The type 2 diabetes 'modern preventable pandemic' and replicable lessons from the COVID-19 crisis.

To frame the substantial prevalence of type 2 diabetes (T2D) as a 'Modern Preventable Pandemic' (MPP) and present certain replicable policy lessons from the COVID-19 crisis to address it. A literature and policy review was performed to analyze data about the COVID-19 and T2D pandemics to establish their multi-factorial health, social, and economic impacts. With the global prevalence of T2D tripling in the last two decades, T2D has become an MPP largely due to modifiable human behaviors. Certain successful elements of the response to the COVID-19 pandemic provide important lessons that can be adapted for the growing T2D MPP. With proper education and access to resources, it is possible to mitigate the T2D MPP through focused government policies as illustrated by many of the lessons of the COVID-19 pandemic response. Without such government intervention, the T2D MPP will continue to grow at an unsustainable pace with enormous health, social and economic implications. Immediate action is necessary. The scale of the T2D pandemic warrants a robust response in health policy as outlined through eight coordinated efforts; the lessons of the COVID-19 crisis should be studied and applied to the T2D MPP.

Transforming the provision of healthcare through emerging technology: A strategic transformation.

Why has the health care delivery paradigm and its integral transactions and interactions been left to muddle through, using archaic, 20th century modes and processes of delivery that are overlaid with byz antine medical record databases that pass for "cut ting-edge" technology? What is stalling the digital revolution in the provision of health care services to consumers? Understanding how and why this has happened requires that we briefly explore the evo lution of health care in the United States. Topics discussed include (1): morbidity and mortality: the public health era: (2) Medicare era: the advance of diagnostic and therapeutic technology; (3) the power of the consumer: patient-centered informatics; and (4) planning and execution of strategic transformation of provision of care informatics. Without an informatics focus, our health care system will continue limping along, costing more money and delivering many years of disability. Our most viable solutions revolve around using informatics to measure, guide and become the transformation. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Neuropsychiatric Implications of Chronic Lead Exposure.

There is growing awareness of chronic exposures to lead, with recent evidence indicating that there is an increased risk of a range of health effects that include cardiovascular, kidney, cognitive, and premature mortality, at blood levels lower than what was previously considered elevated. This report describes the case of a 42-year-old active duty officer with a history of anxiety, cognitive impairment, and paroxysmal hypertensive episodes associated with elevated body burdens of lead as measured in bone, while having low or unremarkable blood level measurements. Challenges related to work-up, treatments, and outcomes are discussed. An elevated body burden of lead may contribute to increased irritability, fatigue, and anxiety, mimicking posttraumatic stress disorder and other primary psychiatric conditions. This presentation highlights the need for an increased index of suspicion of lead poisoning in both medical and psychiatric care, particularly in military populations.

The Physician Shortage: A Red Herring in American Health Care Reform.

Although the USA spends more on health care than any other comparable nation, Americans are less healthy than citizens of high-income countries that spend far less. Over the past 12 years, the number of physicians per capita in the USA has been a concerning problem that may contribute to the disparity between health care costs and health status. Some have argued that remediating the shortage of primary care physicians will improve patient health. Others assert that the relationship between health care costs and health outcomes is more complex, influenced by a broad range of variables intrinsic to health care (i.e., provider availability, continuity, coordination); patient factors (ethnicity, socioeconomic status, health behaviors, health literacy, and other social factors); and systems factors (health information management, health information technology and health care measurement itself). This article contends that increasing the physician supply will not improve the health of Americans. Rather, solutions which lower health care costs while concomitantly improving health status will. Aside from community-level actions, health can improve at lower costs by increasing the prevalence of and proficiency in team-based care models, that address individual patient determinants of health, and poorly coordinated care. Future directions for this research and policy development are discussed.

Person-Centricity: Promoting Self-Determination and Responsibility in Health and Health Care.

The transition from a system focused on the delivery of sickness and illness services to one with a heavy focus of helping people become and remain healthier requires a major shift in how we view the patient and person. The health care system attempts to magically transform us from persons to patients in a context of sickness and disease, in need of medical procedures and interventions. Those few hours we spend a year in formal medical and health care contexts do not define us in the broader life space. We contend that "person-centricity" is more reflective of the life space and as such better supports that shift than do models of consumer or patient empowerment, centeredness, engagement, or activation. "Person-centricity" represents the complexity of how individuals make decisions including health and health care decisions, within the broader context of their lives, and accurately addresses the needs and aspirations of people throughout their life journey. This is not simply a shift in semantics, but an entirely new paradigm that frees the individual from assuming and succumbing to the passive and subservient patient role and dramatically changes the way in which we view ourselves and interact with the health care system.The changes required to create a healthier America and affect costs associated with lifestyle-related diseases need to happen on a personal level, coupled with a supportive infrastructure and public policies to promote and sustain them. This shift is critical to our transition from health care to a healthier way of living and of controlling avoidable costs.

Developing the Next Generation of Physicians.

To improve health care, the USA needs to create a longitudinal medical education system that will develop physicians able to lead the transformation of health care toward a focus on the promotion of healthy behaviors aimed at preventing disease. The development of patient-centered care has been an important step in promoting healthy behaviors. However, to truly develop a meaningful relationship with a patient, a physician must first see them as a person, not as a list of diseases. Medical education should develop physicians able to provide person-centered care - moving beyond patient-centered care to focus more broadly on the entirety of the person, for whom being a patient is merely one aspect of their personhood. Restructuring medical education begins with the admission process itself, followed by longitudinal changes at the undergraduate, graduate, and continuing professional development levels that will reinforce the attributes critical for future physicians. The authors view this longitudinal approach through the theoretical framework of situated cognition, exploring personal, environmental, and social factors leading to success; outline several key stages of medical education from matriculation through continuing professional development; and identify potential areas that merit longitudinal efforts to develop future physicians able to promote positive health behaviors.

Toward a National Conversation on Health: The Transformative Power of Deregulated Markets and Market-Driven Innovation.

The U.S. health care system is broken. Unhealthy behaviors, misaligned incentives, excessive regulations, and a reactive care delivery system have created an unsustainable situation for the American people. Health care reform efforts to date have focused primarily on costs, insurance coverage, and policies and regulations in an attempt to increase access, improve quality and control costs. In addition, the Affordable Care Act has created so much complexity that it is nearly impossible to determine how elements in the health care system interact or impact health outcomes. Health care is more complex than ever, with a myriad of new government regulations that must be considered when designing new models of health.New care delivery models that increase consumer choice, encourage competition through free markets, and accelerate innovation are urgently needed. The longstanding fee-for-service model of health care, which is driven by government regulation and the insurance industry, must be abandoned. In its place, the authors provide examples of several emerging market-driven innovations that are currently being implemented and evaluated for viability, replicability, and scalability. They also recommend specific environments for piloting innovative, consumer-focused models of health care, and for helping the government define a process for eventually backing out of health care in order to create a truly deregulated system.

Toward a National Conversation on Health: Disruptive Intervention and the Transformation from Health Care to Health.

Over a century ago, Abraham Flexner's landmark report on medical education resulted in the most extensive reforms of medical training in history. They led to major advances in the diagnosis and treatment of disease and the relief of suffering. His prediction that "the physician's function is fast becoming social and preventive, rather than individual and curative," however, was never realized.Instead, with the rise of biomedical science, the scientific method and the American Medical Association, the health care system became increasingly distanced from a holistic approach to life that recognizes the critical role social determinants play in people's health. These developments created the beginning of the regulatory controls that have come to define and shape American health care - and our unhealthy obsession with illness, disease and curative medicine that has resulted in a system that has little to do with health.To realize Flexner's prediction, and to transform health care into a holistic system whose primary goals are focused on health outcomes, six disruptive interventions are proposed. First, health needs to be placed in the context of community. Second, the model of primary care needs to be revised. Third, big data need to be harnessed to provide personalized, consumable, and actionable health knowledge. Fourth, there needs to greater patient engagement, but with fewer face-to-face encounters.Fifth, we need revitalized, collaborative medical training for physicians. And finally, true transformation will require market-driven, not regulatory-constrained, innovation. The evolution from health care to health demands consumer-driven choices that only a deregulated, free market can provide.

Tipping points in the Department of Defense's experience with psychologists in primary care.

Psychologists played a crucial role in the successful implementation of integrated behavioral health care services in Department of Defense (DoD) primary care clinics. On the front lines of policy development, training programs, clinical care, and program evaluations, psychologists successfully promoted integrated care as a core component of the DoD patient-centered medical home. We review the development of integrated care and discuss the roles of psychologists in the DoD to provide an exemplar of the impact psychologists can have on the implementation and sustainment of integrated care.

Impact of a patient-centered medical home on access, quality, and cost.

CONTEXT: Patient-centered medical homes (PCMHs) are intended to actively provide effective care by physician-led teams, where patients take a leading role and responsibility. OBJECTIVE: To determine whether the Walter Reed PCMH has reduced costs while at least maintaining if not improving access to and quality of care, and to determine whether access, quality, and cost impacts differ by chronic condition status. DESIGN, SETTING, AND PATIENTS: This study conducted a retrospective analysis using a patient-level utilization database to determine the impact of the Walter Reed PCMH on utilization and cost metrics, and a survey of enrollees in the Walter Reed PCMH to address access to care and quality of care. OUTCOME MEASURES: Inpatient and outpatient utilization, per member per quarter costs, Healthcare Effectiveness Data and Information Set metrics, and composite measures for access, patient satisfaction, provider communication, and customer service are included. RESULTS: Costs were 11% lower for those with chronic conditions compared to 7% lower for those without. Since treating patients with chronic conditions is 4 times more costly than treating patients without such conditions, the vast majority of dollar savings are attributable to chronic care. CONCLUSIONS: Results suggest focusing first on patients with chronic conditions given the greater potential for early gains.

Leveraging the military health system as a laboratory for health care reform.

The Patient Protection and Affordable Care Act recently passed into law is poised to profoundly affect the provision of medical care in the United States. In today's environment, the foundation for most ongoing comparative effectiveness research is financial claims data. However, there is an alternative that possesses much richer data. That alternative, uniquely positioned to serve as a test system for national health reform efforts, is the Department of Defense Military Health System. This article describes how to leverage the Military Health System and provide effective solutions to current health care reform challenges in the United States.

The patient-centered medical home: a case study in transforming the military health system.

This case study describes the Military Health System's (MHS) patient-centered medical home (PCMH) initiative and how it is being delivered across the MHS by the Army, Navy, and Air Force. The MHS, an integrated delivery model that includes both military treatment facilities and civilian providers and health care institutions, is transforming its primary care platforms from the traditional acute, episodic system to the PCMH model of care to maximize patient experience, satisfaction, health care quality, and readiness and to control cost growth. Preliminary performance measures are analyzed to assess the impact of PCMH implementation on the core primary care processes of the MHS. This study also discusses lessons learned and recommendations for improving health care performance through the PCMH care model.

Protecting the culture of a patient-centered medical home.

OBJECTIVE: This study describes and categorizes the cultural frictions and conflicts within a successfully implemented Internal Medicine Patient-Centered Medical Home (PCMH) clinic at the National Naval Medical Center, and provides lessons learned for combating these concerns. METHODS: A semistructured interview protocol was developed, focusing on unique tenets of the PCMH, benefits of the model, and perceived obstacles to practicing medicine within this delivery system. The interviews included questions regarding efforts to foster team cohesion and impediments within the PCMH, as well as unique influences of the larger organization and the patient population, and lingering concerns about threats to the PCMH's viability. KEY RESULTS: Cultural tensions were revealed in four areas: perceived competing values within PCMH, individual resistance to PCMH values, within-team conflicts threatening the acculturation of PCMH values, and threats to the culture from external stakeholders. CONCLUSIONS: Recommendations for addressing these areas include values clarification and empowerment, training for socialization, realistic job previews, selective personnel retention, team building and conflict resolution mechanisms, and increased senior managerial support.

The impact of selected contextual factors on experts' clinical reasoning performance (does context impact clinical reasoning performance in experts?).

Context specificity, or the variation in a participant's performance from one case, or situation, to the next, is a recognized problem in medical education. However, studies have not explored the potential reasons for context specificity in experts using the lens of situated cognition and cognitive load theories (CLT). Using these theories, we explored the influence of selected contextual factors on clinical reasoning performance in internal medicine experts. We constructed and validated a series of videotapes portraying different chief complaints for three common diagnoses seen in internal medicine. Using the situated cognition framework, we modified selected contextual factors--patient, encounter, and/or physician--in each videotape. Following each videotape, participants completed a post-encounter form (PEF) and a think-aloud protocol. A survey estimating recent exposure from their practice to the correct videotape diagnoses was also completed. The time given to complete the PEF was randomly varied with each videotape. Qualitative utterances from the think-aloud procedure were converted to numeric measures of cognitive load. Survey and cognitive load measures were correlated with PEF performance. Pearson correlations were used to assess relations between the independent variables (cognitive load, survey of experience, contextual factors modified) and PEF performance. To further explore context specificity, analysis of covariance (ANCOVA) was used to assess differences in PEF scores, by diagnosis, after controlling for time. Low correlations between PEF sections, both across diagnoses and within each diagnosis, were observed (r values ranged from -.63 to .60). Limiting the time to complete the PEF impacted PEF performance (r = .2 to .4). Context specificity was further substantiated by demonstrating significant differences on most PEF section scores with a diagnosis (ANCOVA). Cognitive load measures were negatively correlated with PEF scores. The presence of selected contextual factors appeared to influence diagnostic more than therapeutic reasoning (r = -.2 to -.38). Contextual factors appear to impact expert physician performance. The impact observed is consistent with situated cognition and CLT's predictions. These findings have potential implications for educational theory and clinical practice.

An internal medicine interest group research program can improve scholarly productivity of medical students and foster mentoring relationships with internists.

BACKGROUND: Shortages in primary care careers such as internal medicine are projected in the future. Conducting research is an explicit requirement for graduate medical education and interest in research is growing in undergraduate medical education. PURPOSE: We hypothesized that a medical student research initiative could increase student research productivity and foster mentoring relationships with internists. METHOD: We compared the number of medical student presentations, awards, and peer-reviewed publications before and after a brief research initiative at a single institution and recorded comments from student participants; data collected before the initiative were retrospective, and data after the initiative were collected prospectively. Mann-Whitney U was used for statistical analysis. RESULTS: Twenty-seven students participated in our workshop initiative during the study period (2000-2005). Eighteen (67%) subsequently had presentations, research awards, and/or publications during the study period. Mann-Whitney U testing of groups (all pre-initiative Uniformed Services University students and initiative participants) showed a statistically significant increase in regional presentations (p = .003), research awards (p = .01), and publications (p = .02) after the research initiative. Student comments not only revealed research mentoring benefits but also commented on receiving career counseling advice from mentors. CONCLUSIONS: Our study findings support the feasibility of this initiative as well as produced significant outcomes in terms of quantified research productivity and student mentoring.

Do residents benefit from participating in internal medicine interest groups? A study of resident perceptions from two institutions.

BACKGROUND: For more than a decade, primary care residency training programs have struggled to attract graduates of U.S. medical schools. Internal medicine (IM) interest groups (IMIGs) have been widely instituted to foster student interest in careers in IM. Residents can participate in many IMIG activities. Studies have not assessed the benefits gained by resident participants in such groups. METHODS: A questionnaire was sent to residents at two IM residency training programs that contribute to IMIG activities at one medical school. Both participating and nonparticipating residents were included. RESULTS: The questionnaire was completed by 44 of 58 IM residents (76% response rate; 25 participants and 19 nonparticipants). Free-text advantages reported were teaching (n=6), mentoring (n=8), and leadership (n=5) opportunities, staying current in IM (n=3), encouraging students to enter IM (n=6), and improving resident morale (n=6). Likert-scale responses were higher for participants than for nonparticipants for all questions; nonparticipants also reported that involvement in IMIG activities is beneficial for residents. Statistically significant results were seen for questions regarding the following: improves resident morale, fosters leadership opportunities, is a valuable experience, and feeling qualified to participate. CONCLUSIONS: Residents perceive that participation in an IMIG confers significant benefit, providing additional justification for conducting these interest groups.