The Leg.Up Local, state and national news of interest to the physician community

March 16, 2016

"Why I Joined the Battle as a Physician"

Grant Woodfin, a third year medical student at the VCU School of Medicine, was kind enough to share this moving essay, "Why I Joined the Battle as a Physician," that he wrote after the death of his 13­year­old son, Caleb. It was first posted on KevinMD.com.

Before losing his son, he wrote, "I knew that experiencing death in medicine would come... In some ways I was prepared for it. The form and razor sharp blade it would wield, I was not prepared for."

After quoting Tolkien's "The Lord of the Rings," Grant continued, "To Tolkien, to be human is to be both confronted by death as to desire to avoid it. As The Woodfin Family: Caleb (left) physicians, I think that is with brother Ethan, and parents where we exist. Daily we are Grant and Tracye reminded of how precarious life sits on the edge, teetering between life and death. Yet we push, scratch, and claw against it to help others avoid what ultimately awaits.

"And so, what is our response as physicians? We are trained to wage war against it: to scratch and claw and to keep it at bay; precisely trained to beat back its advances, to attempt to limit its spread. Like weary soldiers securing our flank against the spreading tide, we use our training to hold it back but for a moment. So why stay and fight? Why battle against a relentless enemy that doggedly pursues our patients, our loved ones, and our very selves?

"In November of last year, my wife and I held hands in a quiet pediatric ICU room as our 13­year­old son, our sweet, sweet boy, slipped from this life to a life we hope and believe awaits. Hours prior to this, many hands were working loudly, feverishly, and frantically to beat back the rapidly advancing grip of that ugly invader for our sweet Caleb. Doctors, nurses, pharmacists, and technicians all relied on their years and years of training to fight for him, for us. Yet as the battle drew to a close, a quiet peace filled that ICU. Nurses held their breath. Doctors grasped our shoulders. We held tight to the hands of those who had been strangers only hours before.

"Why stay and fight? Why join the battle as a physician? Because we care. Our worlds are full of people constantly confronted with death while desperate pushing it away as alluded to by Tolkien. As doctors we are uniquely trained to hold out options and hope against the inevitable, but when those options fail, may we be uniquely trained to care, and love and comfort.

"As I think about those last few hours of Caleb's life, the actions those doctors performed in those dreadful closing moments are just as much about being a physician as healing. Holding our hands as we wept was just as important to us as the attempts to place central lines. The respect they showed our Caleb in how they spoke to him was just as critical as the vasopressors they were pushing. The tears and embraces they shared as we left the PICU, shattered and breathless, were just as important as the ventilator that hummed futilely in the corner. We train to heal. But greater than that, I hope we train to care. I hope we train to love and support and stand by those we love and hardly know. I hope we realize that physicians long desperately to heal; but when we can't, we hold, and cry, and love."

We thank Mark Marinello, MD, Medical Director of the Pediatric ICU and Pediatric Critical Care at Children's Hospital of Richmond at VCU, for sharing this eloquent essay and to Grant, for giving us permission to share it with you.

It serves as reminder of why physicians choose to enter the medical profession, Dr. Marinello wrote. "We, as physicians, play such an important role in people's lives. As complete strangers, we stand there, shoulder to shoulder, toe to toe, with patients and families as they face some of their biggest and most unexpected challenges in life. Remove politics, financial concerns, EMR squabbles, contract negotiations, and policy ­ we stand there in a quiet room as the life of a child of one of our own slips away.

"Sweat, tears, anguish, yet a sense of overarching peace. Grant reminds us of why in his essay. As a physician­in­training, he brings us back to our core beliefs ­ simply because we care. Perhaps his essay can serve as a reminder and allow RAM members to reflect on their core beliefs. In my practice I am constantly humbled by the strength of our families and patients and by the limitations of modern medicine. Yet I, my colleagues, nurses, and staff get up every day and go to work to face some of the most challenging cases and stressed families medicine can find ­ and I wouldn't trade this career in for anything."

Senate Approves Doc Retainer Bill

Before adjourning over the weekend, the Virginia Senate narrowly passed legislation "aimed at protecting a growing health care model where patients pay their doctors a periodic fee in return for agreed­ upon primary care services," reports the Associated Press.

The approval came despite strong opposition from the health insurance industry. "Supporters of direct primary care agreements say they act like a subscription, providing an affordable and predictable way for the uninsured or people with high deductible insurance to cover their primary health care costs," AP reports. "Advocates say passing a law codifying the practice would prevent doctors from facing illegitimate but costly lawsuits from insurance companies."

Gov. Terry McAuliffe is expected to sign the bill since it has received bipartisan support. Read more below, and click here for a wrap up on the 2016 General Assembly and the $105 billion budget sent to the governor. An "emerging new model in primary care," and legislation to protect it, "has sparked a fight this session with Virginia's insurance industry," reports the Daily Press of Newport News.

"The idea is for patients to pay primary care doctors a monthly fee and get an agreed­upon set of services in return," the paper reports. "It's basically a subscription, and it's called a 'direct primary care agreement.'"

Click here to read House Bill 685, "Direct primary care agreements," sponsored by R. Steven Landes, a Republican representing Augusta, Rockingham and part of Albemarle County.

Your Opinion Matters to Us!

We'd like to hear from YOU to help us better understand and serve your needs and those of all our great RAM members. Please click here to take a three­minute survey by this Friday, March 18.

All results and comments will be anonymous. Thank You for taking time to help us learn more about what we can do to better serve you.

CDC Releases New Opioid RX Guidelines

Federal health officials released new recommendations to discourage doctors from prescribing powerful opioid painkillers for chronic pain "when effective drugs that pose less risk of addiction and abuse are available," reports the Times­Dispatch.

Commenting on the voluntary guidelines, RAM member Dr. Randy Chisholm of Midlothian Family Practice told the newspaper, "Everybody is concerned about overprescribing and overuse and abuse of medications. We are kind of walking a razor's edge here of one, helping the patient, and two, making sure that no one is going to abuse them or become addicted."

He noted that "a lot of pain management oftentimes does fall back to the family physician because no one else wants to write pain medication (prescriptions) for fear of being reprimanded, or the rules and [regulations] and penalties are so severe that they have to have everything Dr. Randy Chisholm documented and done right. Everybody is fearful of losing their license because of doing something wrong that we're all afraid to write them."

Dr. Michael Menen, CMO at HCA Virginia's Chippenham and Johnston­Willis hospitals, said the new CDC guidelines appear "fairly common­sensical."

He noted that "probably not a week goes by where we don't have an overdose. It's just sad."

Another RAM member, Dr. Peter Coleman, offered his views as an addiction treatment specialist, citing some other drugs that can be used to treat pain.

The CDC is recommending that opioids such as OxyContin and Percocet should not be the first therapy tried to treat chronic pain. There are exceptions for patients being treated for cancer, who are in palliative care or who are dying and need powerful painkillers.

"When opioids are used, start low and go slow," said Dr. Tom Frieden, director of the CDC. "Start with the lowest possible effective dose and increase only gradually." Click here to read more.

State and Federal Opioid Abuse & Treatment Laws

New laws passed by the Virginia General Assembly require doctors and other prescribers to check the state's Prescription Monitoring Program database before writing an opioid prescription for longer than 14 consecutive days, reports the Times­Dispatch.

"The prescription monitoring legislation and a flurry of other bills were passed by legislators in an attempt to address Virginia's recent epidemic of opioid overdose hospitalizations and death."

Click here to read more about the measures, which reflected "the enormity of the problem," said Dr. David Brown, director of the Virginia Department of Health Professions.

He noted that "for the first time, there is mandatory continuing education" for prescribers who write a lot of prescriptions for narcotic painkillers.

Another VDHP official said she hopes the new law "will cause some prescribers to deliberately write (prescriptions) for 13 days rather than 30 days "simply so they don't have to fall under the requirements to check the PMP," thus leading to fewer opiates left "sitting in people's medicine cabinets."

Noting various exemptions under the laws ­ including for patients in hospice or palliative care, or those who are hospitalized ­ Mike Jorgenson of the Medical Society of Virginia told the TD: "We felt like everything that was within those bills our physicians could get behind... and also help the current problem that the Medical Society of Virginia feels is a very important issue."

Meanwhile, the U.S. Senate passed "a broad treatment and prevention bill, the largest of its kind since a law in 2008 that mandated insurance coverage for addiction treatment," reports The New York Times.

The bipartisan bill passed 94­1 and "is a boon for Republican senators in swing states, which have been hit particularly hard by the drug crisis." These include Ohio and New Hampshire, which has seen a spike in opioid­related crime and addiction.

FDA OKs Genetically Engineered Mosquito to Battle Zika

The federal government last week tentatively "moved to clear the way for the release of genetically engineered mosquitoes into the wild for the first time in the United States, tentatively approving a field test that might help slow the spread of the Zika virus," reports The New York Times.

The genetically­altered insects contain a gene that will kill their offspring and have shown some promise in small tests in Brazil and other countries in suppressing the populations of mosquitoes that transmit both Zika and dengue fever.

Click here to read more, including some opposition in the Florida Keys to the test. The FDA's final approval for the trial must follow a period of public comment, which will probably take months.

"The genetically modified mosquitoes would be released up to three times a week for as long as 22 months, to assess whether the population of wild mosquitos is reduced."

The FDA has jurisdiction because, under federal rules, "genetically engineered animals are regulated as animal drugs, giving jurisdiction to the veterinary medicine division of the FDA."

Writing recently in the Times­ Dispatch, Lt. Gov. Ralph S. Northam, MD, and state Health Commissioner Marissa Levine, MD, told the reading public that "there are three critical things we can all start doing now" to assist in Zika virus prevention:

First, "educate ourselves about Zika virus disease." Second, "create a mosquito­safe living environment." And third, stay up to date about "this emerging Lt. Gov. Northam threat to our health" because information about new diseases such as Zika virus changes rapidly.

For example, they wrote, "Although thought to be rare, the current Zika outbreak has confirmed that Zika can be spread through sexual contact by an infected man to his partner."

Preliminary research suggests that an increase in Gullain­Barré is linked to Zika virus infection. Click here to read more!

There Ought to be a Law

Are you concerned about legislation that affects the practice of medicine?

Do you have an idea for legislation that will help make Virginia the best place to practice medicine?

We encourage you to submit by WEDNESDAY, APRIL 6, 2016 any proposed legislative initiatives that you believe RAM should bring to the Medical Society of Virginia's attention for possible inclusion in their 2017 Legislative Agenda.

We invite you to describe the problem, define the issue and propose a possible solution. The more detail that can be provided, the more likely the RAM Legislative Committee can advocate for this issue at MSV's Legislative Summit on May 13, 2016.

If you or your practice has identified a specific need that may require a change in Virginia law or regulation, and if this change is specifically targeted for the 2017 Virginia General Assembly session, please submit your work to the RAM Legislative Committee by fax at 788­9987 or by e­mail to Lara at [email protected] by APRIL 6, 2016.

There will be a call in the fall for resolutions for the MSV Annual Meeting scheduled for October 14­16, 2016, but any resolutions likely to involve General Assembly legislation in 2017 should be submitted now.

All legislative recommendations must be received by WEDNESDAY, APRIL 6, 2016 to be considered!

MSV Seeks Nominations for Doctors' Day

Is there someone you'd like to celebrate on the national Doctors' Day, March 30?

Click here to nominate a doctor who inspires you. MSV says it will run the photo or story that gets the most Facebook "likes," and will later feature that person in its newsletter, Virginia Medical News. The deadline is March 30.

No Sale: Hospitals Clamping Down on RX $$$$

Alarmed by rising drug prices, hospital administrators are sending docs "not­so­subtle" messages ­ including "$$$$$" popups on patient records ­ when they're ready to prescribe certain drugs, reports The Washington Post.

The basic message? "Think twice before using this drug. Pick an alternative if possible." Among those tagged at one system in Cleveland: Nitropress and Isuprel, injectable heart meds that are a staple at many hospitals. "Their 2015 list prices rose more than 200 percent and 500 percent, respectively, after both were acquired by Canadian­based Valeant Pharmaceuticals."

But many hospital administrators say the problems "extend well beyond the increases that have grabbed headlines and caused public outrage," such as the notorious 5,000 percent spike by Turing Rx and its former CEO, Martin Shkreli, for the drug to treat toxoplasmosis.

"Some companies have raised prices more modestly but repeatedly for a variety of medications old and new, and those increases add up over time," the Post reports, leading to the "$$$$" warnings.

"Shares of Valeant Pharmaceuticals crashed Tuesday after the embattled drugmaker failed to reassure investors that it's getting back on track and even conceded for the first time that it's technically in danger of defaulting on its debt," reports The New York Times.

"The company faces a virtual Murphy's Law of problems," the Times reports, from falling sales to increased pressure to cut drug prices, to a trio of federal probes into its accounting and pricing practices.

Meanwhile, national spending on drugs for insured Americans rose about 5 percent last year, "driven by both greater medication use and higher prices, mainly for very expensive drugs termed specialty medicines," reports the AP.

Despite the rise, that increase was half the rate in 2014, according to the report by the largest U.S. RX manager, Express Scripts.

The report notes a double­digit jump in the price of brand­name drugs already on the market last year, "despite intense criticism from patients and politicians, as well as congressional probes into the pharmaceutical industry's pricing policies."

Does Uber Carry a "Message for Health Care?"

This New England Journal of Medicine column says the ride service Uber has a "message for health care" as a "new solution" that could help disrupt "a highly regulated market" ­ just as Uber has displaced the highly­regulated urban taxi and limo services around the country.

Two physician authors provide interesting food for thought in light of the recent legislative tussle over Virginia's decades­old certificate of public need law. (Last week the state Senate decided to wait until next year to take up reform bills.)

Will Mr. McEachin Go to Washington?

State Sen. A. Donald McEachin, D­Henrico, filed petitions to run for Virginia's redrawn 4th Congressional District, reports the Times­ Dispatch.

Well known to our participants in White Coat Day, McEachin, 54, is an attorney in private practice in eastern Henrico County who has served in the General Assembly for 16 years.

Serving as chairman of the Senate Democratic caucus, he has influenced party policy statewide. So far, the only other Democrat who's announced they plan to run for the seat is Chesapeake City Councilwoman Ella Ward.

Click here to read more about his run in the redrawn congressional district and the race for the seat that's been held by Republican Rep. Randy Forbes. And click here to read about Henrico Sheriff Mike Wade's plans to become the Republican candidate in the 4th.

Republican Forbes is not seeking re­election in the newly­drawn district ­ which is now considered more Democrat­friendly. Instead he's running in the 2nd District in the seat being vacated by Rep. Scott Rigell, a Republican from Virginia Beach who's bowing out.

The new 4th Congressional District includes part of the city of The new 4 Congressional District includes part of the city of Richmond and Henrico, in addition to Petersburg, Surry County, much of the city of Suffolk and half of Chesapeake.

For students of history, one of the more intriguing aspects of the topsy­turvy races is a little­known provision that allows some candidates ­ including Wade and Forbes ­ to run for office outside their home districts because "the U.S. Constitution doesn't require a congressman to live in their districts, only in the states they represent," reports Style Weekly.

As Medical Bills Take Tolls, Evangelicals Go Own Way

Some 26 percent of Americans said in a recent poll that "health care expenses have taken a serious toll on family finances," reports NPR, which conducted the poll along with The Robert Wood Johnson Foundation and Harvard's T.H. Chan School of Public Health.

The poll "shows that even people with medical insurance are still struggling to pay medical bills," NPR reports.

This may be part of the reason why a growing number of evangelical Christians are flocking toward "health care sharing ministry, which requires members to help cover one another's major medical costs as they come up," reports The New York Times.

"While such nonprofit ministries have been around for decades, interest in them has grown since the Affordable Care Act passed in 2010, largely because the law exempts members from the requirement to have health insurance or pay a yearly fine."

The trend raises a number of interesting issues as membership in "sharing ministries" has more than doubled over the last six years, to 535,000 members who seek to "live by their religious beliefs rather than follow a government mandate to buy insurance that may cover things they do want to pay for, like abortion (though half the states do not allow plans sold through the ACA marketplaces, at least, to pay for abortions) or birth control."

The Sad Slide of Olympic Ice Skater, Debi Thomas, MD

Click here for a recent front page article in The Washington Post about Debi Thomas, "the best African American figure skater in the history of the sport," who has lost her license to practice medicine in Virginia.

A Stanford graduate, Thomas ­ a bronze medalist in the 1988 Winter Olympics in Calgary ­ went on to get her MD at Northwestern University and became an orthopedic surgeon.

Today, she "doesn't have health insurance, declared bankruptcy in 2014 and hasn't brought in a steady paycheck in years." Her medical license expired last year after the Virginia Department of Health Professions found "concerns of an ongoing pattern of disciplinary and behavior issues and poor judgment," the Post reports.

Click here to read about last September's hearing before the Virginia of Board Medicine where Thomas contested an earlier diagnosis that she suffers from bipolar disorder.

"In October, the board, citing her expired license, took no action," the Post reports. Click here for her YouTube post from Richlands, a depressed coal mining town in far Southwest Virginia, where she now lives in a trailer.

HCA Virginia Grows Stand‐alone ERs

HCA Virginia has opened its third stand­alone ER in the region ­ the Chippenham Hospital Swift Creek Emergency Center ­ off Hull Street Road in western Chesterfield County, reports the Times­Dispatch.

"That Hull Street corridor is expected to grow by 120,000 new residents over the next 20 years," said Tim McManus, CEO of CJW Medical Center, describing an area that stretches to Chester to the east and southwest to Amelia County.

McManus said Chippenham Hospital already "is the busiest emergency room in Richmond. Last year we did over 105,000 visits."

The TD noted that Bon Secours Health System also operates a free­standing emergency center in Watkins Centre in Chesterfield County and also has one planned for western Henrico. Tim McManus, CEO of CJW Medical The local ER expansions Center seem to confirm a national trend reported recently by NPR. "As many as 1 in 3 Americans sought care in an ER in the past two years, according to a recent poll by NPR, the Robert Wood Foundation and the Harvard T.H. Chan School of Public Health.

Nearly half reported going to ERs for "non­urgent reasons," NPR reports. One way to curb that expensive trend, one Harvard health policy expert said, is for more community doctors to have some office hours on evenings or weekends ­ a trend, it should be noted, that's already well underway among RAM members!

And click here to read how some health analysts say that visiting "minute clinics" in various places has ­ against expectations ­ actually driven up the cost of health care.

How Va. Results Show #NeverTrump is "Doomed"

"The 2016 Virginia Republican Primary results demonstrate the #NeverTump GOP movement gearing up after Super Tuesday probably is doomed," write political science professor Stephen J. Farnsworth and a colleague at the University of Mary Washington, Stephen P. Hanna. Unlike many of the Super Tuesday states, they write, "Virginia's Republican voters are a highly diverse group with something of an identity crisis."

This range of Va. Republicans, from "national security conservatives concentrated in Hampton Roads and near the Pentagon and Quantico; evangelical conservatives who populate the state's rural heartland; libertarians found in the exurbs of northern Virginia and Richmond; and more centrist Republicans ­ who care more about winning elections than ideological purity ­ who are particularly likely to call Fairfax or suburban Richmond home."

With such a diverse makeup, they note that "from time to time, the state's party's deep disagreements have gained national attention, most notably in the tea party­fueled rejection of U.S. House Majority Leader Eric Cantor's bid for a renomination two years ago."

Click more to read this interesting analysis ­ complete with geographic "cartograms!"

Rethinking Population Health

The Doctors' Company has two videos that cover "the unsustainable trajectory of U.S. healthcare spending" and the need to rethink different approaches to different patient populations.

Click here to read about "the healthy majority" and "asymptomatic or early chronic diseases patients" ­ two groups who contribute to a relatively small portion of health care spending.

Click here to read about "full stage chronic disease patients" and "complex episode patients" ­ two groups that contribute "significantly to healthcare spending."

Health Plans Will Rated By Size of Networks

Responding to consumer complaints, the Obama administration says it's going to "begin rating health insurance plans based on how many doctors and hospitals they include in their networks."

Under new rules recently published in the Federal Register, "insurers will still be allowed to sell health plans with narrow networks of providers." Only know the government "will attach a label indicating the breadth of the network for each plan sold on Healthcare.gov." Did Drug Makers Deceive NEJM?

In what was called "a startling accusation," lawyers for patients suing Johnson & Johnson and Bayer over the safety of the anticlotting drug Xarelto say the companies misled editors of The New England Journal of Medicine.

Click here to read more about the claim which "carries echoes ... of an earlier era of drug marketing, when crucial clinical data went missing from journal articles, leading to high­profile corrections and a wave of ethics policies to limit the influence of drug companies on medical literature."

True Confessions of an ER Doc: "The time I stitched a glove to a patient's head"

For a "spot of humor" from across the pond, click here for true confessions of an emergency physician in the United Kingdom ­ ­ Michael Mosley, host of BBC's Trust Me, I'm a Doctor. Part of the Guardian's video series, Confessions from A&E.

Gene Cox's Routine Visit

If you happen to have retired TV anchor Gene Cox as a patient, you might want to read this ­ then give him a call (and maybe a free lunch?).

In his regular "Unprompted" column in Style Weekly, Cox paints a painfully detailed (and comic) picture of waiting too long to be seen ­ and then sit down with his doc for what sounds like a routine visit to check his meds.

"Looking at his laptop more than he does at me, he quickly determines my status and decides what kinds of pills I need. More of what I've been taking for years. The order is mailed to CVS and the visit comes to an end. Five minutes at the most. About $400 that somebody will pay. If there was a patient examination I missed it."

Editor's note: To avoid such scenarios, many of RAM's PCPs and family physicians and practices are working hard to find better ways to take care of routine issues ahead of visits ­ leaving time for doctors to actually make eye contact and talk with their patients.

Comments? Criticisms? Witticisms?

We draw from a wide range of print, online and other sources, including the shifting realm of social media to bring you information we hope is relevant to your practice of medicine.

But as a a former journalist and nonfiction author, I recognize that mistakes do happen. So please contact me if you have any concerns, complaints, or articles you'd like to share by clicking here or calling me at 622­8136.

Click here if you'd like to see some of my other writing. THANK YOU for being part of the Academy and its continuing conversation about the best practice of medicine. With the Marines at Camp Fallujah, And check out some back Iraq, summer 2007 issues.

Chip Jones RAM Communications & Marketing Director

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