The doctor takes off his glasses, moves his swivel seat behind his desk takes out his prescription pad and writes what medication the patient should receive. He says what should be done, and what is necessary, to help the patient feel better.
Unfortunately, most of the conversations don't go enough into the depth of procedure for the disease or illness involved, leaving many patients unprepared to make fully informed decisions about their care, University of Michigan researchers concluded in a national study and survey about medical decisions. The study was funded by the Foundation for Informed Medical Decision Making.
Too often, physicians are leaving patients "in the dark" and do not include enough information about sensitive medical decisions such as screening tests for colorectal or breast cancer, the need for prescription medications for hypertension, and issues related to hip replacement, cataracts, and lower back pain, the researchers say. For instance only 20% of patients considering breast cancer screening reported hearing anything about the "cons" of such screening, while 50% reported hearing mostly about the "pros," according to the study.
Generally, the study found that most patients hear far more from doctors about advantages than the disadvantages of medications, the study says. Patients also do not understand essential facts about common medical decisions, or are mostly offered opinions, without their own preference attached.
So it goes: another study that examines communication issues involving patient and physician, in which seemingly little "tweaks" in the system—improving the one-on-one dialogue, possibly adding more time to the process—could eventually mean a big difference in healthcare.
Variations of the communication theme continually crop up in making the physician-patient experience better. Recently, I reported from a separate University of Michigan study that physicians lacked the confidence to be totally up front with patients about certain issues, such as the need for weight loss, for instance.
It may seem like a blur for the patient as well as the physician, once it is over, but the impact of even the most routine patient visit to the doctor is a time to glean the importance of what it means, and communication often lags—because crucial information is not imparted to the patient, notes Jack Fowler, PhD, senior scientific advisor for the Foundation for Informed Decision-Making and a co-author of the study.
For instance, in discussions about prescription or medication needs, the "patient could be talking with the doctor about a drug they may have for the rest of their life." They should know "what they are getting into, and what's actually involved." Often, those discussions touch on what the patient is dealing with—but not enough, he says.
A patient truly understanding what is happening in communication with his or her doctor "makes for better medicine," Fowler says. Too often, patients "don't' feel involved in the decision making."
The study also indicates what is needed for healthcare reform and the shared decision-making that involves—or should involve—dialogue between informed patients and their providers, according to Fowler and other Michigan researchers.
As Fowler sees it, the study underscores the provisions in the new health reform law that are designed to improve the dialogue between patient and doctors by promoting "shared decision making" and the use of patient decision aids. Ideally, patients are fully informed about the risks and benefits of every option when making a medical decision and their doctor knows which option they prefer.
"The study clearly demonstrates that people routinely make poorly informed medical decisions, informed consent isn't real if patients understand so little about the tests and treatments they are getting," said Michael Barry, MD, professor of medicine at Harvard Medical School and president of the Foundation for Informed Medical Decision Making in a statement.
In other areas of patient care, such as potentially screening for prostate cancer, only half of the male patients reported having been asked about their preferences by their provider, the study states. There was one area studied showing that patients did seem to know risks and benefits of medication: 70% say they had knowledge of the impact of drugs to control hypertension.
On the other hand, few knew the most common side effects of cholesterol drugs or had an appropriate understanding of how much reduction in the risk of a heart attack can be achieved through taking medication, according to the study.
The improved communication allows patients to be "more involved in their care," Fowler says. And that is one of the key elements—and objectives—of healthcare reform to "bridge the dialogue gaps," he says.
He noted that the law encourages shared decision-making by doctors and patients and particularly to help Medicare beneficiaries make informed decisions wrapped around an understanding of options available and the patient's choices. The idea is to educate patients and caregivers to understand various options. Among the unfolding questions will be the impact of potentially new decision-making processes, and whether it improves or reduces the quality of are, and also makes a significant dent on costs.
Physicians are standing in the middle of it all, and the potential for improved communication in so many areas, including the dialogue between patients and physicians about specific medications, their impacts, and the importance or lack thereof of particular screenings, is a big part of the process how we improve the healthcare system. Healthcare reform is setting that stage for quality care by evaluating physicians for what they do, and potentially rewarding them, Fowler says, emphatically, "to do better medicine."
For a long time, waiting has been almost synonymous with emergency departments in American hospitals.
But hospitals are streamlining their emergency departments to reduce waiting times as EDs continue to be swamped with increasing numbers of patients.
In 2009, Americans averaged 4 hours and 7 minutes in ED waiting rooms before being seen. And more people are expected to be crowding into EDs over the next several years. Emergency visits may increase as much as 5% to 10% over the next several years in the wake of the healthcare reform law.
Waiting in the ED often has a negative impact on patients' attitudes, with many simply deciding to leave the hospital, despite needing care, and despite the likely consequence of poorer health outcomes. The unfolding scenario has a potentially detrimental impact not only on the patients themselves, but also on overall hospital business.
To meet demands of patients, hospitals are working diligently to ramp up services and decrease wait times by restructuring waiting areas, placing nurses and physicians in entrance areas for "fast track" services, evaluating serious and nonserious conditions among patients in the ED, or evaluating specialized conditions, such as asthma, to improve patient flow.
Such innovations not only have improved patient care, but they inevitably feed hospital revenue because patient care usually begins with the ED, hospital officials say. There were nearly 117 million patient visits to the nation's emergency rooms in 2007, a 23% increase over a decade earlier, or 39.4 visits per 100 persons, according to the National Health Statistics Reports.
By making improvements to the ED, "there has been a positive impact even though the emergency department is not a money maker, per se," says Valerie Norton, MD, medical director for the ED at Scripps Mercy Hospital in San Diego. "You can't look at it in isolation as a separate silo. It's a feeder of inpatients for the hospital. Urban EDs are admitting 20% of the patients who come through the ED. It's very good revenue for the hospital and we are able to increase the volume."
Hospitals also are under increasing pressure to improve EDs, not only because of the need to serve additional patients but also because of the competitive nature of the services, says John Federspiel, MBA, president and CEO of the 128-staffed-bed Hudson Valley Hospital Center in Cortland Manor, NY.
When HVHC initiated a program in 2005 to speed up review of patients in the ED waiting area, the average time for patients to be evaluated by a medical practitioner dropped by 47%—just one month after the initiative began. Since then, the hospital has gradually reduced waiting times. Federspiel says he attributes an increase of patient volume in the hospital—about 20%—to improvements in the ED.
Having a speeded-up ED process is something "we take advantage of," he says. "We have a half-hour distance from our competitors. People have a choice where to go for their ED treatment. We're doing this because people are voting with their feet."
Success Key No. 1: Decreasing walkout rates
One of the major problems for emergency departments has been dealing with the "walkout rates"?potential patients who grew frustrated waiting in the ED and decide to go home or to another facility. The longer the patient waits, the more likely he or she will leave without treatment, resulting in potential problems for the patient as well as lost income for the hospital.
The Scripps Mercy Hospital, a 700-licensed-bed facility, focused making ED improvements that included targeting the walkout rates. By effectively separating patient groups, by illness, for example, the hospital has reduced the number of walkout rates. In June 2009, the patients who left without treatment were 253; that figure was reduced a year later to 11 in June 2010.
"People were sitting in the waiting room and got fed up," says Norton. At one point, 5% of patients were leaving the ED between July 1, 2009, and February 23, 2010; the hospital has decreased that total to 0.4% between February 23, 2010, and June 30, 2010.
The result has been more patient volume in the hospital "because we've been able to get more patients in, and ambulances that used to be diverted away from the hospital are no longer diverted," she says. "The word has gotten out to the community, and more people are showing up. And that is a savings, too, with the ambulances no longer being diverted."
At the Scripps Mercy ED, patients seeking treatment are immediately assessed by a nurse who determines whether the patient requires a bed or recliner, depending on the severity of the case. When a bed or recliner is available, the patient is taken back to the designated area immediately.
"The biggest challenge was getting rid of the up-front wait," she adds. "In the old traditional way, you'd be in bed for two hours. Now we are taking people out of the beds and have them in chairs. We are turning over the beds rapidly for people who really need them."
Such movement is important, she says, because "really sick patients account for only 30% of the volume" in emergency departments. "Patients are served very poorly by having to wait in waiting rooms."
Success Key No. 2: The asthma lounge
After studies in Oakland, CA, that showed more than the usual number of cases of asthma, Alameda County Medical Center, a 236-licensed-bed facility, established a specialized unit for asthma patients that hospital officials say has resulted in improved overall outcomes for asthma sufferers as well as reduced wait times for other patients in the ED.
With creation of the asthma lounge, the average wait time for ED patients with asthma attacks fell from 128 minutes in 2006 before the lounge opened, to just 4 minutes, according to the hospital.
"Before we had such a backlog of patients who were in the emergency department, often because of asthma patients," says Rosemery Williams, manager of pulmonary services for the hospital. Asthma patients "would come in with shortness of breath or chronic lung problems. They often didn't have a primary care doctor, and would use the emergency department as a drop-in clinic" she says.
The new clinic "has significantly reduced wait times and has enabled asthma patients to be treated before a significant emergency," says Williams.
With its ED triage system, the hospital quickly treats asthma patients and provides immediate assistance to those experiencing attacks. The patients needing assistance go to the asthma lounge, which is located within the ED and includes two beds and two lounge chairs and is staffed 24 hours a day. Nurses and respiratory therapists, often using nebulizers, work to relieve the asthma attacks.
An education component is considered important to the program because patients need to "recognize the symptoms of asthma. Some patients who have asthma don't realize they need urgent care," says Brandy Burrows, ACMC's director of respiratory care services.
Under the education plan, patients learn the triggers of an attack and when there is a need to start treatment, and then they begin to establish a sensible relationship with a primary care physician. It improves and speeds up the process, she says. The hospital expects to expand its coverage in the asthma lounge. "This has been a safety net, and now with the recession more people are coming in, and it's more important than ever," Burrows says.
Success Key No.3: Pharmacists in ED
By having pharmacists in the ED to review high-risk medications prepared for patients, Sarasota (FL) Memorial Hospital has achieved better patient outcomes and reaped substantial savings in pharmaceutical costs, according to Deborah J. Larison, PharmD, CPh, clinical pharmacy specialist
and toxicology/emergency medicine director for the 806-licensed-bed hospital system.
"Most EDs across the nation don't have pharmacists. They have a central pharmacy that processes orders, and have limited hours," says Larison. "By having the ED pharmacy, we head off potential problems before they occur. We can clarify patient allergies for physicians and determine cross-sensitivity to avoid adverse reactions."
Pharmacists are assigned around-the-clock to the Sarasota Memorial Hospital emergency department. "From a business perspective, it enhances the patient care and there are overall decreased costs," Larison says. Pharmacists have reviewed drug supplies in the hospital and there have been reduced costs in budgets when it was determined some pharmaceuticals were not needed as much as others, she says.
"We actually saved money by significantly decreasing the amount of drugs we don't use," Larison says. "If we can intervene at the outset, that is the best choice for better outcomes."
Although Sarasota officials are still compiling revenue figures on pharmacists assigned for the ED, studies conducted for the American Society of Health-System Pharmacists, show significant savings for hospitals, Larison says. In one of the largest studies, in 2003, pharmacists participated over a four-month period in the care of 1,042 patients triaged in the ED, and 2,150 pharmacist interventions were documented—which included recommendations for drug adjustment, alternative drug therapy, drug compatibility, and other issues. The overall savings amounted to about $1 million, according to the study.
The ASHSP has recommended that every pharmacy department provide the ED with pharmacy services to ensure safe and effective patient care. Only a small percentage of hospitals now have pharmacists in the ED, but the numbers are growing, according to Larison.
The idea is "to assist the physicians and nurses and enhance the care of the patients," she says.
Success Key No. 4: Videos for emergencies
Pediatric emergency and critical care physicians at UC Davis Children's Hospital use videoconferencing with patients and physicians and 10 EDs in rural and underserved areas of Northern California. The program has been found to improve diagnostic and treatment processes, while likely resulting in cost savings, better quality of patient care, and increased family satisfaction, says James Marcin, MD, director of pediatric telemedicine for the Center for Health and Technology at the 110-staffed-bed UC Davis Children's Hospital.
The enhanced video technology allows UC Davis to offer expertise to rural healthcare facilities that typically have less access to pediatric subspecialties. Rural EDs may lack the resources to adequately assess and optimally treat acutely ill and injured children, Marcin says.
Using high-speed data linked to video units at the UC Davis Medical Center, outlying California hospitals and clinics, physicians, and patients can have a live interactive connection with a UC Davis specialist by simply dialing the specialist and seeing him or her on video.
The program also provides these remote EDs with standardized triage protocol, laminated reference cards, and periodic pediatric critical care training in an effort to increase physician knowledge and improve consistency and quality of care.
Marcin says the program is especially important for rural areas with geographical barriers, such as those in or near the northern Sierra Mountains. Specialists can't simply fly into certain areas quickly to provide care, but they are able to connect with the video unit, he says.
"Often, it is very difficult to drive a patient many miles to see a specialist," Marcin says. "Telemedicine is a key to access a specialist who can assist in a diagnosis and offer the best possible treatment plan for a patient."
Rural EDs are less likely to have access to pediatricians, pediatric subspecialties, and ancillary services. An Institute of Medicine study found that children account for 27% of all ED visits, but only 6% of EDs in the United States have the necessary supplies for pediatric emergencies, Marcin says.
The hospital also has a "family-link" program that helps families stay connected when a child is hospitalized. Using a special camera and phone unit, the link lets parents see and talk with children in a hospital.
Besides handling emergencies, the UC physicians provide specialty and intensive care consultations. The result has been higher patient satisfaction scores, Marcin says. UC Davis is evaluating patient satisfaction, but records show that a majority of families consider telemedicine extremely important, he says.
Overall, telemedicine can be a solution to the projected physician shortage problems, Marcin says.
It was a fateful meeting of the Baptist Health executive board in May 2003, when the panel adopted an "economic conflict of interest" policy.
At that time, the Baptist Health system, the largest in Arkansas, began a strange, winding journey to nowhere, when it decided that physicians couldn't be part of their establishment if they dared work at a competing hospital in the state.
With its decision, Baptist Health also targeted physicians' family members and relatives. If these relatives of the hospital physicians also worked at other hospitals, the Baptist physician would lose his job, a representative of the Arkansas Medical Society told me. Records filed before the Arkansas Supreme Court confirmed what he said.
The hospital threw down the gauntlet. A big mistake.
After six years of litigation and untold dollars spent on litigation, Baptist Health lost its legal gamble. Arkansas's highest court opinion ruled on September 30 that Baptist Health couldn't deny physicians' privileges if they are financially invested in a competitor.
The court acted on appeals from a lawsuit brought against Baptist Health by a group of 12 physicians, the American Medical Association as well as the Arkansas Medical Society. The decision upholds last year's lower court decision that found Baptist Health had acted improperly by inappropriately restricting hospital admitting privileges and interfering with the patient-physician relationship. Baptist Health apparently was feeling the heat of competition with new healthcare facilities in the Little Rock area and didn't like that one bit. The health system runs the 248-bed Baptist Health Medical Center in North Little Rock and other facilities. But the health system lost track of what the court said was the "heart of this case"—the "patient-physician relationship.
The "strong patient -physician relationships are the underpinning of good medicine," the Supreme Court stated. "It was controverted at trial that patients who have long term relationships have better success."
In the wake of the Supreme Court decision, David Wroten, executive vice president of the Arkansas Medical Society, says gleefully that it has national implications. "The ruling has implications not only for the economic credentialing tool used by some hospitals to interfere with doctor-patient relationships in a knee-jerk reaction to protect themselves to prevent competition in the marketplace."
Credentialing decisions should be within the context of the medical staff, involving competence and quality, and relationships with patients, says Wroten. "But this policy was not up to the medical staff."
The hospital's economic credentialing policy has precluded a physician from working at Baptist hospital "if that physician, or any of several specified family members, holds an ownership or investment interest in any other hospital in Arkansas."
The Baptist policy that blocked family members of physicians from working at competing facilities was particularly a cause for dismay, Wroten says. It was too extreme, he adds.
Baptist Health was trying to force patients to choose between it and the physicians, according to the American Medical Association. The state high court's decision showed the physicians' interest in patient-physician relationships outweighed Baptist's interest in protecting its economic position, Wroten says.
Physicians and their families were deeply affected by the Baptist Health policy decision made in 2003. Several years ago, Janet Cathey, MD, an Arkansas gynecologist, became a "glaring example" of the alleged wrongs that Baptist had wrought, Wroten says.
According to the AMA, Baptist Health several years ago sought to terminate Cathey's staff membership because "her husband, who was also a physician, owned an interest in (Arkansas Surgical Hospital), a competing facility." Cathey sued the hospital, and ultimately Cathey's husband a neurosurgeon, sold his interest in the surgical hospital, which opened in 2005.
"Although Dr. Janet Cathey could not have referred her patients to (Arkansas Surgical Hospital) because ASH does not provide gynecological services, Baptist Health informed Dr. Cathey that it would revoke her privileges pursuant to the policy on the day ASH opened," according to court papers filed by physicians opposing Baptist. She dropped her lawsuit and Baptist Health agreed not to contest her position.
When the Baptist board passed the restrictive policy in 2003, one of the plaintiffs, Bruce Murphy, MD, had an appointment to the Baptist Health board that was to expire in February 2004, according to the court records. At the time, Murphy, a cardiologist, owned 14.5% interest in Arkansas Heart Hospital as well. The Baptist Health policy prohibited him from the ownership.
If the Arkansas Supreme Court ruled in Baptist Health's favor, Murphy, president of a cardiology clinic,told the Arkansas Democrat-Gazette, "It would have allowed patient care to have suffered because the (policy) potentially gives the hospital the authority to interrupt that care."
A spokesman for Baptist Health also told the newspaper the policy is no different from conflict of interest policies at other companies. In the statement to the newspaper, spokesman Mark Lowman said, "Baptist Health believes that it has an absolute right to a conflict of interest policy that denies privileges to a physician to an ownership interest in a competing hospital." Baptist Health was deciding what the next step would be.
His statement addressed only the employed physicians, not relatives.
Next step? U.S. Supreme Court? Will that be a waste of money?
Money, however, seems to be an extremely significant issue here. Baptist Health has said it was concerned that owners in specialty hospitals would "cherry pick" the most profitable patients.
The Arkansas high court acknowledged the economic issues, but said Baptist Health was wrong. "While society has a strong interest in Baptist's continued viability, the evidence showed that its finances were never at risk. These factors, and others, led to the judge's ultimate finding that Baptist had acted improperly," Associate Justice Ronald Sheffield wrote in the opinion.
When physicians have admitting privileges at multiple healthcare facilities, patients benefit, Cecil Wilson, MD, president of the AMA said in a statement.
"Free of Baptist's restrictive policy, physicians can now offer patients the benefit of choosing a facility that best suits their needs for cost, quality and convenience," he said.
Unfortunately, Baptist's unwise policy also came at a cost to physicians, and ultimately, to the hospital itself.
The poor diet and exercise habits of Americans are well chronicled, and will likely continue despite the growing clamor for wellness programs as bloated healthcare costs teeter on the budgetary scale of the country.
A study, "Do Providers' Own Lifestyle Habits Matter?" from the University of Michigan Health System's Department of Internal Medicine and published in Preventive Cardiology, only adds to the discussion, looking at physicians themselves not only in terms of their own wellness, but how they convey information about exercise and eating to their patients.
The conclusions could give a person indigestion. Young physicians, possibly overwhelmed by their workloads, seem to opt more for fries than veggies on their dinner plates, and are less likely to exercise than older physicians. In addition, many physicians lack confidence in their ability to counsel patients regarding lifestyle concerning exercise and diet.
So while we are spending millions of dollars on wellness programs, doctors lack the confidence to influence their patients about weight or exercise habits.
With an estimated two-thirds of Americans overweight or obese, the "ability of healthcare providers to counsel patients regarding lifestyle factors such as obesity is imperative," the study states. Key word there: Imperative.
Meanwhile, the issue of physician health is the subject of growing concern throughout the world. Because of its importance, the American Medical Association is joining the British Medical Association and the Canadian Medical Association in sponsoring an international conference beginning this weekend in Chicago on ways to help physicians achieve a "work-life" balance.
"Striking a balance between caring for patients and maintaining personal health is one of the most difficult tasks physicians face, but it's imperative physicians make their health a priority for themselves and for their patients," AMA President Cecil Wilson, MD, said in a statement.
As researchers at the University of Michigan Health System have found, taking care of their own health and getting that message across to patients has not always been a physician priority, at least in terms of eating and exercise.
"Talking to cardiology fellows, I just find they are not as attuned to healthy lifestyle behaviors, and sometimes they don't get the training they need," says Elizabeth A. Jackson, MD, MPH, a cardiovascular specialist at the University of Michigan Health System and co-author of the study, referring to internists who were studied. "Often they are busy, just grabbing food on the go, and they are young, too. But their lifestyle habits change over time, and health is thought about in a different way, by older physicians."
The study focused on physicians and physician trainees at the University of Michigan Health System regarding their personal lifestyle behaviors. As defined in the survey, physicians were categorized as internists, family practioners, endocrinologists, and cardiologists. Physician trainees included residents from internal medicine, family medicine, and preliminary year interns.
. Among the findings:
Trainees were more likely to consume fast food and less likely to consume fruits and vegetables than attending physicians.
Attending physicians were more likely to exercise 4 or more days per week and more than 150 minutes per week.
Attending physicians were more likely to counsel their patients regarding a healthy diet (70.7%, vs. 36.3%) and have regular exercise, (69.1% vs. 38.2%), compared to trainees.
Generally, however, "few physicians were confident the ability to change patient behaviors," the study states. Only 10.8% of trainees and 17.3% of attending physicians reported "high self efficacy" for changing patients' diet related behaviors, according to the study.
Both trainees and attending physicians reported low levels of fruit and vegetable consumption and relatively "low levels" of exercise. About 9.8% of trainees and 39.5% of attending physicians reported exercising 4 or more days per week
.
If physicians' exercised, however, they were more likely to be engaged in counseling patients. Their own dietary habits did not seem to play a role in how they counseled patients in what to eat.
And here's an interesting twist: While trainees or attending physicians were not confident in their ability to change patients' behaviors, the overweight physicians seemed to do better at it. According to the study, more than 20% of trainees and 27% of attending physicians were overweight.
The study noted that overweight providers were "associated with increased frequency of counseling patients regarding exercise."
Indeed, physicians who are overweight often can be more effective at counseling patients because they know what they are going through, Jackson says.
"If you are trying to go out there to exercise everyday you are going to know what it's like to have barriers, you can understand where they are coming from by relating and understanding," she said.
Previous studies on smoking also showed that physicians who smoked and who considered quitting themselves were more likely to counsel patients on smoking cessation, Jackson noted.
Too often, however, as the study suggests, physicians "don't have the time or training to be effective at counseling patients," Jackson says. The study noted that 12.7% of trainees and 23.5% of attending physicians "agreed that they had received adequate training in counseling on diet."
Jackson says more work needs to be done to understand the issues underlying physician and payment communication regarding exercise and healthy eating.
"There are a lot of physicians who have similar issues to patients regarding diet and exercise," she says. "We can acknowledge this to patients and recognize that we know it's not easy to change behaviors."
For many medical school students, going through the educational process is a grind, and exceedingly difficult. But once they overcome hurdles in the fourth year, they are ready to go on to new levels, with their dream of practice becoming an evolving reality.
For students who are depressed, however, the potential difficulties of medical school are not only exacerbated, but also often put under wraps. Students may not want to talk about the extreme pain or sadness, or even concede the presence of their depression, because doing so reveals some cracks in their armor, meaning they aren't supermen, or superwomen, after all.
If you are a budding superman, why exposing yourself to Kryptonite?
That's what University of Michigan medical school researchers have found, saying that medical students who are depressed often don't bother confronting the situation. And the researchers say that medical students battling depression also fight a nagging stigma toward depression and concede a belief that colleagues and instructors have little use for it. So they stash their collective mental anxieties in a closet. As a result, they don't seek treatment when they should.
As Thomas L. Schwenk, MD, chairman of the University of Michigan family medicine department, sees it, something is very wrong with this picture, especially since it relates to the world of doctors, who are in the healing business, but too often not the business in healing themselves. Schwenk was the main author of the study, "Depression, Stigma, and Suicidal Ideation in Medical Students," in the Journal of the American Medical Association, which showed that 53.5% of medical students who reported high levels of depressive symptoms were worried that revealing their illness would be risky to their potential careers. In addition, about 62% who were depressed said they believed asking for help would mean their coping skills were not what they should be. The study's co-authors were Lindsay Davis, B.S. and Leslie A. Wimsatt, Ph.D. all of U-M Medical School.
Students feared they would be "viewed as less than adequate, that they would be viewed as less able to handle their responsibilities by faculty members, and that telling a counselor about depression would be risky," the study states.
Schwenk says the difficulties involve an "atmosphere and culture" that must be changed. It is no easy task, he admits. The problems are woven in and around a budding physician's sense of duty, a false sense of invulnerability, coupled with a lack of understanding about their depression and its impact on themselves and the reaction of others around them.
Overall, "there is this extreme sense of professional duty," he says. "Physicians will work while they are sick. They know everything, they can never be vulnerable, can never show any deficiency."
Of course, strong professional obligations are essentially good, he says. "But it gets carried way too far."
The study showed 14.3 % of the students reported moderate to severe depression, which is higher than the 10 to 12 % usually found in the general population, says Schwenk. "These results show that students who are depressed feel highly stigmatized by their fellow students and faculty members," says Schwenk.
The report findings suggest that there is a perception by depressed students that "they are in fact viewed as less capable." It adds: "The findings may reflect a medical school environment in which depressed students are stigmatized because of their disease rather than on the basis of performance. In such an environment, revealing depression to friends, faculty members and residency program directors could have real and adverse consequences."
Inevitably, students with moderate to severe depression are concerned that fellow students would respect them less, Schwenk says.
One of the problems of the study is the mix of perception and reality, Schwenk concedes. "Perception is reality: whether the students who are depressed just view their environment more negatively, or think other students are stigmatizing them—it doesn't really as much as students believe it."
Another significant problem is that there appears to be hesitancy on the part of colleagues to reach out and help their peers, says Schwenk. "Why is that we as physicians have a hard time reaching out and helping our colleagues? Is it because we are all scared—a there-but-for-the-grace-of-God kind of thing?"
From a patient's perspective, the study shows that medical students may have some intolerance toward patients with depressive symptoms, says Schwenk.
"If medical students are critical of each other about depression, how does that transfer to patients? We don't want the medical education experience to make them less tolerant of mental illness."
The study needs to be addressed by medical schools, and further research needs to be done, he says. "We want to provide a medical education environment in which depression is treated like any other medical problem, worthy of treatment, detection and prevention," Schwenk says. "Most importantly, we want the medical students to be comfortable seeking help. Somehow we have to change the environment in which we are teaching future physicians."
Stigma over any mental illness "seems to be lessening among the general public," Schwenk says. For the medical profession? It seems certainly to be "lagging behind," he acknowledges.
Boost the number of primary care physicians: It's a refrain we hear repeatedly in the healthcare reform debate.
A new study from the Dartmouth Atlas Project adds another layer to the debate. But here's the rub: the study authors don't expressly call for more primary care physicians. Numbers alone won't do the trick, they say. The study says neither higher amounts of primary care services nor routine visits with a primary care clinician is by itself a guarantee that a patient will get recommended care or experience better health outcomes. What works? Coordination of care, the authors say.
"As is often the case in health care—it's not always how much you spend, but how you spend it," says one of the study's co-authors, Elliot S. Fisher, MD, MPH, co-principal investigator for the Dartmouth Atlas Project. The Dartmouth Atlas Project is run by the Dartmouth Institute for Health Policy and Clinical Practice.
The study, Regional and Racial Variation in Primary Care and Quality of Care Among Medicare Beneficiaries, examined the relationship between the per capita supply of primary care physicians and the percent of Medicare beneficiaries who had at least one annual visit with a primary care physician during 2003-2007. It "suggests that there is no correlation between the supply of physicians and access to primary care," according to Fisher.
"Achieving the benefits of primary care is likely to require both improving the services provided by primary care physicians and more effective integration and coordination with other providers," the study says. "A higher supply supply of primary care may be important in smaller areas, but unfortunately, public policy and reimbursement practices have not matched patient needs with supply at any level, local or regional."
In a study of fee-for-service Medicare population from 2003-2007, the study points out that improving access to primary care doesn't always keep people with chronic conditions out of the hospital, or improve their chances of getting optimal care. Those conditions include diabetes, and congestive heart failure, as well as screenings for breast cancer or eye examinations, and leg amputations.
Access to primary care physicians also may not be enough to overcome racial disparities in quality and outcomes, the study says. Too often, people most in need of primary care simply don't receive the necessary care as well, according to the authors.
"Primary care is the bedrock of a good healthcare system, but this report is saying just having more primary care will not necessarily fix our quality of care," says another co-author, Shannon Brownlee, MS. Other report authors are David C. Goodman, MD, MS and Chiang-Hua Chang, PhD. "It means that healthcare policy should focus on improving the actual services primary care clinicians provide, and make sure their efforts are coordinated with other providers, including specialists, nurses and hospitals."
While improving care delivered by primary care clinicians holds promise for a patient's wellbeing, the "value of primary care can be eroded by episodic delivery that is uncoordinated with specialists and hospitals," the study says. "Thus, simply increasing access to primary care, either by boosting the number of primary care physicians in an area or by ensuring that most patients have better insurance coverage, may not be enough to improve the quality of care or health outcomes; nor is it likely to eliminate racial disparities."
Brownlee, a writer and senior research fellow at the New America Foundation, says she was surprised by the findings. "I think part of what is happening is the chaos factor"—primary care physicians working in isolated practices, with a lack of coordination with specialists, such as for diabetes or other medical conditions, she says.
"Was the heart attack patient prescribed aspirin and a beta blocker on discharge?" she asks rhetorically. Sometimes, or too often, that doesn't happen because of the lack of coordination, Brownlee says. "It is really crucial to keep track of a patient. If the patient only knows what is happening, you've got a big problem." Brownlee is a specialist in healthcare writing and has written "Overtreated: Why Too Much Medicine is Making Us Sicker and Poorer."
In essence, the Dartmouth study shows that "organization of the system is a big part of the problem," Brownlee says, adding that "simply throwing more physicians at a problem is not going to fix it."
"With lots and lots of specialists, it becomes more and more difficult for that primary care physician to really keep track on what is going on," she says. "We see simple stuff fall through the cracks, the more chaotic the care is."
So, there's the need for coordination of care, she says, more than ever. In some variations, we've heard that before, in the calls for Accountable Care Organizations. Fisher, known as one of the innovators of ACOS, wrote in Health Affairs in 2009 his proposal to "achieve more integrated and efficient care by fostering local organizational accountability for quality and costs through performance measurement and "shared savings" payment reform."
With this study, Fisher, Brownlee and their colleagues again are calling 911: coordinated care is needed now.
Lots of people fear visiting the doctor's office for a variety of reasons, among them not wanting to deal with potentially uncomfortable situations, bad news, for instance.
And doctors, what do they fear?
The judge's gavel, for one thing. A recent report in Health Affairs is a reminder how physicians say the threat of malpractice lawsuits forces them to practice defensive medicine, which in turn raises the cost of healthcare by reinforcing needless procedures. This has been a constant over the years, and not exactly startling, as one of the authors, James D. Reschovsky, acknowledged to me.
But Reschovsy, a senior health researcher for the Center for Studying Health System Change, says what is surprising is that it appears to make not much difference in states where there is tort reform their fear of malpractice remains.
The report, "Physicians' Fears of Malpractice Lawsuits Are not Assuaged by Tort Reforms," says that there were high levels of malpractice concerns even when risks are relatively low. Reschovsky reported on the study along with Emily R. Carrier, Michelle M. Mello, Ralph C. Mayrell, and David Katz that individual physician concerns' about their own malpractice risks are pervasive and vary across specialists.
The report is among three published as a themed issue co
ntaining several articles exploring controversial topics of medical mistakes, malpractice lawsuits, and their defense and the patient-provider atmosphere that can provoke them, as Cheryl Clark of HealthLeaders Mediawrote on Sept. 7.
The price tag for malpractice liability and defensive medicine comes to $55.6 billion a year, or 2.4% of healthcare spending, far lower than the American Medical Association's estimate of between $70 billion and $126 billion.
Still, we're talking billions of dollars. I talked to Reschovsky, focusing on the fear of malpractice that he targeted. In the study by Reschovsky and his colleagues, they say the "results raise the possibility that physicians' level of concern reflects a common tendency to overstate the likelihood of 'dread risks'—rare but devastating outcomes—and not an accurate assessment of actual risk."
To deal with litigation and its impacts, various states have adopted tort reform, some more effectively than others. The reforms include changing the way malpractice claims are addressed, including caps on various types of damages, as a way to respond to existing levels of overall practice risk, according to Reschovsky.
Yet, in the end, "many policies aimed at controlling malpractice costs may have a limited effect on physician malpractice concerns," Reschovsky and his colleagues state.
The physicians' attitudes, despite different state responses to malpractice, "were incredibly surprising," Reschovsky says. "Doctors are very fearful of malpractice, irrespective of the objective risk they face," he says.
There were variations in concern across specialties, physicians generally thought to be at higher risk for malpractice claims, such as emergency physicians and obstetrician-gynecologists—expressed greater concern.
"For physicians, the idea of being sued is a great affront, emotionally, hassle-wise, and financially for that matter," Reschovsky adds. "No one wants to be accused of doing harm. Most doctors do their jobs and want to help people."
That is certainly true, and the weight of potential lawsuits is a shadow that physicians try to live with, or elude. The fact is in the proverbial litigious society; nearly anyone in the world invites potential litigation, especially those in the public world, including journalists. In the 1980s, I wrote an investigative piece about a businessman, who later sued the newspaper I worked for, claiming damages, but a jury dismissed the civil lawsuit as invalid.
I wasn't named in the lawsuit, nor was I a defendant; the newspaper was. But the continued presence of the lawsuit, the shadow of the plaintiff's accusation, was an endless stream of constant worry and stress for me. I'll never forget when I asked our lawyer if he thought I would have to testify. "Oh sure," he said cheerfully, "We can't have Hamlet without Hamlet." Thanks, Mr. Attorney, I said.
As a young reporter, in the end, I learned many lessons, including the fact that what you do, even if you feel you are so right, in your motivations and outcome, can certainly be tested in a court of law, with the end result never certain. For at least a month, even after the case was resolved successfully, I felt the most significant journalism I truly wanted to write about was about parades, or Easter egg hunts. Basically, I didn't feel like doing my job; that was my internal defense against potential litigation.
For physicians, defensive medicine is often their barrier against litigation, but it probably isn't the best idea. Although analysts disagree about the scope and cost of defensive medicine, physicians "consistently report they often engage in defensive practices out of fear of becoming the subject of a malpractice lawsuit," according to Reschovsky and his colleagues.
In another Health Affairs report, by Harvard law and public health professor Michelle Mello, associate professor of surgery Atul Gawande, MD and others, it was estimated that defensive medicine was extremely costly, in terms of overall healthcare costs, making up $45.6 billion per year.
Ironically, the fear of litigation may compromise physicians' ability to communicate effectively with patients, particularly in disclosing medical errors. Translation: it affects physicians doing their jobs.
While defensive medicine has been practiced for years, it is a particular problem in healthcare reform, Reschovsky and his co-authors write.
Under healthcare reform, financial and organization changes have introduced new sources of stress for healthcare providers, sharpening their demands for liability reform in exchange for their support for other health reform measures, they write.
And the mere presence of defensive medicine poses a liability risk that is an "obstacle to health reform's ambition of moving physicians toward more cost-effective care," according to the authors.
Referring to the fear of malpractice report, "I think it has important policy implications in terms of how we go forward in terms of reforming malpractice laws," Reschovsky says. "The fundamental way of reforming the system is take it less confrontational. The malpractice system does serve a public benefit, in terms of motivating physicians to stay at the top of their game and making the patient whole for when bad things happen."
"There are some models out there that would take resolution of the malpractice claims out of the court system and make it something more like workers' compensation," he says.
Dealing with the issue is extremely important to reduce costs in healthcare reform because "if physicians are fundamentally fearful of being sued they'll still order that extra test," he says.
Sometimes what President Franklin D. Roosevelt said in his first inaugural address about economic struggles at the time may be important to remember in the battle inside our own heads in dealing with potential litigation. "The only thing we have to fear is fear itself," the president said in 1933 about the U.S.
I reached Bruce Siegel, MD, MPH, on his cell phone as he walked in Washington D.C., and in our 20-minute conversation, we probably used the term "safety net" more than any other, referring to the far-reaching oversight of the National Association of Public Hospitals and Health Systems where he is incoming CEO.
Oh, those safety nets, tattered and torn: amidst economic recession, budget cutbacks, and many more patients in need. Dr. Siegel, are the nets going to hold?
Well, maybe. Surely if Siegel has his way, the safety nets will definitely hold, and become stronger, but there is a long journey ahead and he's just beginning. He is soon to become head of the group that represents 140 metropolitan hospitals and health systems under the NAPH umbrella, which provides "high volumes of care to low income people, the uninsured, the underserved, regardless of ability to pay." In taking his new position in October, Siegel will become the first African-American to lead a major hospital association and, in his words, be a "tireless advocate" for safety net hospitals.
Siegel comes to NAPH from George Washington University School of Public Health and Health Services, where he served as director of the Center for Health Care Quality and as professor of health policy at the George Washington University School of Public Health and Health Services.
"It's exciting and it's a little intimidating," Siegel told the GW Hatchet, the campus paper. "The only thing I can say is I'm going to do the very best job and I'm going to do it for the patients.
Siegel says one of the biggest tasks he faces is the challenge imposed by the upcoming 23 million Americans who potentially may join the health insurance rolls in the wake of healthcare reform. While expanding health insurance is terrific, the access won't be enough, he says. Unless there are available doctors for them in the community, Siegel says, noting the lack of primary care physicians, for instance, it's not going to mean much.
"We have to do a lot more than just give people an insurance card," he says. Look at Massachusetts; "a card isn't enough," he adds.
The strain on the safety net could become overwhelming, he acknowledges, with thousands more turning to emergency departments, and the lack of primary care physicians. For many of the poor, and currently uninsured, they see their main option for care as the ED, Siegel says. "They either don't know about the alternative, or the alternative isn't there," he says, referring to a family physician, for instance.
Educating patients is extremely important, and will become an essential part of the evolving NAPH framework, he says, especially for those patients who speak little English or have English as a second language.
"We have a small window to get ourselves ready," he says referring to the potential influx of the uninsured into the healthcare system. "We have insured who have chronic diseases, and (healthcare) systems are fragmented, and overwhelmed."
Siegel is a polite, dignified man with a gentle demeanor. But as he says, one of his biggest roles will be that of lobbyist for the hospitals. The need is dire.
According to an August NAPH report, "Safety Net Health Systems: An Essential Resource During the Economic Recession," member hospitals have reported a 17% increased in uncompensated care costs, on an average member basis, compared to the beginning of the recession, averaging more than $4.6 million per member, with some incurring more than $30 million in additional costs. These health systems also have treated up to 15% more uninsured and Medicaid payments at a time when states are facing large budget shortfalls. An addition 23% more uninsured patients have been treated under the "safety net" since the beginning of the recession, the report states.
"America's public hospitals are in a precarious situation and Medicaid cuts at the state level will hinder their ability to continue serving as our nation's health care safety net, the impact will weaken the fragile viability of the nation's safety net and force public hospitals to close their doors due to inadequate financing," Larry S. Gage, the NAPH President, has stated."
Siegel is joining the association, says Gage, with a certain degree of understatement, at a "very challenging period."
Last month, the Wall Street Journal reported that public hospitals owned by the government are "drowning in debt caused by rising health-care costs, a spike in uninsured patients, cuts in Medicare and Medicaid and payments on construction bonds sold in fatter times."
Siegel is no stranger to the healthcare maladies facing urban areas, in particular. Siegel had been president and CEO of two different NAPH members: Tampa General Healthcare and the New York City Health and Hospitals Corp. He was also a health commissioner in New Jersey.
Siegel isn't afraid to cause a stir, either. As the GW paper noted, the university's Department of Health Policy under Siegel's leadership "made waves in the healthcare community with its research on minority health care and the reaction of a public rating system of healthcare providers.
"The biggest contribution we've made to research is that we've shown that hospitals and doctors who treat large numbers of minority Americans can really improve the quality of care they provide," he told the campus paper.
Siegel will be applying that social consciousness as he evaluates medical home programs, electronic record innovations, and other "best practices," he says, to improve the standing of the public hospitals.
"A big part of my job will be getting to the policy makers on the Hill, and the executive branch. I have a story to tell." As for being an African-American, "others can decide if that adds to my story or not," Siegel says, quickly adding that civil rights issues are often woven into healthcare issues.
Once he assumes his new post, Siegel won't be walking around Washington D.C., though. "I'll be traveling around the country, telling the story how critical it is to support (public hospitals) and millions of people are dependent on them every day."
"Health reform may have passed, but our work is just beginning," he says.
The article was about Diana Williamson, MD, who allegedly wrote nearly $1 million in prescriptions paid by Medicaid for 11,000 Oxycontin, Percocet, and generic oxycontin pills that were sold in a fraud scheme, authorities said. Eight others were involved in the alleged plot.
It was another sad tale about a doc allegedly gone bad. The small item intrigued me. Williamson is 54 years old, undoubtedly a doctor for years, I figured. There must be an arc to her story, I thought.
Indeed, there is an arc to Williamson's story, as the New York media swarmed around Williamson's unlikely tale. For Williamson, dubbed the "boss" in the alleged drug dealing scheme, is a physician who spent years working with AIDS patients, and helping—yes—drug abusers stop their behaviors. The irony is thick, but we've seen and heard it before, almost to the point of being a cliché: someone who fought so hard against drug abuse is now allegedly entangled in the illicit trade.
It's not the norm, of course, but each of these over-the-edge stories has its own special meaning. No wonder there has been shock that Williamson was arrested and why. In New York, Williamson gained fame in 1998 as an advocate for AIDS patients and drug abusers when Crain's New York described her as one of their "40 under 40" rising stars. Crain's New York Business.
That year, in a story about HIV users, the New York Timessought her out to talk about her involvement with AIDS patients, and the problems of drug abuse. Then medical director of Harlem United, a nonprofit advocacy group for people with AIDS, as well as a clinical research fellow at Mount Sinai Medical Center in Manhattan, she told The Times of what she knew on the streets, saying "it's a world unto itself and (people) don't get respected the way they should."
When she was profiled by Crains, Williamson discussed respect, in terms of those abusing drugs. "My thing is, don't look down on the drug users; don't judge them," Williamson said. "They deserve care."
Respect and care, it's all true what she says about people battling drug issues. But with what authorities allege now, the woman who was among the "40 under 40" rising stars to watch in New York faces the prospect of 20 years in prison if convicted of the charges against her.
She and other defendants are charged with one count of conspiracy to distribute and possess a controlled substance, with also carries a maximum penalty of $1 million. Williamson and another co-defendant are also charged with one count of conspiracy to commit healthcare fraud, which carries another multi-year prison term.
Williamson's attorney, John Marks, could not be reached. Officials of the Citicare Inc., a medical clinic where she recently worked, declined to discuss her case.
The contrast between the Crain's article and the U.S. Attorney's complaint from the Southern District of Manhattan could not be starker.
In the profile of her in 1998, Williamson was quoted as being passionate about her work with drug users who had AIDs. She talked about her techniques in helping patients, and the article noted, "her approach works; less than a year into her tenure, many clients are drug-free."
The recent Department of Justice statement alleged that Williamson's world was anything but drug-free.
Williamson allegedly wrote oxycodone prescriptions to patients who had no legitimate need for the medication, while a co-defendant recruited people to obtain prescriptions from her, between September 2009 and August 2010. The other co-defendants worked as resellers, providing the prescriptions to third parties, according to prosecutors.
In one instance, Williamson was in her Manhattan office, and asked for a blood sample from a patient, who unbeknownst to her was an undercover agent. The agent indicated a fear of needles. So, according to prosecutors, Williamson drew blood from another person, put the undercover agent's name on it, and then wrote a prescription for 120 Oxycontin 80 mg pills, according to U.S. attorney's complaint. Williamson was paid $1,500. Each pill was valued at between $30 and $40 on the street.
In an FBI wiretap, another defendant told Williamson over the phone, "everything would be fine" following one alleged deal. Williamson responded by telling the alleged co-conspirator to "hide the money" inside a car, the complaint states.
It wasn't "fine", according to the U.S. Attorney's Office. "The oath to 'do no harm' is turned on its head when a doctor's prescription pad is used for drug dealing," New York Police Commissioner Raymond W. Kelly said in a statement.
Williamson is now free on $250,000 bond. Among other things, authorities ordered her to relinquish her prescription pads.
One of the joys of being a physician is simply doing what you do: the details of sorting through the complexities of ailments, evaluating medications, exploring the sinew of the body, the interwoven lines that carry the blood, saving a life.
Sometimes the business of what you do gets lost in the hubbub of money, and politics, and healthcare plans, but it’s nice to think about the purity of being a physician: and maybe being part of something that pushes you further into evolving realms of the science of what you do. Or at least spur some debate.
Like the place where Dimitri Karmpaliotis, MD, seems to be right now.
At 39, he is an interventional cardiologist at Piedmont Heart Institute, in Atlanta, GA, where he performs retrograde and antegrade angioplasty, loves it, and sees it expanding in the future in cardiac care. It is for the treatment of complex chronic total occlusion (CTO), and has been dubbed by some academics as being in the “last frontier” of cardiac intervention. Chronic occluded arteries account for 20 to 30% of coronary diseases, experts say.
Karmpaliotis’ specialty is maneuvering the arteries, declogging them with wires and a specificity that he says can be a major tool to help potentially hundreds of thousands of people. These are patients who, for example, had already undergone one bypass surgery operation, and their bypass grafts are failing and need more intensive doctor's care.
Piedmont Heart Institute is only one of about a dozen hospitals nationwide that perform more than 20 retrograde angioplasty cases a year for the treatment of CTO.
It’s an interesting time for Karmapliotis’ field. Piedmont, for instance, is considering doubling its CTO treatment at a time the treatment strategy has not been fully embraced in the U.S., although academic journals note considerable advances, with some criticism. The procedure is extremely popular in Japan, where it is considered home to the foremost experts in retrograde and antegrade angioplasty.
In June, Karmpaliotis was one of five U.S. cardiologists to attend the 2010 Japanese CTO Club conference. Japan is home to the foremost experts in retrograde and antegrade angioplasty. Karmpaliotis says the procedure developed in Japan where patients have been generally reluctant to have bypass surgeries and where cardiologists believe in complete cardiac revascularization.
“In the spectrum of what we do [they are] the most complex, difficult, and fascinating cases,” he says of antegrade or retrograde angioplasty. “One reason it's so complicated is that the artery is closed for a long time, it’s as hard as a rock. If you don’t do it, you don’t get good at it. It’s a different beast than traditional angioplasty.”
For the past four years, Karmpaliotis has devoted much time to the retrograde and antegrade angioplasty, a procedure that can take four times as long as a stent. Since January, he and his team have performed 80 such procedures, with an established success rate of 89%, significantly more than significantly more than the national average of 65%, according to the hospital.
"Developments in guidewire technology, imaging technique, and coronary devices have contributed to the improved prognosis of patients affected by a CTO lesion," according to Current Cardiology Reports, in which "Enhancement in antegrade and retrograde techniques" also result in improved outcomes, the report stated.
Cardiac Interventions Today in 2008 described the strategies for confronting chronic occluded arteries as "conquering the last frontier of interventional cardiology."
The presence of CTOs often result in open heart surgery, though Karmpaliotis believes antegrade or retrograde angioplasty should be considered increasingly as a proper alternative option in carefully selected cases; to relieve a patient, too, of symptoms of angina, shortness of breath or compromised heart function.
In recent years, there has been much debate about the procedure in this country.
In April, Rajesh Sachdeva, MD, Bradley Hughes, MD and Barry F. Uretsky, MD wrote that the retrograde technique has developed into a viable option, as the process continues to evolve, naming their article, in part "The Tale of a Long and Winding Wire." They add, "the retrograde approach for CTO is a relatively new treatment strategy with its attendant complications having not yet been fully appreciated and described."
Karmpaliotis acknowledges that there are skeptics because of the procedure complexities. But he is a firm believer in the procedure as taking on a more important role in the future across the country.
“There has been a lot of scrutiny not just by our peers; (but) the complication rates have been extremely low, almost better than regular angioplasty,” Karmpaliotis says, referring to work at Piedmont.
“For patients with complex CTOs, traditional angioplasty may not be an option, open heart surgery may be risky or undesirable and the medications used for the relief of symptoms may cause side effects,” Karmaliotis says.
“There are hundreds of thousands of patients who had bypass surgery in the past 15 or 20 years,” Karmpaliotis says. “So now we are faced with a problem, patients who had bypass surgery 15 years ago have bypass grafts that are not functioning anymore.They are blocked.”
William D. Knopf, MD, COO at Piedmont Heart Institute and vice president of Cardiovascular Services at Piedmont Hospital, in an interview, praised the “skill set and judgment and passion that Dimitri has.”
“The complexity and time it takes for the procedure is not for the faint of heart,” Knopf says.
Karmapliotis leads a team of specialists who concentrate on the antegrade or retrograde angioplasty. According to Knopf, the hospital hopes to “double our volume in the next six months by adopting the latest technologies and continuing to work with world-renowned specialists in the field.”
Working with other experts around the nation, particularly William Lombardi, MD, based in Bellingham, WA, has been invaluable, says Karmapliotis.
“What he taught us—it wouldn’t have been possible without his leadership,” he says.
“I am convinced there are a lot of opportunities to help people, and there are endless possibilities what we can do with this,” Karmapliotis says.
