Bacteria taints 71 percent of commonly used medical scopes, study finds

Bacteria taints 71 percent of commonly used medical scopes, study finds

Bacteria taints 71 percent of commonly used medical scopes, study finds

In an ominous sign for patient safety, 71 percent of reusable medical scopes deemed ready for use on patients tested positive for bacteria at three major U.S. hospitals, according to a new study.

The paper, published last month in the American Journal of Infection Control, underscores the infection risk posed by a wide range of endoscopes commonly used to peer deep into the body. It signals a lack of progress by manufacturers, hospitals and regulators in reducing contamination despite numerous reports of superbug outbreaks and patient deaths, experts say.

“These results are pretty scary,” said Janet Haas, president of the Association for Professionals in Infection Control and Epidemiology. “These are very complicated pieces of equipment, and even when hospitals do everything right we still have a risk associated with these devices. None of us have the answer right now.”

The study found problems in scopes used for colonoscopies, lung procedures, kidney stone removal and other routine operations. Researchers said the findings confirm earlier work showing that these issues aren’t simply confined to duodenoscopes, gastrointestinal devices tied to at least 35 deaths in the U.S. since 2013, including three at UCLA’s Ronald Reagan Medical Center. Scope-related infections also were reported in 2015 at Cedars-Sinai Medical Center in Los Angeles and Pasadena’s Huntington Hospital.

The bacteria this latest study found weren’t superbugs, but researchers said there were potential pathogens that would put patients at high risk of infection. The study didn’t track whether the patients became sick from possible exposure.

The study’s authors said the intricate design of many endoscopes continues to hinder effective cleaning and those problems are compounded when health-care workers skip steps or ignore basic protocols in a rush to get scopes ready for the next patient. The study identified issues with colonoscopes, bronchoscopes, ureteroscopes and gastroscopes, among others.

“Sadly, in the 10 years since we’ve been looking into the quality of endoscope reprocessing, we haven’t seen improvement in the field,” said Cori Ofstead, the study’s lead author and an epidemiologist in St. Paul, Minn., referring to how the devices are prepared for reuse.

“If anything, the situation is worse because more people are having these minimally invasive procedures and physicians are doing more complicated procedures with endoscopes that, frankly, are not even clean,” Ofstead said.

The rise of antibiotic-resistant superbugs such as CRE (carbapenem-resistant Enterobacteriaceae), which can be fatal in up to half of patients, has made addressing these problems more urgent. About 2 million Americans are sickened by drug-resistant bacteria each year and 23,000 die, according to the federal Centers for Disease Control and Prevention.

“We’re not moving fast enough to a safer world of reusable medical devices,” Michael Drues, an industry consultant in Grafton, Mass., who advises device companies and regulators. “There is plenty of fault to go around on device companies, hospitals, clinicians, on basically everybody.”

Despite the potential risks, medical experts caution patients not to cancel or postpone lifesaving procedures involving endoscopes. These snakelike devices often spare patients from the complications of more invasive surgeries.

“Patients should speak to their provider and think about the risks versus the benefits,” said Haas, who is also director of epidemiology at Lenox Hill Hospital in New York City.

The Food and Drug Administration and Olympus Corp., a leading endoscope manufacturer in the U.S. and worldwide, both said they are reviewing the study.

Last month, the FDA issued warning letters to Olympus and two other scope makers for failing to conduct real-world studies on whether health-care facilities can effectively clean and disinfect their duodenoscopes. The FDA ordered the manufacturers to conduct those reviews in 2015 after several scope-related outbreaks in Los Angeles, Seattle and Chicago made national headlines.

Olympus spokesman Mark Miller said the Tokyo-based company intends to “meet the milestones set forth by the FDA. … Patient safety has always been and remains our highest priority.”

The latest study examined 45 endoscopes, with all but two manufactured by Olympus. The other two were Karl Storz models.

Last year, researchers visited three hospitals, which weren’t named, and performed visual examinations and tests to detect fluid and contamination on reusable endoscopes marked ready for use on patients. One hospital met the current guidelines for cleaning and disinfecting scopes, while the other two committed numerous breaches in protocol.

Nevertheless, 62 percent of the disinfected scopes at the top-performing hospital tested positive for bacteria, including potential pathogens. It was even worse at the other two — 85 and 92 percent.

The study painted a troubling picture at the two lower-performing hospitals, which were well aware researchers were watching.

Among the safety issues: Hospital technicians wore the same gloves for handling soiled scopes fresh after a procedure and later, when they were disinfected and employees wiped down scopes with reused towels. Storage cabinets for scopes were visibly dirty and dripping wet scopes were hung up to dry, which is a known risk because bacteria thrive on the moisture left inside. The two hospitals also turned off a cleaning cycle on a commonly used “washing machine,” known as an automated endoscope reprocessor, to save time.

“It was very disturbing to find such improper practices in big health systems, especially since these institutions were accredited and we assumed that meant everything would have been done properly,” said Ofstead, chief executive of the medical research firm Ofstead & Associates.

Ofstead and her co-authors recommended moving faster toward sterilization of all medical scopes using gas or chemicals. That would be a step above the current requirements for high-level disinfection, which involves manual scrubbing and automated washing. A shift to sterilization would likely require significant changes in equipment design and major investments by hospitals and clinics.

In their current form, many endoscopes aren’t built to withstand repeated sterilization. Some also have long, narrow channels where blood, tissue and other debris can get trapped inside.

In some cases, disposable, single-use scopes are an option, and new products are starting to gain acceptance. In other instances, certain parts of a scope might be disposable or removable to aid cleaning.

The Joint Commission, which accredits many U.S. hospitals and surgery centers, issued a safety alert last year about disinfection and sterilization of medical devices in response to a growing rate of noncompliance. In 2016, the Joint Commission cited 60 percent of accredited hospitals for noncompliance and 74 percent of all “immediate threat to life” citations from surveyors related to improperly sterilized or disinfected equipment.

Michelle Alfa, a professor in the department of medical microbiology at the University of Manitoba, said accreditors may need to conduct more frequent inspections and endoscopy labs should be shut down “if they don’t get their act together. These results are totally unacceptable now,” says NYU’s Dr. Triola. Instead, what’s important is teaching “information-seeking behavior,” he says, such as what sources to trust and how to avoid information overload.

Technology is also changing how med students learn. Simulators that look like patients and can be programmed to go into cardiac arrest, have strokes, spike fevers, cry, vomit and eliminate are particularly useful for teaching.

“Some schools don’t use cadavers anymore,” says the AMA’s Dr. Skochelak. “But others think it’s an important way to learn respect” for the real human body. “They tell students, ‘This is your first patient.’ ”

Some schools are condensing the typical four-year curriculum into three years, to let students start their residencies sooner and graduate with less debt. The Association of American Medical Colleges is also studying ways to let students master needed skills and competencies at their own pace—an innovation that has come to medical residency programs as well.

“We should have done this 10 years ago,” Dr. Decker says of the many med school changes. Then he quotes a Chinese proverb: “The best time to plant a tree is 20 years ago. The next best time is tomorrow.”

Ms. Beck is a health reporter and columnist for The Wall Street Journal in New York. She can be reached at

EHR Implementations: Don’t Be Left Out

EHR Implementations: Don’t Be Left Out

EHR Implementations: Don’t Be Left Out

Lost in the shuffle of minding budgets, keeping the C-suite happy, and ensuring schedules are met, there’s another often-overlooked reality of any EHR implementation: HIM professionals—the legal guardians of the health record—must be key participants in any process involving the integrity of patient records.

While this is undoubtedly true, it isn’t necessarily the reality at most health care organizations. For various reasons, HIM professionals are frequently left out of the EHR implementation process.

Often, this oversight is beyond the HIM manager’s control. Nevertheless, there are several strategies HIM managers can employ to rectify this situation.

The following are a few reasons HIM should advocate to become involved in EHR implementations:

Be seen: There is a tendency for overworked, overstressed HIM professionals who are barely managing to keep up with countless to-do lists, budgets, productivity reports, and committee meetings to lose sight of how to be recognized (seen). When executives witness the strategic value of a subject matter expert, the invitation to be part of the team occurs more frequently.

How is value demonstrated? Education, promoting awareness (via marketing), and report cards demonstrating quantitative improvement trends are among the best tools to illustrate HIM’s EHR sophistication and prowess.

Be involved: Volunteer to talk about new legislative changes (eg, hierarchical condition category coding, MACRA, MIPS) to core executives or a physician group or explain the need to improve documentation and coding skills to accommodate the demand these changes will have on the EHR’s documentation requirements.

Introduce an “open house” day where hospital staff can learn about different HIM functions such as release of information, deficiency analysis, and transcription. Viewing HIM functions through a self-marketing lens allows the HIM manager to enjoy a pat on the back without bragging and boosts the image of expertise, ie, someone who should be involved in an EHR implementation.

Be informative: Providing report cards focused on both the quality and quantity of HIM metrics alerts the executive team to the importance of such data. This makes it easier for executives to recognize the variables and reasons behind productivity slowdowns that may be pinpointed to the EHR.

What are the benefits of being seen, being involved, and being informative? It may seem like an inordinate amount of time and hard work just to be involved in EHR implementations. However, the long-term payoff can be significant.

Benefits of Being on the EHR Team 
Those involved in the EHR implementation process help set the rules. Did you ever volunteer to take minutes at a committee meeting? Some individuals refuse to take on this task, believing it will result in them being perceived as a less skilled participant.

Not true. The person assigned this responsibility gains a greater awareness of the topics discussed and can be sure to include thoughts from an HIM perspective that may otherwise not get noted in the minutes. With items on record, there’s a greater chance HIM will be noticed when the project begins to shape.

HIM managers involved with EHR implementation can ensure certain standards are met during workflow design. For example, are episodes and encounters listed correctly and in chronological order to represent hospital visits and not intermingled with physician office encounters and notes? Do coders and clinical documentation improvement staff view the same documentation and physician queries? Do coders have to reenter diagnoses and procedures into the encoder and query system separately? Are physicians permitted to use copy and paste, potentially resulting in data integrity problems and fraudulent billing?

Another benefit of HIM being part of the EHR team is that it keeps the department in the loop with regard to what’s happening in the organization. For example, being on the team helps ensure staffing and workflow issues surrounding the implementation do not conflict with other HIM-related activities. Imagine attempting to implement an EHR system during a scheduled audit or a Joint Commission survey.

Educating the team—and the EHR vendor—of conflicts when planning master schedules can avert a scheduling disaster.

Understanding Expectations and Responsibilities
When the moment of truth arrives and HIM managers become active members of the EHR implementation team, it carries great responsibilities, some of which may be unfamiliar. To stand out in the new role, preparation is key.

Be sure to network with other colleagues or consultants that have already been through the process of installing an EHR or converting from one system to another.  Vendors are also helpful in providing references and site visits and even a more thorough understanding of any confusing functionality.   Don’t forget vendor user groups—those who participate get to provide input in determining future enhancements and functionality improvement.

The following best practice tips can catapult HIM managers into becoming valuable participants in EHR projects, which builds confidence levels and leads to a rewarding experience.

Understand basic EHR/computer terms. Neophytes to the EHR world must familiarize themselves with the technical and clinical terms they may encounter during the implementation. The quickest way to have one’s input be disregarded is to appear uneducated about the system. Study the available vendor information to help grow that expertise.

HIM professionals are typically accomplished communicators and documenters; once entrenched in the implementation, don’t be afraid to take a leadership role.

Understand the clinician point of view. A thorough understanding of clinical workflow (current and ideal) in each service area allows HIM managers to better represent their constituent workflow needs as they become involved in designing screen flow. This includes inpatient, outpatient, and postacute care settings, as well as physician clinic and ambulatory environments. HIM professionals are unique in that they’re well versed in the clinical, financial, and administrative functionality of the health care environment.

Understand the active vs discharge legal health record. Don’t forget the needs of the active care encounter as well as the postdischarge documentation-based encounter. Once a patient is discharged, all documentation must be visualized in a postdischarge record that should no longer be dynamic in nature. Additionally, all subsequent amended/completed documentation must be added to the record without displacing, replacing, or changing any prior documentation.

Facilities that do not have two types of records (dynamic and postdischarge stable) in place may find it difficult to defend their archived medical records. HIM professionals can help ensure these needs are addressed.

Understand archive policies. Remember to discuss issues such as long-term retention and the purging of records. These topics often get ignored; however, it is just as critical to have these types of policies in place as it was when paper records were commonplace. With interoperability an industrywide goal, defining how records are systematically destroyed is paramount.

One of the most common complaints heard about EHRs is the fragmentation of content. If locating this information is difficult in the active record, how well thought out and documented must be the retention and destruction of all electronic documentation? HIM professionals are trained to identify how to approach this challenge from a policy point of view.

Regardless of environment, participation in an EHR implementation can be a rewarding, career-changing experience for HIM managers who dedicate the time and exert the energy to actively make a difference in the success of such a critical project.

— Darice M. Grzybowski, MA, RHIA, FAHIMA, an AHIMA-approved ICD-10-CM /PCS, trainer, and ambassador, is the president of HIMentors.

Fake News About Health You Need to Stop Believing

Fake News About Health You Need to Stop Believing

Fake News About Health You Need to Stop Believing

Thousands of well-educated people share erroneous beliefs. With the help of my father, Jack Gorman, M.D., I began to explore why people develop these mindsets and wrote the book Denying to the Grave: Why We Ignore the Facts That Will Save Us. You’re about to learn the neurological basis for how such thinking “narrows” the brain and how to reverse the process in yourself and others. But first, let’s take a look at six prevailing health myths that some people still believe.

I met Luke at a professional conference. I’m a public health and behavioral science expert; Luke’s a statistician for a hospital system in New York City. I thought he was brilliant — two Ivy League degrees, decades of experience working with top medical professionals, married to a cardiologist. We stayed in touch. A few months later, after I began speaking out about irrational health beliefs, including the myth that vaccines cause autism, I ran into Luke again.

“I read your piece,” he said.

I smiled awkwardly. His son had autism, but we’d never discussed it. What came next shocked me. “How can you say vaccines don’t cause autism?”

At first I thought he was joking. But no: Luke is an anti-vaxxer, convinced that childhood vaccines are a pharmaceutical conspiracy. He blames vaccines for his son’s autism. He mistrusts doctors in general, and he and his wife (a cardiologist, remember) follow a natural lifestyle that minimizes interaction with them. He also believes eggs and milk cause cancer.

I didn’t know what to say. I never thought someone with Luke’s background and intellect could defend beliefs that science had thoroughly debunked.

Luke isn’t alone. Thousands of well-educated people share such erroneous beliefs. With the help of my father, Jack Gorman, M.D., I began to explore why people develop these mindsets and wrote the book Denying to the Grave: Why We Ignore the Facts That Will Save Us. You’re about to learn the neurological basis for how such thinking “narrows” the brain and how to reverse the process in yourself and others. But first, let’s take a look at six prevailing health myths that some people still believe.



In 1998, the British gastroenterologist Andrew Wakefield published a study in The Lancet claiming a link between autism and the MMR (measles, mumps, rubella) vaccine children receive. The finding terrified parents and reverberates to this day. According to CDC data, nonmedical exemptions for school-required immunizations are rising in 11 states. Measles is an illness that can kill. Despite that, a 2015 CNN poll found anti-vaxxer parents more likely to be wealthier, white, and college educated. Of those surveyed, 57 percent cited “concerns about autism” as the reason for not vaccinating their kids.


The Lancet retracted the Wakefield study in 2010, citing invalid science. As it turns out, Wakefield had committed fraud by taking money from vaccine injury lawyers and falsifying data. He later lost his medical license. The American Academy of Pediatrics now lists 20 pages of studies and other evidence showing no link between vaccines and autism. Researchers also warn that a mere 5 percent decline in MMR immunizations among 2- to 11-year-olds would triple the annual number of measles cases in this age group nationwide, resulting in $2.1 million in yearly health care expenditures and needlessly claiming young lives.



In the 1940s, heart disease was the top killer in the United States. To identify the causes, many studies were launched, including the landmark Framingham Heart Study and the Seven Countries Study. The latter examined risk factors across cultures and linked diets high in saturated fat to heart disease. The American Heart Association endorsed the findings and sounded the alarm on saturated fat. Companies responded with low-fat processed foods. Belief in the heart-healthy benefits of a low-fat diet still persists today, even though heart disease remains the leading cause of death in the nation.


Hundreds of millions of dollars have been spent trying to replicate the Seven Countries finding, without success. In fact, the study’s methodology has come into question. In November, new research in The Lancet spanning 18 countries across five continents concluded that “total fats and types of fat were not associated with cardiovascular disease.” Ironically, reaction to that original flawed science turned out to be the real killer. Since low-fat food is bland, food producers added sugar. We now know that sugar is extremely harmful to health. According to a 2014 JAMA Internal Medicinestudy, people who get 25 percent or more of their daily calories from added sugar are more than twice as likely to die of heart disease as those who get 10 percent or less. And that’s regardless of age, sex, physical activity, and body mass index.



Prostate cancer is the most common cancer among men, and it’s second only to lung cancer in deadliness. PSA stands for “prostate-specific antigen,” and the test measures blood levels of this protein; a high number can suggest prostate cancer. In 1994, the FDA approved routine PSA screening for asymptomatic men. Since it’s such a simple, noninvasive way to apparently detect a dreaded disease, physicians prescribe and patients request an estimated 20 million PSA tests annually.


Mass PSA screening does more harm than good. In a 2010 New York Times editorial, even the doctor who discovered PSA called large-scale testing a “profit-driven public health disaster.” In 2012, the U.S. Preventive Services Task Force advised against routine testing, citing evidence that about 80 percent of results are false positives. Unnecessary treatments can include painful biopsies, surgery, and radiotherapy. Experts estimate that up to five of every 1,000 men who undergo prostate cancer surgery die within a month, and at least 200 of every 1,000 men who have radiotherapy and surgery for prostate cancer suffer complications like urinary incontinence, erectile dysfunction, and/or bowel problems. The American Urological Association no longer recommends routine PSA screening for men younger than 55 unless they have risk factors (like smoking, being overweight, or having a family history of prostate cancer).



It’s difficult to pinpoint when or where this idea started, but the raw milk movement has been gaining momentum. Twelve U.S. states now permit sales of raw milk in stores, and 13 more allow it to be sold on the farm where it was produced. Pasteurization involves heating milk to kill harmful bacteria, but raw milk proponents claim the heat also kills important nutrients and that consuming pasteurized dairy products causes allergic reactions and symptoms of lactose intolerance.


The FDA says no there’s evidence that raw milk is any more beneficial than the pasteurized stuff. In fact, the opposite is true: While unpasteurized dairy products such as milk and cheese are consumed by a little more than 3 percent of the population, they cause 96 percent of the illnesses originating from contaminated dairy products, according to the CDC. That’s 840 times more illness and 45 times more hospitalization than from pasteurized dairy products. Infection from harmful bacteria in raw milk (like salmonella, E. coli, and listeria) can result in organ failure, miscarriage, paralysis, or death.



The vertebrae lining your backbone are cushioned by shock-absorbing discs. Over time, disc damage leads to micromovements that can trigger pain. Also, spinal nerves can be pinched, resulting in radiating leg pain. On an X-ray, CT scan, or MRI, the narrowing of space between vertebrae is often interpreted as disc degeneration and the source of pain. It would seem logical, then, that fusing vertebrae and/or removing bone would limit micromovements, make space for nerves, and ease the ache. This thinking led to a 70 percent spike in such surgeries from 2001 to 2011. About 400,000 are done annually.


A recent study determined that up to 40 percent of people who undergo back surgery could continue to have significant pain afterward. Plus, rates of complication from such operations — some life-threatening — can be upwards of 20 percent. In fact, even with today’s medical advances, finding the cause of lower-back pain is very difficult. About 85 percent is the “nonspecific” type–no cause identified–and surgery is typically not the best option for these cases. In 2017, the American College of Physicians published new guidelines, recommending that doctors choose non-pharmacologic, nonsurgical options, such as exercise, physical therapy, and cognitive behavioral therapy, to treat both acute and chronic lower-back pain.



Passing an electric current through the brain to spark a chemistry-shifting seizure seems crude if not barbaric. Hollywood portrays restrained patients convulsing in pain before becoming passive and sustaining permanent memory loss and personality changes. (See: One Flew Over the Cuckoo’s Nest and American Horror Story: Asylum.) Indeed, in 1950s psychiatric hospitals, electroconvulsive therapy (ECT) was used to “treat” everything from unruly behavior to homosexuality. And those perceptions persist: In a U.K. survey, about 20 percent of respondents said they fear dying if they receive ECT.


For people dealing with severe, treatment-resistant depression, ECT is often the only option. While antidepressant meds generally have a 50 to 60 percent success rate, ECT is effective 70 to 90 percent of the time. Studies consistently show that memory loss from ECT is usually temporary and that the treatment is safe. Patients also experience no pain from the current, and there’s no visible convulsing. Overall, ECT is a highly effective antidepressant treatment–and for suicide prevention, it’s significantly superior to drug therapy. What’s more, patients often see dramatic improvement after just a week or two of ECT, versus the six to eight weeks needed for antidepressants to take full effect. Then there are the drugs’ possible side effects: weight gain, sex drive changes, sleep disturbances, and upset stomach.

Original article:

Why Some Americans Are Risking It and Skipping Health Insurance

Why Some Americans Are Risking It and Skipping Health Insurance

Preparing Doctors to Meet the Demands of the Nation’s Changing Healthcare System

Prices and deductibles are rising. Networks are shrinking. And even some well-off Americans are questioning what they’re paying for. While the share of Americans without health insurance is near historic lows four years after the Affordable Care Act extended coverage to almost 20 million people, the Trump administration has been rolling back parts of the law. At the same time, the cost for many people to buy a health plan—if they don’t get it from a job or the government—is higher than ever.

In tiny Marion, North Carolina, the Buchanans decided that $1,800 a month was too much to pay for health insurance, and are going without it for the first time in their lives.

In Harahan, one bend of the Mississippi River up from New Orleans, the Owenses looked at their doubling insurance premiums and decided no, as well. “We’re not poor people but we can’t afford health insurance,” Mimi Owens said.

And in a Phoenix suburb, the Bobbies and their son Joey will go uninsured so the family can save money to cover their nine-year-old daughter Sophia, who was born with five heart defects.

Across America there are thousands of people like the Buchanans, the Owenses and the Bobbies making the same hard decision to go without health insurance, despite the benefits. They’re risking it—betting that they’ve got enough savings, enough of a back-up plan, or enough luck to get them through a twisted knee, a cancer, or a car wreck.

Bloomberg is following a dozen of these families this year in an effort to understand the trade-offs when a dollar spent on health insurance can’t be spent on something else. Some are financially comfortable. Others are scraping by.

While the share of Americans without health insurance is near historic lows four years after the Affordable Care Act extended coverage to almost 20 million people, the Trump administration has been rolling back parts of the law. At the same time, the cost for many people to buy a health plan—if they don’t get it from a job or the government—is higher than ever.

No one had to tell the Buchanans about the risk. Dianna, 51, survived a bout with cancer 15 years ago. Keith, 48, has high blood pressure and takes testosterone shots. They live in Marion, North Carolina, and make more than $127,000 a year from the small IT business Keith runs and Dianna’s job as a physical therapy assistant, with some additional income from properties they own. That puts them in the top fifth of households by income.

But their insurance premium was $1,691 a month last year, triple their mortgage payment—and was going up to $1,813 this year. They also had a $5,000 per-person deductible, meaning that having and using their coverage could cost more than $30,000.

What sealed the deal was when Blue Cross and Blue Shield of North Carolina and the major hospital system in Asheville, Mission Health, couldn’t reach an agreement, putting the hospital out of network. Keith Buchanan compared the fight to a cable company battling with a broadcaster over what channels to carry.

“It was just two greed monsters fighting over money,” he said. “They’re both doing well, and the patients are the ones that come up short.”

Blue Cross and the hospital eventually made a deal, but enough was enough for the Buchanans. Instead of insurance, they’re paying $198 a month for membership in a local doctors’ practice. They get unlimited office visits and discounts on medications and lab tests. They also signed up for Liberty Health Share, a Christian group that pools members’ money to help pay for medical costs. Liberty costs $450 a month, including a $150 surcharge based on the couple’s blood pressure and weight.

Three days after dropping their Blue Cross coverage at the start of the year, Keith took a wrong step and injured his knee.

It could have been worse. He got it checked out at an urgent care center, where the visit and an X-ray cost him $511. That’s still less than he was paying in premiums to Blue Cross.

“If we can control our health-care costs for a couple of years, the difference that makes on our household income is phenomenal,” Buchanan said. The couple doesn’t have children.

There’s plenty of evidence that having insurance is a good thing. People with health coverage spend less out of pocket on medical care and are less likely to go bankrupt. They see the doctor more often and get more preventive care. They’re less depressed and tell researchers they feel healthier. Some studies suggest having insurance reduces the likelihood of death.

Despite those benefits, some 27.5 million Americans under age 65 were uninsured in 2016, about 10 percent of that population, according to the Kaiser Family Foundation. The most common reason: the cost was too high. A Gallup poll suggests that, after declining for years, the percentage of adults without coverage has increased slightlysince the end of 2016, when President Donald Trump was elected promised to dismantle Obamacare. Other data show no significant change.

The Affordable Care Act wasn’t just an expansion of insurance coverage. It also rearranged how Americans’ medical costs are distributed, favoring some and asking others to pay more.

People near the poverty line got Medicaid for free, while those making more—up to about $100,000 for a family of four—got subsidies to lower the price of private health plans.

Above that threshold, people pay the entire price. Because the law barred insurance companies from charging sick people more or refusing to cover them entirely, costs for healthy people went up as well. Some insurers have left the market, while others have sharply raised premiums to compensate for actions taken by Congress and the administration to weaken the law.

The Bobbie family remembers the problems that the ACA was intended to solve.

Their daughter Sophia was born with serious heart defects, and the organs inside her tiny abdomen were in all the wrong places. She spent the first two weeks of her life in a neonatal intensive care unit. On her six-month birthday, she had open-heart surgery. At nine months, doctors operated on her stomach.

Sophia qualified for Arizona’s Medicaid program. But when she turned 2, the Bobbies were told they made too much money for her to get low-cost state coverage. Her father Joe Bobbie, who co-owns a Philly steak shop with his brother, reduced his take-home pay so Sophia would still qualify.

She had another heart operation just before she turned 3. In just a few short years, her parents were told, Sophia’s medical costs had come to well over $1 million. Before the ACA, no private insurer was willing to cover Sophia’s pre-existing conditions.

“Every door, every option, everything was just slammed in our face,” Sophia’s mother, Corinne, said.  Medical costs that insurance didn’t cover piled up. The family skipped vacations and nights out, and lost their house and car because they couldn’t make the payments.

Corinne and Joe Bobbie, with their children Sophia and Joey.
Source: The Bobbie Family

Those sacrifices have been tough on the Bobbies, but they’ve let Sophia have a relatively normal life. She takes medication for blood pressure and blood-thinners, and a daily antibiotic because she was born without a spleen. She goes to school, rides horses, and plays piano. A recent tumble from her horse frightened her mom, but Sophia jumped up and climbed right back on.

When Obamacare coverage became available in 2014, the Bobbies, who made about $55,000 last year, bought a policy for Sophia that now costs $217 a month.

Adding Sophia’s seven-year-old little brother Joey, who’s healthy, would have cost another $160 per month, with a $6,000 deductible. So he’s uninsured, and so are Joe and Corinne. The money they save risking their own medical and financial health goes to paying Sophia’s bills.

“Every single decision that you make has to be very carefully calculated so that your finances don’t fall apart,” Corinne Bobbie said.

The Trump administration proposes to make it easier for Americans to buy cheaper health plans, which could open more affordable options for the rest of the Bobbie family. But those less-expensive choices, such as short-term health plans, would lack some of the consumer protections created by the Affordable Care Act that allowed Sophia to get coverage in the first place.

The tax proposal that became law in December will also lift the Affordable Care Act’s requirement that every American have coverage or pay a fine. Economists warn that these changes could further weaken insurance markets, pushing up costs for sick patients like Sophia—and forcing more people into similar choices.

Some states are already trying out the new rules, offering plans that don’t adhere to ACA’s requirements. In Idaho, the state’s Blue Cross insurer attempted to offer a “Freedom Plan” with annual limits on care and questionnaires that would let it charge higher premiums to people who are sick or likely to become so. The Trump administration reluctantly judged that such a plan would violate Obamacare’s rules. But federal officials encouraged Idaho to explore offering similar policies as short-term plans that can offer skimpier benefits and lower prices.

In Harahan, Louisiana, outside New Orleans, Mimi Owens learned this year that her family’s $750-a-month plan with Humana Inc. was being discontinued. A new plan for her two daughters and husband on the ACA market would cost close to $1,600. Their family makes about $147,000 from a small business selling class rings and gowns to schools.

Owens said they go to the doctor “for a sniffle, for a flu,” and have a few regular prescriptions, so they looked into short-term health plans and tried out a Christian health-sharing ministry for a few months. The best solution she’s found so far is paying $130 a month to join a direct-primary-care group, which she calls “the best care we’ve ever had.”

It doesn’t cover the big things, though. An accident like a car crash could wipe out their finances.

“We were raised to have insurance,” Owens said. “This is crazy to us.”

What happens when a patient says, ‘Doc, help me die

What happens when a patient says, ‘Doc, help me die

What happens when a patient says, ‘Doc, help me die’

My 54-year-old patient was alone in the intensive care unit, with no family or friends in his life. He slumped in his bed, gasping, staring up at me. Admitted with lung fibrosis and pneumonia, he had scars and infection aggressively replacing his airways, despite our best treatments.

By E. Wes Ely

This piece is the third part of a CNN Opinion series, “What it’s like to be me,” which explores the personal struggles Americans face at a time of profound social change. E. Wesley Ely is a physician and the Grant. W. Liddle Professor of Medicine and Critical Care at Vanderbilt University, Tennessee Valley VA GRECC, and the founder of the Vanderbilt ICU Delirium and Cognitive Impairment Study Group. The views expressed here are solely his.

My 54-year-old patient was alone in the intensive care unit, with no family or friends in his life. He slumped in his bed, gasping, staring up at me. Admitted with lung fibrosis and pneumonia, he had scars and infection aggressively replacing his airways, despite our best treatments.
E. Wes Ely

 E. Wes Ely
As a newly minted doctor years ago, my mind was usually occupied with beeps and buzzers providing me technical information to help calculate choices about patients’ care. Having developed gray hair over many years at the bedside, my first priority is now more straightforward: to hear the voices of the vulnerable people looking up at me from their bed. That is what I try to do as a physician, including, of course, what they tell me in the silences.
I pulled a chair next to his bed so we could talk at eye level. His face was blank. “I want euthanasia. I’m going to die soon, so what’s the point of living longer? I’m just wasted space.”
I felt nauseated. The illegality of euthanasia was not what ran through my mind. Instead I thought about how Paul had lost his sense of personhood. I thought about how I had chosen to become a doctor in the first place.
Caregiving is a partnership

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I chose medicine as my calling after a childhood spent in the Deep South: Shreveport, Louisiana. My mother taught English there after my father, an engineer, had left her for another woman. I remember it was so hot that my siblings and I would fry eggs on the sidewalk. No joke. On most days, we’d walk to a nearby bayou and catch baby alligators for fun and fill up coolers with crawfish for dinner. That last part is important because we had no money at all. Dad wouldn’t pay anything to Mom, who didn’t make much as a teacher. So I started working at the farm of a man who wanted to marry my mother. I worked 14-hour days from about five in the morning doing square bales of hay until seven at night picking vegetables and running the country store.
While I cherish those years and the formation that grueling work provided, I was determined to do something different with my life. Mom told me that Dad had loved math and science, and she taught literature. So I figured it must come naturally for me to split the difference and do something with people, science and the arts. To me, that meant medicine.
Dr. Wes Ely assessing a patient in the Medical Intensive Care Unit at Vanderbilt.

I remember our first big assignment in sixth grade was to write a research paper on what we would be when we grew up. I rode my beat-up bicycle to the local library and began reading about how to become a physician: What was the process and what would it all mean? I walked out of the library that day having spent most of my time reading a long medical essay about truth. The author insisted that to be a physician, one has constantly to seek truth about the patient’s diagnosis, the best treatment, and the best way to serve each and every person. What I learned from the essay was that truth doesn’t change depending on our ability to stomach it. As I progressed through Jesuit high school and Tulane, this became a common theme in my pursuit of a life as a doctor: “Wrong is wrong even if everybody is wrong. Right is right even if nobody is right.” Numerous people are credited with some version of this quote, from actors to philosophers to theologians. That sense of truth drove my study and training and my realization that each person’s life has value beyond measure.
I knew long before I met Paul that I couldn’t kill another person just because he or she wanted me to, but I still had to find a way to respond to Paul’s request to die.

‘Just don’t abandon me’

My response came in parts over my days with him. First, I explained that, as his physician, I wanted to be with him through the dying process. I told him that I considered us to be in a mutual covenant. We both had a degree of autonomy that had to be respected, but I would never intentionally harm him. “Paul, our covenant includes my limiting your suffering,” I said. “You are the best judge of when you need more meds for pain, anxiety and breathing. All of us will work day and night to end your distress, but we won’t deliberately end your life.”
With our eyes locked, Paul gave his instruction: “Just don’t abandon me.” And we sat there, as partners.
As a physician, there is no better place to be. Perhaps especially amid the uncertainty, we must learn to partner with each person in the bonds of this two-way relationship. He in need of help and me in need of helping.
Paul was receiving excellent palliative care for his physical symptoms, but it wasn’t enough. It never is. Emotional isolation and despair can cast a shadow darker than disease. Physicians fail our patients on a human level. We forget that our patients are more than the sum of their medical conditions, so I asked Paul about other types of therapy — art, music, spirituality, pets, sunshine — that might help him.

‘He who has a “why” to live can bear almost any “how”‘

“I want my music. Can you get me the soundtrack for ‘Lord of the Rings’?” Within minutes we had the songs playing in his room, and his demeanor changed from desolate to alert and engaged. “I love music. It’s always been a motivator, but now … I don’t know.” He shifted in his bed. “My goals are gone.”
Nietzsche’s words came to my mind, “He who has a ‘why’ to live can bear almost any ‘how.'”
Viktor Frankl, as a physician-survivor of Auschwitz, used Nietzsche’s quote four times in his crucial analysis, “Man’s Search for Meaning.” I think this book should be required reading for medical students.
As with many patients, Paul’s story needed unpacking. “Paul, what did you do in life?”
He smiled and shrugged. “I’m a rare beast: a plumber who acts. I do Shakespeare festivals. You know, ‘The quality of mercy is not strained.’ I’ve been mulling over that line. Years ago I didn’t understand it. I do now. Mercy should not be forced. It’s better as a natural infusion, one person to another.”
I described for Paul the many years I spent alongside my single-mom-turned-Shakespeare-director, helping her cue actors. As we talked, I watched his erratic oxygen levels fall and then partially recover, obliging us to take breaks. Sweat would build up on his forehead, and, more than once, I worried that our conversation was too much of a strain. But we were unpacking, and it was essential.

The quality of mercy

That night I asked Christine, a nurse who loves theater, to sit and talk with Paul. Soon their lives were interwoven, too.
“I think I helped Christine,” Paul said the next day. “My own illness made me forget that one of my ‘things’ is seeing when someone is hurting. And Christine is. She came to help me, but it turns out some really personal things in our background are weirdly similar. I told her my way through the worst of it.” He paused, his thoughts far away.
It seemed like a good time to return to his previous request. “Paul, you’ve asked for euthanasia, and you brought up Portia’s line from ‘Merchant of Venice’ about mercy. Can we talk about these things?” He nodded, and closed his eyes.
“We all want to be here with you in your suffering. I want your opinion: I don’t think injecting you with a lethal drug would be truly merciful, but it would, in every sense of the word, be ‘strained.’ It would be a forced and unnatural ‘false’ mercy. Whenever possible, mercy must also be lifting and healing. I don’t want to abandon those key elements in serving you.”
His eyes opened wide. “Doc, talking with you and Christine about life’s best and worst times has helped.” He took a deep breath, and I heard the whoosh of high-flow oxygen into his nostrils. “Things I confided to Christine are helping her sort through her own struggles. She said she’s coming back tonight, and that means the world to me.” Then, unwittingly, Paul paraphrased Nietzsche: “When we met, I was afraid of being a burden and not mattering. Now I feel different. I’m not a believer like others, but I guess I remembered the ‘why’ to live.”
Short of a war zone, there are few settings as raw as an ICU. Yet treasured moments of human transformation come when people like Paul rediscover their “why,” even if just for an hour or a day.

‘I’m glad I didn’t miss this time’

I see many paths toward survival in the ICU, and for non-survivors, myriad paths toward death: sudden, prolonged, stuttering, reluctant, stoical — and these paths are dynamic, not static.
It is a rare patient who asks me for euthanasia, but it is nearly universal that dying patients seek help with suffering. Sitting on their beds brings me right up against their fears, the greatest of which is usually not intolerable pain.
Lack of control is what bothers people the most, and it drives most requests for euthanasia, which is predominantly a first-world phenomenon. As we have gained more and more ability to dictate so many aspects of our lives, looking ahead in uncertainty has become something people are not willing to tolerate. As a physician, I find this is a very important “teachable moment” for most patients: helping them (and me) to live in the moment. Whitewashed along a wall in the home for destitute and dying in Kolkata, these words of Saint Mother Teresa became emblazoned in my mind, and I recalled them for Paul: “Yesterday is gone. Tomorrow has not yet come. We have only today. Let us begin.” He nodded in agreement.
Paul reminded me that the best remedy for angst is human relationship and community.
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The problem with assisted suicide and euthanasia for Paul — and for others — is that it presented him with an illusion of ‘cure,’ when in reality it would have left him devoid of the healing he received.
And alongside the patient, of course, sits the physician. The problem for me with intentionally administering lethal medications to end the life of another person is that it would rob me as a healer. I would be qualitatively changed. If I were ever to assume that I had authority over life to take it deliberately, it would, for me, create an irrevocable cavern of emptiness. The infinite worth of every person outprices autonomy: What you and I want is less important than who we are.
Obviously, the approach I took with Paul won’t be an answer for everyone, yet it is too often left untried. Some will say Paul’s story is merely an uplifting anecdote. Nevertheless, I hope to embrace the lessons I learned at his bedside for most of my patients, and I hope my colleagues do the same.
Caregiving is a partnership

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We are sent to heal even when cure is not possible. What we should be trying to heal is often not physical disease or clinical depression, but a person’s sense of insignificance and hopelessness, which we cannot heal by eliminating the person.
Paul died a week later. By then he realized his life was of value even with a terminal disease. In fact, the last thing he said to me, between gasps, was: “I’m glad I didn’t miss this time. I never saw it coming, Doc. … In losing my breath, I gained it.”
Note: The patient’s name and age have been changed for privacy. These conversations reproduce Paul’s words as accurately as possible from the author’s memory.
The Doctor of the Future

The Doctor of the Future

The Doctor of the Future

When patients go to see Dr. C.T. Lin for a checkup, they don’t see just Dr. Lin. They see Dr. Lin and Becky.

Becky Peterson, the medical assistant who works with Lin, sits down with patients first and asks them about their symptoms and medical history—questions Lin used to ask. When Lin comes in the room, she stays to take notes and cue up orders for tests and services such as physical therapy. When he leaves, she makes sure the patient understands his instructions.

The division of labor lets Lin stay focused on listening to patients and solving problems. “Now I’m just left with the assessment and the plan—the medical decisions—which is really my job,” Lin says in a quiet moment after seeing a patient at the Denver clinic where he works.

When patients go to see Dr. C.T. Lin for a checkup, they don’t see just Dr. Lin. They see Dr. Lin and Becky.

Becky Peterson, the medical assistant who works with Lin, sits down with patients first and asks them about their symptoms and medical history—questions Lin used to ask. When Lin comes in the room, she stays to take notes and cue up orders for tests and services such as physical therapy. When he leaves, she makes sure the patient understands his instructions.

The division of labor lets Lin stay focused on listening to patients and solving problems. “Now I’m just left with the assessment and the plan—the medical decisions—which is really my job,” Lin says in a quiet moment after seeing a patient at the Denver clinic where he works.

For generations, when Americans sought health care, they went to see their family doctor. But these days, they’ll often sit down with a physician assistant or nurse practitioner instead. Or they’ll spend a large part of their visit talking to a non-doctor, like Peterson, who takes care of an increasing number of tasks doctors used to handle.

Driven by efforts to control costs and improve outcomes, it’s one of the biggest shifts in the American health care workforce. Medicine increasingly looks like team sport, with duties and jobs that used to fall to a family doctor now executed by a team, from nurses who sit down with patients to discuss diet and exercise to clinical pharmacists who monitor a patient’s medication. The doctor, in this model, is a kind of quarterback, overseeing care plans, stepping in mostly for the toughest cases and most difficult decisions.

Under some models, the doctor may recede even further into the background, leaving advanced practice nurses or other highly qualified professionals in charge.

It’s no longer true “that you’re a sole cowboy out there, saving the patient on your own,” says Mark Earnest, head of internal medicine at the University of Colorado medical school.

The shifting role of doctors is expected to accelerate in the coming decades, as the number of older Americans increases dramatically, many of them living longer with chronic diseases that need monitoring but not necessarily the expensive attention of a physician at every visit.

This isn’t the job many physicians trained for—or that some want. Even doctors who support team-based care have trouble adjusting to the new workflow. Some don’t like the idea that they aren’t always the ones in charge. Others, sick of the industry pressures, are opting out and setting up independent practices that don’t accept health insurance.

But most doctors will have to adapt. Change is coming, regardless of the fate of the Affordable Care Act or other laws designed to reward health systems for outcomes rather than the number of procedures performed, says Randall Wilson, an associate research director for Jobs for the Future, a nonprofit that advocates for increasing job skills. “People see the writing on the wall,” he says.

New models

Americans spend more on health care than people in other wealthy nations. Yet Americans live shorter lives and are more likely to be obese or hospitalized for chronic conditions, such as asthma or diabetes.

Health care experts have long blamed these lousy results on our fragmented health care system. Americans rely on a mix of specialists and settings for care, but those pieces of the health care system don’t necessarily communicate or coordinate with each other.

They also blame the high costs partly on the fee-for-service payment system, which rewards hospitals, clinics and doctors for the volume of procedures they provide. Health insurers will pay for a patient sit down with a doctor. What they sometimes don’t pay for are other services that help patients stay healthy, such as a visit from a community health or a phone call with a nurse. Yet such services can prevent medical emergencies and save her and her insurer a lot of money on expensive treatments.

New payment models encourage health systems to deploy their workers more efficiently — while also avoiding unnecessary services and costly errors. For instance, Medicare already gives some hospitals a single payment to cover everything that happens to a patient from the moment he enters a hospital for knee replacement surgery to three months after he goes home.

Distributing work across team members can help keep costs down, relieve doctors of the busywork that jams up their day, and make everyone more productive.

At least, that’s the idea. There isn’t yet strong research that proves teams provide better or cheaper care, says Erin Fraher, director of the Carolina Health Workforce Research Center, a national research center at the University of North Carolina. Studies do show that nurse practitioners can deliver care as well as physicians, “but talking about substitution of one provider for another is not team-based care,” she says.

Major physician associations support improving teamwork and collaboration among health care professionals. So do medical school leaders. For some years now, accreditors have required colleges and universities that train doctors, nurses, pharmacists, dentists and public health experts to teach students to work in interprofessional teams.

But when it comes to the question of who is in charge, that’s where friction arises. Many doctors aren’t comfortable with the idea that they don’t always need to be in charge. The American College of Physicians will say a physician must always lead care teams, says Ken Shine, professor of medicine at the Dell Medical School at the University of Texas at Austin, but he disagrees.

“My argument is there are situations where another health professional needs to be directing the team,” Shine says. For instance, a nutritionist could create and manage a care plan for a diabetic patient.

Medical associations have also pushed back against proposals to expand the medical decisions non-doctors are able to do make on their own. Health professionals’ so-called “scope of practice” is governed by laws that vary from state to state. “While some scope expansions may be appropriate, others definitely are not,” the American Medical Association says on its website.

In a statement, the association says it “encourages physician-led health care teams that utilize the unique knowledge and valuable contributions of all clinicians to enhance patient outcomes.” It noted that top hospital systems are using physician-led teams to improve patients’ health while reducing costs.

To be sure, doctors aren’t being displaced anytime soon. But shifting tasks to other professionals reduces the need to train so many of them. According to a study by the Rand Corporation, a nonpartisan think tank, a standard primary care team model requires about 7 doctors per 10,000 patients. Increasing the numbers of nurse practitioners and physician assistants can drop that ratio to six doctors per 10,000, and in clinics run by highly trained nurses (known as nurse-managed health centers) the ratio drops to less than one doctor per 10,000.

Culture Change

Hospital systems like UCHealth, the University of Colorado-affiliated system where Lin and Peterson work, are betting that the future of health care involves a mix of professionals sharing responsibility for patients. Doctors will still run the show, but they’ll have to give up some control.

That culture change makes many doctors uneasy at first. Doctors want to protect their one-one-one relationship with patients. They may not understand what their non-physician colleagues have been trained to do, or are legally able to do. And many worry that change will make them even busier, by forcing them to manage the lower-credentialed professionals around them.

Lin is the chief information officer for UCHealth. As an administrator, he’s always pushing for change—his latest project is a system that releases certain test results to patients in real time. But as a practicing doctor, he also understands that change is hard.

He says that having Peterson in the examination room with him took some getting used to. “Like many doctors, I have a fear of letting go of all the things I traditionally do,” he says. That includes documenting a visit. “I’m getting over it, because I don’t want to be the only one here at 8 o’clock at night, typing.”

Matt Moles, a doctor who practices in the same clinic, says he also initially felt uncomfortable. Sharing the examination room went against his medical training, he says: “We’re trained to trust no one.”

It’s still possible for doctors to have jobs that resemble the Norman Rockwell era of long consultations—if they’re willing to opt out of the mainstream. A small but growing number are setting up or joining practices that, rather than taking health insurance, charge patients a monthly fee—typically around $75— for unlimited visits.

“I personally have the mentality of—leave me alone, I’ll take care of my patients,” says Dr. Cory Carroll, when reached by phone at his family care practice in Fort Collins, Colorado. He’s been a solo practitioner for most of his 25-year career.

Carroll has about 300 patients, a fraction of the patient load of a typical doctor in a big health care system. He sits with patients for over an hour if he has to. He visits them at home. He helps them connect with social services and community organizations. And he can focus on what he loves most: teaching patients to eat a healthier diet.

His practice is proof that it’s still possible for a family doctor to do it all. But he emphasizes that his experience is unusual. “I’m absolutely an outlier,” he says. Less than a quarter of all internal medicine doctors in the U.S. have a solo practice, according to the American Medical Association’s latest survey. And although the model Carroll has embraced is growing, it serves a more affluent slice of the patient population than a major hospital system such as UCHealth.

The team-based future

UCHealth’s leaders are so sure that team-based care is the future that newly built clinics, such as the one in Denver’s Lowry neighborhood at which Lin and Peterson work, are literally built for teamwork. Examination rooms don’t line long hallways; instead, they ring desk space where nurses, physicians and medical assistants sit side-by-side.

But the clinic is still in the early stages of transforming its teams. The best place in Denver to watch a diverse set of health professionals working together is across town, at a facility run by Denver Health, the city’s public safety-net hospital system. The facility includes a primary care clinic, an urgent care center and a pharmacy.

One recent morning, the distant wail of a baby in the waiting room announced the start of another busy day. Doctors, physician assistants, nurse practitioners and medical assistants were already typing away at the computers in their cubicles, trying to get a head start before the first patients were shown in to examination rooms.

“A lot of Denver Health patients are so complex,” explains Dr. Benjamin Feijoo, looking up from his desk. Patients often have multiple health issues, too many to handle in a typical 20-minute visit. “It’s a bit of a crunch,” he says.

So Feijoo turns to his colleagues for help. For instance, if a patient has both a medical and a mental health issue, Feijoo can address the medical problem and then ask a mental health specialist to step into the examination room and tackle the mental health problem.

If a patient needs, say, a crash course on prenatal health, she can meet with a nurse for an hourlong discussion. And if a living situation is compromising a patient’s health—such as unstable housing, or insufficient access to healthy food—the clinic’s social worker will try to find a solution.

The clinic also employs two community health workers, who spread the word about Denver Health in low-income neighborhoods, and a patient navigator, who calls the clinic’s patients when they leave a Denver Health hospital (and, for a subset of patients, other major local hospitals) and helps them schedule a follow-up appointment with their primary care provider.

Denver Health began expanding its care teams in 2012, when it received a $20 million federal grant. The system spent about half the money on hiring staff such as social workers, patient navigators and clinical pharmacists and the rest on software that identifies patients who are spending avoidable time in the hospital, including people who are homeless or have a serious but treatable condition, such as HIV. New, smaller clinics wrap even more services around those patients, allowing them to come in for multi-hour visits.

The new system now saves Denver Health—an integrated system, which includes a health plan—so much money on hospital stays and emergency room visits that it covers the salaries of the additional hires, says Tracy Johnson, the director of health reform initiatives for the system.

Reconfiguring care teams has made financial sense for UCHealth, too. Although the clinic where Lin and Peterson work has roughly twice as many medical assistants today as it had a year ago—plus a social worker and nurse manager—the configuration saves doctors so much time that they’re able to see more patients each day. The extra visits bring in enough money to cover the cost of adding more employees.

“The reason a lot of this happened is physician burnout was significant, especially in primary care,” says Dr. Carmen Lewis, the medical director of the Lowry clinic. The redesigned teams launched earlier this year aim to make doctors’ lives less stressful.

Patients across the UCHealth system don’t seem to mind the change. A few will ask to speak with their doctor in private, but others are more open with the medical assistant than with their doctor. “Sometimes, they don’t feel as judged,” Peterson says.

Lin says that since he’s started working with Peterson, his patients have been better able to keep their blood pressure and diabetes under control. “Patients will forget to tell me that they’re out of prescriptions,” he says—or he’ll be so busy tackling a more immediate problem that he’ll forget to ask.

With a medical assistant methodically asking all the opening questions, crucial details such as prescription renewals no longer slip through the cracks.

Rethinking medical school

Medical school leaders want to make sure the next generation of doctors has the skills and mind-set the jobs of the future will require—such as the ability to lead teams effectively, draw insights from data sets and guide patients through a system full of bewildering treatments, care settings and payment options.

Students traditionally spend the first two years of medical school learning science in classrooms and two years getting hands-on experience at clinical sites. That’s no longer enough, says Susan Skochelak, group vice president for medical education at the American Medical Association.

She says students need to understand “health system science”—everything from how health insurance works to how factors such as income and education affect health. “We had medical students who were graduating, not knowing the difference between Medicare and Medicaid,” she says.

So in 2013 the AMA began issuing grants to medical schools that wanted to do things differently. One program allowed Indiana University to put anonymous patient data into an electronic health record students can use to search for clues to a patient’s health—such as whether he is showing signs of opioid addiction. Another grant allowed Pennsylvania State University to create a new curriculum that requires medical students to work as patient navigators.

“Brand new medical students—they totally get the need for this,” says Robert Pendleton, a professor of internal medicine at the University of Utah and the university hospital system’s chief medical quality officer. At this year’s kickoff for an elective curriculum on data and performance measurement, he says, students packed the auditorium.

And all medical schools are trying to emphasize teamwork. At the University of Colorado medical school, the idea that doctors should treat non-doctors as partners—not subordinates—is impressed on students from Day One, says Harin Parikh, a second-year student.

The medical school shares a campus with education programs for six other health professions. Students hang out on the same quad, grab lunch in the same places, and even take some classes together. In a required first-year class, students from a mix of health fields are split into teams and are asked to plan a response to given scenarios. One day, a nursing student might lead the team; the next, a pharmacy student.

Parikh says the team-based approach makes sense to him. “From a provider perspective, it’s about checks and balances,” he says. When multiple people, with different kinds of expertise, come together around a patient, one may notice something the others don’t.

Reorienting medical schools, like reorienting hospital systems, will take time. Scheduling barriers can make it hard to get students from different health fields in one room, for instance. Some faculty members aren’t prepared to teach a new kind of curriculum. And when students leave school for their clinical training, they work in real-life settings that are all over the spectrum when it comes to teamwork.

“We’re working on an ideal,” says John Luk, assistant dean for interprofessional integration at the Dell Medical School at the University of Texas at Austin. “But the reality is, many of us have not been practicing at the ideal.”

Author: Sophie Quinton is a reporter for Stateline, a nonprofit journalism project funded by the Pew Charitable Trusts.