In My Own Words
by Flora Bessey, Pharm.D., BCGP
We are in the throes of political season! Each candidate and each party wants to take credit for lowering the cost of insulin to $35 per month. This has been a long standing talking point. A perfect example of this is: after the pandemic, California briefly had a budget surplus. With the surplus funds the state said it wanted to build its own insulin factory to ostensibly compete with the cost that the manufacturers were charging. No prizes for guessing the CA cost to patients; correct, it was going to be $35 per month.

I find this rhetoric to be very funny, and disingenuous, for multiple reasons. First, why are prescribers using insulin to treat patients so often, especially our long-term care residents? The prevalence of type 2 Diabetes is significantly higher than Type 1. Of course, type 1 can only be managed with insulin, but for type 2, we have so many better options. Many are dosed only once per week, and are covered by Part D plans and private insurance. The newer diabetes drugs even help with weight loss, and in many cases have been rebranded as anti-obesity drugs. These same drugs also have significant cardiovascular protective properties.

In My Own Words

by Flora Bessey, PharmD, BCGP

In a “Back to the Future” surreal moment, several San Francisco Bay Area counties are reintroducing mask mandates in health care facilities starting Nov 1. The plan is to continue these mandates through the end of the flu season, which is traditionally March 31 or early April depending upon the severity of the season.

Each county will be responsible for instituting its own mandates, as this is not statewide guidance, which would be administered by the CDPH.

This brings up a significant question:  what are the benefits of a mask often (or usually) used incorrectly versus the downsides associated with obscuring the faces of health care workers who take care of patients and residents?

As it is, nursing home admissions are in decline, and many older patients are choosing to age at home.  Archaic, unproven guidelines like mask mandates will accelerate this trend, and further the reluctance for those who could most benefit from professional, residential long term care.

The greater question is: why are professional organizations not speaking out against these mandates?

At this time it appears the mandates are only for caregivers and not patients, but as we all know, in long term care “guidelines” are often misconstrued and practiced more conservatively.

by KJ Page, RN-BC, LNHA

“Almost everyone dies.”  These were the first words spoken by the physician at the start of the family meeting. 

Working in long-term care, in skilled nursing facilities, let me start by admitting my distress at this statement.  In all fairness, this physician did not know me, or what I do; I immediately gave up hope.

I quietly countered with: “Wow, in California, there is no way out alive, everyone dies.” Not willing to take the lifeline I threw to her, she responded with: “Well, sooner or later they die.”

The meeting went downhill from there.  Rose (I changed her name to represent the flowers she hates but grew with a nearly religious fervor in past years) is 85, diabetic, and now is in end-stage renal disease. She had an advance directive we spent agonizing hours over at a time when she was not in a medical crisis. She was very clear about no dialysis. She made me promise her I would help her get her way when the time came.  Since she lives on the Right Coast and I live on the Left, her son who lives with her gets to be the Agent. I am the second call if he won’t respond or freaks out. She wrote that into the DPOA.

The reason I insisted on this meeting, having flown to the East Coast in a mad dash after getting the 5 am phone call: “Mom was rushed to the hospital with kidney failure. They want her on dialysis and she is saying no. We need you here. All the plans are changing.” 

In the world’s history of pandemics, doctors have taken center stage: as healers, as companions, as chroniclers, and as innovators. Doctors and scientists figured out the germ theory of disease, identified organisms, created vaccines and therapeutics, and advised nations on pandemic response.

In the COVID pandemic, a lot has changed. These changes have upset the entire foundation of medical practice, and yet there is very little discussion about them. I am talking about the disappearance of fundamental ethical principles of medicine, and the substitution of non-medically-based directives and prohibitions. 

Yes, doctors created the COVID vaccines and some new therapeutics, and a few doctors advised world leaders. But the response to this pandemic has been strangely non-medical. Common sense medical practice has been ignored in many instances. Ethical principles have been left quietly by the wayside. Doctors have been enjoined by politicians to treat a disease this way and not that way, and have largely been forbidden to question what is happening, or to assert those ethical principles that, until two years ago, we had all accepted as good and true. And there has been very little push-back by doctors and medical organizations. 

Examples?

“Coming to the finish line of my first 100 miler! Thank you for getting me into this Robert Key!”

I finally wrote my comments regarding the proposed changes to E&M coding, figured I'd share. This proposed change could destroy #Geriatrics and #HPM. Here are my comments:

I agree that the existing CPT coding system is inadequate. However, lumping together four E&M codes into one will have a serious unintended consequence. It will lead to clinicians spending less time with patients. When it comes to the care of older adults, this is profoundly disturbing. The simpler solution would be to pay physicians for the time that they take caring for patients. The risk of abuse of this methodology is very limited, especially because the patients themselves become the auditors! The greatest negative impact of this proposal will be its effect on the care of patients with complex problems, and frail older adults are the most obvious population that could be harmed by this change.

In my PA / LTC practice I have been admitting more young patients with complications of serious obesity.  In recognition of this emerging consequence of our obesity epidemic, our CALTCM Education committee has designed a half-day workshop for our 2017 annual meeting on Bariatric Care.  One exciting aspect of this workshop will be the emphasis on improving the health and wellness of not only our patients with obesity, but also our staff and ourselves.  A number of years ago, I had the privilege of learning motivational interviewing at an AMDA annual meeting under the instruction of Drs. Daniel Bluestein and Patricia Bach.  This has revolutionized how I approach difficult lifestyle problems integral to successful self-management of many chronic health problems like obesity, drug misuse disorders, diabetes, and most chronic diseases.

Two years ago I made the transition from full time Hospitalist to full time SNFist.  I am quite satisfied with this change, for a number of reasons. It is very clear that the changes in the delivery of healthcare will make the post-acute space one of the most highlighted and focused places for improvement in the care continuum.

by Dan Osterweil, MD, FACP, CMD
CEO, CALTCM

Reflecting on the increase in physician burnout and attrition and my own struggle to balance the Industrialization of medicine with the old person-focused compassion, I stumbled upon this article in WSJ,  When Doctors Stop ‘Seeing’ Patients By Abraham M. Nussbaum, which resonated with me by a physician lamenting the loss of humanity from the practice of medicine. I am inspired by the quote of the last line of the Hippocratic Oath: "May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help". He believes, as do I, that "finest tradition of physician physician's calling are those moments when we look patients in the eyes, understand their pain and anxiety and help the resolve, relieve or endure it." That means not staring at the computer screen while talking to our patient in distress and saying everything is fine, but rather listening to the patient's concern who may be far removed from the numbers on the screen."

A recent article in the WSJ (95% of people have genetic variations that affect if a drug will work for them or not http://on.wsj.com/1S0IC8I) points out an important phenomenon of gene variation and its effect on drug metabolism. The article points to variations in enzyme activity that impact clearance of various drug classes. While in many instances the variation has minimal clinical relevance, in selected cases, such as multiple drug use, lack of effect of certain medications used concomitantly with others or in smokers, there may be adverse effects or lack of effect.