Blaming the Patient, Then Asking Forgiveness
By ANAHAD O'CONNOR
Dr. Peter Attia thinks about his former patient often, the woman who came to him in the emergency room at Johns Hopkins Hospital one night seven years ago.
She was obese and suffering from a severe complication of Type 2 diabetes, a foot ulcer, which required an urgent amputation. At the time, Dr. Attia admits, he silently judged her. If she had only taken better care of her health, maybe exercised more and eaten less, he thought to himself, this never would have happened to her.
But a few months ago, in a TED talk, Dr. Attia stepped onto a stage and offered a few words to his former patient: “I hope you can forgive me.”
“As a doctor, I delivered the best clinical care I could, but as a human being, I let you down,” Dr. Attia, his voice breaking, said in his talk. “You didn’t need my judgment and my contempt. You needed my empathy and compassion.”
For many, Dr. Attia’s talk, delivered at a TEDMED conference in April and opened to the public on the TED Web site in June, has struck a chord, in part for its unusual candor.
Dr. Attia admits to something he believes many doctors may in fact be guilty of. That compassion for overweight and obese patients often is not quite as deep as it is for those who are sick for other reasons – the “unlucky” ones, for instance, who develop cancer or another disease through no apparent fault of their own.
“I probably spent a lot of my time in medicine judging people who I thought brought conditions on themselves,” he said in an interview on Thursday, “without thinking, ‘Maybe I need to walk a mile in that person’s shoes. There’s probably a reason this person lived the life that they did, and maybe I have a privilege that they didn’t have.’”
Dr. Attia’s insight was informed, in part, by the startling discovery a few years ago that despite paying close attention to his diet and exercising frequently, often for hours at a time, he had developed metabolic syndrome, a precursor to Type 2 diabetes. He had made all the right lifestyle choices, he thought, and yet he was overweight and on a fast track toward obesity and diabetes.
Health Providers Bracing for Medicaid Enrollment
By BECCA AARONSON
Under Gov. Rick Perry’s leadership, Texas will not expand Medicaid eligibility to poor adults. But enrollment in the state’s health program for indigent children and the disabled will still swell in 2014 under new rules created by the federal Affordable Care Act.
Texas’ health care provider safety net and the state agency that oversees Medicaid are preparing for the anticipated increase and other challenges that lie ahead.
The Texas Health and Human Services Commission projects 240,000 children currently eligible for Medicaid but not participating will enroll in 2014 and 2015, as families seek coverage to comply with the individual insurance mandate, which takes effect on Jan. 1. An additional 200,000 people could enroll in Medicaid as a result of other new requirements created by the law, according to state health officials.
This presents a challenge for health providers like Su Clinica Familiar in South Texas, which already serves patients who are predominantly uninsured or enrolled in Medicaid.
“As demand comes forward, we’d have to hire doctors, and that could take some time,” said Dr. Elena Marin, the center’s executive director, who estimates that an additional 5,000 patients in her service area could enroll in Medicaid. “If there’s more that are enrolling, then, well, that would be more of a problem.”
Texas has the highest rate of uninsured residents in the nation; nearly 29 percent lacked health coverage in 2012, according to the Gallup-Healthways Well-Being Index.
Although the new federal health law exempts extremely poor individuals from the insurance mandate, millions of uninsured Texans will need to determine whether they qualify for Medicaid or sliding-scale tax subsidies to help them buy coverage.
“We’re going to have one of the more complex systems, unfortunately,” said José E. Camacho, executive director of the Texas Association of Community Health Centers, which represents 71 centers with 350 locations statewide. More than half of the patients served by those centers in 2012 were uninsured. (The Texas Association of Community Health Centers is a corporate sponsor of The Texas Tribune.)
When Aggression Follows Dementia
By PAULA SPAN
For more than five years, Phyllis Edelstein managed to care for her husband Richard in their Long Island home as his dementia slowly progressed. She felt fortunate to have found, and to be able to pay for, a live-in couple to help her.
But last fall, “he was becoming more negative about things like showering,” she told me. “There’d be flare-ups of anger.” She saw her husband, a retired dentist, try to strike his hired helper one day, and she was startled, as they watched a Western together, to see him jump up and lunge toward the TV, as if he intended to beat up the bad guy. “It reached the point where I was uncertain being alone with him on weekends,” she said.
In January, she moved Dr. Edelstein, 82, into a nearby assisted living facility. He seemed to be settling in, though he did once hit another resident. But one Saturday last spring “he just lost it,” Mrs. Edelstein said. “A tremendous physical outburst.” He broke planters, upended furniture, pulled a closet door off its hinges.
Dr. Edelstein was found to have a urinary tract infection, long known to cause suddenly aggressive or bizarre behavior in dementia patients. But although his infection was treated, he hasn’t regained his previous level of function. He remains in a hospital psychiatric unit, where doctors are trying to adjust his medications so that he is calm but not somnolent.
Let’s be clear: physically aggressive behavior arises in a sizable minority of dementia patients — a German study of nursing home patients published last year put the proportion at nearly 29 percent – but those most endangered are the people with dementia themselves and their caregivers. It is irrational to fear an assisted living/dementia care complex near a residential neighborhood, as some Minnesotans did a few years back, as though its elderly residents would break out and menace passers-by.
But violent behavior presents a particularly knotty problem for families. They know their loved ones with dementia generally don’t intend to cause harm. Yet when confused, fearful, angry or in pain, they may kick, hit, bite, throw or shove.
Our View: State feels loss of funds as result of failed policy
Posted:TodayUpdated: 8:19 AM
A health clinic for the homeless can't use a grant because MaineCare wasn't expanded.
The shortsightedness of Gov. LePage's crusade againstMaineCare was exposed earlier than expected, when the federal government gave a Portland clinic $74,000 that it can't use last week because its homeless clients are ineligible for health coverage in Maine.
The grant came a little more than a week after the Legislature failed to override the governor's veto of a bill which would have accepted federal funds to insure about 70,000 Mainers for the next three years.
The governor and his Republican allies in the Legislature were able to block the bill, even though it had majority support (including some Republicans) because they claimed that Maine couldn't afford to expand its program.
Democrats argued that we couldn't afford not to, and the situation in Portland is the first indication that they were right.
The state of Maine does not save any money by denying health insurance to these homeless adults. Including them in MaineCare with 100 percent federal funding would not have added to the state budget.
Hospital repayment a boon for health network
1:00 AMThe Franklin Community Health Network says $15.4 million will help pay its mortgage and pay for new technology.
By KAITLIN SCHROEDER Morning Sentinel
FARMINGTON - Lawmakers' decision this session to pay millions in MaineCare debt to the state's 39 hospitals is expected to have a big effect on the Franklin Community Health Network, which is struggling with job cuts and a deficit.
Franklin is being paid $15.4 million the state of Maine owes the hospital for MaineCare, meaning it can pay about one-third of its $25 million mortgage and invest in new technology.
"It's a real feeling of relief," Chief Financial Officer Wayne Bennett said. "Running a hospital these days is like walking on a tight wire."
Obamacare struggles to meet make-or-break October deadline
Posted July 15, 2013, at 7:46 a.m.
WASHINGTON — With time running out, U.S. officials are struggling to cope with the task of launching the new online health insurance exchanges at the heart of President Barack Obama’s signature health reforms by an Oct. 1 deadline.
The White House, and federal agencies including the Department of Health and Human Services and the Internal Revenue Service, must ensure that working marketplaces open for enrollment in all 50 states in less than 80 days, and are responding to mounting pressure by concentrating on three essential areas that will determine whether the most critical phase of Obamacare succeeds or fails.
“The administration right now is in a triage mode. Seriously, they do not have the resources to implement all of the provisions on time,” Washington and Lee University professor Timothy Jost, a healthcare reform expert and advocate, told an oversight panel in the U.S. House of Representatives last week.
Current and former administration officials, independent experts and business representatives say the three priorities are the creation of an online portal that will make it easy for consumers to compare insurance plans and enroll in coverage; the capacity to effectively process and deliver government subsidies that help consumers pay for the insurance; and retention of the law’s individual mandate, which requires nearly all Americans to have health insurance when Obama’s healthcare reform law comes into full force in 2014.
Measures deemed less essential, such as making larger employers provide health insurance to their full-time workers next year or face fines, and requiring exchanges to verify the health insurance and income status of applicants, have already been postponed or scaled back.
“The closer you get to the actual launch, the more you focus on what is essential versus what could be second-order issues,” said a former administration official. “That concentrates the mind in a different kind of way, and that’s what’s happening here.”
But the risk of failure in the form of major delays is palpable, given the administration’s limited staff and financial resources, as well as the stubborn political opposition of Republicans, who have denied new money for the effort in Congress and prevented dozens of states from cooperating with initiatives that offer subsidized health coverage to millions of lower income uninsured people.
Should we really call it a health care system?
Dr. Michael Noonan, an Old Town chiropractor
When I was a freshman at chiropractic school, on the first day of our Principles of Chiropractic class we were required to memorize the definition of health. (Ironically, the source was Dorland’s Medical Dictionary.) It went like this: “Health is the normal functioning of all parts of the body, and not just the absence of symptoms or disease.”
That sentence is deceptively simple. And it contains some important insights about our current system.
If health is normal function, it makes sense that health care should restore disturbed function (disease) to normal. And this is where the rubber meets the road — while it is restoring one function, it should not disrupt others. If it does, it violates the part of the definition that states “all parts of the body,” and we really shouldn’t call it health care.
The mainstay of our current system is medications. Currently, about 50 percent of the U.S. population is on at least one prescription, and the number swells to 80 percent when over-the-counter drugs are added in.
The percentage of people on several meds, as well as the number of children given prescriptions, also are rising rapidly.
The purpose of a drug is to restore a function to “normal.” Drugs lower blood pressure, reduce swelling and fevers, shrink swollen prostates and raise low hormonal levels. But is that all they do?
W.H.O. Recognition Is Boost for New Drugs
By DONALD G. McNEIL Jr.
A 10-year-old program to develop drugs for “neglected” diseases scored an important victory this month when three of its medicines were named essential drugs by the World Health Organization.
The W.H.O. list, first issued in 1977 and updated every two years, is the guideline that most poor countries’ health ministers use to decide which treatments to use. Many donors, including United Nations agencies, rely on the list to decide which drugs they will pay for.
Acceptance on to the list “is a label that indicates that it’s a priority treatment for a priority disease,” said Dr. Nathalie Strub Wourgaft, the medical director of the Drugs for Neglected Diseases Initiative, which was founded by Doctors Without Borders and partners in 2003. “This validates the credibility of what we and our partners have been doing.”
The medicines that made the list are for three lethal insect-borne diseases: malaria, Chagas and sleeping sickness.
They exemplify how complicated it can be to develop a new drug with a low profit margin.
The antimalarial, for example, is a blend of artesunate and mefloquine, two drugs originally developed during the Vietnam War to fight malaria — artesunate by the Chinese for its North Vietnamese allies, mefloquine by the United States for its troops. The neglected diseases initiative persuaded a Brazilian drug company to combine the two in a single pill. Then, after its 2008 introduction in Brazil, the manufacturing process was licensed to Cipla, an Indian company, which made the version the W.H.O. approved.
The first drug the initiative developed was also an antimalarial, a blend of artesunate and amodiaquine, an older French drug.
The other two drugs new to the list are for children: a form of benznidazole that dissolves in water and a pediatric version of nifurtimox-eflornithine, which was approved in 2009 for adults as a new way to treat sleeping sickness. It replaced a toxic arsenic-based drug that burned the veins as it was injected.DONALD G. McNEIL Jr.
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