By Dave Davies
NPR, Fresh Air, February 21, 2023

Dr. Farzon Nahvi spent the first few months of the pandemic as an emergency room physician in Manhattan. He talks about trying to improvise treatments during that time. His new book is Code Gray.

Transcript

DAVE DAVIES, HOST: This is FRESH AIR. I’m Dave Davies, in for Terry Gross. In the first year of the pandemic, more than 3,600 American health care workers died after being infected with the COVID-19 virus. Our guest, emergency room physician Farzon Nahvi, says that was a time when he and his colleagues were improvising means to treat patients and protect themselves. He writes in his new book that public health officials and hospital administrators were, like frontline medical workers, in over their heads and not quite sure what to do. For a time, some hospitals banned physicians and nurses from wearing masks at work, fearing it would frighten patients more than reassure them.

Most of Nahvi’s memoir, though, focuses on his life as an ER doc and the health care system in pre-COVID times. He writes that COVID was not a wrecking ball for health care delivery, but a magnifying glass illuminating flaws already inherent in the system. He describes systemic failures in American health care and dilemmas that physicians face in treating and communicating with patients and their families.

Farzon Nahvi is an ER physician at Concord Hospital in New Hampshire and the clinical assistant professor of emergency medicine at the Dartmouth Medical School. Before that, he worked in hospitals in Manhattan. He’s written for The New York Times, The Washington Post and other publications, and has testified before a congressional committee on health care reform. His new book is “Code Gray: Death, Life And Uncertainty In The ER.” Well, Farzon Nahvi, welcome to FRESH AIR.

FARZON NAHVI: Thank you for having me, Dave. It’s a pleasure to be here.

DAVIES: You know, in the early part of this book about the early months of the pandemic, it’s interesting. The book is filled with excerpts of text messages exchanged among you and other doctors you’ve known. You know, I guess you guys met in training and spread out around the country. And you’re talking about really important stuff that you didn’t feel you had clear guidance from public health authorities or your own hospital management. What kinds of things were you sharing with each other?

NAHVI: Well, you’re absolutely right. This is a text message exchange between 15 of us. They’re all 15 ER doctors that – we did our residency training together, and we spread out all over the country. And the text message thread had been there for a while. It’s usually a benign thread where we talk about our lives and experiences. But then it really came to life in the earlier parts of COVID. And we shared all sorts of experiences.

It felt in that moment that we were one step ahead of all the guidance we were getting because we were there on the ground experiencing this. And then the guidance we would get would often come one or two weeks later. So we were really relying on each other for everything – what to do, how to treat people, what our situations were like in our different hospitals. If our family members got sick, we would ask each other to check up on each other’s family members. So it really covered every aspect of life during that early part of the pandemic where things were really being done on the fly.

DAVIES: Yeah. Among the things that you communicated with your colleagues about was, you know, physicians and other health care workers who had died from the infection. And you write that in the first 12 months, 3,600 American health care workers would die of COVID-19, and that a Kaiser Health News investigation found that many were preventable. How could they have been prevented?

NAHVI: I think the early stance that COVID is not an airborne disease, when in fact we later on learned that it was, and other countries said that it was – by not treating it that way, I think we put a lot of ourselves at risk by not encouraging mask use early on. Two physicians that I worked with died early on. There was one patient transporter I know and one overnight clerk that I worked alongside – both of them died. And two PAs, two physician assistants that worked in the ER very closely with me – they didn’t die, but they were young guys. They were in their 30s and 40s, and they were intubated in the ICU with COVID.

So it was a very different time period. And it’s very difficult to kind of get into that mindset again, to remember what it was really like, because we’ve come such a long way with vaccines and kind of with time and the virus mutating on its own. I was speaking with a colleague of mine a while back, and she’s an internal medicine doctor, and she related it to childbirth, actually. She had just given birth to a child. And she said that earlier period, just like that childbirth period where you kind of have this very huge, very dramatic experience and then it’s over so quickly and everything is more or less back to normal.

And you look back and you say, hey, is that really as I remembered it? Was it really as crazy? And it was. But it was just so brief that it’s hard to look back and appreciate it for that dramatic episode that it really was.

DAVIES: You were working very, very long hours. You know, you described getting home and having to think about how do I not bring the virus into my apartment. So were there was this whole crazy thing of disrobing and hitting the shower immediately. And then you’re losing people. I mean, friends die. And you got to get right back in the ER. I mean, do you feel like there was post-traumatic stress here?

NAHVI: I’d say, yeah. I mean, in the text message thread in the book, there are parts where we have colleagues kind of asking each other, hey, is it safe to use our work health insurance to see a psychiatrist for this? And I know a lot of people that saw therapists for the first time because of this. And I think it’s not just that people were dying, and it’s not just that this was a scary time for us. It’s also, as I was saying, this kind of loss of confidence in our system making the right calls to protect us.

The CDC and kind of our health care institutions at the highest levels weren’t making the right calls to make us feel safe because it’s one thing to say, hey, you know, there’s this big scary thing that’s happening, but you guys are in the position to help, and we’re calling on you to help out. And it might be risky, but we’re all in it together. But it’s another thing to say, hey, this big thing is happening. We’re calling on you to help out, and, you know, we’re going to support you 50% of the way. So I think a lot of people had that sense that there wasn’t as much trust in our institutions as we would like to have had. And because of that, it became a much scarier time. And I think maybe the PTSD comes from that.

DAVIES: You mentioned a lot of colleagues for the first time sought therapy. Did you seek help yourself?

NAHVI: I did, yeah, for the first time in my life. There’s this wonderful collaboration between those of us who are in it together and texting one another. And one of those things was there’s a group of therapists that actually got together, and they weren’t ER doctors, so they couldn’t help out in those early stages of COVID in the ER, but they decided that they wanted to help out by supporting us who were working in the ER. And they got together and provided free therapy for anyone who wanted it, no questions asked.

I’ve never experienced that in my life where I felt that I needed therapy. But because it was so available and because these people were coming from just this genuine desire to help us, I took him up on it, and it really was – it was very helpful, actually. And I appreciate that. And I think, right now, three years later, I’m doing OK, and I’m doing pretty well. And it’s probably largely because of that experience I had.

DAVIES: Therapy is, of course, a private matter, but if you feel comfortable sharing, what do you think about it helped you get through this?

NAHVI: You know, there was just a lot of anger at that time. I’m not necessarily an angry person by nature. That’s not my go-to. But I just remember being kind of uncharacteristically angry during that time period and having someone there to help me through that, I think was extraordinarily valuable.

DAVIES: We need to take a break here. Let me reintroduce you. We’re speaking with Farzon Nahvi. He’s an emergency room doctor at Concord Hospital in New Hampshire. He spent the early months of the COVID pandemic as an emergency room physician in Manhattan. His new memoir is “Code Gray: Death, Life, And Uncertainty In The ER.” We’ll continue our conversation in just a moment. This is FRESH AIR.

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(SOUNDBITE OF YO LA TENGO’S “HOW SOME JELLYFISH ARE BORN”)

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DAVIES: This is FRESH AIR. And my guest is Farzon Nahvi. He’s an emergency room physician at Concord Hospital in Concord, N.H. His new memoir is called “Code Gray: Death, Life, And Uncertainty In The ER.”

So the book is about life in the ER. And you describe being on duty in an outer borough of New York once when you get word that an ambulance is on its way with a 43-year-old woman who has not had a pulse for 30 minutes, and the ambulance is still six minutes away. It’s clear to you that she’s died and is not going to be revived. What do you and your team prepare to do when the ambulance arrives?

NAHVI: Well, yeah, like you said, just from hearing that report, it’s clear that she’s died, and there’s going to be no successful chance at bringing her back. And yet we do what we always do, which is that we prepare to do everything in full capacity. You always worry that there’s some sort of miscommunication or something else might have happened that we didn’t really catch word of ’cause the communications in the pre-hospital setting, they can be a little rocky. We could lose our phone connection. Who knows? So we get ready for everything. So it’s this funny kind of feeling where you kind of know everything is done, and yet you get prepared to do everything. And that’s kind of how we – where we live in the ER. We live in that space where you do everything, but you’re kind of prepared for the worst. And then, yeah, so she comes in, we get ready to receive her, and we continue that first set our paramedics had initiated, which is CPR, a bunch of medications, an intubation for her airway protection and all that stuff until we eventually do call her time of death.

DAVIES: Now, her husband arrives a few minutes later, and you and the team are still working on her. And you give him the option of staying in the room and watching. And I’m picturing this ’cause you describe it. And she is, you know, on the table, naked and unresponsive, being subjected to a lot of, you know, invasive stuff. There are tubes and IVs and chest compressions going on. I could imagine it would be traumatizing for a husband to see this. What goes into your thinking about whether it’s a good idea to have, you know, a relative or a loved one in the room?

NAHVI: I think there’s two ways to think about that. The first way – and for me, the most important way – is that that’s their right. It’s their right to have the option whether to come in or not. The second thing is – your question has a lot of validity. In previous generation, in previous eras, we didn’t used to let people in the room. We used to protect them from that experience. But more recent research has demonstrated that actually helps the people who survive that experience. The family members who witness their loved one having died and are in the room with them actually have a less difficult grieving experience than those who are not witness to that. And you can imagine it gives you some kind of closure, some kind of understanding what – to what happened and also an understanding that the medical team that was there was really doing everything that they could have done.

And so if the person didn’t make it and they did end up dead, that every effort to keep them alive was made. And, I mean, we could go through the research and the data, but I think a lot of people experienced this during COVID itself, when people weren’t allowed there. I think we think that it’s horrifying to watch someone during the final moment as they die, and it is, but the more horrifying thing is to not watch it, is to not be allowed to be in that room. And a lot of people had to go through that during COVID.

DAVIES: You know, as you describe what happens here – and this is a conversation that moves as a thread throughout the book while you discuss related topics. But it’s interesting that you tell us in the book that there’s no set standard for how long you continue CPR after you’re not getting a pulse. And you and this team – and it’s quite a team – really work on this woman. I mean, it’s clear at some point that it’s not going to be successful. And you have the husband here, and you want him to feel comfortable that everything that could be done was done. And so you talked to the team. I’d like you to kind of just reconstruct this, what you say to your team, ’cause it sounds to me like part of that is done for the benefit of the husband.

NAHVI: You know, it is. Yeah. Well, we also need to make sure that we’re all on the same page. So what we do is that we – we’re communicating my thoughts to the team as I lead this resuscitation attempt, this code, and we talk out loud, and we say, hey, we have a 45-year-old female. She came in with X, Y or Z. We did X, Y, or Z. We felt no pulse. We have no return of spontaneous circulation. It’s been 45 minutes. I think it’s time to call this code and call a time of death. Does anybody else have any ideas? And we do this to review to make sure we’re not missing anything because we want input from everyone on the team. Sometimes our nurses have great ideas, our physician assistants have great ideas that we’re missing, and it’s very important to continue that.

But also, it’s this dramatic thing where someone’s about to die, and we want everyone in that room, whether that’s the patient’s family members or anyone that’s on my team with me, to feel comfortable with that. The last thing I would want as a physician leading a code is for someone to say, hey, I think we should have done this, afterwards. So we do review that. As long as everyone buys in and we’re all on the same page, then we proceed, and we say, OK, time of death, 10:32 a.m. or whatever it is. And that’s usually how it ends.

DAVIES: It was really striking to me that you’re saying to everyone, OK, we have this woman; is there anything else we’re missing? And when you all agree, then it is over. You have to, here – at some point here, communicate this to the husband. And a good part of what you discuss in the book is communicating with patients and patients’ families. And it’s not easy. And one of – you write about a moment early in your career where you had to communicate bad news. And it was a woman who had come in with a persistent cough. It turns out when she gets – what? – I don’t know. Was it a scan of some kind?

NAHVI: Yeah, she had a CAT scan.

DAVIES: That it appeared she had metastatic cancer, and you had to talk to her. You felt you didn’t handle it well at the time. Tell us about it.

NAHVI: Yeah. No, I didn’t handle it well at all because they teach this stuff in med school and residency but it’s all theoretical. The real-life doing it is an entire different level. And in that particular example, I knew the information I had to tell her, and yet I just found myself literally unable to speak the words. Up until that in my whole entire life, I’ve never had to confirm someone’s deepest anxieties and fears.

Generally in life, if we have friends or family members and they’re going through a hard time, we tell them everything’s going to be fine. We give them reassurance ’cause usually it is. And this was the first time in my life where someone came in, and they probably had some fear deep back in their mind that something catastrophic was happening, and I had to go confirm that. And I was fighting this deep, deep desire inside of me to not want to tell her that truth, to try to avoid that as much as possible.

So I went through the whole conversation, and I walked away realizing that I didn’t tell her she had cancer. I had used all these euphemisms. I told her, you know, the CAT scan came back, and there were some masses in there. And she said, what could those masses be? And I said, oh, they could be some pretty bad things. And then, she eventually asked me, what could those bad things be? And I said, oh, you know, we’re going to need a biopsy to confirm it. And I just couldn’t get myself to do it ’cause I – it just went so against the grain of everything that I want to do and everything I had done before that. So it was a troubling experience in that sense.

DAVIES: So you left her kind of maybe a little unclear as to how serious this was. Did you go back and have another conversation with her?

NAHVI: Well, yeah, absolutely. I had this recognition immediately after I walked away. I just – kind of my mind was reeling, that, oh, geez, I didn’t even tell her (laughter). And then, I had to have this awkward about-face where I walked back and say, hey, you know, I don’t think I actually communicated as well as I could have, and I had to. So those things that I was talking about, those bad things, it does look like you have metastatic cancer.

And the ER’s a tough place to break that news because we have no information except that you have cancer, right? If you go somewhere else and you get a biopsy, we might be able to say this is the type of cancer, or this is what the next step is in your treatment, or this is the prognosis. But we know so little. So all I could tell her was that she had cancer. And every follow-up question, we don’t really have the answer to that. So it makes it quite difficult.

DAVIES: I mean, this was terrible news to her, I’m sure. I’m curious, when you came back the second time, had she been confused before? Did she think it was something more benign or it wasn’t cancer?

NAHVI: I don’t think that she was confused. I think she knew. I think she probably held on to some hope ’cause I didn’t close that book for her. But I think that she knew.

DAVIES: I’m sure she went on and got, you know, treatment beyond the ER. Do you know what happened with her illness?

NAHVI: That’s one of the kind of funny things about the ER. We see patients – we see them one time, and often, we never see them again. And some patients, I am able to follow up on. I track down their medical record number. I’ll follow them up in the hospital the next day and see what happened. But if they go to a different hospital or they don’t have a clinic appointment for a few months, we don’t necessarily always follow up or know what happened. So for her, no, I can’t say that I actually know what happened to her.

DAVIES: When it was time to talk to the husband of the woman who had come in and had died – and he watched your team try and resuscitate her. When you sat down – by then, you were more experienced – what was your approach in talking to him? What was that like?

NAHVI: Well, the first thing you do is just ask them what they know. Before I even say anything, I say, hey, we were in the same room together. Tell me what you know up until this point, and let me fill you in on the rest. And that gives me some time to actually get a better understanding of who this person is. What do they know medically? What have they seen? But also, how am I going to speak with them? And it kind of helps me frame my conversation. And then, I might fill them in on the rest.

And generally, when I try to do this, when someone’s died, there’s not a lot of information that I feel that I need to give in terms of, this is the next step in your process, or this is your treatment. A lot of it is just reassurance for that person that they did the right thing, that the paramedics that took care of the patient on the way to the hospital did the right thing, that, you know, we in the hospital did all of these things. And I might give them specific examples of the things we did to try to resuscitate her and how those were unsuccessful. And it’s very important to me to try to let them know that everything that could have been done to save that person’s life was done, and it was just an event that was outside of our capacity to treat.

DAVIES: And then, when it was over, you said, you can stay in the room if you like. And he chose to do that – right? – that is to say, with his deceased wife?

NAHVI: Yeah. Yeah, a lot of things – the ER is a busy place. It’s a chaotic place. And we have a lot of rules on visitors, on who is allowed where and who is allowed to do what. But when someone’s died, we generally let their family members do what they feel that they need to do. There’s no more visitor rules. If four or five people want to come in, that’s OK. If they want to stay in the room with the patient, that’s OK.

DAVIES: We’re going to take another break here. Let me reintroduce you. We are speaking with Farzon Nahvi. He’s an emergency room doctor at Concord Hospital in New Hampshire. He spent the early months of the COVID pandemic as an emergency room physician in New York. His new memoir is “Code Gray: Death, Life, And Uncertainty In The ER.” He’ll be back to talk more after this short break. I’m Dave Davies, and this is FRESH AIR.

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(SOUNDBITE OF DAVID ZINMAN, DAWN UPSHAW AND LONDON SINFONIETTA PERFORMANCE OF GORECKI’S “SYMPHONY NO.3, OP.36: II. LENTO E LARGO – TRANQUILLISSIMO”)

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DAVIES: This is FRESH AIR. I’m Dave Davies, in for Terry Gross. We’re speaking with Dr. Farzon Nahvi, an emergency room physician at Concord Hospital in Concord, N.H. He spent the early months of the COVID pandemic on the front lines in emergency rooms in New York City. His new memoir is about his experiences in the ER and his frustrations with American health care. It’s called “Code Gray: Death, Life, And Uncertainty in the ER.”

You write about death and how physicians deal with it. I’ve asked you to read a little selection from this here. This is in the middle of the book. You want to just share this with us?

NAHVI: Absolutely. (Reading) Upon learning that I’m an emergency medicine doctor, people often ask how I deal with encountering death. It must be stressful. How do you do it? It’s a difficult question to answer. I usually shrug it off. You get used to it, I say. That is a lie. You don’t get used to it. I have been intimately involved in a wide variety of deaths. I have experienced grandparents dying of cancer and heart disease and have seen children die of illness and injury. I’ve filled out the morbid paperwork required after a successful suicide attempt. I have informed a pair of French tourists that the precarious selfie they warned their daughter not to take would be the last picture they would have of her. I’ve told an intoxicated driver of a rollover car crash that he would be spending the remainder of spring break and beyond without his best friend. I have never gotten used to any of it.

DAVIES: It’s something that’s a part of your life. You mentioned in the book that your father-in-law became ill with COVID and had stopped breathing once. He was not near you. And he had been picked up by an ambulance crew that had inserted a breathing tube. You called the ER where he was being treated to check on him. And when a clerk answered the phone, you knew immediately, you write, without her telling you that he had died. How did you know?

NAHVI: When you work in the ER, you kind of get used to every little detail in every little tone of voice. And I remember our beginning of our conversation was normal. She was a little bit hurried. She was helpful, but she wanted to get to know kind of why I was calling. And I told her the name of who I was calling for. And immediately, once she heard that name, she slowed down her cadence. And she took the time to speak with me. She didn’t necessarily get kinder. She was nice from the beginning. But she just slowed down to a degree that I knew that that’s the kind of slowing down that you get on the other end of the phone when someone’s died.

I know her job. I know what she’s doing. She’s sitting by a computer reviewing a list of patients. And she has a lot of stuff going on. And she’s very busy. And if it’s a patient with an ankle sprain or with, you know, even a heart attack, you get that information. And you look it up. And you kind of say, all right, I’ll get back to you in a little bit. But when she looked at the board, I presume, and she saw that we were calling for my wife’s father and he died, she just changed her tone completely. And it was very evident to me of exactly what happened on the other end of that line.

DAVIES: You know, you write that you’ve never gotten used to death despite being around it so much. And people wonder how you deal with it. How do you?

NAHVI: People give all sorts of answers for this. And I think the honest, honest truth of what we do is that we kind of just ignore it. We pretend that it doesn’t exist. And we don’t really acknowledge it. And that’s our culture. I think medicine is a very apprenticeship kind of culture where we see people before us, and we emulate the way they do things. And I think, for better or for worse, the way it’s always been, we kind of just ignore it.

And I think there’s a lot of people out there who say that this kind of compartmentalization and detachment is necessary, that if you get too close to those experiences and take them too seriously that you’re going to get too attached and you can’t perform your job. But I think that’s a misread. I think that’s certainly a coping mechanism, but I think it’s a poor coping mechanism. I don’t think you could pretend to be unaffected by this stuff. And one of the reasons I wrote this book was to kind of explore that, for myself and for others to share in that experience.

DAVIES: Yeah. Well, it’s interesting, you know? You say that ignoring it is, I guess, a way to function and get back in there and handle the next day. But it’s, in the long run, not healthy. And I’m wondering what the alternative is. I mean, writing a book, for you, was helpful. But that’s…

NAHVI: (Laughter).

DAVIES: Not everybody’s going to do that. And you’re not going to do it, you know, all the time.

NAHVI: Yeah.

DAVIES: Is there an alternate?

NAHVI: Well, I could share an experience I had, actually. It was about three, four years ago now. And it’s an example of how we can do better. So I – in the ER when someone dies, traditionally, we call a time of death. And I just can’t overstate, it’s just an awkward, strange circumstance. We call a time of death. Everyone kind of just shuffles about and makes awkward eye contact. And then we just walk away. And nothing happened. And that’s always felt so unsatisfying to me because you’re a part of this very important thing. You don’t know the person. You’re anonymous. You might not even know their name. But they died. And it’s a human being that died. And we do nothing. And I never did any better. I didn’t have an answer to this question of how we could do better if you asked me five, six years ago.

But then one time, I was an attending physician. I was supervising one of the residents that I worked with. And at the end of a code, someone had died. We called a time of death. And he just spoke up on his own. And he said, hey, I just hope everyone can stay in the room for another 30 seconds. I just want to appreciate that a human being has died. And what he said was – word for word, he said, we didn’t know this gentleman. We don’t know his name. But just as we have people in our lives that we love and people who love us, we can assume that this gentleman had people in his life that he loved and people who loved him. So in recognition of that and in recognition that someone has died, let’s just have a moment of silence. And the whole thing lasted maybe 15 seconds. But it just transformed the way I experienced those things from then on out.

And I copied him. He was my resident. I was supposed to be a supervisor teaching him, but I took that from him. And since then, I’ve been doing that every time that someone dies in the ER. And every time I do that, I have people come up to me – nurses that I work with, technicians, respiratory therapists – and they say, thank you for what you’re doing. So you can tell that there’s this unmet need of how we deal with things in the ER. And I don’t know that I have all the answers of all the things we could do to make this better. But from this experience that I’ve had, I know that there are ways that we can do better. And I think the first thing we need to do is start talking about it to see how we can kind of have that conversation and begin this process.

DAVIES: Oh, that’s so interesting, you know? I mean, everybody is so busy. They have other tasks to get to. But taking a moment to just acknowledge this pain makes a difference.

NAHVI: Huge difference. Yes.

DAVIES: In the case of the woman who – the 43-year-old woman who had died and, you know, you let the husband sit with the wife’s body, and then you spoke to him. And at some point, then you have to put in your notes. I mean, you fill out a death certificate. You put in your notes. And one of the note – things that you note is that these notes that you are writing are going to be gone over in detail by the hospital’s business department. What are they going to be looking for?

NAHVI: They’re looking for profit, Dave. So there’s billers and coders, and they exist in a whole different universe than we exist in. We live in the clinical space, but we are employees of a hospital, and they too are employees of a hospital. And they live in different buildings, working on computers, and they use software, and they have methods to extract what we write for profit. So they look for phrases that say, hey, this indicates a level of sickness which can be a code that we put in to get billed for this or that. And they generate a bill from what we do.

And in this particular case, it’s kind of disconcerting for me because this person just died, and it’s not really front of mind for me, but I have to write this note, and I do it. And the note itself is not problematic because you do have to write a note to document what happened medically. But then kind of I’m very well aware of all the steps that happen down the line.

DAVIES: Do you get training or advice or pressure to write notes which will generate the most expensive billing opportunities?

NAHVI: It depends on the hospital I’ve worked for. I’ve worked for public hospitals who do have a mission to just take care of people. And no, I don’t get that pressure there. But many of the private hospitals I work for, there’s a phrase that’s called strive to five, meaning try to get that Level 5 billing code, you could say.

DAVIES: Level 5 of service is higher priced, more profitable.

NAHVI: Correct.

DAVIES: Let’s take another break here. Let me reintroduce you. We are speaking with Farzon Nahvi. He’s an emergency room doctor at Concord Hospital in New Hampshire. His new book is “Code Gray: Death, Life, And Uncertainty In The ER.” We’ll continue our conversation after this break. This is FRESH AIR.

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(SOUNDBITE OF SOLANGE SONG, “WEARY”)

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DAVIES: This is FRESH AIR, and we’re speaking with Dr. Farzon Nahvi. He’s an emergency room physician at Concord Hospital in Concord, New Hampshire. He spent the early months of the COVID pandemic on the front lines in emergency rooms in New York City. His new memoir is about his experiences in the ER and his frustrations with American health care. It’s called “Code Gray: Death, Life, And Uncertainty In The ER.”

There are plenty of cases in this book where you find just frustration with the way our health care system works or does not work. You know, one interesting story you tell is of a woman who comes into the emergency room. This is not during the COVID days. She comes into the emergency room, and she wants chemotherapy treatments, and she knows she has cancer. And in fact, she has detailed instructions from the oncologist who has been treating her. Why was she coming to the emergency room?

NAHVI: Well, she came to the emergency room because her oncologist had stopped treating her. So what her story was – she was a young lady. She was diagnosed with cancer. And then she started getting treatment for her cancer with an oncologist at a private – not-for-profit but private institution. And then what happened was that because of her chemotherapy and her cancer treatments, she took too many sick days from her job. So she ended up losing her job. Then she lost her health insurance because of losing her job.

So her chemo – her oncologist wasn’t able to see her anymore because she didn’t have insurance anymore. So he or she referred this patient to our hospital, which was a public hospital where I was working at the time. She didn’t understand that she had to go see an oncologist. So she just came to the emergency room. And I thought there was a misunderstanding.

I saw her, and I said, you know, I’m an ER doctor. I – if I could treat you, I absolutely would. I just don’t have these tools. I don’t have that capability. And then we ended up kind of going from there. But that’s how she ended up in the emergency room with me.

DAVIES: But it’s interesting – I mean, it would take her, I think she said, weeks or months to get an appointment with an oncologist. And she knew that if you come to the ER, they have to treat you, right? I mean, so she figured, hey, you can’t send me away.

NAHVI: That was what she told us, yes. She said that she was familiar, that there was some law out there, that if you are uninsured under any circumstances, you come to an emergency room, we have to treat you. And she’s right. Except the caveat to that, which kind of is what made me so uncomfortable at that time, was that she had a great understanding of the situation, except that what we have to do in the ER is stabilize you, not necessarily treat you. So you have to be evaluated by law. And whatever we can do to stabilize you, we have to do.

In the eyes of this legislation, she was stable. So she had cancer, and she was dying, but she was dying slowly. She wasn’t dying quickly. So she was technically stable. And it became this kind of horrible thing that I had to explain to her that, yes, you’re protected by this law and yes, you have cancer and yes, you’re dying, but I can’t help you.

And not that I don’t want to, again, is just that I am not an oncologist. I don’t have chemotherapy. I’m not trained for that. I don’t know how to do that. And in the eyes of the law, you’re stable. And she kind of got a little upset, rightfully so. And she said, you know, if I was dying quickly, you had to take care of me. But because I’m dying slowly, all bets are off. And I had kind of no choice but to agree with her.

DAVIES: Yeah. So what does that do to you emotionally? I mean, how do you – what did you say?

NAHVI: Well, it’s terrible. I mean, I think there’s a lot of injustices in our health care system. And we see this stuff all the time. And it’s funny because I think when you’re in med school, you’re told by your professors all the time that you’re going to be entrusted with these important situation with your patients, and you have to really value that trust that patients put in you. But they don’t tell you about the opposite. They don’t tell you about the shame of being a doctor, sometimes, the shame of being a part of a system where you’re complicit in these problems, and you can’t do anything to help people that – despite seeing them and knowing that they need your help and the system is not serving them.

DAVIES: Right. One other case – you mentioned a time when a patient came in and had had serious complications from having taken antibiotics that they had bought, I think on a pet supplies website. And you called poison control. And the guy who answered immediately had a guess about what kind of antibiotics. Share this with us.

NAHVI: Well, yeah. So the patient – for a lot of reasons, she thought she was ill. She didn’t have health insurance, and she thought that she needed antibiotics. So she went ahead and took pet antibiotics. And I went to report this to the poison control center, who keep logs of this kind of thing to protect the public. And I told him, you know, you’re never going to believe this, but this patient took pet antibiotics. And far from not believing me, he responded immediately. He says, let me guess – is it the fish formulation? And I said, how do you know? And he said, whenever people have problems with this and they overdose, it’s always with the fish formulation.

What he told me was that people take veterinary antibiotics all the time, and he gets cases reported about that routinely. But when you take dog or cat antibiotics, people usually do fine because they’re pills, and they’re the right dosage. Whereas fish formulation, it’s just highly dense, highly concentrated ’cause you’re supposed to dissolve it into a fish tank so that the fish can eventually drink it when they have their water. So people who take fish antibiotics, generally, they overdose by an order of magnitude. So it was kind of shocking how often it must happen.

DAVIES: Right. And to get the dog or cat antibiotics, they actually need a prescription from a vet. Whereas…

NAHVI: Right.

DAVIES: …For the fish antibiotics, they can just order them. What kind of complications does one risk by taking fish antibiotics?

NAHVI: Well, so this lady, she took – actually, I remember the specific antibiotic was erythromycin. She took fish erythromycin, and she had some neurological side effects. So she had something called ataxia, which is a change in your balance and your gait. So she lost her balance. And she had nystagmus, so her eyes were twitching, and she couldn’t walk well. And the grand irony – and you can’t make this stuff up. It’s just so terrible. She came in, and the whole reason she had taken the fish antibiotics was that she had a job interview coming up. So she took the fish antibiotics, she overdosed, and she had some balance issues, and she fell down a staircase during her job interview.

I just can’t identify where she went wrong – right? – where someone would argue that she should have done better. She – here we have this lady trying to do everything right. She was working hard to try to get a job so that she could get health insurance, but she didn’t at the time, so she did the best that she could to try to get herself a job and health insurance. And yet even that process caused her to have some CNS – central nervous system – toxicity and then fall down a staircase, and she ended up in the ICU.

DAVIES: You know, at the end of the book, you say that there are a lot of these tough questions about patients and their treatment and how you talk to them and their families. And you write that you don’t have a chapter where you can answer these questions, I mean, that these are unsolved dilemmas that – you say you hope you provide we, your readers, with a measure of discomfort so we can consider some of life’s important questions…

NAHVI: Yeah.

DAVIES: …That defy easy answers. I mean, that makes sense. These aren’t easy questions. They aren’t easy answers. I’m wondering, has writing these stories and the process of considering these dilemmas, do you think, made you a better doctor?

NAHVI: I think it’s made me a better doctor and a better person (laughter). I think these stories live within us, whether we acknowledge them or not. And they percolate, and they come out in different ways. And I think really sitting down and processing them and kind of getting a better understanding of them has made me get a better understanding of life itself. I think what the funny thing is, these stories are – it’s an exploration of life in the ER, but really, they’re just an exploration of life in general. The ER is just life in its most extreme. There’s nothing unique about it, right?

I think the ER is this fascinating place where it exists as a contradiction. It’s this place where there’s a whole team of people who are ready, willing and able to take care of you at any time of day, no matter when you want to come. And yet no one ever wants to go there, right? We stick you with needles. There’s long wait times. You can’t get any rest. It’s America, so it’s expensive. So it’s this funny place where the only people that will ever come there are people that don’t want to be there. And we see extremes as a result. So we see medical, ethical, social and health care extremes and kind of going through that process and understanding those things helps you understand how you feel about things in life in general.

DAVIES: Well, Dr. Farzon Nahvi, thanks for all your good work and thanks for speaking with us.

NAHVI: Thank you so much, Dave. It was a pleasure to be here. I really appreciate it.

DAVIES: Farzon Nahvi is an emergency room doctor at Concord Hospital in New Hampshire. He spent the early months of the COVID pandemic as an emergency room physician in New York. His new memoir is “Code Gray: Death, Life, And Uncertainty In The ER.” Coming up, TV critic David Bianculli reviews the 10th anniversary episode of “Last Week Tonight With John Oliver.” This is FRESH AIR.

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(SOUNDBITE OF KYLE EASTWOOD’S “SAMBA DE PARIS”)

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https://www.npr.org…

By Gregg Gonsalves
The Nation, February 16, 2023

The injustices at the heart of the American health care system are clear to anyone with eyes and common sense. So is the need for dramatic reform of that system. Yet the status quo in American medicine is well-defended, and little real change has been forthcoming. One could even make the case that the situation has gotten appreciably worse over the past few decades.

But, at long last, there are signs that something might be changing from within the system itself. More and more physicians are rejecting the forces of self-interest and conservatism within their field and joining the emerging grassroots movements that are trying to revolutionize American medicine and safeguard the public health institutions that so many people rely on.

February 15, 2023

PNHP board secretary and Mo. chapter chair Dr. Ed Weisbart describes the latest managed care boondoggle to threaten traditional—public—Medicare: the recently launched REACH program.

“REACH is new clothing for the old wolf of managed care HMOs,” he says, adding that “we’ve got mountains of data that shows this doesn’t work.”

Additional episodes will be uploaded twice monthly. Subscribe in iTunes, or access a complete archive of the podcast, below.

https://medicareforallexplained.podbean.com

By Brenda Gazzar
Code Wack Podcast, February 13, 2023

What’s the latest threat to original Medicare? What could happen if we link health outcomes to physician compensation? How is it that a whole new program affecting millions of Americans on original Medicare can be rolled out without congressional oversight? 

To find out, we spoke to the new president of Physicians for a National Health Program (PNHP), Dr. Philip Verhoef, an adult and pediatric intensivist and Clinical Associate Professor of Medicine at the John A. Burns School of Medicine at the University of Hawaii-Manoa.

Learn more about the new program called ACO REACH, and the issues it raises around physician compensation. Could ACO REACH threaten the trust between patients and their doctors?

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Transcript

Dispatcher: 911, what’s your emergency?

Caller: America’s healthcare system is broken and people are dying!

(ambulance siren)

Welcome to Code WACK!, where we shine a light on America’s callous healthcare system, how it hurts us and what we can do about it. I’m your host, Brenda Gazzar.

This time on Code WACK! Why are some physicians sounding the alarm over the privatization of Medicare? How could a program called ACO REACH be influencing the way physicians treat patients and patient care? To find out, we spoke to Dr. Philip Verhoef, president of Physicians for a National Health Program, a physician-led organization that advocates for single-payer health care in America. Dr. Verhoef is an adult and pediatric intensive care doctor and clinical associate professor of medicine at the John A. Burns School of Medicine at the University of Hawaii-Manoa.

Welcome back to Code WACK! Dr. Verhoef.

Verhoef: Thank You. It’s great to be here again.

Q: Tell us a little bit about yourself and your background.

Verhoef: Sure. So I am an ICU physician. I take care of both pediatric intensive care unit patients as well as adults who require the ICU and I’ve been doing this for about 15 years. I’m currently based in Hawaii, so I’m an associate clinical professor of medicine at the John A. Burns School of Medicine at the University of Hawaii and have been here for about four years taking care of patients.

I’ve been active in the single-payer movement since I was a resident at UCLA when I first heard a talk about our healthcare system and how single payer might be a potential solution, and this was back in 2006, I was absolutely blown away by the prospects and so decided to start getting more active in healthcare reform and healthcare advocacy at that time.

Q: Thank you. Today we’re facing a formidable challenge to Medicare. It’s increasing privatization through a government program called ACO REACH. Can you briefly explain what ACO REACH is in layman’s terms?

Verhoef: ACO stands for Accountable Care Organization and we saw ACOs be introduced into the healthcare system with the Affordable Care Act or the ACA and the notion of an ACO is that it’s an organization or a group where the outcomes for how patients do determine how much reimbursement doctors get in that context. And so that’s the accountable part of it, right?

So the idea is if your patients do well, then that’s a good thing. If your patients don’t do well, that may impact how much reimbursement that you get and it’s honestly not that different from the old school HMO or health maintenance organization. We saw the rise of those back in the eighties and nineties. The real difference is that ACOs are now groups of physicians. That’s kind of the idea. The idea behind the ACO REACH program is that the government will support enrolling Medicare patients into one of these ACO REACH programs.

You know, a Medicare patient would become a part of an ACO as a function of their doctor and their doctor would be a part of this ACO and then that would determine the kind of care that patients get, at least at some level. Now, this is a pilot program that’s been introduced through the Centers for Medicare and Medicaid Innovation and the reason that that’s important is [that] programs introduced under CMMI are not subject to the same degree of congressional oversight. In essence, the Centers for Medicare and Medicaid innovation was created also in the ACA back in 2010. The idea was “let’s create a program to allow innovative ideas to be tested out on Medicare patients potentially, or Medicaid patients.” Well, that seems like a nice idea in the sense that maybe this lets us get engaged in quality improvement more easily without having to have an act of Congress or some other kind of massive bureaucratic obstruction.

I think the problem here is with the ACO REACH program, the pilot is to take Medicare patients and put them in an ACO. That happens without the patient necessarily knowing. It happens, without Congress being able to oversee that and the reason that’s a problem is that these ACOs, even though they’re comprised of docs, they can actually be run by pretty much anybody. It could be run by a health insurance company. It could be run by a private equity company. It could be run by some individual who just wants to run their own ACO and that means that this is a defacto form of privatization of Medicare. And you know, I guess you’d ask yourself, why would an investor want to get involved in this? Well, if docs are reimbursed as a function of the patients that they have in their ACO and how much it costs to provide care for them, this is one of the common criticisms of capitation that if I give you x amount of money to take care of this patient, the only way you make money is by doing the least that you can for them.

And so ACO REACH is another way of saying to the doc, ‘Hey doc, do the least amount that you can for this patient because that’s the way that you are going to make the most money.’ Or more importantly, to the private equity investor, they are operating under the same sort of idea that they want to do the least that they can for patients in these ACOs because that means they recap the most money and so this kind of privatization is I think really sinister because it’s not putting patients’ health first, it’s putting the shareholders and whoever is vested in these ACOs, whoever’s running them, it’s putting their profits first.

Q: Mm-Hmm. You said ACO REACH is supposed to hold physicians or providers accountable for patient outcomes. So does it do that?

Verhoef: The short answer is potentially, but the problem is we’re creating financial incentives that are linked to outcomes and I think that that’s always going to be a problem, right? The real reason I take care of patients is to make people better and that’s enough. I don’t actually need financial incentives to improve the health of my patient. I want them to get better. So when you create a company or an organization or a process that gets in the middle of that and says, ‘hey, there’s an opportunity to make money here,’ you know, I think it sort of creates this problematic scenario where you’re saying, ‘Hey, you can make money and have healthier patients.’ People are making money, but that’s money that’s going into people’s pocket. It doesn’t necessarily mean that patients are absolutely getting better health. How do you measure that somebody’s doing better? I think that’s a really, really difficult thing to measure.

And in the end, we’ll see, or we would anticipate the same kinds of processes within these ACO REACHs that we see in Medicare Advantage, which is to say you do what we call cherry picking. You pick only the healthiest patients to bring them into your ACO because of course if they’re healthy, they’re not going to cost you any money. And you get to keep all of the money that you get for having that patient. And then you do what we call lemon dropping, which is get rid of the patients who cost the most, right? Find ways to kick them out or not provide care for them because again, they cost too much money and so those kinds of incentives are not geared towards the health of the population on the whole, it’s geared towards making money for somebody at, you know, within their own scale.

Got it. Thank you for explaining that.

Verhoef: Let me add one more point. The thing about the ACO REACH program is that it’s effectively a rebranding of a program that was initially going to be rolled out in the Trump administration called DCE – Direct Contracting Entity. These were plans that were designed to group patients from traditional Medicare into these ACOs and a DCE was no different, but they rebranded the program because, you know, the Biden administration doesn’t want to roll out a Trump administration program so let’s basically change the name, call it ACO REACH, where REACH stands for realizing equity access and community health and it really sounds like it’s a well-intentioned program, but I think the truth of the matter is it’s relying on a bunch of mechanisms that are really simply easily able to be gamed, mechanisms that involve opportunities for profit depending on what your outcomes are.

And whenever you do that, I think that it’s going to inevitably provide inequitable care. It’s not going to actually realize equity at all. It’s just going to allow organizations to find the patients that do the best and not take care of the ones that are the sickest and need it the most. And the thing that’s bothersome for us at PNHP is that one, this is a move towards privatizing Medicare, but also it’s done without Congressional oversight and it’s done without patients even knowing that they’re being enrolled into such a program. And the only way a patient could get out of an ACO REACH program is by changing their doctor cuz their doctor is getting enrolled into it and so you actually have to leave your doctor if you don’t want to be a participant in a program like this. And you know, it’s sort of ironic that people are talking about choice, right? I mean, what more does a patient want but to be able to stay with their doctor? And yet here we are creating a system where if a patient doesn’t want to be involved, they actually have to change doctors and that’s actually, I think, counter to the notion that you could see whatever doctor that you want and get the kind of care that you need that’s appropriate. These kinds of agreements actually limit that for patients.

Q: Hmm. I guess one of the questions I have is if doctors or providers are incentivized to not spend money on their patients and the concern is that doctors aren’t going to do the best thing for their patients to make more money. Isn’t that an awful thought?

Verhoef: And I think that’s a really astute question, right? You have to understand that the opportunities to make money are twofold. It’s doing the least that costs money, but it’s also trying to, because there are going to be incentives for you to, as a function of the outcomes for your patients, you know, you’ll actually get paid extra money, right? So the capitated part is you may not be penalized, but you may not have access to the additional money if all of your patients – sort of just trying to be much more of a carrot than a stick, right? You’ll still get paid for taking care of them under the regular fee for service agreements. You’re just not gonna get the extra amount of money that you would get depending on their outcomes or depending on whatever metric the ACO is using. So for instance, if the goal is to have patients have the least long length of stay in the hospital and you don’t achieve that, then you’re basically not going to get that bonus.

Right? If that makes sense. And so there is an inherent conflict in all of this with doing the right thing for the patient. I actually think the vast majority of doctors do want to do the right thing for the patient. And to be honest, I’ve actually heard from docs who like the idea of an ACO REACH where they’ve said, ‘look, this extra money that we’ve been given based on the good work that we’re doing has given us a little bit more flexibility to be able to provide other kinds of care for our patients.’ Right? I love that. Right? I love that it’s actually liberating for some docs and that’s exactly what the program was intended to do.

The problem is the program doesn’t have any restrictions on profiteers getting in there and finding a way to skim money off and make money themselves. And so, you know, like many things, I think this program was perhaps designed with good intentions, but there were enough back doors left open that you could get your way in there and in effect, privatize this thing and really be motivated more by at least somebody would be motivated more by finances than by truly the health of patients

Right, or maybe they could convince themselves that this other treatment or this other option might be just as good, it costs less, let’s try this first and maybe you’re wasting precious time in the patient’s treatment.

Verhoef: Yeah, it’s interesting. I think the fear also is that if you’re a doc enrolled in an ACO and you end up having patients that tend to be pretty expensive, that an ACO can actually just kick the doctor out and therefore sort of deny them the opportunity to get, you know, this additional funding to support taking care of patients and this gets at sort of a different but still really important problem with Medicare as we currently know it. The reimbursement rates are not terrific. You know, in general, Medicare’s reimbursement rates are less than they are for commercial insurance and so many physicians have to sort of ask themselves this question, can I even afford to take Medicare? Does the reimbursement that I get from Medicare, is it enough for me to pay the rent? Is it enough for me to pay my staff? Is it enough for me to keep the lights on and continue to do the work that I want to do?

And so physicians or physician group practices will very clearly monitor the number of commercially insured patients they have versus the number of Medicare patients versus the number of potentially Medicaid patients. And so one of the real problems is that Medicare reimbursement isn’t always very high relative to commercial reimbursement. And so, you know, this is in a way, a way of incentivizing docs to take Medicare patients cuz you can get this additional money on top of that. The problem is that that then begins to set up some incentives that aren’t really very sound right, where we’re doing things to make money more than anything else. Now, I would love to see Medicare overhauled, I would love to see reimbursement rates better than they are and so that physicians wouldn’t even have to make this choice. You know, I’ve, I’ve certainly known docs who don’t want to stop taking Medicare, but they simply can’t afford to based on the rates that Medicare reimburses if you’re in a particularly expensive area to practice medicine.

And so in a way a program like this can attract physicians because they want to take care of Medicare patients. They say, ‘oh, this is an opportunity for me to get a little additional income in the context of maybe meeting some of these metrics and whatnot and then that’s good for me, it’s good for patient care, it’s good that I can continue to take Medicare patients.’

There are more and more physicians who simply don’t take Medicare at all. Or even worse, they just choose to not even accept commercial insurance because they don’t like the headaches of having to deal with, you know, insurance companies denying care or limiting who you can go see or prior authorizations. The good thing about Medicare is it doesn’t have prior authorizations. It doesn’t have denial of care, it doesn’t have narrow networks like commercial insurance does, but commercial insurance just pays a whole lot better.

You know, and so this is definitely something that PNHP thinks about too, is it’s not just fighting the privatization of Medicare, it’s also how do we just make Medicare better? You know, how do we make it function more effectively for more people? You know, how do we make it so that you don’t have to buy separate insurance for your hearing and your dental? How do we make it so you don’t have to buy separate insurance to cover the co-payments, right? You know, Medicare doesn’t provide first dollar reimbursement for all of your care. And so there are certainly ways that Medicare itself can be improved.

We certainly don’t think that privatizing Medicare is the key to that improvement, but there are a number of ways that we could make it better. These ACO REACH programs are not it though. We really feel like this is, you know, privatization and potentially if all of traditional Medicare gets involved in this, that will make our job so much harder to try and actually advocate for a government-run insurance program that doesn’t have any middlemen in it.

Thank you Dr. Verhoef.

Do you have a personal story you’d like to share about our wack healthcare system? Contact us through our website at heal-ca.org.

Find more Code WACK! episodes on ProgressiveVoices.com and on Nurse Talk Media. You can also subscribe to Code WACK! wherever you find your podcasts.

This podcast is powered by HEAL California, uplifting the voices of those fighting for healthcare reform around the country. I’m Brenda Gazzar.

https://heal-ca.org…

By Farzon A. Nahvi, M.D.
The Washington Post, February 8, 2023

For many health-care workers watching the Super Bowl in recent years, the hardest hits have often come not during gameplay but in the commercial breaks. 

Emergency rooms across the country have become chronically overcrowded and understaffed. Hospitals often claim they don’t have the funds to hire more employees to meet the urgent needs of patients. Yet in between Super Bowl advertisements for Flamin’ Hot Cheetos and Bud Light Seltzer Hard Soda, it’s now commonplace to see commercials for institutions such as the University of Rochester Medical Center, NYU Langone Health and Inspira Health. 

To understand why this situation is so troublesome, we must first appreciate the stakes: Hospital crowding, which gets worse when institutions are understaffed, is a national problem — and a deadly one. Multiple studies have demonstrated that overcrowding is directly associated with an increase in patient mortality.

To make matters worse, a 2016 report by the American College of Emergency Physicians found that over 90 percent of American emergency rooms are routinely crowded; that number has only increased since then. If you’ve been to an emergency room recently, the overwhelming odds are that it was packed. As a result, your chances of dying were higher than they should have been. 

Given what’s at stake, one would assume that hospitals would invest in a solution: If they were to simply hire more staff, the ratio of patients to nurses and doctors would be lowered — and lives would be saved. 

But hospitals have been doing the opposite. 

A recent investigation by the New York Times revealed that many American hospitals have spent years pursuing an “industrywide movement” of keeping labor costs low by wringing “more work out of fewer employees.” Indeed, hospital administrators often measure success by determining how much they can lower operating expenses by reducing the number of “employees per occupied bed.” In other words, low staffing levels are not a result of the coronavirus pandemic, staff burnout or a tight labor market — they are a business model. 

Simultaneously, as hospitals save money by cutting staffing, hospital marketing budgets have skyrocketed. According to a report in the Journal of the American Medical Association, between 2004 and 2016, direct-to-consumer advertising by hospitals and health-care systems jumped 74 percent to $1.4 billion per year. 

A brief stroll through New York City reveals billboards in Times Square, posters on bus stops and in subway stations, illuminated signs on city taxis, and newsstands full of magazines flush with advertisements for local hospitals. Prime-time TV slots feature ads from cancer centers and children’s hospitals. And beyond simply advertising during the Super Bowl, health-care systems have become official corporate partners of the Super Bowl. 

As hospitals invest liberally in marketing while tightening their wallets when it comes to bedside patient care, it’s hard to view the billions spent on ads as anything other than waste. 

Many hospital executives would say that deciding whether to spend on advertising or patient care presents a false choice. They would insist that marketing is a necessary operating expense that a modern hospital must invest in to succeed. This argument is often referred to as “no margin, no mission” — a shorthand way of saying that for a hospital to perform good work, it must first generate the money with which to do so. 

On the surface, this argument seems reasonable. But when hospital wings are closing because of staffing shortages, nurses are being asked to attend to more than four to five times the patients they can safely care for, and firefighters and the National Guard are stepping in to provide what hospitals themselves are failing to, can it really be argued that spending on television commercials remains a necessity?

If spending on advertisements is nonnegotiable but hiring enough nurses to save patients’ lives isn’t, who is our health-care system truly serving? At what point can it be said that this system has lost its way and the margin has, in fact, become the mission? 

Legislators in several states, including Massachusetts, Oregon and Washington, are trying to rectify the situation by considering legislation that would mandate safe staffing ratios. Predictably, hospital lobbying organizations say they “strongly oppose” these legislative attempts, citing the “financial burden” of higher operating costs that such laws would impose. 

In light of these claims, these bills should go a step further. They should also ban hospitals from engaging in costly direct-to-consumer advertising. What better way to save billions of dollars to offset the “financial burden” of hiring more lifesaving medical personnel? 

The Super Bowl provides us with a clarifying lens. It is American television’s most watched event and its most expensive airtime, and the very idea of hospitals advertising during the game is symbolic. It heralds an era when it’s no longer unusual for enormous amounts of money to be frivolously spent faster than a single touchdown play, while at the same time nurses are going on strike to demand safe staffing levels for their patients. 

So when people see any TV commercial or billboard highlighting a hospital system’s quality of care, then walk into that same hospital system’s emergency room only to find it dangerously overcrowded and understaffed, it is worth connecting the dots. Imagine how many lives would be saved if only we were to take the bold step of demanding that our health-care dollars be spent on actual health care.

Dr. Farzon A. Nahvi is an emergency medicine physician, the author of “Code Gray: Death, Life, and Uncertainty in the ER,” and a member of Physicians for a National Health Program. 

https://www.washingtonpost.com…

By Brenda Gazzar
Code Wack Podcast, February 6, 2023

What say should doctors have in reforming America’s healthcare system? Are their decades-long efforts to stop the commercialization of medicine having an impact? How can health professionals, and students in the health sciences, get involved in the movement for single-payer health care?

To find out, we spoke to the new president of Physicians for a National Health Program (PNHP), Dr. Philip Verhoef, an adult and pediatric intensivist and Clinical Associate Professor of Medicine at the John A. Burns School of Medicine at the University of Hawaii-Manoa.

Find out the main strategies, goals and challenges of PNHP, the only single-issue, physician-led organization advocating for Medicare for All in America. And learn about the growing influence of Students for a National Health Program (SNaHP) in the single-payer movement.

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Transcript

Dispatcher: 911, what’s your emergency?

Caller: America’s healthcare system is broken and people are dying!

(ambulance siren)

Welcome to Code WACK!, where we shine a light on America’s callous healthcare system, how it hurts us and what we can do about it. I’m your host, Brenda Gazzar.

This time on Code WACK! What role do physicians and other healthcare professionals play when it comes to advocating for a single-payer healthcare system? What are the main goals of Physicians for a National Health Program, the only single-issue physician-led organization advocating for Medicare for All in America? To find out, we spoke to the new president of PNHP, Dr. Philip Verhoef. Verhoef is also an adult and pediatric intensivist and clinical associate professor of medicine at the John A. Burns School of Medicine at the University of Hawaii-Manoa.

So welcome to Code WACK!, Dr. Verhoef!

Verhoef: Thank you.

Q: Let’s talk about Physicians for a National Health Program. It was founded in 1987, and here we are 36 years later, still fighting the commercialization of health care. Would you say the prospects for PNHP’S vision of a truly equitable healthcare system for all have improved since then?

Verhoef: I wish I could say that we were closer now than we were then to achieving a universal healthcare system. If you look over these last 35 years or so, we’ve seen attempts at getting a universal system up and running only to be completely squashed by corporate interests. So you might recall Hillary Clinton actually pushed a universal healthcare system that was just squarely defeated by everyone at the time in the early 90s. We tried as an organization to get single payer, at least at the table for the talks around the ACA back when Obama got elected and we were roundly shut out.

You know, we’ve had a bill introduced in Congress now for every Congress for the last 20 years since Rep. (John) Conyers introduced the first one in 2003. That was a bill that we helped work with his office staff on to be the aspirational single-payer bill that we want to see and yet here we are, since PNHP’s forming, we’ve got more and more privatization of Medicare out there in the forms of Medicare Advantage and this upcoming ACO REACH program. These are all ways that the federal government is actually taking Medicare and putting it in the hands of private insurance companies without, you know, holding onto it themselves and so, in many ways, you might argue we’re in worse shape now than we were 35 years ago in spite of the efforts that we have made on this particular front.

Yes, that’s a little depressing.

Verhoef: <Laugh> It is totally depressing. But, you know what? We’re not going to stop fighting, right? We want what’s best for our patients. We want what’s best for our whole country. You know, it’s hard. Every year I update my slides for PNHP, for the talks that I give, and you just watch how much more we spend than other countries in the world and then you watch our inequities get worse and you watch our life expectancy go down year after year and you say, ‘golly, how is it that we just keep making things worse in spite of ourselves?’ But on the other hand, if we weren’t fighting this fight, I would hate to imagine where things might actually be if we didn’t have folks actually protesting and fighting some of these really awful moves that will only hurt our American citizens.

Q: Right. Good point. PNHP membership includes doctors, other health professionals, and even members of the public. How does PNHP recruit doctors?

Verhoef: So we spend a lot of time just trying to get the word out there about what PNHP is, who PNHP is, and what single payer is. And so I can talk about my own personal experience. You know, honestly, I started getting involved when I was a resident, and then as I continued my training and became a faculty member, I was frequently giving talks to physicians, right? To educate them about our American healthcare system and about ways that we could change it or make it better. I’ve worked with student groups. I’ve worked with community groups where I’ve gone out and talked about what this is because, you know, it’s interesting. In 2016, single payer actually made it onto the main stage, right, as Sen. (Bernie) Sanders was engaged in his presidential campaign, we started talking about it and a lot of people had no idea what it is.

And, you know, we at PNHP said, ‘hey, we’ve been talking about this for 25 years. Come to us, we will educate you.’ And so that’s a big part of what PNHP does. But I think one of the things that we see now is that we won’t achieve single payer unless we get more healthcare professionals, more people behind it and so a lot of the work that we’re doing now is really targeted at expanding our membership, expanding the knowledge base among professional organizations and state medical societies. So we’re making a real concerted effort to shore up our ranks a little bit to get the buzz out there when you actually poll physicians, the vast majority support single payer. So of those that are out there that know about it, they like the idea. We just need to basically get those folks motivated and marching and supporting and actively working with us to make this a reality for our country.

Q: What do you see as the organization’s biggest challenges today?

Verhoef: You know, our biggest challenge is the fact that the fight that we’re up against is a fight against resources and money that outnumber anything that we have by orders of magnitude. You know, the private insurance industry, the pharmaceutical industry, for-profit hospital corporations, they have pockets that are so, so deep, and they will use those resources to influence legislation, to influence legislators. It’s not that we’re not going to win, but we’re not going to win by outspending them, right? We’re not going to be able to spend more money trying to influence legislators, that’s not going to be how we get single payer. We have to get single payer by organizing all of the physicians out there to say, ‘look, we’re not going to participate in this system that actively hurts patients, that actively leads to thousands of deaths per year in this country, simply by virtue of not having health insurance.’

I mean, that’s crazy. We literally watch people die as a function of lack of healthcare coverage. And so we’re not going to get single payer, I think, until we can get the majority of physicians out there saying, ‘we’re not going to participate in this system.’ You know, I’m not advocating for people to strike because I think that hurts people too. But I think we have to use our power within physician organizations and taking a cue from some of the labor organizing that’s out there to say, look, we can’t do this anymore. This is killing people. It goes against what we all join this profession for. So our biggest challenge is that we’re fighting a beast that’s just so much stronger than we are. I think there’s still a lot of physicians that don’t know entirely what single payer is and how it could benefit them.

And so it’s really on us to try and spread this out there so that people really understand. But we welcome doing that. I’ll give a talk every day if folks want to hear it about, you know, why I think single payer is the solution. We just need to, to bring people in and get them listening and understanding what’s going on. But we have the army of folks to do that. But, you know, it’s combating some of the misinformation that’s out there and really trying to say, ‘look, we don’t want corporate interests involved in our healthcare anymore. We don’t want people profiteering off of us.’ And so that’s the battle that we’re, that we’re really up against.

Q: PNHP also sponsors a program for medical students called Students for a National Health Program or snap. How’s that going? And why do you think it’s important to include these students?

Verhoef: Oh, it’s going awesome. It’s been one of the most inspiring things that we’ve done in the organization over the last 10 years. And, you know, I was involved in some of the earliest SNaHP chapter formations when we were just building this thing out when I was in Chicago and it was really incredible to see the enthusiasm of medical students who want to do what’s right for patients and it’s kind of remarkable because most medical schools don’t teach a lot about what our healthcare system is, or what are the economics or the ways that coverage happens or any of these kinds of topics and yet at the same time, I want students to understand that this is the career that they’re getting into. And so as an organization, we committed to building up these student chapters, to supporting students learning about single payer themselves.

And honestly, it’s been tremendously exciting because students, they haven’t been influenced by whatever healthcare system they end up going to work in. You know, they’re still open books ready to learn about what’s out there, and I want to see them advocate. I believe that physicians have a duty to advocate for their patients. And so, you know, I often tell students, ‘look, I don’t care what you advocate for. I want you to advocate for something, right? Something that you believe in that will make patient care better.’ And you know, I often tell ’em, ‘but you should advocate for single payer, right? You should advocate for healthcare reform because you know, because of how hurt patients are by our American healthcare system.’ And so our ranks have grown by substantial numbers and when we were at our national meeting this last fall, our numbers of students were almost as great as the numbers of non-students.

And that’s really exciting, right? Because now we have students who know all about our healthcare system. They know about a potential solution. They take that into their residency training, they take that into their clinical practice, and they can continue to fight. I don’t have to educate them anymore about what the optimal solution is to our broken healthcare system. They already know they’re already bought in and so we look at this as part of the long game. Yeah, I don’t know when single payer’s going to happen in this country. I have faith that it will, and I’m going to continue to work to make it so, but the more students that we can bring into this, the more physicians we will have out there who support this as a solution, who can get behind it. And so they have brought an amazing energy to PNHP’S efforts. We have now SNaHP representatives serving on our national board. Several of them are serving on our board, so they’re literally influencing the direction that PNHP goes and I just couldn’t be more excited about the involvement of students in PNHP.

Q: So Dr. Verhoef, what do you hope to accomplish in your two-year term as president of PNHP?

Verhoef: So I’ll tell you what I don’t think we’re going to get, I don’t think we’re going to get single payer in these two years, but I want to see us move the needle substantially, right? And what does that look like to me? It means fighting off privatization at every opportunity, continuing to raise the specter of the harm that privatization does. So I think that’s the first thing. The second thing is let’s build our ranks much, much greater, right? So let’s reach out to medical societies, professional organizations. Let’s get the word of single payer out there to these physician groups. We know that there are folks out there that support this. Let’s make single payer a mainstream thing that the American College of Physicians says, ‘we’re going to actively support this.’ The American Academy of Pediatrics says, you know, ‘single payer is the best thing for our children’s health in this country,’ right?

We want to bring it up to that level and so we also want to work with state medical societies to really move the AMA on this, right? You know, every state medical society has a delegation to the American Medical Association. If we can change the AMA from within and use the AMA, which is the largest physician group in this country, if we can get the AMA to start advocating for single payer, I think that’s going to be a game changer.

I want to see us continue to work with our allies. So these are other political organizations, labor movements, anybody who feels like healthcare is an important part of what they advocate for, we want to support them and give them the tools to argue that single payer is critical for the labor movement, right? That it should be a critical part of the Green New Deal, right? Or that it should be part of any progressive agenda and so you know, building further those relationships I think is also really, really critical.

Q: So how likely is it that the AMA, or the American Medical Association, would support single payer anytime in the near future?

Verhoef: You know, we make progress every year, and a lot of that progress comes from the students. Every year, they introduce single-payer support sort of resolutions within the AMA, and they get further and further to those being adopted as part of AMA policy. It’s been a stunning thing to watch and a real, you know, the students are taking the bull by the horns here. They got remarkably close to a supportive vote on single payer at the last AMA meeting. And so we expect, you know, to continue to work within the student chapters or through people’s state and local medical societies, I think it’s possible.

You know, it’s funny, I personally stopped being a member of the AMA a number of years ago because I didn’t feel like they represented my interests. They were representing sort of corporate conservative interests and not my interests. But as I take on this role as PNHP president, I’m strongly considering reengaging with the AMA now that I can take some time to work from within, you know. Let’s change this organization. Let’s bring this narrative up. Let’s fight hard for this. And I think that that’s going to be key, you know, is for physicians to look at this as an opportunity and not as a barrier, you know?

Q: Wow, that’s great. Where would you like to see PNHP in five years?

Verhoef: Oh, in five years, I would love us to have four times as many members as we do. I would love our staff to be twice as big. I’d love to see us out there building new SNaHP chapters and creating the next wave of physician activists. I’d love to see us with a real consistent permanent presence in DC. We aren’t a big enough organization, and, and we’re a 501c3 so honestly, we’re not going to engage in a lot of aggressive lobbying, but there is so much education to be done and if we could begin to build that presence and work with, you know, legislators on Capitol Hill to help them understand why this is the solution, these are all directions that I’d love to see us be in five years, you know, so we’re going to work towards that.

It’s a bit of a cycle in a good way, a spiral in the sense that if we get more members, we get more resources. If we get more resources, we can build this and if we build this out further, we can bring in even more members and these kinds of things feed forward and that’s very much where I’d like to see us going is really expanding as an organization and then building the amount of power that we have to truly influence the direction of health care in this country.

Q: How many members does PNHP have right now?

Verhoef: So on the books, we say around 25,000 members, and that’s primarily physicians, although again, anyone can join.

Q: Is there anything else you want to mention, Dr. Verhoef, about PNHP?

Verhoef: You know, I’m really proud to be a part of PNHP because it represents, I think, what so many of us, we simply want the best care for our patients. We want them to be able to get what they need, and we want to see people healthy. Those of us that engage in this advocacy, it’s not stuff we do because we seek fame. It certainly doesn’t pay us anything. This is work that we do as physicians outside of our otherwise, you know, busy lives. But it’s because we believe in it and we really believe that this is the best solution to really help out patients in this country and so we’re going to keep fighting. If you meet a doc who’s an PNHP active member, they are fighting like crazy for what they think is right and I’m really proud of that.

Thank you, Dr Verhoef. Stay tuned. Next time we’ll talk to Dr. Verhoef about the privatization of Medicare.

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