COMMENTARY

State of the Union Redux: A Physician's Wish List

Melissa Walton-Shirley

Disclosures

January 30, 2014

President Obama remains the consummate orator, charismatic and endearing. In his January 28 State of the Union address, his magnanimity was laced with flashes of sarcasm and rarely irritation. He covered a lot of ground, but every president's discussion of America's healthcare status, whether it is framed as reformation or the reallocation of funds, always leaves me with a deep sense of dissatisfaction. Watching a presidential address from a physician's perspective is much like standing in line for a widely acclaimed roller-coaster ride only to find there are no stomach-churning descents or loops; it's a kiddy ride after all.

I'd love my presidential SOTU address to include points that demonstrate his understanding of the basic nuts and bolts that make Americans healthier and wealthier. More important, I'd like him to actually advocate for it. When he's finished, I want him to step back, fold his hands and say "Namaste" to the citizens of his country, acknowledging that the American spirit within is best nurtured by wellness, prevention, early detection, and access to therapy. These are the keys to our nation's quest for happiness. There is hardly a politician who seems to get that. The ones who do are like hobbits with a gold ring who can't seem to find its best use or how to hold onto it.

From that great pulpit in the House chamber have come many historic speeches: FDR's four freedoms, the Monroe doctrine, and the birth of the war on poverty in the 1960s are fine examples. I'd like to rewrite that short paragraph on healthcare for President Obama from a physician's perspective. Let's call it the Namaste speech—the birth of true reformation of wellness in our country.

"Master Speaker, the President of the United States!"

Happy Democrats and glum Republicans rise to their feet. Massive applause greets the president as hands extend toward him in greeting. During his speech, he makes his points about national security, the economy, and international relations, and then comes to his main point. He looks up at the balcony where he's planted several American citizens to make his point.

"Ladies and gentlemen, I submit to you that the greatest challenge in our country is to reform our approach to wellness. It's one of the greatest drivers of our national indebtedness, but there's a way to address it, and if we work together as champions of our constituents instead of politicians, we can get the job done. (Applause interrupts him briefly.) Like all great architectural structures that dot our nation's landscape, a firm foundation is essential. In order to make that foundation last, we must go back to the basics, so I'm going to submit to you that true healthcare reform starts with education.

Health Education in School

"Take, for instance, Mrs J, a school superintendent who didn't like her school system's approach to health education—now she's a true reformation leader." (Mrs J is seated on the right hand of Michelle Obama. The camera gives her an adequate cameo as she blushes with gratitude).

"She sat down with all of the physical-education, biology, and health-education teachers in her system, and together they outlined a plan to change the curriculum such that health education starts in kindergarten. In their system, by the time children reach the 12th grade, they know which side hurts when their appendix is about to rupture. They know the warning signs of a heart attack. They know when to start screening for colon cancer, and they know when it's appropriate to access the doctor's office, the urgent-care clinic, or the ER. They understand the basic dangers and positives of over-the-counter medications. In other words, by the time someone puts a high school diploma in their hands, they are as well equipped to take care of their bodies as they are to find their favorite iPhone app.

"They understand the difference between a carbohydrate and a fat and which foods fuel their systems to fight cancer, heart attack, and stroke. They are not going to be obese because they know to exercise at least 150 minutes per week. Mrs J's students are going to cost us less and live longer. They will live better with more money in their pockets, because they won't have to buy a laundry list of prescription medications every year until they die prematurely from a preventable illness.

Make America Smoke-Free

"Then, there's Congressman X (who really would have preferred to remain anonymous), born and raised in tobacco country. He stood up against the machine that's caused more early heartache, cost, death, and disability than any other industry in America. (The camera pans to a 40-year-old man with a clenched jaw and a look of determination. Mrs Obama raises her hands in accolade.) He endured threats, disappointments, and at times, certain defeat to gather support to make every public building in his state smoke-free. Because of him, there will be fewer teenage smokers, fewer pregnant women smoking, and fewer cases of lung cancer, heart attack, and emphysema in his state. He got it after a cardiologist showed him the bill for just one 50-year-old heart patient whose repetitive stents, bypass surgery, and heart-failure admissions had already amounted to over $500 000. He understood that America couldn't afford it any more. We need a smoke-free America. We need to stop breeding illness and disability. We need to explain to our children that you should never breathe anything you can't see through. Our lungs aren't built for smoke, and if you become addicted like I did at a young age, you’ll spend the rest of your life fighting the results of the chemical manipulation of cigarettes by the tobacco companies. Those secret talks and plans to change our brain electricity and increase our addiction to their products should never have been allowed. My hat's off to you, Congressman X. We need more like you.

Devise EHR Systems that Work

"Then, there's Dr P [for practical]. Although we acknowledge the necessity of electronic health records [EHR], our earliest efforts have failed the patient. A doctor's daily work has ground down to a snail's pace. Patients complain about the basic lack of eye contact during an office visit because the doctor is focused on a screen. Dr P revolted against that practice. He designed a system where there are shorter updates at each visit and there is a symptom-limited entry into each subsequent visit. You don't have to go through 900 reviews of systems that have nothing to do with why this particular patient has come to see you. He does only a positive review of systems. He took the time away from his EHR and gave it back to his patients, and his patients are more satisfied and better taken care of because of it.

Revise the Hospitalist System

"I see Dr H [for hybrid]. He's up there in the balcony behind Michelle. Now, he saw that the hospitalist system that was initially thought to be in the patient's best interest was largely a disjointed mess writhing with failure in communication and continuity of care. He saw patients die from lack of communication and accountability. He understood the importance of a patient's long-term physician being involved in the inpatient process. He developed a comfortable approach with a team of hospitalists from his office practice group. They all go to the hospital and take calls, but on a scheduled basis. After 4 pm, the office physicians of the day aren't on call, so they can have a life, but during the day they can be accessed by phone, text, and email to discuss cases. They round on their patients every morning, and patients are happy, and the doctors make better money because they are seeing more satisfied patients who seek them out. I'd be proud to have Dr H as my doctor.

Treat All Doctors Fairly, Whether Employee or Independent

"Then there is CEO I [for intelligent]. The acquisition of doctors in this country by hospital systems across the board has caused a great shift in our physicians' focus. Although hospital groups have better buying power, can streamline services, and access electronic records physicians couldn't afford otherwise, patients don't like being on an assembly line. Doctors don't like being told at the three-year reup that the deal has now changed from when they first signed on. CEO I recognized that situation and welcomed doctors onto his staff whether they were employed by the hospital system or not. He insisted they be treated fairly, listened to their concerns, and made certain that everyone (acquired or independent) was treated with respect.

"We need to reward independent physicians with the same reimbursement tier as clinics and hospitals. Physicians who have chosen to remain independent are doctors, too. We need to have incentives to avoid acquired doctors suddenly shifting their referrals to their newly acquired colleagues rather than longstanding colleagues because this disrupts patient-physician relationships and hurts feelings. We need to be fair across the board to all physicians who have spent decades dedicating their lives to improving the health of their communities.

Design EMS Systems to Coordinate Cardiac Care ASAP

"I see EMS Director S [for savvy] up there. Now, she decided that her state, although it had a great transport system for trauma patients, didn't quite have the same system for heart-attack care. She mapped her state and made certain that every hospital in her jurisdiction had the facilities to get every single ST-segment-elevation MI patient to a primary PCI facility within 90 minutes. As EMS director, she may not be a doctor, but even she understands that better heart-attack care equals less heart failure, which is our nation's most expensive diagnosis-related group [DRG] code; we need to attack heart failure at its roots. In addition, she's made sure that EMS systems provide blood-pressure and diabetes screening to their citizens. She should be commended, and we should emulate her enthusiasm all over this country. (The crowd erupts in applause.)

Finally, the president addresses the current emergency-department crisis by acknowledging, "Emergency doctors have some of the most difficult tasks in the healthcare system. They have to figure out if it's 'live or Memorex' for every single patient at every single visit. As great a job as our ER staff do, our emergency departments are sometimes lacking protocols that reduce wait times, facilitate correct diagnosis, and ensure proper follow-up. Our systems have to meet specific requirements to be labeled as trauma systems, for instance. We would all benefit if every single hospital in this country that has an emergency department employed a board-certified and an ER-residency–trained physician to sign off on protocols that streamline efficiency and accuracy. Now, I'm not saying they have to employ a full-time ER-residency–trained physician for every shift; what I am saying is that their protocols have to be honed by those who spent three years understanding what works best to unclog the system and make emergency care safer. We need to make that knowledge and expertise available to all hospitals of every size." (There is a short, half-hearted clap.)

One Thing He Got Right

There is one thing I wouldn't change in President Obama's address. He congratulated Gov Steve Beshear last evening for making health insurance available to all Kentuckians. It was a moment well deserved. I would only add one sentence to that paragraph: "Now, Governor, take it home. Land the plane and seal the deal by getting all the votes you need to make your state smoke-free. That would really get your savings going."

Namaste

This post may seem pompous, ridiculous, and even insulting to some of you, but it's a culmination of what patients and physicians tell me every day of my practice life. I readily admit that I don't have all the answers, but all physicians have some of the answers to our current healthcare conundrum. The problem is that we aren't being asked the questions. Those of us who are in the trenches fighting the war on preventable illness, the lack of affordability, and access to competent care are the ones who should be afforded a voice and the opportunity to help it.

In my imaginary "perfect" POTUS SOTU address, which includes several key points listed above as well as many more that physicians and healthcare providers could do to fuel wellness, I then imagine that the president would conclude by stepping back and basking in the soft afterglow of a five–minute-long standing ovation with rousing applause. He could then fold his hands and say "Namaste" to the American public and really mean it.

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