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More Women Are Pursuing Majority-Male Specialties and Changing Patients’ Perceptions

By AMY E. KRAMBECK, MD

With the exceptions of pediatrics and obstetrics/gynecology, women make up fewer than half of all medical specialists. Representation is lowest in orthopedics (8%), followed by my own specialty, urology (12%). I can testify that the numbers are changing in urology – women are up from just 8% in 2015, and the breakdown in our residency program here at Indiana University is now about 20% of the 5-year program.

One reason for the increase is likely the growth of women in medicine – 60% of doctors under 35 are women, as are more than half of medical school enrollees. I also credit a generational shift in attitudes. The female residents I work with do not anticipate hostility from men in the profession and they expect male patients to give them a fair shake. They may be right – their male contemporaries are more egalitarian than mine – but challenges still exist in our field.

Urologists see both men and women, but the majority of patients are male. Urology focuses on many conditions that only affect men such as enlarged prostate, prostate cancer, and penile cancer.  Furthermore, stone disease is more common in men, as are many urologic cancers such as bladder cancer and kidney cancer. So the greatest challenge for young women in urology is to gain acceptance among older men who require examination of their genital region and often need surgery. I’m hopeful that women entering urology today can meet that challenge, largely because we have already made significant progress. For the barriers we still face, leading urologists have blazed a clear path to follow with these three guideposts.

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Patient Worries as a Central Feature of their Health Care Experiences

By JOHN JAMES, ROBERT R. SCULLY, CASEY QUINLAN, BILL ADAMS, HELEN HASKELL, and POPPY ARFORD

Political forces trying to shape and reshape American healthcare without hearing the voice of patients provided the rationale for this work. Our experiences as patients, caregivers, and users of media sources cause us to worry. The Patient Council of the Right Care Alliance developed 6 questions to form a national survey of Americans to guide policy makers. The questions and our rationale were as follows:

1) Finding a doctor I can trust. Trust in our doctors is not as high as it once was. There are stories of serious patient abuse that appear in the media; two of the more notorious examples include a neurosurgeon harming many patients before being stopped and an oncologist who was deliberately misdiagnosing cancer to sell chemotherapy. Patients perceive this as the reluctance of the physician community to effectively ‘police their own.’

2) I will be misdiagnosed. Misdiagnosis happens far too often at all levels of healthcare. The problem is so common that the National Academy of Medicine turned its attention to the problem and published Improving Diagnosis in Health Care in 2015. The solution to the misdiagnosis problem is complex and has yet to arrive at the clinician-patient interface.

3) I will get an infection while receiving treatment. Healthcare-associated infections have dropped somewhat in the past decade, yet there are still about 720,000 infections and 75,000 deaths per year from healthcare-associated infections. Many of these are becoming nearly impossible to effectively treat. The improper use of ordinary antibiotics continues to be a problem in clinical settings.

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“Chasing My Cure”: A Book Review

By CHADI NABHAN, MD, MBA, FACP

Have you thought about your own mortality?

Who hasn’t, given the frequency of seeing death and grief depicted in the media or through real life encounters with friends, relatives, neighbors, or patients? These incidents trigger uncomfortable and sometimes uneasy thoughts of how we might personally deal with potential illness and disease. The same thoughts are soon displaced by the busyness of living. 

Despite dealing with the death of his mother from a brain tumor, we learn David Fajgenbaum was healthy, living life to its fullest, and a future doctor in the making. He may have thought about his own mortality as he grieved the death of his mother, but likely never imagined anything dire would happen to him. Fajgenbaum was pushing forward on several fronts, including leading a non-for-profit organization for grieving college students, symbolically named “Actively Moving Forward” or “AMF” after his mother’s initials, all while first playing college football and then attending medical school. By all accounts, this was a vigorous young man, meticulous about his diet and physicality.  When he became ill, it was a blunt reminder that life is unpredictable.

In his book “Chasing my Cure”, Dr. Fajgenbaum takes us back to the time when he first got ill.  He vividly describes his physical symptoms and various scans which detected his enlarged nodes. Interestingly, we learn how long he was in denial of these symptoms, thereby delaying medical attention in favor of studying. This neglect of self-care highlights part of his personality, but also represents the pressure and expectations placed upon a majority of medical students. 

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Doctors Will Vote With Their Patients

By MIKE MAGEE, MD

As Robert Muller’s testimony before Congress made clear, we owe President Trump a debt of gratitude on two counts. First, his unlawful and predatory actions have clearly exposed the fault lines in our still young Democracy. As the Founders well realized, the road would be rocky on our way to “a more perfect union”, and checks and balances would, sooner or later, be counter-checked and thrown out of balance.

On the second count, Trump has most effectively revealed weaknesses that are neither structural nor easily repaired with the wave of the wand. Those weaknesses are cultural and deeply embedded in a portion of our citizenry. The weakness he has so easily exposed is within us. It is reflected in our stubborn embrace of prejudice, our tolerance of family separations at the border, our penchant for violence and romanticism of firearms, our suspicion of “good government”, and –unlike any other developed nation – our historic desire to withhold access to health services to our fellow Americans.

In the dust-up that followed the New York Times publication of Ross Douthat’s May 16, 2017 article, “The 25th Amendment Solution for Removing Trump”, Dahlia Lithwick wrote in SLATE, “Donald Trump isn’t the disease that plagues modern America, he’s the symptom. Let’s stop calling it a disability and call it what it is: What we are now.”

Recently a long-time health advocate from California told me she did not believe that the majority of doctors would support a universal health care system in some form due to their conservative bend. I disagreed.

It is true that, to become a physician involves significant investment of time and effort, and deferring a decade worth of earnings to pursue a training program that, at times, resembles war-zone conditions can create an ultra-focus on future earnings. But it is also true that these individuals, increasingly salaried and employed within organizations struggling to improve their collective performance, deliver (most of the time) three critical virtues in our society.

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Can we move on?

By CHADI NABHAN MD, MBA, FACP

Every so often, my cynical self emerges from the dead. Maybe it’s a byproduct of social media, or from following Saurabh Jha, who pontificates about everything from Indian elections to the Brexit fiasco. Regardless, there are times when my attempts at refraining from being opinionated are successful, but there are rare occasions when they are not. Have I earned the right to opine freely about moving on from financial toxicity, anti-vaxers, who has ‘skin in the game’ when it comes to the health care system, the patient & their data, and if we should call patients “consumers”? You’ll have to decide.

I endorse academic publications; they can be stimulating and may delve into more research and are essential if you crave academic recognition. I also enjoy listening to live debates and podcasts, as well as reading, social media rants, but some of the debates and publications are annoying me. I have tried to address some of them in my own podcast series “Outspoken Oncology” as a remedy, but my remedy was no cure. Instead, I find myself typing away these words as a last therapeutic intervention.

Here are my random thoughts on the topics that have been rehashed & restated all over social media outlets (think: Twitter feeds, LinkedIn posts, Pubmed articles, the list goes on), that you will simply find no way out. Disclaimer, these are NOT organized by level of importance but simply based on what struck me over the past week as grossly overstated issues in health care.  Forgive my blunt honesty.

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Trauma-Informed Primary Care

Samyukta Mullangi

By SAMYUKTA MULLANGI MD, MBA, DANIEL W. BERLAND MD, and SUSAN DORR GOOLD MD, MHSA, MA

Jenny, a woman in her twenties with morbid obesity (not her real name), had already been through multiple visits with specialists, primary care physicians (PCPs), and the emergency department (ED) for unexplained abdominal pain. A plethora of tests could not explain her suffering. Monthly visits with a consistent primary care physician also had little impact on her ED visits or her pain. Some clinicians had broached the diagnosis of functional abdominal pain related to her central adiposity, and recommended weight loss. This suggestion inevitably led her to become defensive and angry.

Though our standard screen for safety at home had been completed long ago, I wanted to probe further, knowing that many patients with obesity, chronic pain and other chronic conditions have suffered an adverse childhood – or adulthood – experience (ACE). Yet, I hesitated. Would a busy primary care setting offer enough latitude for me to ask about a history of trauma when it can occur in so many forms, in so many ways and at different times of life? Furthermore, suppose she did report a history of trauma or adverse experience. What then? Would I be able to help her?

Nonetheless, I began: “Jenny, many patients with symptoms like yours have been abused, either emotionally, physically, or sexually, or neglected in their past. Sometimes they have suffered loss of a loved one, or experienced or witnessed violence. Has anything like this ever happened to you?”

This yielded our first breakthrough. Yes, she had experienced neglect, with parents who were separated for much of her childhood, and then later divorced. She had seen her father physically abuse her mother. With little parental oversight, she had engaged in drug and alcohol use throughout her teenage years. But, she wanted to be sure we understood that this was all behind her. She had gotten an education, was in a committed relationship, and had a stable job as a teacher. That part of her life was thankfully now closed.

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Financial Toxicity is Hurting my Cancer Patients

By LEILA ALI-AKBARIAN MD, MPH

As news of Tom Brokaw’s cancer diagnosis spreads, so does his revelation that his cancer treatments cost nearly $10,000 per day. In spite of this devastating diagnosis, Mr. Brokaw is not taking his financial privilege for granted.  He is using his voice to bring attention to the millions of Americans who are unable to afford their cancer treatments.

My patient Phil is among them. At a recent appointment, Phil mentioned that his wife has asked for divorce. When I inquired, he revealed a situation so common in oncology, we have a name for it: Financial Toxicity.  This occurs when the burden of medical costs becomes so high, it worsens health and increases distress.  

Phil, at the age of 53, suffers with the same type of bone cancer as Mr. Brokaw.  Phil had to stop working because of treatments and increasing pain. His wife’s full time job was barely enough to support them. Even with health insurance, the medical bills were mounting. Many plans require co-pays of 20 percent or more of total costs, leading to insurmountable patient debt.  Phil’s wife began to panic about their future and her debt inheritance. In spite of loving her husband, divorce has felt like the only solution to avoiding financial devastation. 

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The Burning Question: Who Will Foot the Bill for America’s Increasing Burn-Care Costs?

By CELIA BELT 

Each year in the United States, half a million Americans will be treated for burns so severe as to require hospitalization. The “survivors”—including more than three hundred children each day and a drastically increasing number of U.S. military members since the turn of the millennium—can be expected to undergo arduous, agonizing surgeries and painful rehabilitation lasting for years.

The emotional and physical trauma of these fellow citizens is not a pretty picture, nor is it an inexpensive one. According to estimates, patients with severe burns with no complications can expect a whopping $1.6 million bill for treatment over the cost of their lifetime. For patients who do go on to develop complications as the result of severe burns, hospital bills can run more than $10 million.

Where is that money coming from? Partly, it comes from you and me in the form of increased healthcare premiums. But oftentimes, it comes from directly people like me, the cofounder of the Moonlight Fund, a Texas-based non-profit organization for burn survivors and their families. We’re often tasked with raising funds to help with the costs of expensive procedures in addition to the emotional support and caregiver assistance our organization was founded for. Many times, I’ve reached into my own pocket—not because I’m a saint, but because I’ve been there.  As a childhood burn survivor myself, scalded over 32% of my body, I’m well aware that infections resulting from burns—which occur in one out of three cases—add between $58,000 and $120,000 to treatment costs.  Skin breakdown—which happens one out of two times—adds up to $107,000 more. Disfigurement and scarring? Up to $35,000 on top of that. Then, of course, there are the psychological issues associated with severe trauma. 57% of burn victims need help for these, help that costs as much as $75,000 per patient.

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Life-Saving Data That Is Nowhere To Be Found: Hospitals’ C-section Rates

By DANI BRADLEY MS, MPH 

The United States is the only developed nation in the world with a steadily increasing maternal mortality rate — and C-sections are to blame. Nearly 32% of babies are born via C-section in the United States, a rate of double or almost triple what the World Health Organization recommends. While C-sections are an incredibly important life-saving intervention when vaginal delivery is too dangerous, they are not devoid of risks for mom or for baby. Hospitals and doctors alike are aware, as it’s been widely reported that unnecessary C-sections are dangerous — and hospitals and doctors agree that the number one way to reduce this risk is to choose a delivery hospital with low a C-section rate. However, information on hospitals’ C-section rates is incredibly hard to find, which leaves women in the dark as they try to make this important choice.

In an effort to help women make informed decisions about where to deliver their babies, we set out to collect a comprehensive, nationwide database of hospitals’ C-section rates. Knowing that the federal government mandates surveillance and reporting of vital statistics through the National Vital Statistics System, we contacted all 50 states’ (+Washington D.C.) Departments of Public Health (DPH) asking for access to de-identified birth data from all of their hospitals. What we learned might not surprise you — the lack of transparency in the United States healthcare system extends to quality information, and specifically C-section data.
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Part 2: Bypassing Prior Authorizations

By NIRAN AL-AGBA, MD

A few weeks ago, I saw a young patient who was suffering from an ear infection. It was his fourth visit in eight weeks, as the infection had proven resistant to an escalating series of antibiotics prescribed so far. It was time to bring out a heavier hitter. I prescribed Ciprofloxacin, an antibiotic rarely used in pediatrics, yet effective for some drug-resistant pediatric infections.

The patient was on the state Medicaid insurance and required a so-called prior authorization, or PA, for Ciprofloxacin. Consisting of additional paperwork that physicians are required to fill out before pharmacists can fill prescriptions for certain drugs, PAs boil down to yet another cost-cutting measure implemented by insurers to stand between patients and certain costly drugs.

The PA process usually takes from 48-72 hours, and it’s not infrequent for requests to be denied, even when the physician has demonstrated an undeniable medical need for the drug in question.

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