleep apnea, to name just a few. When the heart goes into atrial fibrillation, the upper chambers go into a fast, chaotic and irregular rhythm that often makes the pulse race and feel irregular. Other symptoms can include palpitations, shortness of breath, and dizziness. Some people may not have any symptoms at all. Stroke is the most devastating consequence of atrial fibrillation, but is rarely the first manifestation of the disease.
It is also important to note that afib may not always be present. For this reason, often the arrhythmia is gone by the time someone seeks medical attention, making the arrhythmia harder to diagnose. Fortunately, consumer devices, such as the new Apple Watch, have algorithms to help detect atrial fibrillation. These technologies hold immense promise. They are already helping many people manage their health, and even potentially diagnose some people who never knew they had afib.
As the globe faces a novel, highly transmissible,
lethal virus, I am most struck by a medicine cabinet that is embarrassingly
empty for doctors in this battle. This
means much of the debate centers on mitigation of spread of the virus. Tempers flare over discussions on travel
bans, social distancing, and self quarantines, yet the inescapable fact remains
that the medical community can do little more than support the varying
fractions of patients who progress from mild to severe and life threatening
disease. This isn’t meant to minimize the
massive efforts brought to bear to keep patients alive by health care workers
but those massive efforts to support failing organs in the severely ill are in
large part because we lack any effective therapy to combat the virus. It is akin to taking care of patients with
bacterial infections in an era before antibiotics, or HIV/AIDS in an era before
It should be a familiar feeling for at least
one of the leading physicians charged with managing the current crisis – Dr.
Anthony Fauci. Dr. Fauci started as an
immunologist at the NIH in the 1960s and quickly made breakthroughs in
previously fatal diseases marked by an overactive immune response. Strange reports of a new disease that was
sweeping through the gay community in the early 1980’s caused him to shift
focus to join the great battle against the AIDS epidemic.
Healthcare today, in the broadest sense, is not a benevolent giant that wraps its powerful arms around the sick and vulnerable. It is a world of opposing forces such as Government public health ambitions and more or less unfettered market ambitions by hospitals and downright profiteering by some of the middlemen who stand between doctors and patients, such as insurers, Pharmacy Benefits Managers, EMR vendors and other technology companies.
Within healthcare there is also a growing, more or less money-focused sector of paramedicine, promoting “alternative” belief systems, some of which may be right on and showing the future direction for us all and some of which are pure quackery.
I stand by my conviction that physicians must embrace the role of guide for their patients. If we see ourselves only as instruments or tools in the service of the Government, the insurance companies or our healthcare organizations, patients are likely to mistrust our motives when we make diagnoses or recommend treatments.
Today, primary care is considered the bee’s knees of value-based care delivery. Instead of being viewed as the punter of the football team, the primary care physician (PCP) has become the quarterback of the patient’s care team, calling plays for both clinical and social services. The entire concept of the accountable care organization (ACO) or patient-centered medical home (PCMH) crumbles without financially- and clinically-aligned PCPs. This sea change has resulted in rapid employment or alignment to health systems, as well as a surge in venture capital being invested into the primary care space.
Before we get too far in the weeds, let’s first begin with the definition of primary care. The American Academy of Family Physicians (AAFP) defines a primary care physician as a specialist typically trained in Family Medicine, Internal Medicine, or Pediatrics. Some women do use their OB/GYN as their PCP, but these specialists are not traditionally considered PCPs. Now if you’ve gone to your local PCP and noticed that your care provider is not wearing a white coat with the “MD” or “DO” credentials, you are either receiving treatment from a hipster physician, nurse practitioner (NP), or physician assistant (PA). Two of the three professionals are trained in family medicine and can provide primary care services under the responsibility of an associated PCP. At least one of the three has a beard.
The crazy thing is, despite the industries heightened focus on the importance of PCPs, we’re still expecting a shortage of primary care providers. In April 2019, the Association of American Medical Colleges (AAMC) released a report estimating a shortage of between 21,100 and 55,200 PCPs by 2032. Given we just passed 2020, this not that far off. The primary reason for the shortage is the growing and aging population. Thanks mom and dad. Digging into the numbers will really knock your socks off, with the U.S. Census estimating that individuals over the age of 65 will increase 48% over that same time period. Like a double-edged sword, the issue is not just on the patient demand side though. One-third of all currently active doctors will be older than 65 in the next decade and could begin to retire. Many of these individuals are independent PCPs who have resisted employment by large health systems.
The Primary Cares Initiative provides new value-based payment models aiming to enhance the delivery of primary care to promote efficiency and quality while decreasing healthcare costs. In the second part of this two-part series, we explore how eConsults directly support this new initiative across several key metrics.
The Primary Cares Initiative aims to enhance the delivery of primary care through value-based payment models. In Part One of this two-part series, we broke down the five payment models offered through this initiative, including two performance-based models (Primary Care First) and three risk-sharing plans (Direct Contracting). Alongside previous programs such as Patient-Centered Medical Home (PCMH), the Comprehensive Primary Care (CPC+) program, and the Medicare Advantage Value-based Insurance Design (VBID), the Primary Cares Initiative represents the most recent push for enhancing primary care within health care systems.
as programs such as these continue to emphasize primary care providers as a
locus of optimal care, the question becomes: how can primary care providers (PCPs)
best work within initiatives such as these to enhance care delivery efficiency
and effectiveness, and what kinds of services and technologies can support this?
If you are not an IKEA
fan, or haven’t been spending any time in Dubai, you may have missed the
chain’s marketing campaign to help promote its second store in the area.
Titled “Buy With Your Time,” customers got store credits for how long
they spent getting to the store.
Gosh, that’s something
that should make any self-respecting critic of the U.S. healthcare system perk
up. Count me as intrigued.
The campaign involved
checking the customer’s Google Maps’ Trip tab to determine how long it took
them to get to the store. IKEA benchmarked the average hourly wage in
Dubai, and converted the travel time into how much credit they’d
generated. It works out to about $29/hour, or $0.48 per minute.
Spend long enough getting there and you could get a free coffee table or even a
bookcase. Prices in the store include the equivalent time currency.
Swedish Healthcare seemed competent but a bit uninspired and rigid to me but my medical school class trip to the Soviet Union showed me a healthcare system and a culture I could never have fully imagined in a country that had the brain power and resources to have already landed space probes on Mars and Venus by the time my classmates and I arrived in Moscow in the cold winter of 1977.
The first time we sat down for breakfast at two big tables in the restaurant of the big Россия hotel near the Red Square, our two male waiters asked if we wanted coffee or tea and people started stating their preferences. The waiters shook their heads and put their hands up in the air. No, they couldn’t split the beverage order, they explained. We had to all decide on one beverage with no substitutions.
The restaurant obviously had both coffee and tea, and as far as I know, they cost about the same. The only thing standing between the tea drinkers and their favorite morning beverage (the coffe crowd won the popular vote) was convention and attitude. I don’t know if this was a policy set by the hotel management or a complete lack of service-mindedness by he staff, but my classmates and I felt as if we, the customers, did not matter.
As a Petersdorf Scholar-in-Residence at the Association of American Medical Colleges (AAMC) in 2002, Dr. Thomas S. Inui opened his mind and heart to try to understand whether and how professionalism could be taught to medical students and residents. His seminal piece, “A Flag In The Wind: Educating For Professionalism In Medicine”, seems written for today.
Nearly two decades ago, Inui keyed in on words. In our modern world of “fake news”, concrete actions carry far greater weight than words ever did, and the caring environments we are exposed to in training are “formative”—that is, they shape our future capacity to express trust, compassion, understanding and partnership.
Inui reflected on the varied definitions or lists of characteristics of professionalism that had been compiled by multiple organizations and experts, commenting:
my own perspective, I have no reservations about accepting any, or all of the
foregoing articulations of various qualities, attitudes, and activities of the
physician as legitimate representations of important attributes for the
trustworthy professional. In fact, I find it difficult to choose one list over
others, since they each in turn seem to refer largely to the same general set
of admirable qualities. While we in medicine might see these as our lists of
the desirable attributes of professionalism in the physician, as the father of
an Eagle Scout I know that Boy Scout leaders use a very similar list to
describe the important qualities of scouts: ‘A Scout is trustworthy, loyal,
helpful, friendly, courteous, kind, obedient, cheerful, thrifty, brave, clean,
reverent (respecting everyone’s beliefs).’ I make this observation not to
descend into parody, but to make a point. These various descriptions are so
similar because when we examine the field of medicine as a profession, a field
of work in which the workers must be implicitly trustworthy, we end by
realizing and asserting that they must pursue their work as a virtuous
activity, a moral undertaking.”
Tesla is now, by market cap, the second largest auto manufacturer (after Toyota). Its market cap exceeds U.S. auto makers Ford, G.M., and Fiat/Chrysler — combined. This despite selling less than 400,000 vehicles in 2019, a figure that is more than the prior two years combined.
Tesla has made its bet on the future of electric cars. It didn’t invent them. It isn’t the only auto manufacturer selling them. But, as The Wall Street Journalrecently said:
Investors increasingly see the future of the car as electric—even if most car buyers haven’t yet. And lately, those investors are placing bets on Tesla Inc. to bring about that future versus auto makers with deeper pockets and generations of experience.
A recent analysis
suggested a big reason why, and its findings should give those in healthcare
some pause. Tesla’s advantage may come, in large part, from its supply
In the 1970s, Jean Whitehorse, a member of the Navajo Nation, went to a hospital in New Mexico for acute appendicitis. Years later, she found out the procedure performed was not just an appendectomy – she had been sterilized via tubal ligation. Around the same time, a Northern Cheyenne woman was told by a doctor that a hysterectomy would cure her headaches. After the procedure, her headaches persisted. Later, she found out a brain tumor was causing her pain, not a uterine problem. Like Whitehorse and the Northern Cheyenne woman, thousands of Native American women have suffered irreversible changes to their bodies and psychological trauma that continues to this day. Most medical providers are unaware of our own profession’s role in implementing these racists policies that have direct links to the Eugenics movement.
Eugenics was a “movement that is aimed at improving the genetic composition of the human race” through breeding. From its origin in 1883, eugenics became the driving rationale behind using sterilization as a tool to breed out unwanted members of society in the United States. With the 1927 Supreme Court case Buck v. Bell permitting eugenic sterilization, 32 states followed suit and passed eugenic-sterilization laws. Although the outward use of sterilization declined after World War II because of its association with Nazi practices, sterilization rates in poor communities of color remained high throughout the United States.