A thought is like cotton – it can be processed hundreds of times and each time it becomes more refined.


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Support a Primary Care Physician

I remember the day I felt like I was a “doctor.” I was rotating through my Ambulatory Clinic – a resident staffed facility that sees patients that have Medicaid or self-pay for medical care. What does self-pay mean? Well, for one reason or another, they are unable to qualify for Medicaid and are too poor to afford health insurance. (Yes, we still have this population in today’s post-ACA era.)

Back to that glorious day. I was excited because my patient’s blood pressure was finally in control. Her hypertension was an illness that had plagued her for too long. The satisfaction of helping my patient accomplish this long-term goal is inexplicable. I shared the sentiments of Rocky (movie character) as he completed the famous climb. Chronic illnesses are a marathon & not a sprint. And achieving control over it was equivocal to reaching the finish line. This feeling convinced me that I wanted to be a Primary Care Physician (PCP). As I began understanding the art of Primary Care, I realized that a significant portion of it was influenced by Health Policy. I became interested in policies related to financial compensation of Primary Care Physicians and its effects on population health. I learned that under Obamacare Medicaid reimbursement had significantly increased! It was a reason to celebrate…finally NYS would not be the third-lowest state in Medicaid reimbursements to Primary Care Physicians. For every $1 given by Medicare, Medicaid would also give $1 for the same diagnosis (up from $0.42). This is known as Medicaid Parity. And, it would certainly increase the PCP workforce for NYS, which means that our patients would have more time with their physician per visit. Wonderful news, right? Of course! But I forgot that all good things come to an end.

Starting January 1, 2015, Medicaid will no longer reimburse at Medicare levels. This translates into a 58% decrease in reimbursement for Primary Care Physicians from Medicaid. Under the environment of Medicaid expansion, our patient population will need increasing numbers of Primary Care Physicians. In a recent NY-ACP survey (April 2014), 46% of PCPs indicated that they had recently began to see Medicaid patients by enrolling in the Medicaid Primary Care Pay Parity Program. The same respondents said that they were likely to accept fewer Medicaid patients in 2015 (approx 40%) if the Parity Program was not extended. This potential loss of physician workforce is expected nationwide because the Parity Program was a federally sponsored initiative. It also effects population health because decrease in physicians causes increased wait-times for diagnosis & treatment of illnesses, increased patient to physician ratio, and of course decreased allotted time per patient.

This is where my Health Policy conscience rises up and urges me to spread the word. It is imperative that patients and physicians advocate for continuing the Parity Program because we need good physicians to take care of our population. We cannot afford to lose physicians at such a critical time when our Medicaid population is expanding significantly. It would a significant missed opportunity if these patients go undiagnosed or untreated. If the goal of Obamacare is to improve the health status of Americans, we need to encourage and retain PCPs, so that we can help our communities be healthier.

If you are interested in supporting the Parity Program, there is legislation in the US Congress “Ensuring Access to Primary Care for Women & Children Act” (S.2694) that looks to continue the federal funding through 2016. I urge you to at least read & become knowledgeable about the legislation before you decide to support or refute it. Medicaid Parity Bill in US Congress.  If you want to Support: Click Here!

“He is the best physician who is the most ingenious inspirer of hope.” – Samuel Taylor Coleridge


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Another year older, another year wiser?

I saw an elderly couple – they were walking on the sidewalk with hands interlocked as she used a cane to help her support herself a little more than her husband could offer. As time has passed, I find elderly people so much cuter and wiser than ever before. It brought me to thinking about my experiences over the last year. Being another year older begs the question whether I am another year wiser?

 

Things I know:
  1. I can eat 3.5lbs of Hershey’s kisses over 1 year.
  2. Love is a verb.
  3. An extra moment of calm can resolve conflicts that seemed out-of-control.
  4. Be thankful.
  5. Weekend getaways are a wonderful ideas.
  6. Sleeping is a luxury as I grow older.
  7. Nature is beautiful.
  8. Fate always deals me a new puzzle to solve.
  9. Parties are more fun to plan than to clean up after.
  10. Cake at 2 AM tastes better than cake at 10 AM.

Things I don’t know:

  1. How does it to fly with my own wings?
  2. When can I start my yoga classes?
  3. Will I run a 5K this year?
  4. What makes people hateful?
  5. What makes people fall in love?
  6. How does the Earth go round without falling off it’s axis?
  7. How long is the galaxy?
  8. Does my puppy know that I can understand his language?
  9. What is world peace?
  10. Will I be just as curious next year?

 

I dont know if I am a year wiser. But I hope this time next year I have another list of “Things I know!”

 

Thanks world!


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Awkwardness in the Waiting Room

I pretended to read my magazine, but I could feel the lady across the waiting room observing me intently. She was trying to figure out what my Hospital ID said…was I a doctor here? Was I a patient here? Was I visiting a family member? It made me feel a little unsure about my place in the waiting room of my physician.

Last time I felt this awkwardness dates back to my Intern year & my very first Code Blue. I was the first one at the Code and I felt awkward telling the much more experienced nurses what to do, after all I was just the Intern. Furthermore, it was my first week at the job! I was not confident in my own skin & identity. Today, I felt a bit the same.

 I had purposely left my white coat in our office because I did not want to play the role of a doctor. It was time for me to be the patient. However, I carried my ID (unknowingly) and it added more weight than I had expected. The thing about doctors is that they are terrible patients. I admit it! It begs the question…why?

If I don’t see it, it doesn’t exist. Have you heard this theory? It is very popular among children. The idea is that if I don’t face my shortcomings in health on a routine basis, I can go on pretending that my health is perfect. Physicians do not have time to see their own physician because that requires a multitude of scheduling maneuvers between the patients, the physician, the other physician, and the almighty luck. So, we instead treat ourselves for minor complaints, or we curbside our colleagues, or we just delay that appointment (the good old – I have a  sick patient I have to care for). My observation is that when other busy professions can make time for their doctors’ appointments, can physicians make a much more concerted effort to care for themselves as well?

I am not sick! I know that I have to cut back on my sugar but I am not sick! Sounds familiar? To me, sounds like some of my patients who have a tough time coming to terms with being “labeled” with an illness. It is usually because labeling reflects a deep vulnerability. I admit that sitting in the waiting room, as I was being watched, made me feel vulnerable. I felt that somehow I was letting my patients down by not being an all-star, Xena-like, physician… a physician with perfect physical and mental health. Patients do not ask me whether I am healthy or whether I follow my own advice.  I subconsciously ask that of myself. The “labeling” is more jolting to me than it would be to my patients. I am sure if I told my patient that I forgot take my medications today, they would not think less of me as a physician. In fact, we might even form a pact to reach our goals together. But to achieve that, I have to keep myself anchored to the idea that I am not Xena. I am a human. And just like every other human, I will have health concerns that need to be addressed timely.

So, my advice to all the fellow Xena-like or Hercules-like physicians out there – be real with yourself and go see your primary care physician. Be proud as you wait in the reception area because you are setting a good example for your patients. After all, sometimes the best medicine is the one that comes for your doctor (and not you).


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Happy birthday America!

It is America’s Independence Day ! Happy birthday America!  Summer is one of the best seasons in America because all regional differences are put aside and America celebrates. This fourth of July,  V & I decided to head to a local eatery which served southern food.  For me,  nothing spells American more than the Southern home cooking.  We headed out to a place called Biscuits and Barbeque in Mineola,  Long Island. It is a housed in a smal trailer attached to a permanent kitchen in the back.  As we entered, the chalkboard in the restaurant listed the desserts.. turtle pie,  peach cobbler, key lime pie,  coconut cream pie,  and good old bread pudding. I knew right away that this was theplace for me!  Underneath it all,  it said BYOB… how could celebrate an American night without enjoying some local brewed beer.  We chose our window booth and the lovely Southern waitress approached us. We took one look at the menu and already knew what we wanted…Chicken & waffles with honey butter, smoked bbq chicken (half) with cole slaw and grits,  of course our starter was a country biscuit with sweet onion gravy. 

Let me tell you.. the food was delicious!  It took us less than ten mins to finish our country biscuit.  And we absolutely cleaned both our plates. I had the smoked bbq chicken. ..It was tender, well seasoned,  and truly made to perfection.  The restaurant takes pride in its bbq sauces…I tried them all: Texan kick with Chipotle peppers,  Louisiana bourbon,  Memphis whiskey,  and the original southern smoked bbq. Who can go wrong with all those additions?  When it came time for dessert, we wondered whether we were being gluttonous? Then we realized that indulging in food is very American as well.  So we ordered the turtle pie. .. oreo cookie chocolate crust with chocolate cake and chocolate mousse center.  Delicious! 
We capped the evening by watching some beautiful but very illegal fireworks in front of my apartment building. (Truly American! )
The evening made me wonder…How would you define the American spirit? We all have our takes on what it means to be American.  But what does it mean to embrace the American spirit? 


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41 years later – Can you tell the difference?

What is the difference in the images below?

You guessed it – the year! Oh and also – there is more diversity in age, gender, and ethnicity. More pertinent to our discussion today, the 1973 group compromised and decided to uphold the 14th amendment – Right to Privacy- for women seeking medical care for the purposes of abortions. While, the latter group may have allowed a challenge to the landmark Roe v. Wade. On June 30, for-profit companies (Hobby Lobby) sought an exception from the ACA that would allow the company to restrict the cost coverage for oral contraceptive methods under the Employer-sponsored health insurance plan. As per the ACA, only non-profit & religious organizations could seek this exception. For-profit companies would be subject to a large fine in the event oral contraception was not covered in an Employer-sponsored health insurance plan.

The Supreme Court cited that Religious Freedom Restoration Act of 1993 (RFRA) would limit the government’s ability to “substantially” impose upon a person’s exercise of religion by limiting the allowed mandates especially when a person’s religion was unfairly burdened or the mandate would not be neutral in its application across religions. Since the Affordable Care Act (ACA) would impose a large fine upon Hobby Lobby for upholding its religious beliefs & limiting the coverage for oral contraception, the ACA was violating the Religious Freedom Restoration Act. The reasoning behind the Supreme Court decision has little to do with the actual science and reasoning behind the ACA’s oral contraception mandate. It is based upon a broad view of the RFRA. Some believe that this decision (Burwell v. Hobby Lobby) may not have far-reaching effects while others fear the opposite.

For health care providers & women, this decision highlights the continued gap in providing health care to all members of society. At this time, we provide health care to those with minimal resources or those with plentiful resouces. The purpose of the ACA was to secure health care resources for the middle man/woman. In addition, the ACA was touted as the provider of primary care coverage and essentials to all, regardless of gender, age, ethnicity, economic status, or pre-existing illnesses. However, this decision does not allow the ACA to be religion neutral. It enforces the deeply held belief that the woman’s ability to chose will be directly affected by the religion of the company for which she works.

The future implications of this decision can be narrow or far-reaching. At this time the results are unpredictable. However, I leave you with a few questions…

If a woman was to seek oral contraception for Secondary Amenorrhea, would she be denied coverage for the treatment? If so, would this denial be considered a violation of the ACA since insurers cannot reject coverage for a pre-existing illness (in this case – secondary amenorrhea)?

If a woman was to seek oral contraception after a rape, would she be denied coverage for the treatment? If so, would this denial be considered a violation of the ACA?

If oral contraception mandate is the exception to the ACA, can this decision be interpreted to allow denial of coverage for other treatments based on the religious practices of a for-profit company? The NEJM Article so aptly points toward the treatments “such as vaccinations, infertility treatments, blood transfusions, certain psychiatric treatments, and even hospice care.” (Cohen IG, Lynch HF, Curfman GD. When Religious Freedom Clashes with Access to Care. NEJM. DOI: 10.1056/NEJMp1407965)

Certainly the Supreme Court Justices had entertained the possibilities and implications of this ruling. However, the dissent among the Justices re-affirms the possibility that this judgment was not a compromise. I don’t perceive the ruling as a backwards step for our nation & women. However, I perceive the ruling as a reflection of our society’s acceptance in taking away freedoms that were previously granted, purely for religious, political, and above all financial reasons. After all, Hobby Lobby did not cite that the ACA threatened their religious freedom. It cited that in order to uphold the religious beliefs of its owners, the financial burden for violating the ACA (a fine of $475 million per year) was too large for a “closely-held” for-profit organization to take on. Did financial implications take precedence over protecting the rights of women and employees? I suppose that is still up for debate!


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It is the start of a new year!

The thought of having a desk and a room to call my own is every Resident’s dream. I am very fortunate to be given this office as one of the Chief Residents for Internal Medicine. As I planned my first week of Chief Residency, I suddenly felt the immense responsibility that comes along with being a Chief Resident. The feelings of excitement mixed with nervousness are not unusual for me, or anyone who has experienced Intern year. Yet, there was a slight difference – I was responsible for more than patient care; I was also responsible for the education of our house-staff. As chiefs, we are the liaison between the house-staff and the various moving parts of a health institution. We are also teachers, counselors, and cheerleaders. These roles are different from the roles I had fulfilled in the past 3 years, and I was nervous about what to expect and how to fulfill my responsibilities. Then, I was asked to give a few pointers to the new Interns as they started their residency, and I realized that these pearls applied to me as well. After all, we are both starting a new job that we have never experienced before.

Over the course of Residency, I have collected a few “Pearls of Wisdom” from various sources, including my senior residents, former Chief Residents, Attendings, mentors, nurses, case managers, parents, and of course my patients. Today, July 1, there are hundreds of new Medicine Interns around the nation starting their first job as a doctor, and the best guidance I can give them is the following:

Pearls of being a Resident Physician

1)      Be there. Mind, Body, Spirit – as I enter the hospital, I leave my outside stresses and concerns at the door step. I am physically & mentally available to my interns, residents, colleagues, & patients. It is difficult to devote my efforts 100% if I am continually distracted by other happenings in life. Which brings me to Pearl #2…

2)       Ask for help. Keeping in mind that life happens, to achieve #1, I realize that I have to ask help. When I need to take care of myself or a family member, I can ask for help from my colleagues. Sharing stresses and anxieties can be a wonderful outlet.

3)      Appreciate the work of others. When someone offers help or makes an effort on behalf of the healthcare team, acknowledging and appreciating that effort is good karma. I always feel better when there is a sense of camaraderie amongst the team.

4)      Find solutions as a team. “If you want to bring an end to long-standing conflict, you have to be prepared to compromise.” – Aung San Suu Kyi. (This is quite self-explanatory.)

5)      Say I don’t know. Humility is very important as a physician. We have science & technology to help our decision making, but there are so many times when I don’t know the answer. I have learned that it is okay to say I am not sure.

6)      Keep reading. I have a love for books and if I could I would sit down to read every book that is written. In our busy daily schedule, I found it very difficult to take time to read. And then, I learned to multitask & carve out time from my schedule for reading. The funny thing about reading is that the more I engage, the more curious I become about other subjects.

7)      Set up for success. Studies have shown that people with a morning routine are less likely to develop Cognitive dysfunction as they age. It might not apply to me always, but no harm in trying! Getting in before my day starts helps me organize my day & week well before crunch time.

8)      Be enthusiastic. There are so many obstacles in a physician’s day that will detract from the excitement of practicing medicine. But there is always something to look forward to or be excited about – ie. Getting a patient placed into a Rehab Facility, getting that Noon Conf question correct, or Ice cream rounds during On-call days. Enthusiasm is infectious…as is Pearl #9

9)      Be kind to others. When I go to bed, one thought that comes to mind – did I do something nice for someone today? Not because of karma or self-gain; but purely because my behavior is affects others. People make mistakes, and I have to remember to be kind to them when they make a mistake. At various points I have made mistakes but I was more open to learning when my seniors were bringing them to my attention kindly

10)   Always Believe. This is the hardest one. We witness the passing of life on a frequent basis, and sometimes it is unexpected. These situations can be heartbreaking and unsettling because we are made to believe that we can control illnesses. I remember losing hope after one of my youngest patients died suddenly. And, I think it is more common among young physicians than we may acknowledge as a society. However, I always remember that hope can arise in the strangest of places and settings, and as a physician it is my responsibility to share that hope with the rest of the healthcare team. And, when I can’t find it – it is time to ask for help!

When all else is forgotten, just remember this:

“You’ll get mixed up, of course, as you already know. You’ll get mixed up with many strange birds as you go. So be sure when you step. Step with care and great tact and remember that Life’s a Great Balancing Act.” –Dr. Seuss

 

 

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