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A Health System That Works
Oliver Fein, M.D., is a Professor of Clinical Public Health in the Department of Public Health at the Weill Medical College of Cornell University.
His research and policy interests include health system reform, national health insurance and medical education. Dr. Fein has been interested in access to care for vulnerable populations and the social responsibility of the Academic Health Center to its community. He has published work in ambulatory case-mix measurement, different methods of measuring social class and health inequalities, and comparative international health systems.
Oliver Fein: What is it that allows an individual to express their humanity, to essentially be able to fulfill their human promise? Well, there are certain things, like education, that we think allow for that, like political expression, freedom of expression; but, if you don’t have health, all the education will mean nothing.
My name is Oliver Fein and I am a physician working at the Weill Cornell Medical College where I am the Associate Dean and also Professor of Clinical Medicine and Clinical Public Health.
Question: What obstacles limit access to quality healthcare?
Oliver Fein: The financial access is extremely important as a primary baseline. That’s why I’m interested in the issue of national health insurance. But, once you get over that barrier, there are going to be other barriers that have to be transcended. Among those, it seems to me, are things like health literacy, the degree to which things are interpreted for people so they really understand the decisions that they’re making when they access healthcare. In terms of the rural side of the United States, there is a whole issue of geographic accessibility, the ability to get to healthcare and frankly we’re going to be able to do some great things in that territory, given the whole internet and ways in which consultations should be possible for physicians and nurse practitioners that are in remote areas. They’ll be able to use technology to get to consultations with specialists, that kind of thing.
And then thirdly, there’s the whole issue of the doctor-patient relationship and communication within it. There I think what we should be moving towards is what increasingly is being called the “patient-centered medical home.” Everybody should feel that they have a medical home in this country. What does that home consist of? Not just a doctor, not just a nurse practitioner, but a whole team of people who are there to provide care to people.
Question: How would you design a medical home?
Oliver Fein: The way it works, in my mind, is that there would be a group of providers, so to speak, in an office. If I am dealing with patients who have diabetes and hypertension, a number of chronic illnesses, I will have access, right in that office, to a nutritionist who could advise patients how to alter their diets, to deal with their problems with diabetes, with obesity, with hypertension, those kinds of things.
That in addition, there might be an outreach worker in the office. Someone misses an appointment, they’re called up, and we ascertain why they missed the appointment. We might even arrange for some kind of a home visit to that patient as a way of really having the office extend beyond just the office.
And then thirdly, and very importantly, is that a lot of what we would do is coordinate a person’s care, be able to link them to the appropriate specialist when that was needed, to become a real gateway to care. I’m no talking about this whole idea of a gate keeper that kind of keeps people away from care, but rather facilitates and coordinates the care that people get from specialists.
Question: How can we improve healthcare outcomes?
Oliver Fein: When we measure quality in healthcare, there are kind of three different types of metrics.
One of them is what we call a structural method. Do you have a license? That means have you passed an exam of some kind. Not a very really good measure of quality, to be honest, because it’s not continuing and so forth.
Secondly, are process measures like, did the doctor actually get a mammogram on a woman to rule out breast cancer? Did the doctor do a test for diabetes? Those kinds of measures, and they’re good, but they’re important but the goal standard usually is outcome.
Has there been a difference made in terms of the control of the diabetes, the control of the blood pressure and so on? So increasingly there is discussion about, do we reimburse doctors? Do we pay them in any way relative to quality? And do we pay them to perform well? I think that’s a good idea provided that one is aware of some of the pitfalls, and the vulnerable populations are the pitfalls, frankly. Let’s say we’re going to pay people more if, in fact, they did preventive interventions, had good outcomes, and what happened was that we would pay people less who didn’t have that, doctors who didn’t have that, and those doctors frequently might be serving poor communities where people didn’t always take their medications because they couldn’t afford them. Where there might have been problems with the job they got lost, and they got unemployed and really their health was the second priority, getting the job was the first.
We would have to think of ways to deal with those kinds of circumstances in a, what we will call pay for performance system, so that the doctors serving the vulnerable populations didn’t get paid less and less because they weren’t able to provide the outcomes that somebody who was dealing with an Upper East Side population was dealing with.
Question: Is there hope for a fully integrative medicine?
Oliver Fein: Actually, integrative medicine is an important component of what medicine should be delivering today. By that I mean, let’s think in terms of, again, diabetes, hypertension, obesity, those chronic illnesses that are very prevalent in our society. The physician intervention is frequently, take this pill, or take insulin for the diabetes, and the pill for the hypertension. But we we need to pair that with nutritionists who are helping people deal with their diet, weight loss and things of that sort. We need to pair that, frankly, in high blood pressure, with stress reducers. We should be, in fact, incorporating in our practices referrals for exercise training, maybe even yoga training to deal with stress. That’s why this team-based care that I was describing earlier, the patient-centered medical home, which had really a whole variety of providers in it, not just doctors, seems to me be the way to move. So, integrative medicine should be very much a part of what doctors are involved with.
Question: How important are electronic medical records to your practice?
Oliver Fein: I can say, from my own practice, that we are completely paperless now. The hospital is just about completely paperless.
What it means for patients is that when I’m not able to be on call, let’s say over a weekend, but my partner is, my partner can go directly to my medical record, and see what the patient’s medication are, can see what’s happened recently, what the latest laboratory studies were, and so on. It really provides a way of improving the quality of the relationship between doctor and patient.
Then the other thing is, that it does lead to things that I would call better patient safety. That is to say that, prescriptions that used to be handwritten could be misinterpreted, particularly with my handwriting, by the pharmacist. Now, all of my prescriptions are printed out. There is no chance for this kind of misinterpretation.
What we’re not doing, now, in medical records is that my medical records aren’t accessible if my patient is in Florida, or on the West Coast, or for that matter, frankly, going to another hospital here in New York City.
Somebody is brought by an ambulance to St. Luke’s Roosevelt, rather than to New York Presbyterian, they don’t know what I’ve done. And that interconnectivity of medical records is really the promise of a good computerized medical records system.
Question: What is the next big medical breakthrough?
Oliver Fein: The real thing that I think isn’t talked about a lot is the phenomenon of what is now being called epigenetics. What that means is that the gene may not be as important as the environment in which it develops. That gets back to the medical home, that gets back to trying to truly alter essentially the problem of obesity, which is rampant now in the country. If we can deal with those epigenetic phenomenon, if we can create practices that are really able to embrace dealing with those problems, then in fact, the true benefit of genetic technology will be able to be realized. But up until that time, the epigenetics are going to shape a lot of what’s possible in the genetic revolution.
Recorded on: May 22, 2009.
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Health officials in China reported that a man was infected with bubonic plague, the infectious disease that caused the Black Death.
- The case was reported in the city of Bayannur, which has issued a level-three plague prevention warning.
- Modern antibiotics can effectively treat bubonic plague, which spreads mainly by fleas.
- Chinese health officials are also monitoring a newly discovered type of swine flu that has the potential to develop into a pandemic virus.
Bacteria under microscope
needpix.com<p>Today, bubonic plague can be treated effectively with antibiotics.</p><p style="margin-left: 20px;">"Unlike in the 14th century, we now have an understanding of how this disease is transmitted," Dr. Shanthi Kappagoda, an infectious disease physician at Stanford Health Care, told <a href="https://www.healthline.com/health-news/seriously-dont-worry-about-the-plague#Heres-how-the-plague-spreads" target="_blank">Healthline</a>. "We know how to prevent it — avoid handling sick or dead animals in areas where there is transmission. We are also able to treat patients who are infected with effective antibiotics, and can give antibiotics to people who may have been exposed to the bacteria [and] prevent them [from] getting sick."</p>
This plague patient is displaying a swollen, ruptured inguinal lymph node, or buboe.
Centers for Disease Control and Prevention<p>Still, hundreds of people develop bubonic plague every year. In the U.S., a handful of cases occur annually, particularly in New Mexico, Arizona and Colorado, <a href="https://www.cdc.gov/plague/faq/index.html" target="_blank">where habitats allow the bacteria to spread more easily among wild rodent populations</a>. But these cases are very rare, mainly because you need to be in close contact with rodents in order to get infected. And though plague can spread from human to human, this <a href="https://www.healthline.com/health-news/seriously-dont-worry-about-the-plague#Heres-how-the-plague-spreads" target="_blank">only occurs with pneumonic plague</a>, and transmission is also rare.</p>
A new swine flu in China<p>Last week, researchers in China also reported another public health concern: a new virus that has "all the essential hallmarks" of a pandemic virus.<br></p><p>In a paper published in the <a href="https://www.pnas.org/content/early/2020/06/23/1921186117" target="_blank">Proceedings of the National Academy of Sciences</a>, researchers say the virus was discovered in pigs in China, and it descended from the H1N1 virus, commonly called "swine flu." That virus was able to transmit from human to human, and it killed an estimated 151,700 to 575,400 people worldwide from 2009 to 2010, according to the Centers for Disease Control and Prevention.</p>There's no evidence showing that the new virus can spread from person to person. But the researchers did find that 10 percent of swine workers had been infected by the virus, called G4 reassortant EA H1N1. This level of infectivity raises concerns, because it "greatly enhances the opportunity for virus adaptation in humans and raises concerns for the possible generation of pandemic viruses," the researchers wrote.
The word "learning" opens up space for more people, places, and ideas.
- The terms 'education' and 'learning' are often used interchangeably, but there is a cultural connotation to the former that can be limiting. Education naturally links to schooling, which is only one form of learning.
- Gregg Behr, founder and co-chair of Remake Learning, believes that this small word shift opens up the possibilities in terms of how and where learning can happen. It also becomes a more inclusive practice, welcoming in a larger, more diverse group of thinkers.
- Post-COVID, the way we think about what learning looks like will inevitably change, so it's crucial to adjust and begin building the necessary support systems today.
Scientists uncovered the secrets of what drove some of the world's last remaining woolly mammoths to extinction.
Every summer, children on the Alaskan island of St Paul cool down in Lake Hill, a crater lake in an extinct volcano – unaware of the mysteries that lie beneath.
The coronavirus pandemic has brought out the perception of selfishness among many.
- Selfish behavior has been analyzed by philosophers and psychologists for centuries.
- New research shows people may be wired for altruistic behavior and get more benefits from it.
- Times of crisis tend to increase self-centered acts.