By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“On National Rural Health Day, we recommit to investing in rural communities and delivering affordable, quality health care so that generations of rural Americans can thrive.”

– Joe Biden
President of the United States of America

November 15 was National Rural Health Day, a time to reflect how health policy affects rural communities.

Much of the legislation and policy in California is written with an urban or suburban point of view. This is not surprising, as nearly 95% of all Californians live in an urban or suburban setting – this includes those who develop the regulations in various state departments.

From a health policy perspective, the Enhanced Care Management (ECM) program is a current example of an urban focus that creates challenges for rural communities. The Department of Health Care Services (DHCS) is directing Medi-Cal Health Plans to contract with non-traditional Medi-Cal providers and organizations for ECM Services, directing plans to contract with community- based organizations (CBOs). In urban communities, with hundreds or thousands of CBOs, this represents an attempt to direct resources to organizations who are working directly with communities in nimble ways, getting at the underlying social drivers of health status – this work is often more challenging for mega-Primary Care Physician (PCP) sites.

In rural areas, Health Centers are smaller and more deeply connected with the special needs of their communities, and sometimes, the only provider of social and medical services. Unfortunately, DHCS has shared that community health centers were not the provider types they had envisioned for this new benefit – although they may be the only ones in their community able to perform the work. The number of local, rural, CBOs interested in developing a business infrastructure to deliver Medi-Cal regulated services is small, certainly not enough to meet the need for care management in the first few years of the program.

A few other examples:

1. Medicare’s policy of paying rural providers less than urban providers.
2. Medi-Cal’s Pediatric Palliative Care Benefit, whose service requirements are not possible in rural areas.
3. Medi-Cal’s non-medical transportation benefit (NMT) which does not account for limited public transportation options, limited internet availability, limited public infrastructure such as passable roads, highways, etc. and challenges with time and distance for rural and remote communities.
4. Medi-Cal’s new Community Health Worker benefit, whose service delivery relies heavily on in-person outreach and engagement that will not have a quick update in rural communities due to rural and remote communities, along with a lack of readily available workforce.

Density accounts for the difference in the implementation of health policy in urban and rural settings: the density of clinicians, the density of patients, and the density of available support services.  Poverty exists in cities and rural areas, but higher-density provides larger urban areas with more governmental resources and economies to help address underlying economic inequities.

With advocacy, Partnership and other organizations representing rural health care providers, can request exceptions and workarounds for health policies that are not feasible in rural communities.  The energy needed to go through the exemption process takes away from other activities, like innovation, community engagement, and solidifying core management and operations.

It would be more efficient and equitable to have proposed health policies and regulations undergo a rural health analysis in the drafting stages.

Here are a few opportunities that can be implemented immediately:

1. In the policy development process, add a rural analysis that identifies any challenges in applying the policy equally and equitably in rural communities. This analysis should include direct feedback from key advisors and associations that represent rural communities.
2. If a difference is identified, the policy is amended to equitably affect rural areas. This may mean that a policy that is hard to operationalize in rural areas needs a higher level of funding than in urban areas, so that it can be applied equitably.
3. Department attests that this process has been followed.

A policy that is promulgated without accommodations for rural areas is inequitable and in fact creates risk for greater health disparities in rural communities.  Rural Native Americans face the largest health inequities in the state (and in the Partnership service area), any policy that is inequitable from a rural perspective, is also inequitable from a Native American perspective, with an effect that multiplies their historic trauma and inequities.

Health Policy that systematically, if unintentionally, disadvantages residents and health care providers in rural areas is a reflection of “Structural Urbanism.”  Just as intentionality is needed to address Structural Racism, so too is intentional policy analysis needed to ensure that health policy and regulations are not perpetuating inequities for rural Californians, including Native Americans.

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“From Asclepius through Hippocrates to Galen, and until very recently [about 100 years ago], the history of medical treatment was largely the history of the placebo effect, because all medical treatments, with rare exceptions, were at best placebos, at worst unknowingly deadly.”

– Arthur Shapiro and Elaine Shapiro
Professors of Medicine, Singapore National University Hospital

“Just about everyone on this blog mailing list has been in a leadership role at their PCP practice for fewer than 10 years.  For the next few months, as new physicians from Partnership’s 10 new counties join this mailing list, I will be reprinting some of my favorite lead articles from past blogs, with updates as appropriate.  This post was first included in the phcprimarycare.org blog in 2012 and was republished in Marin Medicine afterwards. It is part one of a series of three articles on the placebo effect.”   Enjoy! –Bob Moore

Case Study: A primary care clinician recently diagnosed a patient with major depression. She prescribed citalopram 20 mg per day. One month later the patient felt less depressed and her PHQ-9 had dropped from 16 (moderate depression) to 12. Since the patient was not in remission, the clinician increased the dose to 40 mg per day. One month later the PHQ-9 score was 8 (mild depression) and two months later, the score was 3 (not depressed). Should the citalopram be continued? Which one of the following answers is most correct?

1. Yes. The citalopram worked and the patient is at risk of recurrence if the treatment is stopped.
2. Yes. Although the citalopram helped no better than placebo in this patient, stopping it will remove the placebo effect and increase the risk of recurrence.
3. No. The citalopram worked and remission is likely to continue without continued treatment.
4. No. The citalopram had no effect and the patient became better on her own, so continued treatment is not indicated.

I’ll make it easier for you – 1 and 3 are not correct. A 2008 meta-analysis demonstrated that anti-depressants work well in severe depression (PHQ 9 score greater than 20) but are no better than placebo for mild to moderate depression, as was the case in this patient. Her improvement was not due to the pharmacology of citalopram. She might have improved without taking any pill, or she may have improved taking any pill she believed to be helpful – the placebo effect.

We will return to this case and find which answer is most correct at the end of this post. First, though, please explore with me the implications of some new studies and thoughts on the placebo effect.

All clinicians must have a mastery of the placebo effect, not for nefarious purposes such as pushing sham treatments on patients, but to understand the natural history of disease and the role of the placebo effect in mainstream treatments that sometimes provide benefit.

History of Placebo

The word placebo comes from the Latin “I shall please.” It was used in the 14th Century to refer to sham mourners hired to sob and wail for the deceased at funerals. By 1785 it appeared in the New Medical Dictionary, referring to what were considered (at the time) marginal practices of medicine. In retrospect, of course, we now know that the effect of many treatments available at that time were due to the placebo effect. These included worm secretions for toothache (worked 68% of the time) and powdered Egyptian mummy (formerly available from Merck), which was used by President Lincoln’s physician on the bullet wounds inflicted by John Wilkes Booth. (For more, see the reference by behavioral economist Daniel Ariely.)

The use of placebo in controlled clinical trials became common only in the last 50 years. In controlled trials, the “placebo effect” actually includes two effects: the effect of the natural history of the condition being studied (is it improved even if there is no treatment at all?) and the physiologic placebo effect (requires the patient’s cognitive ability to understand what the treatment is attempting to do). The physiologic placebo effect is influenced by two factors: the expectation or belief that the intervention will work, and classical conditioning.

The Power of Belief

The strength of the placebo effect depends on the strength of the patient’s belief that it will help. The placebo response in studies ranges from 0% to almost 100%, depending on the circumstances. Children tend to have greater responses than adults and patients with Alzheimer’s dementia progressively lose placebo responsiveness.

I would like to highlight five factors that increase the strength of the belief of effectiveness: the invasiveness of the intervention, the confidence with which the prescriber associates the treatment with improvement, advertising/marketing, the cultural background of the patient, and the price of the treatment.

1. No pain, no gain, part I. Cutting the skin has a powerful effect. From 1930 to 1955, internal mammary artery ligation was used to treat angina. Doctors opened the chest wall, tied off the internal mammary arteries, and closed the chest wall. Patients noted immediate relief which gradually decreased over time. In 1955, this treatment was compared to placebo: a sham surgery, with the patient put to sleep, the skin was cut and sutured, but the arteries were not ligated. The result rocked the medical world: there was no benefit of internal mammary artery ligation over sham surgery. Tens of thousands of individuals had had open thoracic surgery for an ineffective treatment. The placebo effect was strong because of the invasiveness of the surgery, compounded by the certainty conveyed by the physicians (who really believed in it), and the high price for the surgery.
2. No pain, no gain, part II. Have we learned our lesson from the internal mammary artery example? Apparently not. How effective is viscosupplementation injection (using hyaluronic acid) of the knee for painful osteoarthritis? A 2012 meta-analysis of high quality trials of intra-articular hyaluronic acid showed a clinically insignificant benefit over saline injection, and increased side effects. Piercing a knee with a large needle and injecting a liquid works particularly well as a placebo. What is more interesting is the size of the placebo effect: 30-50% improvement in pain and 10-30% improvement in function. Finding the size of the placebo effect can sometimes be a challenge in reading scientific studies; they tend to focus on the “true” effect of the treatment, after adjusting out the placebo effect, even when the placebo effect is far greater in magnitude.
3. Is brand name really better? Many patients and even many clinicians believe brand name drugs work better than generic medications. Again, the belief of the patient impacts the strength of the placebo response. In a recent appeal process, a PHC patient stated with great conviction that brand name Concerta helped his symptoms while the generic version did not work. Investigation showed that the same manufacturer produced both the brand name and the generic pills in the same factory, in the same way. The only difference: the brand name pills are labeled Concerta. Thinking through the implications: this patient should receive neither the brand name drug nor the placebo, because the entire benefit of the brand name appears due to its placebo effect, since the exact same medication, when generic, did not work. Please consider this every time a patient says the brand name works better: it is likely placebo effect instead of a true difference in efficacy.
4. The effect of culture. Many studies have shown the placebo effect can be stronger in some cultures than others, depending on the condition. This is related to the meaning through which people of different cultures experience illness and treatment. For example: the placebo effect in treating gastric ulcers is low in Brazil, higher in northern Europe, and extremely high in Germany. However, the placebo effect in treating hypertension is lower in Germany then elsewhere.
5. The effect of price: higher cost medications work better. Most of us subconsciously use price as a surrogate indicator of quality. Taking this a step further, a higher price increases the belief a treatment will work and increases the strength of the placebo effect. This was best shown in a brilliant little study performed by four economists published in 2008. Volunteers were recruited to study a “new” pain medication. Their baseline pain threshold was established with a series of electric shocks to the wrist. They were then divided into two groups. Each was given one of two identical placebo pills, with one group told this new treatment for pain would cost 10 cents per pill and the other told the treatment would cost $2.50 per pill. Pain was reduced by 55% in the low-price pill group and by 80% in the high-price pill group. Another key finding in this study was related to conditioning from prior use of pain medication, and will be described below. Before considering this, though, think through the implications of this study. What does it mean for a patient who requests a brand name medication, perhaps because of an advertisement seen on television? How should we clinicians interpret our patients’ lack of response to low-cost generics? More on this below.

The Power of Conditioning

The placebo effect in the placebo pain pill study was stronger in patients with a history of chronic pain for which they had taken pain medication in the past. This illustrates the effect of conditioning, the second factor contributing to the effectiveness of the placebo effect. It is well documented that in patients with chronic pain, their pain begins to subside when they know their pain medication is coming, before they even receive the medication. The end result is to reinforce the benefit of the pain medication (or placebo).

Conditioning can also affect prescribers! When multiple patients state with great conviction that the expensive brand name medication works better than the inexpensive generic equivalent, the clinician may start to believe this also and discount FDA studies showing bio-equivalence. Even worse, the clinician’s belief can affect their prescribing pattern, leading them to initiate treatment with more expensive medications. It can also influence the degree to which they reassure their patients that the medication they prescribe will help them.

The over-use of expensive medications by prescribers because of conditioning leads to the important and disturbing conclusion that the placebo effect impacts not just the patient being treated, but also affects the clinician recommending the treatment. Here are some examples of the placebo effect on prescribers:

1. Generic citalopram contains both the active levo-isomer and the inactive dextro-isomer of the medication. Brand name Lexapro contains only the l-isomer. While there is a small possibility of an unfavorable side effect profile from the d-isomer, the presence of the d-isomer should have no effect on the efficacy of the l-isomer. If the l-isomer dose is the same, the efficacy should be equivalent. Only the price and the brand designation could explain increased perceived efficacy.
2. This same principle applies to proton pump inhibitors. When prescribers select a more expensive agent like Nexium, they are not helping their patients, but only contributing to the high cost of health care. Brand name medications are on average about 15 times more expensive than equivalent generic medications.
3. Patients with chronic, non-malignant pain on greater than 120 mg of morphine per day will often, with time, develop more pain and request ever higher doses of narcotics. It is a vicious cycle, with higher doses temporarily alleviating pain. But with time, the pain becomes more severe and disabling. As narcotic overdoses have surpassed auto accidents as a cause of mortality in California in the decade prior to 2010, the medical community is now aware of the danger high dose narcotics pose for patients and the community, without really alleviating pain or improving function of the patients taking this therapy. Counseling patients on this vicious cycle is difficult because of their belief in the power of narcotic medications and the conditioning that changes the physiology of patients taking these medications chronically. This belief is reinforced by withdrawal symptoms when a dose is missed or a clinician begins reducing the dose. Any drug with withdrawal symptoms will be harder for a patient to stop, because they often deeply believe that only that medication is actually controlling the disease. This is true of narcotic medications, benzodiazepine anxiolytics, many antidepressants, muscle relaxants, and even NSAIDS. In all these cases, prolonged use of the medication produces long-term changes in the synapses. These changes cause patients to feel symptoms when the medication is withdrawn. Thus, withdrawal symptoms strengthen the placebo effect! In fact, if the patient can get through the withdrawal, they may feel the same or better than they did on chronic therapy, but it is hard to get the patient there. Trust between the clinician and patient and detailed education are keys to success, but may not be enough in some cases. For this reason, we should avoid initiating prolonged use of medications which can cause withdrawal symptoms until all other options are exhausted.
4. When reviewing evidence for effectiveness of a given treatment, journal articles often compare only the effectiveness relative to placebo because this is the standard for FDA approval. I recommend always digging into the article to look at the treatment’s effect on the control/placebo group; it gives valuable information. For example, early studies comparing amoxicillin to placebo for treatment of acute otitis media (AOM) in children showed the control group improved in 82% of cases (presumably most cases were viral and did not need antibiotics), while about 90% of the amoxicillin group improved. In this case, the mechanism of the placebo effect is not related to belief or conditioning, but on the natural course of the disease. Nonetheless, use of antibiotics in pediatric otalgia conditions parents to expect antibiotics for treatment of all ear pain, since their child improved with treatment the last time antibiotics were prescribed. Looking closely at the placebo effect in studies helps clinicians interpret marketing for new products. For example, should we preferentially prescribe a more expensive, more powerful antibiotic that is reported to improve 50% more cases of AOM than amoxicillin (i.e. a 12% benefit over placebo compared to 8%)? Perhaps we should just recommend ibuprofen for a few days (which would work 82% of the time) and reserve antibacterial treatment for cases where this conservative approach fails. This approach has been recommended by the American Academy of Pediatrics as an option since 2004, but clinicians in the U.S. have been slow to adopt it due to clinician conditioning.

Adapting our clinical practice and communication with patients to account for the placebo effect may be the most important skill we develop. We must use our scientific training to inform the art of medicine. As clinicians, we owe it to our patients and society to account for the placebo effect and use only low cost, relatively safe treatments when the major effect is likely to be placebo.

If the patient really wants a pill – when education about the nature of the condition doesn’t seem to work – what should we do? Because it is ethically problematic to give a treatment the provider knows is placebo, clinicians tend to resort to medically acceptable treatments (especially pharmaceuticals), even if they know or strongly believe their benefit is most likely due to the placebo effect. One way around this conundrum is to consider lifestyle interventions. Examples include: recommending gentle physical activity for low back strain, headaches, depression, etc.; working with the patient to decrease fat intake or make other beneficial dietary changes for gastrointestinal symptoms, depression, anxiety, etc.; or recommending a low cost multivitamin-with-mineral supplement to boost the immune system’s ability to heal. If there is not time or resources for the more in-depth support required to encourage dietary and physical activity changes, the vitamin option may be more attractive.

An important word of caution: the placebo effect does not prove that a serious condition is not present. Patients with life threatening conditions can get some temporary relief from a placebo treatment.

Going back to our original case involving citalopram for moderate depression: There is likely some effect of placebo, in which case the relapse may occur no matter what choice is selected. If a relapse of moderate depression happens after citalopram is stopped, it may be attributed to stopping the medication. If it happens while taking citalopram, it may be attributed to the medication not working as well. In the first case the clinician perhaps “stopped the medication too early” and will restart it. If a recurrence occurs on citalopram, however, the clinician may then move to another medication that might “work” better, perhaps a nice expensive brand name product. The clinician gives four weeks of Lexapro samples, which the patient reports works very well (the placebo effect enhanced by the use of expensive, brand name samples). The clinician then requests that Medi-Cal cover the medication. Suppose Medi-Cal denies the request and the patient appeals (Actually, since the pharmacy benefit has been carved out since 2022, MediCal prefers brand name medications due to rebates, but set that consideration aside for the moment to think about the principle). This puts the PCP in the position of supporting the selection of an expensive brand name medication whose effectiveness is entirely due to the placebo effect.

An alternative: use your influence with the patient to increase their belief that a particular low-cost treatment will work and is the safest medication for them. Use your word choice to increase the patient’s perception that the treatment is effective and lessen their belief that high cost or brand name equates to more effective treatment.

The correct answer (in 2012)? Option 4 (stop the medication) is the most cost-effective option. It avoids escalation of treatments with no proven efficacy. For the best option of all, based on an understanding of the placebo effect, consider trying non-pharmacological treatment: brief intervention counseling or referral for cognitive behavioral therapy if you have these available in your health center or in your community.

References:

Ariely, Dan. The Power of Price: Why a 50-Cent Aspirin Can Do What a Penny Aspirin Can’t. Predictably Irrational: The Hidden Forces that Shape our Decisions. HarperCollins Publishers, 2008.

Lieberthal et al. Clinical Practice Guideline: The Diagnosis and Management of Acute Otitis Media. Pediatrics. 2013; 131:e964-e999. American Academy of Pediatrics.

Moerman DE. Cultural variations in the Placebo Effect: ulcers, anxiety, and blood pressure. Med Anthropology Quarterly 14:51-72.

Rutjes, et al. Viscosupplementation for Osteoarthritis of the Knee: A Systematic Review and Meta[1]analysis. Ann Intern Med 2012;157(3):180-191.

Venekamp et al. Antibiotics for acute otitis media in children (Cochrane Review).The Cochrane Library 2013 Issue 1.

Waber, et al. Commercial Features of Placebo and Therapeutic Efficacy. JAMA March 5, 2008, 299(9), p. 1016-1017.

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“Leadership requires two things: a vision of the world that does not yet exist and the ability to communicate it.”

– Author Simon Sinek

After being in leadership roles for 25 years, I have conflicted feelings about Simon Sinek’s central message in his famous 2009 TED Talk and book Start with Why: How Great Leaders Inspire Everyone to Take Action.
Sinek argues that communicating the underlying Why behind a company, a product, a service, or a proposal is key to engaged, charismatic leadership.

Not What your staff do.  Not How a service works.

But Why does our team come to work every day? Why is the basis of our inner motivation to work where we do, and to do the work we do.  It is a powerful idea and one missing from communications of uninspiring leaders.  It is undeniable that all of us as leaders need to effectively communicate the Why when are interacting with our staff, and when presenting new ideas to our executive leaders or governing board.

However, since this idea was popularized, I have seen troubling side to this:  leaders who passionately articulate the Why to justify an operational plan or regulatory framework (i.e. the How and What) which are not based on past experience or wisdom, not logically thought out, and really doomed to failure.  These leaders feel that their passion for a worthy Why renders mundane or unneeded activities such as starting with the wisdom of principles, weighing options, and seeking skeptical feedback.

For example, we all agree that eliminating health inequities is a very important goal and may be the Why that some of us are working in health care.  However, if my passion for this Why is so strong that I begin to believe that whatever ideas to reduce inequities that pop into my head are worthy of everyone’s support, without wisdom, analysis, or discussion, I’m likely to create programs or policies that will have significant unintended negative consequences.

Having passion and understanding and articulating the Why are important leadership abilities, but no less important than:

1. Having the wisdom to search out knowledge on what has worked and what has failed in the past to address this problem.  Learn from the past to prevent making the same mistakes.
2. Testing ideas on a smaller scale before spreading a new program widely.
3. Use the scientific method and an understanding of statistics (and not wishful thinking) to judge the success or failure of these pilots.
4. When the situation calls for widespread adoption of something new, use sound management principles, project management, and implementation science methodology.

Explaining the Why is motivating.  Having a well thought-out and logical What and How will still end up being a key to enduring success and excellence.

Acknowledge the importance of the underlying Why, but leverage your wisdom and experience to move to a sounder What and How.

Robert Moore, MD, MPH, MBA, Chief Medical Officer

“We can’t let our empathy get so overwhelming that we stop making good decisions.”

– Abraham Verghese, MD

Abraham Verghese is a professor of Internal Medicine at Stanford University, and author of four books. His most recent novel—Covenant of Water—was released in May of this year. It is a 70-plus year multi-generational story that follows a medical mystery, a family with an inherited trait that predisposes them to death from drowning in a part of India where water is everywhere, and most everyone is an excellent swimmer. It is a beautifully crafted tale; his descriptions of diseases, diagnosis, treatment, and medical education are understandable to a non-medical audience but are strikingly realistic given Dr. Verghese’s unique combination of being an excellent physician and an excellent writer. It is long (775 pages), but well worth the time. The audio version takes longer to get through, but the author narratives it nicely.

While there is much to take away from this story, I was stuck by three leadership lessons which I can share without spoilers.

The first is a theme in many writings and dramas about physicians and nurses: the tension between empathy and distance from our patients, and how both are needed to best care for those we serve. Our patients need to sense that we care about them as individuals, that we respect who they are and where they came from. At the same time, they expect us to be able to ensure that our empathy does not inhibit considering unpleasant alternative diagnoses, using reason and effort to determine the diagnostic possibilities, balancing the wisdom of our experience with the humility of uncertainty. Since this tension is always present in our profession, reading a book or seeing a drama about how this plays out indifferent settings is good for us, from time to time, to maintain our humanity and our commitment to excellence.

The second and third lessons come from a memorable side character who seems to live forever, given his role throughout the book: the local marriage matchmaker. Toward the end, a few months before his planned retirement, he shares a few of his ten rules of thumb for success.

One of these lessons is that every family has small problems, and since they are small problems, they are really not problems at all for achieving his goal (a successful match). This is a generalizable leadership lesson: there are always small problems. If we are looking for a time when there are no problems or a staff member who is perfect, we will paralyze ourselves. Changing our mindset to think of small problems as really no problem allows us to move forward with less worry.

The other lesson was, “Set a date!” Setting a date creates a sense of purpose, of urgency, and increases substantially the probability that all will come together by the date set. Another way to think of this: don’t wait for everyone to agree on a date or what would need to happen before a date is set. Plan the party and send out the invitations!

There are some potential traps to setting dates that are unrealistically soon or unchangeable, depending on the degree of bureaucracy of those you are counting on to achieve that date (remember the Healthcare.gov rollout!). However, even in the setting of a bureaucratic impossibility of meeting an initial deadline, setting a date gets the process moving along, so that the first postponement is more likely to be an achievable deadline.

All three leadership lessons involve an element of intentional self-deception, suppressing our empathy in the first lesson, choosing to ignore small problems in the second, and selecting a deadline with doubts that all barriers can be overcome in the third. Self-deception is not unique to leaders; it is part of being human. A group of leadership philosophers called the Arbinger Institute published a book in 2000, Leadership and Self-Deception, which dissects this idea with an extended parable.

Two summer recommendations for long drives or plane flights in the months to come–enjoy!

By Robert Moore, MD, MPH, MBA, Chief Medical Officer

“Vaccines are the tugboats of preventive health.”

– William Foege, MD, architect on the global strategy for eradication of smallpox

Now is a good time to have your teams meet to prepare for the coming fall vaccination season.  There are new vaccines, new recommendations and key populations to consider. You will want to be sure you know which vaccines to pre-purchase, which you might get from your County Health Department, and what your outreach strategies will be.

Even before the fall vaccines, in July through September, you will have a rush of kindergarteners and 7th graders needing to catch up on mandated vaccines in order to start school!

For young teens, while only an additional TDAP vaccine (beyond the K-12 admission vaccines) is required by the State, the CDC also recommends Meningococcal vaccination and a series of two HPV vaccinations for this age group. Be sure the medical assistants and your clinicians present this series as the expectation, noting that the HPV vaccine prevents cancer in both men and women. Begin the series early so it can be completed before the 13th birthday!

For infants between 6 months of age and 23 months of age, starting the primary influenza vaccination series as soon as possible in September (when it first becomes available) is worthwhile, since they need a second dose at least one month later to have full protection if they have not had the vaccine before. Parents, medical assistants, nurses and clinicians must reinforce that, unlike other age groups, infants are receiving the vaccine to develop primary immunity, and thus need two doses instead of one for older children and adults.

A new seasonal vaccine will be available this year against the Respiratory Syncytial Virus, but only for older adults (age 60 and over).  The RSV vaccine has just been approved by the FDA, and a CDC recommendation is likely forthcoming, so asking your vaccine supplier to let you know when it is available for ordering may help assure you a supply.  It is unlikely that County Health Departments will have much supply this first year.

For the fall COVID vaccine, last week the FDA recommended that vaccine manufacturers focus on a monovalent Omicron vaccination against subvariant XBB.1.5. The vaccine production infrastructure is gearing up to meet this need, with the mRNA vaccines having the fastest time from sequence to vaccine. Judging from last year, the vaccine will first be available in August or September 2023.  It is unclear which age groups will have the XBB.1.5 vaccine recommended. It could be all children age 6 months and older, or it could be a narrower recommendation. Since the vaccine will not be provided directly by the government, if you have capacity to store this vaccine in the primary care setting, consider pre-ordering some now.

Finally, keep in mind other recommended adult vaccinations! When ordering or recommending influenza and COVID vaccination, consider vaccination status for other adult vaccinations: TDAP booster status, Pneumococcal vaccination, Shingles vaccination, and Hepatitis B vaccination (see separate article on new recommendation for universal testing). If a patient requests one vaccine, take the time to talk about other recommended vaccines and get them at the same time!

Plan ahead! Talk to your health department and your local pharmacies!  Work together on educational campaigns!

Immunizations are one of the most valuable services offered by primary care. We must proudly offer our expertise to talk to our patients about how they can support their body’s immune system to fight future infections with early vaccination.

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“What ever happened to the confident generalist?”

– Sachin Jain and Balu Gadhe, Health Affairs, 2021

Sixty years ago, in 1973, the United States passed the Endangered Species Act, creating special protections to prevent the extinction of species of animals and plants.  In those days before modern DNA sequencing and cloning technology, the thought was that once a species became extinct, any special attributes and features of that species would be lost from the world forever.

Are generalist physicians and generalist nurses endangered species?

Twenty-five years ago, much of the primary care for Partnership members was provided by small private practices of family physicians, general internists, and pediatricians, who cared for their patients in their offices, saw their patients when they were hospitalized, and took phone calls from patients after closing time to provide guidance and advice.  In those days before hospitalists became the norm, they worked hard, and the deep appreciation of their patients helped sustain them through this hard work.  Generalists worked across settings consistent with their broad training.

In the past 30 years, Medi-Cal reimbursement has been largely stagnant, and in the last 20 years, Medicare reimbursement for outpatient care has risen far below the rate of inflation.  Somewhat protected from this financial pressure were Health Centers, whose prospective payment reimbursement system did a better job of going up over time.  The result has been a steady decline in the proportion of Partnership members cared for in private practices and an increase in the number cared for by Health Centers. Primary Care practices have expanded the use of Physician Assistants and Nurse Practitioners to reduce costs and allow increased capacity.  The production pressure of many primary care settings compounds the pressure to not take the time to care for the broad range of patient problems.

In the midst of this, hospitalists took over the care of hospitalized patients, and the expectation of many primary care trainees seeking work-life balance is that they will not work in the evening or weekends, and not need to care for complex hospitalized patients.  As a result, primary care physicians and non-physician clinicians such as Nurse Practitioners and Physician Assistants are largely caring for patients with similar levels of acuity.

The generalist physician is an endangered species.

Is something similar happening in nursing care?

While nursing school has brief rotations in different clinical settings, these are not enough to competently provide care in these settings without additional training.  This extra training may be in rehab nursing, or critical care nursing, or ER nursing, or acute inpatient nursing, or pediatric nursing, or NICU nursing, or SNF nursing.  Nurses may occasionally float to other settings due to staffing issues, but with the complexity of expected competencies, they are generally not well trained for these assignments.  Training nurses to be generalists to care for several different settings in the hospital, where they have the training and experience to provide excellent nursing care in all these settings, is now rare.  The result is that nurses express that they feel unsafe in covering nursing duties outside their narrow area of training.

One consequence of this for rural hospitals: they are likely to narrow their scope of activities over time due to the lack of specialty-trained nurses.  This was the key contributory factor behind the closure of maternity units in three rural hospitals in the Partnership region in the past few years.

Well-trained generalist nurses are also an endangered species.

When a species is endangered, and saving the species would require economic sacrifice (not building a dam or a highway, for example), society actively chooses between allowing that species to go extinct in the name of progress, or preserving the species, even if that comes with an economic cost.

If the species becomes extinct, we can read about that species in books and stories, and reminisce about the days when that species existed.

Should we celebrate the endangered species of truly generalist physicians and nurses, and save a few from extinction, so we can learn from them and allow them to thrive in some protected environments?

Alternatively, is this just delaying their inevitable extinction?  Should we carefully log what we know now, for future posterity and stop wasting our time training generalists who never actually become generalists?

The answers to these questions will impact how we think about residency training, nursing education, and the scope of care we can accept in rural communities.  At a minimum, I think it is worth supporting pockets of excellence in generalist training and practice, particularly to better serve patients living in more rural areas. Not every physician or nurse will want to pursue a robust generalist path, but for those who are willing, we as leaders need to find ways to support them.

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“The average patient’s Electronic Health Record has 56% as many words as Shakespeare’s longest play, Hamlet.”

– Jackson Steinkamp et al, JAMA Open Network 2022

Consider these statistics:

1. The average electronic visit note in the United States is four times longer than notes in other developed countries
2. Email messages from patients to their clinicians grew by an average of 57% in the past 3 years.
3. Focused efforts to reduce useless alerts led to a quick reduction in alerts by 45%.

In an era when many policymakers think that the key to improving health outcomes is more data, and more data exchange, there is a contrary voice that is articulating the opposite view: that the way we have implemented our technology is contributing to clinician burnout, decreased patient satisfaction, and sloppy decision-making with poor outcomes.

Hence the need for “Digital Minimalism.” The term was coined by a computer scientist and has implications for everyone, from middle school students to doctors to managers to policy makers. An excellent, concise and compelling summary of a theoretical framework for Digital Minimalism was published in the March 30, 2023 edition of New England Journal of Medicine by physicians from New York University and the American Medical Association (pages 1158 to 1159).

This framework has three tenets, which, on reflection, are key principles of the Lean approach to Quality Improvement popularized by Toyota in the middle of the last century. The framework also has echoes of author and uber-decluttering guru Marie Kondo.

1. Clutter is costly. Find ways to remove yourself at strategic times from the clutter of email, text, and social media interruptions to dedicate your cognitive power to core work.
2. Optimization is vital: optimize workflows and set boundaries. This includes programing out useless alerts and extra steps that could be done by someone else, automated or eliminated.
3. Intentionality is satisfying. The idea is that systematically working to optimize workflows and reducing clutter will quickly yield results that decrease cognitive load and stress; that makes work more satisfying and medical decision-making more accurate.

An even catchier name for Digital Minimalism is “Getting Rid of Stupid Stuff,” a term coined by Hawaii Pacific Health, in which 86% of “Stupid Stuff” identified by their medical staff was changed in some way, or even eliminated.

Having a dedicated staff member focused on EMR configuration and EMR workflows is a key step to addressing the “stupid stuff” problem. The improvement in efficiency and decreased clinician burnout alone justify the cost of such a position. The other key is finding some time for different staff to work on this effort. While it may feel like you are too short-staffed and busy to be able to afford to take them away from clinical activities, this pressure-cooker environment is perhaps the most critical place to begin the process of Digital Minimalization in order to make the staff you still have feel better about the work they are doing and for them to have more control over their work environment.

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“The Half-Life of Knowledge: The amount of time elapsed before half of the knowledge in a particular field is superseded or becomes obsolete.”

– First described by Fritz Machlup in 1962

About 25 years ago, I read an article that looked at the current recommendations for a variety of medical conditions and circumstances. Over time, these recommendations change, gradually at first, then more rapidly and finally slowing down as a few best practices persist over the decades.

Those of us who have been in practice for a while can think of many examples. Few in the United States use the medications for type 2 diabetes that I used as a resident physician. Vaccine recommendations change, but many vaccines haven’t changed in decades. Suspected appendicitis used to invariably mean surgery; now many cases are managed with antibiotics. Hormone replacement therapy was prescribed long-term for most post-menopausal women years ago. The list is long.

Twenty-five years ago, the half-life of medical knowledge was estimated to be six years based on a review of all recommendations made in a group of best-practice documents released by CMS (this was the predecessor to the USPSTF). This meant that if you failed to keep up with the latest developments, half of what you did today would be incorrect in six years and 90% would be incorrect in about 12 years. The decrease is not constant. Here is a graphical representation of the way I think about this with the X axis in years from today (T=0), and the steepest part of the decrease being at 6 years (50% of current best practices at T=0 are no longer best practices; the half-life).

The shape of the graph reflects the fact that published best practices are not updated continuously, but on a cycle of every few years. Thus, the slow downward slope initially.

A couple of implications of the shape of this curve jump out. First, if one assumes that the peak of one’s knowledge of best practices is at the end of formal clinical training, for the first few years, the knowledge you have from residency will serve you well. If you don’t adopt a system for keeping up on changes, however, the subsequent years will make you quickly lose touch with how best to practice medicine. Second, if someone takes a break from clinical medicine for up to 2-3 years, they will be able to get back up to speed quickly. A longer break will require more extensive re-training, mentorship and formal education.

A study in 2011 estimated that the half-life of medical knowledge had dropped to 3.5 years. It seems likely this trend has continued, especially in the age of COVID.

There are three primary strategies for maintaining high quality care in this setting.

1.)   Diligent self-education, regularly reading medical journals in your area of expertise, and attending (and paying close attention to) conferences that summarize updates in your field. For primary care clinicians, American Family Physician is a good resource.

2.)   Liberally use the rapid on-line resources we now have available to check on current recommendations for any condition that is somewhat infrequently seen, and for which you haven’t recently read a review article or attended a presentation. Up to Date is an excellent option, although the American Family Physician website gives rapid access to previous review articles that are often more accessible.

There is a new variation on Board Certification examination for Family Physicians in which difficult clinical questions must be answered within two minutes, using any computerized resources you like. This reinforces this ability to think about where to find the best answer quickly, but critical thinking is definitely needed to sift through all you find to come up with the best plan.

3.)   Interact with clinician colleagues regularly, and “talk shop”. Clinicians will remember well lessons learned from peers. Back when primary care clinicians rounded in the hospital, this interaction with many different specialists happened regularly. Now, you will need to seek out peers if you want to have these interactions.

In all cases, we must be humble about what we know about diagnosis and therapeutics. Use the computer in your exam room to quickly confirms that your treatment plan is the best. I find that patients are reassured by this. Find ways to talk to colleagues about the most challenging cases, perhaps at peer review rounds, morbidity and mortality reviews, or even at a Balint group.

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“If I had an hour to solve a problem I’d spend 55 minutes thinking about the problem and 5 minutes thinking about solutions.”

– Albert Einstein

As we emerge from the COVID pandemic, the health care delivery system is not yet recovered.

A point-in-time survey of medium and large primary care physicians (PCPs) in the Partnership HealthPlan of California (PHC) network showed an overall current vacancy rate of 24% of which two thirds were openings for PCP physicians (about 200 openings) and one third were openings for nurse practitioners/physician assistants (about 100 openings). The current PCP openings are in all 14 counties and in all practice settings. The overall need for PCPs is even greater if we want to have sufficient clinicians to do all the preventive and chronic disease care that is recommended by the United States Preventive Services Task Force (USPSTF), the American Academy of Pediatrics, and the Department of Health Care Services (DHCS).

This is not just true in the PHC service area but also nationally and internationally. The United Kingdom is having the largest primary care physician shortage since the start of the National Health Service in 1948. A few clinicians died of COVID, more were disabled by long COVID, and others retired early or stopped doing primary care. As the supply dries up, the demand per clinician remaining in practice increases causing stress and burnout. This leads clinicians to take a break from practice or reduce their hours per week making the shortage worse.

The rise of hospitalists has been a major driver of loss of primary care access. Twenty years ago, about 40% of all internal medicine residents became PCPs. Now that number is about 15% with most of the shift occurring in the rise of the number of hospitalists caring for patients in the inpatient setting.

The number of PCPs plus hospitalists is equal to the number of PCPs needed in a community. The steady decrease in the number of internal medicine specialists in primary care (as older primary care internists retired) was not accompanied by a sufficient increase in training family physicians, nurse practitioners, and physician assistants to overcome this loss. This trend started reversing in the mid-2010s with an increased number of primary care physician residencies as well as a substantial increase in the number of new nurse practitioners and physician assistant graduates.

While the hospitalist movement promised to improve quality and utilization, this has absolutely not happened. Hospital length of stay in the PHC service area is at an all-time high (6.23 days) and increasing steadily over many years. (Part of this increase length of stay is a shortage of skilled nursing facility beds.)  Poor continuity of care for discharged patients is now common as compared to when PCPs rounded on their own patients. The major benefit for PCPs was that they no longer had to get up in the middle of the night to admit patients; the hospitalist could take care of it. While this may have made their lives feel better in the short run, the disconnection from hospital care and the loss of collegial relationships with hospital specialists makes PCPs more professionally isolated (and unmentored if they are in small practices), and contributes to a loss of a sense of professionalism. This increases stress and burnout.

If any particular medical system raises primary care salaries, they will recruit away some clinicians from other settings, at least temporarily. This happened in the prison health care system in California and the Permanente Medical Group about 20 years ago. The invisible hand of market forces soon intervenes. Other organizations soon raise PCP salaries in response, to stem the loss of staff. With the nationwide and international shortage of primary care, migration of PCPs to greener pastures will contribute to more severe shortages in other communities.

What Can We Do?

Train more PCPs. First and foremost, we need to train more primary care clinicians who will work in primary care. If all the primary care resident physicians in our service area stay in the PHC service area after graduation (unlikely), it would still take ten years just to staff the current open positions. In the past decade, the number of family medicine residencies in our current 14 county region increased from two to seven, with two additional programs in gestation. Nurse practitioner residencies are springing up in many health centers.

Community connections. Secondly, we need to help new primary care clinicians and their families form deep roots in the community and the clinical setting where they practice. The average length of time that new PCPs are staying at their first jobs is now about three to five years in our service area. Whenever a clinician moves to a new setting, the time they invested in learning the systems of care and learning about the lives and medical histories of their patients is lost. Reducing turnover thus instantly has the effect of increasing primary care capacity where the same number of clinicians can care for heavier patient workloads as they get to know their patients better.

A place-based business or career for a physician spouse can build longevity in the community. A friend from residency moved to rural Alaska to practice for what he and his wife thought would be a three-year stint to repay his substantial medical student loans. His wife liked dogs, and this grew into a hobby of racing sleds driven by Alaskan Huskies. They are still in rural Alaska 30 years later. This is an extreme example of a common phenomenon. Most PCPs who stay in one town their whole career do this because of family connections to the community.

Life-long love of primary care. Third, we need to find ways to help our PCPs feel the joy and pleasure of providing primary care. If clinicians only enjoy their lives outside of the workplace, they will want to work less hours, retire early, and/or change jobs more frequently. Ways to build this joy are building friendships with peers, matching new providers with enthusiastic mentors who love primary care, and finding ways to minimize non-value added administrative activities.

Shake it up. Another tactic that works well is to break up the office practice routine. This could be a clinical activity like becoming the primary care “specialist” in the office for opioid treatment or dermatology or seeing patients weekly in a homeless shelter-based clinic site. The change in routine can also be from working with a team to improve quality outcomes, improving internal operational efficiency, or working on some other special project.

Reduce non-value-added activities. Electronic health records are here to stay, but they are a major contributor to clinicians having less enjoyment in the workplace in the past two decades. The PCP office needs to have support staff off-loading computer documentation activities and adapting the EMR to make it ever more efficient to use and less of a drain on clinician morale. Trying to cut costs by reducing support staff and keeping billable providers will improve the bottom line only temporarily before clinicians start leaving because they don’t feel supported or valued.

As clinical leaders we are all devoting ourselves to this challenge using the five tactics listed above and others. Alleviating the PCP shortage is a long-game imperative for the entire health care delivery system, as well as your individual practices. We at PHC appreciate all you are doing!

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“Mistakes are a fact of life: It is the response to the error that counts.”

-Nikki Giovanni, poet

Many years ago, a Primary Care Provider (PCP) unintentionally placed an intrauterine device (IUD) into a women who turned out to be pregnant. The pre-procedure protocol was to time the insertion of the IUD to be a few days after completing menstruation, and checking a pregnancy test. In this case, the medical assistant did not conduct the pregnancy test and the provider did not confirm a negative test before the procedure. The patient later discovered she was pregnant and had a miscarriage.

The PCP instituted a number of process changes. They developed a standardized form which listed the pregnancy test result prominently so the medical assistant is reminded to do the test and the provider could readily see it. A check box, requiring the clinician to confirm that the pregnancy test was negative, was added to the progress note template.

A Partnership HealthPlan (PHC) nurse noted this adverse outcome referred it to the PHC quality team for investigation.

Like many of your organizations, PHC has a peer-review process where we review referred cases in which a potential quality issue is identified. PHC doctors, nurses, and pharmacists review patient care while conducting care coordination or utilization management activities, the results of which could generate complaints from our members (your patients).

PHC typically gathers documents (medical records, grievances etc.) to see if the initial concern is confirmed. If the concern for a quality-of-care issue is not resolved by this documentation, we will typically send a letter to the clinician whose care we are concerned about, asking them to review the case and respond to our concerns.

Clinicians may respond in one of these ways.

1. Respond giving some additional information or context which makes clear that there were no quality-of-care issues after all.
2. No response, in spite of multiple attempts. We are then forced to make a finding based on the information we have. These clinicians may be afraid of liability or feel like they are too busy to get around to responding; hard to know.
3. Respond defensively, saying they did everything right, often blaming the patient in some direct or indirect way for the outcome.
4. Respond reflectively and humbly, noting the complexity of the case but clearly identifying opportunities for them to improve practices, systems of care, or thought processes they will apply for future cases.

We are all human and make mistakes. When clinicians respond with reflection and humility, looking for ways to learn and improve ourselves, we are making ourselves better diagnosticians and clinical decision makers. This approach is a reflection of a “growth mindset”.

On the other hand, if we look around for excuses and others to blame for poor outcomes – unwilling to look in the mirror at how our biases and thought processes played a role in our own poor choices – we are not learning, and we are likely to make similar errors in judgment in the future. This approach is a reflection of a “fixed mindset”.

Psychologist Carol Dweck’s 2006 book Mindset: The New Psychology of Success suggests that our world view and behavior is influenced by these two mindsets. While our mindset is not easily changed, becoming aware of this dichotomy may help some people consciously move themselves from a fixed mindset in the direction of more growth.

When confronted with an complex adverse outcome with many causes, we should take the time and effort to look at how our decisions or systems could have been different, actively looking for opportunities to change systems and cognitive processes to help future patients.

When the PHC peer-review team receives responses indicating a growth mindset –acknowledging errors and explicitly listing changes for better care in the future – we are reassured these clinicians will learn and improve throughout their careers. When the peer-review team receives no response or a response showing no introspection and searching for others to blame, we are more concerned, and more likely to escalate to appropriate oversight organizations.

As medical leaders within your organization, you play a key role in this process. If you have been a medical leader long enough, you have had to confront the issue of clinicians without a growth mindset. To enable you to conduct your own investigations and assess competency concerns, PHC will ensure the medical director overseeing a clinician is aware of potential quality issues. We hope you can mentor and counsel your clinicians, using potential quality investigations as opportunities for them to grow and learn.

One approach to building a culture of growth is the “Just Culture” approach pioneered in patient safety work. Ensure that peer review and mentoring activities are supportive and don’t shame individual providers. This helps model the a learning approach to feedback with a growth mindset.