This months episode of “News you can Use” in the traditions of “Ask Me Anything” on HealthcareNOWRadio features news from the month of August
You can read more about the series here and the concept of keeping up with innovating in healthcare. Please send me your suggestions on topics you’d like to see covered. You can reach out direct via the contact form on my website, send me a message on LinkedIn or on my Facebook page (DrNickvT), or on Twitter tagging me (@DrNic1) and #TheIncrementalist or you can click this link to generate a ready-made tweet to fill in:
As I did last month I am talking to Craig Joseph, MD (@CraigJoseph) Chief Medical Officer at Nordic Consulting Partners.
This week we dive into the extended Pandemic that continue to cause significant challenges in the US and around the world with cases rising again despite the availability of vaccines. With the increase in incidence courtesy of the delta variant and the likely emergence of another variant, Epsilon and beyond, as a result our failure to suppress the virus from replication.
We review the COVID19 Public Health Emergency that is set to expire and likely extended at least for some additional period of time. Meanwhile some states and legislatures are starting to pull back on the rules allowing for the use of Telehealth practice based what Craig points out was the old arguments prior to the pandemic, that have all been shown to be incorrect with the widespread successful roll out during the pandemic.
Physician Use of Stigmatizing Language
Source: https://cdn.jamanetwork.com/ama/content_public/journal/jamanetworkopen/938726/zoi210509t1_1625605520.07593.png
Listen in to hear us talk about the recent article in JAMA: Physician Use of Stigmatizing Language in Patient Medical Records that highlights the use of stigmatizing language we have used in medical notes with both of us realizing we used many of these phrases in terms in our own clinical notes
Listen live at 4:00 AM, 12:00 Noon or 8:00 PM ET, Monday through Friday for the next week at HealthcareNOW Radio. After that, you can listen on demand (See podcast information below.) Join the conversation on Twitter at #TheIncrementalist.
Listen along on HealthcareNowRadio or on SoundCloud
Raw Transcript
Nick van Terheyden
Today, I’m delighted to be joined by Dr. Craig Joseph as I am each and every month. He’s the Chief Medical Officer of Nordic consulting partners. And we’re talking about news you can use, Craig, thanks for joining me today.
Craig Joseph
Thank you for having me again.
Nick van Terheyden
So, unfortunately, we’re still needing to talk about COVID-19. And I think we’re seeing a rise in cases, obviously, the Delta variant is playing a big impact, and change back to the policy of masking. But the question is, where does this end? And what’s the end point for this?
Craig Joseph
Well, I know I actually know the answer, Nick. But I, I don’t want to share it with you. Right now. I’m writing a book. And when my book is done, I’ll everyone can go out and read it. But I
Nick van Terheyden
just think your book will never be finished on this particular point.
Craig Joseph
All right. All right. If you’re gonna push me I’m not writing a book about COVID-19. I don’t know where it ends. It’s very confusing. I thought I understood what was happening and what was, you know, the path forward. And and now, you know, there’s just a significant chunk of the US population that is resistant to or will never get vaccinated against COVID-19. And as a significant reason, because of that. We’re seeing we’re seeing numbers rise again. And it’s, it’s clearly it’s not everywhere, it’s it’s where people who are less vaccinated for either because they don’t have access to the vaccine, or because they choose not to get the vaccine. And so, as you mentioned, LA County and other areas are now reverting and putting back in restrictions. So far, I haven’t heard about anything being closed. But certainly, indoor use of of masks is back in Los Angeles and other areas. And, you know, the question is like, well, how long is this going to go on for not meaningless? Just one masking episode, but are we just going to go from you know, variant of concern to a new variant of concern that that hasn’t spread yet. Until it’s kind of burned through the population.
Nick van Terheyden
And I can predict the next name of the variants of concern, it will be e echo or E epsilon, depending on which version of the phonetic alphabet that they decide to use. So that is amazing. Your powers of perception are, are great. I’m never going to be proven wrong, because there’s probably going to be a jump there or something. But
Craig Joseph
no, I think it’s going to be I think they’re using Greek letters, right. So we’ll be probably be epsilon and I
Nick van Terheyden
proudest moments was to learn that phonetic alphabet, because I was heavily into flying. And I overheard it one day and thought, Wow, that’s really cool. I must learn it. So now I use it all the time, just to impress people.
Craig Joseph
I also use it and for similar reason learned the Greek alphabet, because I pledged a fraternity in college and was forced to so obviously, you did it for good reasons I did it for for bad reasons. But we’re at the same point, Nick, that we’re at the point where we know what comes after Delta. That’s really, that’s what the listeners wanted to know about. And it’s epsilon. But yeah, there will be an epsilon. And there’ll be more after that. And, and the reason you have variance is because you still have viruses. And, you know, from a scientific standpoint, the reason at least in the US, and most areas that we still have viruses is because people are not getting vaccinated quickly, or not getting or choosing not to get back at all.
Nick van Terheyden
Let’s Let’s be categoric about this, if you haven’t been vaccinated, and this viruses still circulating, you are essentially a variant factory. There’s been a lot of commentary on that, because the only way this virus creates variants is by replicating and if we suppress the replication and suppress this virus, so that it disappears as it should, then these variants whilst they could still occur, when at least I’m not aware of a reservoir of COVID 19 or SARS covi to appropriately called in another animal species or in another pool, for it to sort of hide away as seems to happen with Ebola for example, because it’s Sort of disappears and then re emerges. So if we suppress it, then we suppress all of the potential emergence, and it disappeared. So it goes from being a pandemic to nothing. But what we seem to be on course for is no, let’s just allow it to sort of muddle along. And every time it replicates, it has an opposite. That’s what it does. I mean, I don’t think it’s a, it’s not a thoughtful process. To be clear, it’s just a piece of the science and the replication, it’s, you know, it’s a bit like copying down letters from, you know, when you had to copy down from the, the Blackboard, in the old days, gosh, I’m really dating myself, I say, you would make mistakes, you know, the more you did it, the more opportunities for mistakes, and that’s what creates them, not all of them become concerns, variants of concern, some just disappear, because they’re no good. But the more you have, the more chance there is. So ultimately, unless we get this vaccination thing, right, and not just in the US, let’s be clear, but worldwide, we are essentially on a path that sounds like we’re going to keep going in and out of this methodology you think?
Craig Joseph
I don’t, I don’t know it, I think you’re everything you just said was right. And, you know, if everyone if you get COVID, and it replicates inside you and it makes a mutation, and it becomes one of those, you know, that mutation, again, most of the time mutations are very bad for the virus. But every now and then it does something that gives it superpowers. And that’s what we have with this delta variant. If everyone around you is immune, and typically that’s because they’ve been vaccinated, then that mutation goes nowhere. Because it stays with you. And as you get better, hopefully, it’s done. It’s so that, as you point out, it’s really not this is not an individual problem. Unfortunately, what you do affects those around you and what they do affects you. And it does seem to be like this is going to be going on at this rate for some time. And the question has always been will there need to be a booster? And people were asking that from the from the beginning, long before, you know Delta variant was was was even a thing. And it seems like that that might be the case so far. So far, the Delta variant again, there are other variants, of course, but that’s the big one does seem to be responsive to the vaccine, meaning the vaccine does protect you, it may not protect you from getting the disease at all. Right. So let’s again, let’s emphasize, you can get by getting vaccinated doesn’t mean you’re totally unclear, it actually doesn’t promise you anything, what it does tell you is you’re significantly less likely to die or be hospitalized because of COVID-19. And that’s still the case for the Delta variant. However, it the worry is about the epsilon variant that doesn’t yet exist, right? Or that we haven’t identified yet. And will that respond as well to the vaccine? And if not, then how do we get a booster? And let’s hope that we can as quickly as we came up with these vaccines that we can find another one that works against that other SARS cov. Two variant? It’s just it is it’s it’s just now looking like it’s just going in circles, it’s a cycle. And the question is, how do you break that cycle of if lots of people are not going to get vaccinated? And I think, again, the science shows that it’s not the same. There are some who say, Well, if I get if I get the disease, that’s my protections. Great. Well, that might be true. The science, I think, is showing that the vaccines are getting better protection in general, than getting the disease itself. So and you don’t want the disease. It’s not a it’s not something. Well, most people do fine and don’t and don’t die, over well over 600,000 have in the United States alone. And that’s with, you know, one of the best health care systems in the world. Theoretically,
Nick van Terheyden
yeah. So I think the overwhelming point here is that we have to find ways to help people understand that these vaccines are extraordinarily safe. Let’s be clear. Is it possible to say that there is no risk? Nope. We’ve discussed that at length I think extensively. It’s impossible to do that even with something that is zero risk, because we can never really be sure. But the incidence of any problems is infant testimony smaller than the risk of getting the disease and not just dying from it, but also suffering from what is termed long co But I think they tried to rename it. I’m guessing that’s not been successful, because I certainly haven’t persisted with whatever the new naming convention was. And that’s a significant long term effect. I’ve certainly heard of extensive numbers of people. So that’s not what you want. And if nothing else, you don’t want to give this to your grandparents, your parents, even to the younger generation. So why be a spreader when you can be a preventer? I don’t know how else to say it, the history, the science 100 years plus a science that has gone into making this vaccine safe and effective is second to none. Can we be certain of anything? No. But everything that we know tells us that it’s safe. And for those of you that haven’t, I would implore you to get it. And if you don’t want to get it, perhaps you can help us understand why that’s the case. So that maybe we can try and explain some of the reasons, we’re just not very good at assessing risk, I think is part of the problem. So you know, we’ll get into a car where you’re at much greater risk, but might be fearful of flying, which is a much safer activity as an example. So that’s all I can say on this topic. So let’s, let’s move on. We’ve, I think we’re gonna see, well, maybe not see, but the extension of the public health emergency that was declared that essentially allowed for telehealth to explode onto the scene. It’s been two years away for the last 10 years. And it was still two years away, right up until the point that every said, Oh, my God, it works. We should use this, but maybe things are gonna change. What are your feelings about that?
Craig Joseph
I am quite pessimistic. So I’m hoping that you’re going to. Yeah, well, I. So as we know, you know, it wasn’t like no one knew how to do telehealth, right, we, we’ve had this thing called phones, we’ve had phones. So we’ve had the technology to be able to do a certain kind of visit over the phone. And we’ve even in the last five years, easily, even longer had the ability to do an online visit, where you could look at your doctor or the clinician and, and talk back and forth. The reason it never picked up that we never really went anywhere within the US is because most payers including the government didn’t want to pay for it. Because they were questioning whether or not that was a quality medicine and how do you root out abuse? And you know, lots of other reasons why people questioned it well, and then the pandemic happened, and it was that or nothing, right? You either had to tell an online visit a telehealth visit, or you didn’t have anything because doctors offices were by and large, closed. And, and so permission was given because of the pandemic and payers paid for it. And it turned out to be incredibly effective. And that for everything, of course, you can’t do a proper physical exam. And there are other reasons why you’d want to see your doctor in person. But for us, for a big chunk of visits, no need to go, no need to go in. And now I’m just seeing as as one by one payer saying, Oh, well, the, as this national disaster recedes and the you know, the legal definition, from state by state is changing and saying, okay, we don’t have this pandemic anymore. We still have it, but the, the, the emergency is done. Everything’s going back. And peers, like making the same statements. Again, I’m stereotyping, but these are what I’m hearing like, well, there might be a lot of abuse and well, the quality might not be there. And sometimes citing the the exceptions instead of the rules, right? There are always going to be people who are abusing the system. But it’s it’s, I just don’t feel the love. I don’t feel the love from the government and the companies that pay for for telehealth. I do think there’s lots of people who don’t want to go back. I mean, I for one have have used to have had both in person and telehealth visits with my doctor and I think it’s great and and there are times where I want to be there and there are times where I need to be there to talk with with my doctor but other times where especially follow up or reminder things like it’s just I just need some advice, you know, me to poke and prod me to give me those that that advice. So anyway, I don’t have a lot of strong evidence, but my spidey senses are not not telling me to feel good. What about you, Nick? Is this my completely off here?
Nick van Terheyden
Well, for those of you just joining, I’m Dr. Nick the incrementalist and today I’m talking to Dr. Craig Joseph, the Chief Medical Officer for nautic Consulting, he was just identifying as spider man just right there, his spidey sense was going off with telehealth. And I’m, I, my glass is always half full. I’m well known for this. It’s half full of whiskey and half full of air. And I’m delighted by that particular view of the world. I agree there’s a lot of pushback. But what I’m banking on is an overwhelming majority of people who are going, No, I’m not accepting this, this is ridiculous. Why should I haul all the way in spend 40 minutes, take a day off work, or half a day or whatever it is to have to drive in to see somebody sit in a waiting room where I stand the risk of, you know, all sorts of potential negative consequences by mixing and matching in those circumstances unless I really have to, for the purposes of a follow up visit, or a simple visit, where somebody needed to talk to me, I had some advice, and we moved on. This just for me is plain on acceptable. And I do not think you can put that particular genie back in the bottle. And I think it’s the onus is on us, as clinicians, as healthcare providers, as patients patience to stand up and say, No, I’m not willing to accept this. This is my driver. But ultimately, it’s the purse strings that control this. So how do you influence those folks? To allow them so that they see the value? I mean, this has to save money in some respects, doesn’t it? I mean, isn’t this an economic validity to this, that we can still do they save money by doing it? I’m all who saves money? That’s what he does, ultimately, because they’re the ones that are saying, I’m gonna pay for this. They’re just paying less. And I know, there’s a lot of pushback on that, because it still demands the same amount of medical decision making, should it be at the same price, right?
Craig Joseph
So that’s, and that’s where, yeah, and don’t get me wrong, I think everything you said is right, and that patients are demanding. And, and providers are demanding that we’d be able to continue to do this. But, you know, this is how I see it kind of potentially eroding, like, Well, you know, we used to pay you, I’m just gonna make up a number $100, for an office visit, we’re beating the big insurance company or the government, we will pay you $100. Because we assumed like, you know, you have to pay rent, and you have to have a nurse, and you have to have a front office person. And all of that kind of got into what we thought the value was, well, now it’s just you doctor, and a computer. And we don’t really I need an IT
Nick van Terheyden
person to support and deliver against that, I still need my nurse, because I need somebody to help me with the pre and post and the follow up and the documentation, all of that stuff that still took place in the office still needs to take place. And I still need the front office person, because they’ve got to do all the coordination to make sure those appointments are set up that if things are running late, that they can schedule, yes, you can use some technology, but you still need people behind them. Do I need the physical office space? Well, that depends on whether I can do it in my office space, and I’m still seeing patients, so I still need to see them. So I’m going to say, No, that’s not true.
Craig Joseph
I am going to continue to be upset with you for trying to use logic and common sense. And dealing with arguments I make on behalf of big payers. So again, all of that, all of that makes sense. And I hope that your your calm demeanor, and and a sense of normalcy and and just you know, common sense, makes the day holds the day. But I’m not confident that it always works that way. And when we’re talking about some of these things, so interesting to talk about. I I this is one of those things where I hope I’m wrong.
Nick van Terheyden
Well, let’s watch this space. So telehealth and the pandemic health emergency may or may not change things. We’ve got to stay on top of it. Last few minutes. I think we both saw the article in JAMA that talked about physician language that did a survey of you know the way that we right now. I certainly read it with tremendous interest because I looked at the example specifically this was talking to stigmatizing language in the patient of Medicare patient medical records. And, you know, I, I’m, I’ll be honest here, I looked at some of those things and thought, yeah, I have absolutely use those terms. Not I’ll say, not within 10 that stigmatizing. You know, some of the specific examples that they use, specifically on the negative, you know, reports, denies, you know, even what they described as implying disbelief, you know, patients insist that the pain is, you know, and I’m thinking, gosh, I used all of those terms. And I, I struggle with this, because I wasn’t sure how to sort of rectify, and they had the other side, what was your view?
Craig Joseph
Well, first of all, I think this is very helpful, because I did not know you were a horrible person. And thanks very much, horrible doctor. But now it’s been confirmed. So by you actually, not by other people. No, seriously, these this is kind of the language that we were brought up with, right? When we went through medical school and residency and all that training. These are the words, you know, all industries, including healthcare, I think, have words, and that are terminologies that you either unique to that, that industry, or if not unique, or used in a, in a way differently than than the lay the lay public. And so, I have absolutely done everything that you’ve set. I have, I’ve quoted people to, to not, in my mind to shame them or to show disapproval. But to say like, well, these are, these are the words that this person used. Now, the question is, Could someone look at that and go, Well, you just did that, because you didn’t really believe them? Or you wanted to, you know, you were making fun of the way that they talk, which I don’t think was true. But, you know, some of the words like you mentioned, Where, where, where you’re, you’re questioning, you know, I’m looking at some of the examples, they put, like, you know, he insists the pain is behind his knee? Well, that’s what he said. But with by using the word insist, or by using the claim, right, he claims that this medication doesn’t work for him, you’re implying there that you’re not really sure it should work, and why doesn’t it work, and it’s probably just them. I thought this was something to again, something that I don’t think of unilateral decision. So language that doctors used to imply they have authority over the patient. So the patient was told to stop doing x, or I’ve instructed him to start doing why, again, language I would use all the time. And, and it does, now that we have open notes, right, we’ve talked about this in the past, now that patients have the legal right to easily see their notes, they’ll always have the right to see them. But we can easily see that now online, more people are going to be reading their notes, and they’re going to see this language and they’re going to, you know, potentially lose some trust or or have a have a more negative view of the doctor or healthcare in general. And it is important to kind of look back at ourselves and understand how others are perceiving what we’re writing. And, and, and making that better if we can, while still having a medical record that explains what happened and why it happened.
Nick van Terheyden
Yeah, so I think that the good news is it sort of gives you an opportunity to look back and say, Okay, I certainly not intend or at least not in, in my case, your case, I think in the majority of cases. But I think what’s important out of this is we find new ways, you know, because as I’m listening to you, I’m thinking about my sort of process of stating, you know, patient states that stated this, you know, I would have it would have been my process of recording and part of it is you’re trying in the good old days, bad old days, not sure which we were handwriting so there was a big challenge of capturing information to grab what you could it was illegible Of course, or at least it wasn’t my case. And we need better ways. Maybe we’ll get better with listening in with technology can then turn it with, you know, some of the speech enabled solutions, but let’s hope they’re not programmed with our old you know, in a pro great use of language. So, again, I think, you know, interesting place. I’m always open. I just hope people don’t judge immediately and have discussions about it versus jumping to conclusions that there was an intent. And it doesn’t create that divide. I think that’s a big desire out of that.
Craig Joseph
Yep, I agree.
Nick van Terheyden
Unfortunately, as usual, we’ve run out of time. So just remains for me to thank you as I do each and every month for joining me for this show. Always a pleasure, Craig. Thanks for joining me.
Craig Joseph
All right, look forward to the next one.
