The Future of Healthcare: “Let’s make a two-tiered system: a basic safety net for all and a private market for those who could afford to pay for more conveniently scheduled care” with Dr. Gayle Woodson

If I had a magic wand, or if I were a genie, I would convert US Medical Care into a two-tiered system: a basic safety net for all and a private market for those who could afford to pay for more conveniently scheduled care. I have experience with both the Canadian and British systems. Canadians […]

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If I had a magic wand, or if I were a genie, I would convert US Medical Care into a two-tiered system: a basic safety net for all and a private market for those who could afford to pay for more conveniently scheduled care. I have experience with both the Canadian and British systems. Canadians love their system until they have to wait two years for a hernia repair. The UK, which has both private and public care, has arguably the best medical outcomes in the world. So here are some measures that would be helpful pending major changes.

Asa part of my interview series with leaders in healthcare, I had the pleasure to interview Dr. Gayle Woodson. Dr. Woodson is a surgeon who began her training at John’s Hopkins when women surgeons were an oddity, and went on to a successful career in academic medicine, more than 30 years of clinical practice, teaching residents, running a research program, and doing medical outreach in Africa, Central America, and the Middle East. She completed an ENT residency at Baylor College of Medicine, and a fellowship in laryngology in London, at the Royal National Throat, Nose, and Ear Hospital. She was the first woman elected to the American Board of Otolaryngology (ENT) and chaired its specialty board Exam for five year. She has served as several national medical organizations, has received numerous awards. She is widely known for her research in laryngeal nerve damage and has been an invited speaker on 6 continents. Now semi-retired, she volunteers in a free clinic near her home in Florida, spends 2 months each year teaching at a hospital in Tanzania, and writes short stories, novels, and essays.

Thank you so much for doing this with us! Can you tell us a story about what brought you to this specific career path?

I come from a long line of physicians. One in every generation, all the way back to Jamestown in the 17th Century. I am the first woman in that line. When I was a child and said that I wanted to be a doctor like my daddy, people would say, “Oh, you mean a nurse.” It wasn’t until I was in college, that I interviewed a female pediatrician (for a Sociology assignment) and realized I could actually have a career in medicine. In 1972, there were 18 women out of 180 in my med school class, a significant increase from the year before when there were six women in a class of 96 and only two in a class of 96 in 1970. I thought that the uptick in women students was due to a dawning age of enlightenment — women’s liberation. But a 1970 article in Time Magazine revealed the real reason. Anticipating a looming physician shortage, med schools were expanding enrollment. But there were not enough of qualified applicants to medical schools. The only way to solve this problem was to start admitting blacks and women!

Can you share the most interesting story that happened to you since you began leading your company?

This is a very hard question, because when you are a surgeon, interesting things happen all the time. But one of my more unusual experiences happened in Jordan. I was lecturing at a conference about one hour north of Amman. I spoke in the morning, and by lunchtime, jetlag hit me, so my hosts arranged to have a car take me back to my hotel in Amman. I stood on the curb waiting with my roller bag for what seemed like forever, until a car pulled up. It was old, not like the limo that had fetched me from the airport, and the driver who jumped out of the car spoke no English — just opened the back door and gestured for me to get in. He took off like the proverbial bat out of hell, leaning forward, clutching the steering wheel. There was no air conditioning and a hot wind blew in through the window, which I could not close because it was jammed. This was 2003, not too long after 911, and my mind drifted to images of beheadings. The road was desolate until we saw a car pulled off the side of the road, its driver standing beside it, looking back at us. My chest tightened as our car slowed, and two women clad in gray from head to toe emerged from the two back doors. We were in the middle of nowhere, so I figured I had no choice but to climb into the car. A voce called to me from the front seat. “Hello!” She was a midwife from Australia, also speaking at the conference, and the two women were Jordanian midwives. Turns out, when they decided to send me, this car had already left, so they called ahead to have them wait. All three women were delightful: intelligent and outspoken feminists. I was sorry when we got to my hotel and had to say goodbye to my new friends. The world is full of good people. We all really want the same things.

Can you share a story about the funniest mistake you made when you were first starting? Can you tell us what lesson you learned from that?

As first year medical students, we were sent around the hospital in pairs, to practice interviewing patients. While I have great admiration for people who donate their bodies to science, I absolutely revere patients who submit themselves to barrages of questions and pokes from wannabee doctors. I mean, they are actually conscious during this grilling. Ben, my partner in this course, was very (obsessively) thorough, in conducting the Review of Systems. The ROS is a critical component of any medical workup, a bit like a pre-flight checklist, making sure that all the patient’s problems are considered. In modern electronic records, this really has devolved into box checking. (Is the patient breathing? Yes. Respiratory System Checks Out. But I digress.) One day, Ben and I were interviewing a patient with Crohn’s disease (inflammatory bowels) and I dozed while he asked every single question about every possible complaint. I startled from my reverie when I heard him ask, “Do you have diarrhea?” and the patient answered, “No.” I sat bolt upright and asked, “What, no diarrhea? Don’t you have Crohn’s?” They both stared at me for a moment. Then Ben said, “I asked if she had PYORRHEA.” I slumped down in my chair, too embarrassed to let on that I had no idea what pyorrhea was. I looked it up later: it’s sore gums. What I learned from this episode is that there actually IS such a thing as a stupid question. As they say, ‘Better to be silent and thought a fool, than to open your mouth and remove all doubt.” I always try to listen carefully before jumping into any conversation. It is a strategy that has served me well in every situation.

What do you think makes your company stand out? Can you share a story?

I chaired the Division of Otolaryngology at Southern Illinois Medical School. We provided state of the art medical care, because all physicians were actively involved in all three parts of practice:

  • Clinical service to our patients and referring physicians. This included an emphasis on availability for phone consults, emergency work-ins, and patient questions.
  • Teaching of students, residents, patients, and community.
  • Research, continually seeking better solutions to our patient’s problems.

One morning, before a day in the operating room, I had a split fingernail and was looking for an emery board. I went to the hospital gift shop but was disappointed to find it closed. The hospital CEO happened to walk by and asked what I needed. He had a key to open the shop and gave me what I needed, gratis. He said it was the least he could do, seeing that our division had better relationship with community physicians than any other department.

What advice would you give to other healthcare leaders to help their team to thrive?

Keep focused on the patients and the morale of staff. Compassion is driven from the top down.

Ok, thank you for that. Let’s jump to the main focus of our interview. According to this study cited by Newsweek, the US healthcare system is ranked as the worst among high income nations. This seems shocking. Can you share with us 3–5 reasons why you think the US is ranked so poorly?

The overarching issue is lack of access to care. The USA leads the world in medical research and in spending for clinical care, yet people die because basic medical care is too costly. It’s like starving in the midst of plenty. I saw a man nearly die in the parking lot of our clinic because he waited to seek help for a throat tumor until his airway collapsed. I have treated many patients with near fatal neck infections because they could not afford to go to a dentist. Since retiring from my career in academic medicine, I now volunteer in a free clinic, and am amazed by the suffering I encounter in patients who are between jobs and not poor enough to qualify for Medicaid. The Trump administration recently announced a plan to address kidney failure, facilitating transplants, and diverting patients from hemodialysis to home peritoneal dialysis. (I won’t go into the relative merits of hemodialysis vs peritoneal dialysis). More lives could be saved and with less money by preventing Kidney failure: treating diabetes and hypertension.

Access to care is not assured by having “coverage.” Having insurance does not guarantee the availability of a physician or hospital that accepts your plan. Even if you locate a doctor on the plan website, there may be no appointment time available, or the physician may have been dropped from the plan. Once a person gets in to see a doctor, there are often delays in testing or in referral to a specialist, because of the need for approval by the insurance company. As a physician, I frequently had to take time away from patients in my clinic to explain over the phone to a “peer” why my patient with severe headache and a possible brain tumor needed to have a CAT scan. Established care can be interrupted by a change in insurance coverage. I once treated a woman with an unusually severe fracture of her throat. Her voice box had been sliced in two, with one half pulled up and the other dropping into her chest. I performed an emergency tracheotomy and a complex reconstruction. She required close follow-up and secondary surgery, but I never saw her back in my office, because I was not on her plan. The doctor who eventually saw her never contacted me, so I have no idea what the outcome was.

There is a great disincentive for patients to undergo recommended screening, because of the time and expense. For example, a woman may know she needs a mammogram, but she has to find a physician, get an appointment, then get a prescription to schedule the test, then often requires a follow-up appointment to review the request. And lack of access to care in normal business hours results in clogging of emergency rooms with both non-urgent problems, and emergencies that arise because a problem was not managed sooner by a timely office visit.

A lot of what health insurance pays for is not really insurance. That is, the insurance company takes in and holds money to pay for costs that the person is certainly going to incur. Take for example, dental insurance. You give money to the insurance company and they pay to have your teeth cleaned, plus insurance company management costs and profit. You need insurance for the cracked tooth or the bad infection, but it would be cheaper to pay for the cleaning, and then pay a lower amount to cover those less likely, but more costly events. The same concept applies to health care in general. You know you are going to need some medical care or medications during any given year. The health insurance company takes your prepayment and doles it back to you, but not until you have spent the deductibles, which can be high. Even after you pay your deductibles, some costs are likely to be denied. Hence, the enduring popularity of medical savings accounts.

The cost of prescription drugs is a major problem. A patient with diabetes who cannot afford insulin winds up in the emergency room with ketoacidosis. A patient with hypertension who stops medication has a stroke or a heart attack. Effective generic drugs become unavailable because the pharmacy industry is focused on recently patented medications, which often are only marginally different than the predecessor drugs and may offer no real benefit over other options. Too often, treatment must be based on what the patient can afford, not what would be best care. For example, treatment for common external infections is optimally combination of steroid and antimicrobial. For some reason, there is a quantum leap in cost from a pure antibiotic drop to one including steroids, and oddly, gentamycin eye drops are cheaper than gentamycin ear drops. So, for patients paying out of pocket, I recommend that they put a steroid cream in the opening of the ear canal, and then flush it down with an antimicrobial eye drop. Complicated jury rigging.

One of the most disturbing trends is the increase in US maternal mortality, which stands in stark contrast to the 44% decrease in global pregnancy related death worldwide between 1990 and 2015. A recent article in the Journal of the American Medical Association cited evidence that “the US is the most dangerous place in the developed world to deliver a baby.” A recent study concluded that 60% of these deaths were preventable. And we aren’t doing so well with newborn mortality, either. Although our outcomes for premature infants is fairly good, we lose babies at term due to maternal complications. Access to care plays a major role in our mortality rate, but lack of standardized management is also at play, as is our failure to keep and review databases of outcomes.

Electronic medical records were supposed to make care better, with a more accurate record that could be immediately available for follow ups or for information for future doctors. Instead, the EMR has become a mammoth headache for providers. We spend hours at the computer, hours that could be spent with patients during clinic, hours that we should be spending with family and in relaxation. Meanwhile, when we see a patient in clinic, we must sort through pages of obligatory garbage that has often been cut and pasted from a prior record. It makes it much harder to locate the important information. Even worse, it can promulgate something that was entered in error, or fail to account for an issue that has been resolved. Last year, I was hospitalized for a hand infection (my cat bit me), and months later, at my primary care check-up, my record indicated that I was still taking opioid pain pills (which I flushed down the toilet when I was discharged) and antibiotics. Also, the hormones that I took for hot flashes 5 years ago. No harm was done in that error, it just illustrates the kind of echoes that reverberate in an electronic record. Another problem with EHR is the lack of communication between systems. When I was in practice, each hospital had its own system, and our practice had another. So, this concept of portable medical records has never been realized.

Medical fads are a menace. Unfortunately, it is not illegal to promulgate misinformation, and the internet has facilitated an epidemic of rumors and wives’ tales and “snake oil” claims. Anti-vaxing rhetoric is particularly harmful and perplexing. Tanzania, one of the poorest countries on earth, has a 99% vaccination rate. But the US is backsliding in this area of public health.

You are a “healthcare insider”. If you had the power to make a change, can you share 5 changes that need to be made to improve the overall US healthcare system? Please share a story or example for each.

If I had a magic wand, or if I were a genie, I would convert US Medical Care into a two-tiered system: a basic safety net for all and a private market for those who could afford to pay for more conveniently scheduled care. I have experience with both the Canadian and British systems. Canadians love their system until they have to wait two years for a hernia repair. The UK, which has both private and public care, has arguably the best medical outcomes in the world. So here are some measures that would be helpful pending major changes.

Public health clinics to provide basic screening and maintenance: immunizations, pap smears, blood pressure checks, etc. One step down from an actual urgent care facility, the clinic could serve as triage intake to direct appropriate referrals. Public health clinics could also provide some pre-natal care and identifying high risk pregnancies that require referral. These should be available to all — no need to go through the paperwork of proving that you are poor. Even if you are not poor, a clinic like this would be a time-saving godsend. Some may argue that this would allow “illegals” to get free care. But even undocumented people pay sales tax and gas tax (and with holdings go into some black hole at the IRS).

Pharmaceutical companies should be required to produce a certain percentage or volume of generic drugs, especially the important drugs that are often in short supply or not available.

Establish common requirements for pre-authorization of surgical procedures and tests, such as CT scans. Physicians and patients should not have to play a guessing game with the variations between plans and within a plan over time.

Reduce the bullet requirements in medical records, eliminate cut and pasting of clinic notes. (I think the AMA may be looking into an initiative regarding this)

Require compatibility of EHR systems, to facilitate transfer of patient records and to simplify the tasks of physician as they operate in different facilities.

Regulate false medical claims. Saying the FDA has not yet evaluated this pill that magically melts fat is not an adequate disclaimer.

Ok, it’s very nice to suggest changes, but what concrete steps would have to be done to actually manifest these changes? What can a) individuals, b) corporations, c) communities and d) leaders do to help?

“Medicare for All” has been proposed as a public option, but this is a vague term that does not deal realistically with how the program would be funded and ignores the fact that Medicare currently grossly underpays the costs. Thus, a sudden expansion of Medicare would bankrupt the system. In fact, any sudden and seismic shift to such a public system would wreak havoc, including job losses in the insurance industry. Loss of this vast army of clerical people involved in processing (and denying) claims, would have a net positive effect on efficient quality care, but the transition would be painful for many, but a gradual transition would lessen the economic shocks and allow fine tuning of programs as they are implemented. I recently heard a sound bite in a political debate, to the effect that anything that would take 10 years to implement must be worthless. That statement was a symptom of a major problem, that our Health Care is a hostage in political battles that verge onto Civil War.

a) Individuals need to take charge of personal health: follow healthy lifestyles, watch for warning signs of illnesses, and seek treatment as soon as a problem is suspected. People also need to be wary of false claims of baseless treatments that often are not only ineffective, but harmful. Getting information from websites or media can be helpful in understanding medical issues but should be validated through discussions with medical professionals. And let your elected officials know of your concerns and wishes.

b) Corporations: Establish programs that improve health. For example, some companies provide perks or incentives for things such as weight loss, smoking cessation. Health fairs or screenings on site can encourage patients to address health needs (and decrease the need to take time off work.) Employer health insurance policies should be understandable. Consider offering health savings accounts.

c) Communities can offer programs for those who “fall through the cracks.” For example, I volunteer in a free clinic for people between jobs who do not qualify for public aid. Communities can also sponsor a variety of health promoting activities, like group walks for elders, blood pressure screening, etc.

d) Leaders need to stop treating health care as a political football. Stop saying “my way or the highway.” We desperately need common sense collaboration and negotiation to migrate toward a healthier country. Put the health of the people first, instead of caving into the fiscal influence of Pharma and insurance companies.

Right now we have two parallel tracks mental/behavioral health and general health. What are your thoughts about this status quo? What would you suggest to improve this?

Mental health profoundly impacts physical health, and vice versa. Moreover, we are constantly uncovering evidence for a physical basis for so many problems previously regarded as “mental.” Think fibromyalgia, spasmodic dysphonia, etc. Some of the most frustrating problems I encountered in my practice involved patients with severe medical problems that were exacerbated by medical issues, when I was unable to find a psychiatrist or psychologist to share in the care of my patient. The problem was not that these specialists were unwilling. Either there were just not enough of them or I had no idea how to contact them.

I don’t have insight into ways to improve the “two tracks” paradigm. I only know it must change. A health care system is not comprehensive unless it includes mental health treatment as well.

There is also insufficient coverage of other types of non-physician management. My husband had persistent pain after a shoulder repair, and insurance would not pay for more therapy. Fortunately, he could afford the therapy and eventually returned to work as a surgeon. Many patients who are denied physical therapy wind up disabled and on pain meds. I saw many patients with voice issues who would have responded very well to voice therapy, but insurance would not cover that treatment. Those same companies are very liberal in approving vocal cord surgery, even when voice therapy would clearly obviate the need for surgery.

How would you define an “excellent healthcare provider”?

Compassionate, well-educated, continuous learner and teacher.

Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?

“All great truths begin as blasphemies.” –George Bernard Shaw. So many medical advances are initially regarded as heresy, such as laparoscopic surgery, treatment for sleep apnea, even hand washing. We cannot be gullible to every new claim that comes along, but a true skeptic suspends, rather than refusing belief, pending information. This has helped me navigate advances in medical care and in conducting my own pioneering work in laryngeal paralysis. It should also apply to health care changes. We cannot reject things just because we have not done it that way before.

Are you working on any exciting new projects now? How do you think that will help people?

I am now writing fiction that informs medical issues. My first novel, set in Africa, addresses maternal morbidity and mortality, and my second is about the opioid epidemic, as seen in a small Texas town. My theory is that many people who won’t read dry news items could learn from entertaining stories.

I spend two months each year in Tanzania, teaching at a medical school. I believe that improving the health of a country also boosts its economy and relieves some burden of disease and disability.

What are your favorite books, podcasts, or resources that inspire you to be a better healthcare leader? Can you explain why you like them?

JAMA is my go-to journal. I am a great fan of the “A Piece of My Mind’ essays — published one of my own (Rose) a few years ago. I always look through the table of contents and read the articles that seem impactful. I also subscribe to Medscape, STAT, and NIH, FDA, and CDC bulletins.

You are a person of great influence. If you could inspire a movement that would bring the most amount of good to the most amount of people, what would that be? You never know what your idea can trigger.

I was thirteen when our house caught fire. As I stood in the driveway, watching it burn, I kept thinking that it was not real; that I would awake in my cozy bed with my fluffy orange cat on the pillow. I felt like that last week, when I came out of shopping at a Walmart in Newfoundland and heard what had happened at a Walmart in my home state. My country is not on fire, but it burns with hatred. There are plenty of guns here in Newfoundland, where we spend our summers. Many families depend on the annual moose to feed them through the winter. I don’t sense hate here in this province with the people who gave succor to stranded souls on 911. My home state of Texas has lots of guns, too. When I was in high school, there were pickup trucks with racks for shotguns, because boys went goose hunting before school. We did not shoot each other. So today, it is the hate that is the driving the gun violence. People raging into social media echo chambers. I tried to enter a Facebook conversation with friends and was rebuffed by people who can only see their own side as being right, no possibility for common ground.

So, if I could inspire a movement, I would ask people to spend some time with someone who sees things differently. There was a sixties song, I think it was called, “Reach out in the darkness” that spoke to this. I would call the movement Purple Friendships.

How can our readers follow you on social media?

Facebook: @GayleWoodsonwriter

Twitter @GayleWoodson

Thank you so much for these insights! This was so inspiring!

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