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Demystifying Medicine One Month at a Time

Category: primary care (page 1 of 12)

Doctoring the CIA

One of the biggest attractions at medical meetings is the exhibition space, where publishers and companies peddle their wares and outfits looking to hire doctors sing what they hope will be a siren’s song.

The Exhibitors’ Hall at the annual American College of Physicians meeting is certainly among the most grandiose medical marketplace, if not the world’s largest. When I approach the hall, I’m always reminded of Louis Winthorp’s description of the NY Commodities Exchange to Billy Ray Valentine in the 1983 film Trading Places:

“This is it. The last bastion of pure capitalism left on earth.”

At ACP 2019 there were dozens and dozens of exhibitors, ranging from tech startups to health insurance providers. Digital stethoscopes? Check. Work for the newest telemedicine outfit? You bet. There were also journal and textbook publishers and purveyors of online medical information..

But by number, no category is larger than the recruiters — health enterprises all looking for medical personnel. Passersby definitely are made to feel needed in such a milieu.

Recruiting at ACP 2019 were hospitals, ambulatory groups, and academic practices all looking for help. There were also state, county and correctional facilities on the market for docs.

But I was surprised to see a recruiting booth from the CIA: America’s Central Intelligence Agency. It was one of the smaller booths, with but a flag, some brochures, and a lone recruiter, who by Agency policy couldn’t officially speak to me or be quoted.

So who is the Agency looking for? Primary care doctors and psychiatrists.

What does the job entail? Working abroad in embassies caring for CIA staff and their families.

Why, I wondered, if the job involves serving at U.S. embassies abroad, does the State Department not handle the recruiting?

Turns out that CIA doctors must be eligible for and able to obtain security clearances. In order to be considered, you must be physically and mentally fit, and able to pass both a background check and a polygraph test. You need to be a U.S. citizen, too.

The best of the brochures on the table dispelled 12 of the most common myths about working for the CIA: essentially, it ain’t what you see in the movies. Forget about car chases or secret gadgets.

Other brochures led with catchy slogans like, “Everything you do here matters,” or “Utilize your medical skills on the world stage.”

The CIA is not just interested in doctors. Like the real world around us, the CIA is looking for nurses (particularly with experience in occupational health), physician assistants, nurse practitioners, and clinical and research psychologists.

I asked the recruiter what a primary care doctor like me would do in the CIA. I’d once read about the CIA hiring doctors as medical analysts to render opinions on the health of world leaders. The recruiter told me that she was not charged with finding medical analysts at the ACP or her other recruiting stops–only doctors to work as medical professionals. Though with adequate experience and interest, changing roles while in the Agency is considered.

Through the conversation I learned that the CIA operates in five “directorates:”

  1. Analysis (think information gathering and synthesis);
  2. Digital Innovation (think cybersecurity and warfare);
  3. Operations (think spies–these are the folks in the famous clandestine service who handle missions and collect human intelligence);
  4. Science and Technology (think ‘tradecraft’) and lastly;
  5. the humble Directorate of Support (‘delivers everything the CIA needs to accomplish its critical mission of defending our nation.’)

Would-be CIA physicians apply for jobs in the Directorate of Support.

How much does a CIA doc earn? According to their website, the salary range is $157,000 to $164,000 per year, with ‘a progressive physician comparability allowance up to $30K per year.’

This might be the kicker, though. How young does one have to be to join up?

It might surprise you like it did me, but the recruiter said the Agency considers hiring doctors up to 60 years old!

So should you tire of domestic life and the day-to-day of clinical care here in the U.S., the CIA is an unusual way you can serve your country.


“Public Charge” is a Public Health Disaster in the Making

The following post was written by Sam Aptekar and Dr. Phuoc Le, Associate Professor of Medicine and Pediatrics at the University of California – San Francisco and Co-Founder of Arc Health.

I was born in a rural village outside of Hue, Vietnam in 1976, a year after Saigon fell and the war ended. My family of four struggled to survive in the post-war shambles, and in 1981, my mother had no choice but to flee Vietnam by boat with my older sister and myself. Through the support of the refugee resettlement program, we began our lives in the United States in 1982, wearing all of our belongings on our backs and not knowing a word of English.


Though we struggled for years to make ends meet, we sustained ourselves through public benefit programs: food stamps, Medicaid, Section 8 Housing, and cash aid. These programs were lifelines that enabled me to focus on my education, and they allowed me to be the physician and public health expert that I am today. Looking back, I firmly believe that the more we invest in the lives and livelihoods of immigrants, the more we invest in the United States, its ideals, and its future.

So, when I first learned of the current administration’s plan to make it harder for immigrants with lower socioeconomic statuses to gain permanent U.S. residence, the so-called changes to the “Public Charge” rule, I felt outraged and baffled by its short-sightedness.

Chart courtesy of www.cgdev.org

If this proposal comes into effect, government officials would be forced to consider whether an applicant has used, or is deemed likely to use, public benefit programs like Section 8 Housing, Medicaid, the Supplemental Nutrition Program (SNAP), and Temporary Assistance for Needy Families (TANF).  Additionally, applicants with pre-existing health conditions could be rejected purely on these bases.[1]

The implications of this rule are not hard to predict (and have already been observed throughout the country)[2]: noncitizen parents who are hoping to get green cards will not enroll their citizen children in government healthcare, which they have a legal right to obtain, out of fear that harnessing public benefits will prevent them from gaining legal permanent residence. According to the Kaiser Family Foundation, President Trump’s proposal could lead to a decrease in Medicaid and CHIP enrollment by a minimum of 15% and as much as 35%.[3]  Any proposal that decreases the number of insured American citizens, as this measure surely would, would increasethe financial strain on taxpayers who will be forced to compensate for unpaid coverage. Furthermore, Forbes estimates that Trump’s proposal would decrease legal immigration to the United States by more than 200,000 people a year and therefore “would have a negative impact on the Social Security System”- a deficit that American taxpayers would have to help cover.[4]

If the moral argument that every human being deserves the pursuit of a better life doesn’t work for you, then let the economic one suffice. A 2016 study by the National Academies of Science, Engineering, and Medicine concluded “immigration has an overall positive impact on long-run economic growth in the United States” and “immigration is integral to the nation’s economic growth.”[5]

Whether you are an immigrant or were born in the US, we all have a responsibility to vocalize dissent against the Department of Homeland Security’s morally and fiscally-flawed anti-immigrant proposal. Vote, attend town-hall meetings, write to your representatives, conduct personal research, engage in constructive dialogue, and comment below to get the conversation started. Remember, the Statue of Liberty reads: “give me your poor, your tired, your huddled masses.” If we match xenophobia and ignorance with empathy and facts, we can ensure that America remains a beacon of hope for future immigrants, just as it was for me in 1982.

[1] http://apps.washingtonpost.com/g/documents/world/read-the-trump-administrations-draft-proposal-penalizing-immigrants-who-accept-almost-any-public-benefit/2841/

[2] https://www.washingtonpost.com/outlook/2018/12/18/proposed-new-public-charge-rule-puts-childrens-health-insurance-risk/?utm_term=.82971bc137f9

[3] https://www.washingtonpost.com/outlook/2018/12/18/proposed-new-public-charge-rule-puts-childrens-health-insurance-risk/?utm_term=.0ac0803db1a9

[4] https://www.forbes.com/sites/stuartanderson/2018/12/14/these-flaws-may-kill-the-public-charge-rule/#17d961c72884

[5] http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=23550

J.P. Berkazon

It was a big story: It held the news cycle for more than 24 hours, until something about some memo sucked up all our oxygen.

It was about business. And health care.

BIG businesses doing something to TRANSFORM health care.

The announcement caused the stock prices of other big companies in the ‘health care space’ to drop.

We’re still fuzzy on the WHAT.

As to the WHO: Amazon, Berkshire Hathaway, and JP Morgan Chase. The three behemoths plan to come together to form a non-profit entity to ‘disrupt’ health care.

The WHY: health care for their > 1 million combined employees (and all over the U.S.) costs too damn much.

The headlines were breathless, e.g. Forbes: “Amazon, Berkshire Hathaway, and JP Morgan Could Disrupt U.S. Health Care and Capitalism as we Know It.”

Capitalism as we know it.

It’s a great story. It has compelling figures. I, like many, want to believe that it’s possible to disrupt our piecemeal, overwrought, and insanely expensive health care non-system.

Many others have tried. And failed.

Here’s a contrarian view on the big announcement from a seasoned observer. Is his skepticism warranted or can Amazon and friends do for health care what they’ve done in retail and web services?

What do you think? Can J.P. Berkazon crack the U.S.  health care nut?

@GlassHospital

The ‘One Stop Shop’

“How can you expect patients to look after their health, when they don’t know where they will be living next week? You can not separate people’s physical health from their psychological, social and spiritual health.”

So asked community health nurse Ruth Chorley, in an article by Rachel Pugh in the Guardian.

The story reported on a local program in Oldham, one of the UK’s National Health Service districts, in which nurse specialists work to help people whose social and economic problems prevent them from managing their health.

From the story:

Chorley is a focused care practitioner – one of four employed by Hope Citadel Healthcare, a not-for-profit community interest company, to lead a pioneering approach to delivering healthcare to the most needy families in its four Greater Manchester NHS GP practices, by filling in the gaps between health and social care.

I think this small scale NHS experiment is one right way to truly improve a  community’s health.

Anxiety

How are you feeling post-election?

In the practice of medicine, we use validated questionnaires like the PHQ-9 to screen for depression or the GAD-7 to screen for anxiety.

My wife, a family doctor, administered the GAD-7 to a patient of hers this week; post-election, I started wondering how many Americans could be diagnosed with generalized anxiety disorder* right now.

Go ahead and take the quiz yourself:

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What’s your score?

A score of five or more indicates mild symptoms. Ten or more moves you to moderate. Fifteen or more means you are highly likely to have diagnosable anxiety disorder–what the experts call generalized anxiety disorder.*

If you’re in this highest category, think about getting help. You can start with your primary care physician. She can help you directly or refer you to other community mental health resources that can be helpful.

*Generalized Anxiety Disorder (GAD), according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5):

A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).
B. The individual finds it difficult to control the worry.
C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months):
Note: Only one item is required in children.

  1. Restlessness or feeling keyed up or on edge.
  2. Being easily fatigued.
  3. Difficulty concentrating or mind going blank.
  4. Irritability.
  5. Muscle tension.
  6. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep).

D. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism).

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