Monthly Archives: February 2018

Fig 1. CNN. America’s Opioid Epidemic.

Drug overdose is the leading cause of accidental death in the United States. In 2015 alone, there were 52,303 lethal drug overdoses. As the American Society of Addiction Medicine (ASAM) points out, opioid addiction is the leading cause of this epidemic. The ASAM is quick to highlight the over-20,000 overdoses related to prescription pain relievers in 2015, as well as the nearly 13,000 heroin related deaths in the same year. America’s opioid epidemic is a huge problem that we should all be well aware of. Opioid prescriptions are fairly easy to come by. I can say that I have heard first hand of people selling extra pain killers following common procedures in the youth demographic, such as wisdom teeth removal or ACL reconstruction. It is stated that most opioid addicts are introduced to the drugs through the gifting of family members and friends. The fact that teens, and Americans as a whole, aren’t aware of the severity of this epidemic and the ease of developing an addiction to opioids, is highly concerning.

Fig 2. New York Times. The Opioid Epidemic: A Crisis Years in the Making.

The opioid epidemic has been a problem of mounting degree over the past decade. Above is an image created by the New York Times to illustrate the growth in the number of overdoses across the US. As you may see, the scope and density of overdoses have increased dramatically since 1999 to 2014. In 2016, the government produced the first national data to break down this rise by drug and state. The account of drug deaths showed that deaths by the use of synthetic opioids, primarily fentanyls, had gone up 540 percent in only 3 years. Though President Trump claimed to bring this problem to the level of national emergency, he has only deemed it a public health emergency thus far. No additional federal funding has been put towards deterring this epidemic.

Fig 3. Board Vitals. Are Doctors Addicted to Prescribing Opioids?.

In terms of enabling the spread of this problem, the healthcare industry needs to shoulder a large part of the blame. While the New York Times points out that pharmaceutical companies and physicians have been catching most of the flak, it also calls out insurers for their hand in the matter. The problem lies with insurers restricting more expensive, but less addictive painkillers. These alternatives to addictive painkillers such as morphine and oxycodone are safer, but come at a greater cost to insurance companies. Insurers, in conjunction with pharmacy benefit managers who coordinate drug plans, are coming into the spotlight more though now. The New York State attorney general’s office, as of 2017, reached out to CVS Caremark, Express Scripts, and OptumRx (3 of the largest pharmacy benefit managers) to inquire about how they were looking to curb the issue. Hopefully, this pressure will force action and results toward solving the problem. Currently though, the state of the situation is dire. While it is easy to obtain highly addictive opioids, it is still incredibly hard to get the drugs prescribed for treatment against addictive substances. Behind what seems to be an easy conspiracy is solely the desire for cost-savings and a reduced hit to Big Pharma and the insurance companies’ expenses per patient. What this accomplishes in the medical community is the incentivization of cheap and fast treatments. Despite the immediate gratification, these have no shortage of consequences, as seen in the overdose death toll.

Another, lesser known, problem is the proliferation of hepatitis C in young America because of the epidemic. Those injecting themselves with opioids and sharing needles are causing a rapid spread of the disease. According to a post on Reuters, the number of hepatitis C infections has almost tripled from 2010 to 2015. This has caused the under 30 population to now be the most at-risk for contracting and transmitting hepatitis C. This virus kills nearly 20,000 Americans every year—that figure is more than HIV and all other infectious diseases combined. Hepatitis C results in cirrhosis of the liver and, eventually, liver cancer or liver failure. With such a large associated death rate tied to the opioid epidemic, the price tag only gets bigger for what it’s costing our country’s welfare.

Fig 4. Spine Health. Narcotic Pain Medication.

Not enough people are aware of how severe the opioid epidemic is. While the legalization and popularization of marijuana in many states has affirmed for many that one form of drug consumption is safe, a large crackdown on drug culture is still necessary in America. Having heard personal accounts of young Americans contributing to the normalization and spread of prescription painkillers, I fear the outcomes in my generation if we don’t work to stop this crisis. I think there is a direct tie to a more laissez-faire attitude on drugs as of late, regardless of one’s view on marijuana and its legalization. Prescription painkillers are true gateway drugs to the other names of the opioid epidemic, such as heroin, and their overprescribing and high addiction rates should be better known.

Fig 1. Heroic Stories. The Amazing Doctor.

With all the hang-ups in administering care to the public, one of the biggest setbacks might be the fact that we simply don’t have enough physicians.  With the years of training required to enter the field of medicine and a growing price tag that comes along with the education needed, less people are pursuing the long-honored profession. This is a problem especially when looking back at some of the past articles we’ve read in Hall on Health. With unhealthiness trending in the forms of rising obesity rates, hospital-associated infections still tallying large numbers in deaths, an ever-growing aging population of Baby Boomers, and with millions of new beneficiaries under the Affordable Care Act, we need physicians now more than ever.

“The cost is too great, and it’s a lousy job,” said Regnal Jones, executive director of the Chicago Area Health and Medical Careers Program. “The minute you say to me that you want to be a physician, it’s tantamount to saying you want to be an indentured servant.”

Jones was fielding questions from Dawn Trice, a Chicago Tribune reporter. In 2013, Trice took to speak with Jones upon hearing word of his then-unorthodox advice. For years Jones had preached and encouraged the medical school route to his students from underrepresented racial and socioeconomic groups. Having helped nearly 5,000 students at the time of the interview, Jones had helped many along the way to medical school admittance. However, over time his view of that decision had changed.

Fig 2. New York Times Blogs. Should Medical School Last Just 3 Years?.

Many have begun to think this way as well, and for the same reasons. Jones goes on in the article to highlight the years of commitment required through schooling, the nearly insurmountable debt that accompanies it, and the grueling hours required during lengthy residencies that only net you as little as $40,000 a year.

For these reasons, many would-be physicians are turning to the physician assistant track. Physician assistants, or PAs, are growing in demand—both by health care systems who see them as cheap alternatives to physicians and future health professionals. The allure of the position lies in the time commitment to training, the liberties of the position, and the opening salaries.

To become a physician assistant, significantly less time is required when compared to the schooling a physician must do. Following your undergraduate years and a entry exam, students typically complete an accredited Physician Assistant program, which is usually only a 25 month process. While this is 2 years, it is still only half that of a med school program. Once this program is completed, PAs must successfully finish a year-long clinical rotation, giving them experience in the field. From there, they are free to practice as fully trained physician assistants (with the caveat of regular re-testing and continued education throughout their career).

Fig 3. Hartford Courant. Quinnipiac Physician Assistant Students Volunteer Time, Skills As Urban Health Scholars.

The liberties of the profession are fairly numerous. While a PA operates beneath a physician’s supervision, they are able to perform many of the same duties: examinations, diagnostics, developing treatment plans, counseling patients, and—in some states—writing prescriptions.

Compared to the entry-level salary of doctors at $40,000, a PA’s average salary out the gate falls around $90,000. This stark contrast is something that entices many to the position. While there is a about a $100,000 disparity between the average salaries of the two positions ($201k for physicians vs. $102k for PAs), many argue that the time spent in the workforce before physicians are fully practicing makes up for it. With less schooling debt and not as much need for heavy malpractice insurance due to lower liability, the salary of a physician assistant comes with less catches.

For this reason and many others, there is a growing shortage of doctors in the United States. The Association of American Medical Colleges (AAMC) calculates that the United States will have a shortage of between 40,800 and 104,900 physicians by the year 2030. The study run by the AAMC uncovered that the numbers of new primary care physicians and medical specialists aren’t tracking with the increasing volume of the growing and aging US population. Like mentioned before, the study also calls on America’s growing aging population as the primary stressor and concern. The article published calls to attention that by 2030 the 65 and older population is expected to increase by 55% and the 75 and older population by 73%. The CEO and President of the AAMC, Darrel G. Kirch, MD is quoted saying, “This makes the projected shortage especially troubling, since as patients get older they need two to three times as many services, mostly in specialty care, which is where the shortages are particularly severe”.

Fig 4. Medical Recruiting. Part- Time Physician | Post Injury Care| Salt Lake City, UT.

This is an issue that is perhaps greater than any covered before in these posts. Without physicians, we will be hard-pressed to even treat anything you’ve read here. The AAMC advocates a multifaceted solution that covers healthcare delivery innovations, team-based and coordinated care, and a better use of technology. The association is also pushing hard for increased federal support of residency positions in the US. It states that, while many medical schools have expanded their class sizes, there are still not enough openings in graduate medical education. By proposing an additional 3,000 spots in residency over a 5-year span, more doctors will be practicing in the field and lending their services to people and the country.

Fig 1. The New York Times. Bad Hospital Design Is Making Us Sicker.

Nosocomial infections, healthcare-associated infections, hospital-acquired infections… there are a number of buzzwords and shifting terms to describe what is a grave epidemic in the United States. Though these are often preventable cases, the fact of the matter is that, what we will call healthcare-associated infections of HAIs, are a major problem in the delivery of care and a patient’s wellbeing.

According to the Center for Disease Control, about 1 in 25 hospital patients has at least one healthcare-associated infection a day. The CDC collects data on HAIs via the National Healthcare Safety Network (NHSN) and the Emerging Infections Program Healthcare-Associated Infections Community Interface (EIP HAIC). This is an important metric in understanding healthcare and the systems that make it up. Using the data collected, the CDC pushes out yearly reports for states to see their progress and their areas that need improvement. According to the National Institutes of Health, HAIs have become increasingly common in medical care as the field and its patients have grown more complex. Without implementing comprehensive programs to curb disease outbreak and promote infection-prevention practices, it will only get worse. The CDC reports that HAIs affect 5 to 10 percent of US hospital patients per year. Roughly 1.7 million of these infections occur on a yearly basis and result in 99,000 deaths in the US alone. HAIs incur an estimated $20 billion in healthcare costs every year.

Fig 2. Huffington Post. Do You Know Who Used Your Hospital Bed Before You?.

A healthcare-associated infection is one that is caught while hospitalized. The medical term, nosocomial infection, comes from two Greek words, “nosus” meaning disease and “komeion” meaning to “to take care of”. The sad irony of a disease contracted while under medical care is highlighted by what is practically an oxymoron.

The history of the nosocomial infection began in the early 1700’s. Before that time, cross-infection due to unsanitary practices in the medical field were unknown and unheard of. Real breakthroughs came about though in the 1860’s with the development of germ theory by Louis Pasteur. Pasteur proved the before-speculated hypothesis that microscopic organisms were the cause for diseases. He then suggested the cleaning of surgical sites with boric acid. Joseph Lister, having read Pasteur’s work, took this to practice with carbolic acid instead. By disinfecting wounds, and later experimenting with the sanitation of hands, instruments, and the operating theatre, with carbolic acid, Lister was able to significantly lower the rates of infection. Because of this, Lister is now known as the “father of antiseptic surgery” and his Listerian surgical principles are still learned today. Before these leaps in understanding though, surgery was a very dangerous thing to undergo. During the Civil War, the most common surgery was the amputation. Amputations during the war had very high mortality rates due to the field operations occurring in dirty, makeshift operating rooms and poor sanitation of instruments and the doctors’ garbs. Ohio State University’s History Department states that upper arm amputations had mortality rates of about 24%– meaning that over 1 in every 5 men to receive one died. The problem with amputations is that because of their high rates of infection at the time, another would often be required, usually having an even higher mortality rate. Pyemia, a form of blood poisoning that is the result of pus in the bloodstream, had a mortality rate of 90%, so often times, a secondary amputation would be necessary. Other infections such as tetanus had 87% mortality rates and would require the same. During this time period of concentrated surgeries that showcased an especial need for updated surgical practices, primary amputation mortality rate was a high 28% and secondary amputation mortality rate was 52%. These numbers are in large part due to the absence of sanitary practices that prevent nosocomial infections from occurring.

Fig 3. AA2Day. Bacterial growth in IV extension tubing after propofol injection.

Today, some of the most common HAIs include Central Line-Associated Bloodstream Infections (CLABSIs), Cather-Associated Urinary Tract Infections (CAUTIs), Ventilator-Associated Events (VAEs), Surgical Site Infections (SSIs), C. Difficile Events, and Methicillin-Resistant Staphylococcus aureus (MRSA) Bacteremia. Most HAIs are bacteria-based infections that occur at orifices and intravenous or surgical openings, high-risk areas for introducing foreign bodies into the blood-stream or tissues.

Despite the nature of HAIs and the large ramifications of their prevalence, their prevention is simple. Through simple practices such as proper donning and doffing of personal protective equipment (which includes gloves, goggles, caps, foot coverings, and a gown), disinfecting operating equipment, and proper cleaning of operating rooms, HAIs can be curbed significantly. All hospitals have some form of department or service they use that handles sterile processing. A sterile processing unit is an extremely thorough, technician-manned department that handles the cleaning and redistribution of operating instruments. With different chemicals and autoclaves (which are essentially very large pressure cookers that uses steam to sterilize), technicians are able to completely kill any bacteria, spores, or germs, that might be on the tools.

Though this is still a great problem in the United States, many organizations are doing the best they can to eliminate the occurrence of healthcare-associated infections. The CDC’s annual reports allow hospitals to track their progress against the rates that are associated with HAIs and many hospitals have quality assurance and sterilization adherence departments within them. As of now, we already know the greatest methods of lowering HAI rates. What we need to do is eliminate the negligence and procedural mistakes that cause them.