Is 90 Days Too Little or Too Much?

When I wrote my original piece discussing the prescription policy of the free clinics, my primary concern was for patients without adequate access to transportation. I argued for increased scrutiny into the policy because these patients might have been better served with longer supplies of prescriptions. Ultimately, I suggested that implementing better collaboration between the clinics would be a great first step to addressing the larger issue.

In that piece, I did mention the potential for prescription abuse. One form, I explained, was that “patients can game the system, traveling from clinic to clinic to obtain duplicate prescriptions.” While this was not backed up by any specific examples, it was based on anecdotal evidence from my conversations with the clinic leaders and other medical professionals at the clinics.

One form of prescription abuse that I overlooked is the risk of suicide or overdose due to an excessive amount of prescriptions. This is particularly true with psychiatric medications where patients are already at heightened risk. Brian Barnett, in his piece, “The 90-Day Prescription Isn’t for Everyone,” provides a succinct rebuttal to the idea that patients should be given longer supplies of prescriptions, emphasizing that “psychiatric drugs play an outsize role in intentional overdoses.” Therefore, like in the free clinics, he explains that “prescribing conservative quantities to these patients is standard practice” (Barnett 2019).

Do the free clinics follow this same ideology? I wanted to investigate this issue and determine if there is a difference in the number of days of medication given out for psychiatric prescriptions versus others at the Epworth Free Medical Program.

For each instance of a psychiatric prescription between 2014 and 2019, the daily intake of pills, number of pills, and number of refills was recorded. The total daily supply was calculated by dividing the number of pills by the daily intake and multiplying by one more than the number of refills. This resulted in a new metric describing the total number of days of medication prescribed to patients.

total_supply = num_pills / daily_intake * (num_refills + 1)

These calculations showed that, on average, providers prescribed 42.9 days worth of psychiatric medication to patients. The breakdown of days by prescription is shown below.

In the future, it would provide an immense benefit to analyze the data in greater detail. For example, we can examine “at risk” patients, defined as having a chief complaint of psychiatric nature or diagnosis of psychiatric nature.

I think this issue warrants extensive discussion to determine the best practice for the free clinics. Maybe the policy currently in place is already the best practice in consideration of these points and those I raised in the earlier piece.

At the end of the day, the general consensus amongst the physicians and providers at the free clinics is that patients should not be given more than 90 days worth of prescriptions. Ultimately, patients should follow up to review their prescriptions, get additional treatment, or get a primary care provider. This should be made easier for patients struggling with transportation Potentially, the clinics can help subsidize a mail pharmacy so patients in need can get their prescriptions through the mail, don’t have to keep picking up new ones, and get only a limited quantity at once.

Note: the fully anonymized data is obtained from an IRB-approved research project at Worcester Polytechnic Institute, under the direction of Brenton Faber, PhD.

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“The 90-Day Prescription Isn’t for Everyone,” by Brian Barnett, February 6, 2020. https://www.wsj.com/articles/the-90-day-prescription-isnt-for-everyone-11581032892

“Prescriptions and Policy in the Free Clinics,” by Sahil Nawab, December 30, 2019. http://www.sahilnawab.com/wfcc/q4_2019.pdf

“Top 25 Psychiatric Medications for 2016,” by John Grohol, July 8, 2018. https://psychcentral.com/blog/top-25-psychiatric-medications-for-2016/

Prescriptions and Policy in the Free Clinics

Note: This article was originally published as part of the Q4 2019 issue of the WFCC Newsletter and is reproduced here with permission. See original: http://www.sahilnawab.com/wfcc/q4_2019.pdf

Part of human nature is to make assumptions about others. This cognitive heuristic, while somewhat valuable in the past, now simply perpetuates ideals that are no longer relevant to modern society. When analyzed from the collective perspective, that is, by looking at systematic prejudices in institutions and professions, we can begin to tease out the less visible, but often more subversive prejudices that impact people at the population scale. This is particularly true in medicine, where the impacts of these institutional assumptions disproportionately harm those who we seek to help in the free clinics.

In this piece, I want to examine the prescription policies in place at the free clinics and invite discussion about the various factors in play. With that said, this is only a first step in addressing this complex issue rife with nuance. No amount of standardization can remove the necessary professional judgement of physicians and healthcare providers, but this may be an area where healthcare policy can make a tangible impact in patient care for the uninsured patient population in greater Worcester area.

The standard protocol encourages providers to prescribe the minimum necessary amount of medication. In practice, this often results in common chronic disease prescriptions being written for 30 days during the first visit, bumped up to 60 days on a following visit, and a maximum of 90 days on all subsequent visits. This procedure is grounded in real concerns – most prominently the potential for prescription abuse. However, it leaves the most vulnerable patients in limbo.

Uninsured or underinsured patients suffering from chronic diseases, such as diabetes or hypertension, are often the ones that have the most challenges associated with physically accessing prescriptions. Lack of transportation and difficulty taking time off from work during working hours are primary contributors to patients skipping their medications, along with insufficient funds to cover the prescriptions. These diverse issues cannot be solved without a large scale political effort and potentially restructuring the entire employment scheme. Regardless, being aware of these fundamental issues is vital to effective policy proposals on the part of the Coalition and the individual clinics.

Providers are rightly concerned that patients can game the system, traveling from clinic to clinic to obtain duplicate prescriptions, especially in light of the opioid epidemic. Despite this, a more benign, yet potentially even more subversive justification for the policy is the idea that the clinics are simply stop-gap measures rather than primary care facilities and provide care to any person without question.

On the face of it, the answer is simple: the clinics are not, in fact, primary care facilities. A better analogy might be that of urgent care centers, but even this falls apart because the clinics do not have the staff, equipment, or funding to address more serious illnesses. The clinics are simply not equipped to provide the long term, personal care that is required of a primary care facility, nor are they equipped to provide immediate care for the types of injuries and illnesses that urgent care centers treat. Patients inevitably still end up using the clinics for both primary care and urgent care.

Keeping in mind these conflicting messages, that the clinics provide care to anyone without question, and that they are neither primary nor urgent care facilities, updates to the standard operating procedures need to be made to better address the dichotomy. Without these changes, patients will remain in limbo, especially those looking for long term prescriptions for chronic illnesses.

Currently, 28.2% of patient encounters at Epworth result in the patient receiving one or more written prescriptions. A full 10.1% of patients arrive at Epworth seeking prescription refills. Providing prescriptions that take into account patient transportation challenges may be addressed by, for example, encouraging prescribing physicians to ask patients about the accessibility of prescriptions.

Another suggestion might include updating the standard operating procedures at the clinics to enable cross referencing of prescriptions, especially for some medications that are more prone to abuse. This does not reduce the importance of professional judgement, but rather reduces biases and provides objective measures that can ultimately lead to better patient care. An even more ambitious solution, but one that might address a larger range of the issues that the uninsured and underinsured population faces, is creating a mobile pharmacy that travels to each of the clinics. Patients can pick up their subsidized prescriptions immediately, while they are already at the clinic without need of further coordination. Even just having pharmacists available to discuss prescriptions during sign out may be immensely helpful to get patients to understand complex medications, their side effects, the proper time frame to take them, and answer any lingering questions.

Coordinating between the multiple bastions of healthcare falls more and more on the patient. Rather than institutions playing this vital role, increasingly patients are responsible for making the phone calls to get prescriptions, understand the side effects, and ensure that they can afford the medication.

This makes a strong case for increased collaboration between the clinics, especially for prescriptions that have higher potential for abuse. Yet while the proposal for a system-wide EMR has yet to gain the full support of the Coalition for a variety of reasons, significant strides have been made thus far in bringing the individual clinics together. Careful policy that balances these multiple factors, on the part of the WFCC and individual clinics, can help defray the costs associated with being uninsured or underinsured in the greater Worcester area.

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“Unpaid, stressed, and confused: patients are the health care system’s free labor,” by Sarah Kliff, June 1, 2016. https://www.vox.com/2016/6/1/11712776/healthcare-footprint.

This article describes “the considerable burden our fragmented system puts on patients to coordinate their own care,” and how the challenges associated with dealing with multiple systems in person and over the phone to get prescriptions can be akin to a part-time job.

When Clear Writing Really Matters

I know that this is certainly quite late — I had saved this article a few months back and am only now getting to writing about it. Nonetheless, I think it is valuable enough to warrant another look.

When the report, and Rozenweig’s ensuing article, first came out, it reminded me of the importance of brevity and directness. In science writing, conciseness and clarity are prized. However, in the pursuit of objectivity, we often use the third-person passive voice, and this style has deeply impacted my own writing. I now resolve to use more active verbs to provide narrative and agency to the words on the page and to show responsibility of actions.

On a whim, I took a class about teaching writing, and it taught me quite a bit about the pedagogical philosophy of college-level writing instructors around the world. In particular, I developed my own ideas about what writing is supposed to be, what purposes it is supposed to serve, and how my own particular style of writing fits in amidst a great variety of different forms of communication.

This class was invaluable, and I encourage anyone who has the chance to take such an opportunity because, “some day they may have something to say that really matters to them and possibly to the world — and they will want to convey it when the moment arrives in writing that’s clear and concise” (Rosenzweig 2019).

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“The Whistle-Blower Knows How to Write,” by Jane Rosenzweig, September 27, 2019. https://www.nytimes.com/2019/09/27/opinion/whistleblower-complaint.html

The Pioneering Spirit of General Aviation in the US

The rich legacy of aviation in the United States, from the first flight of the Wright brothers’ plane through to modern commercial jet airliners, has allowed the United States to develop the most widely dispersed general aviation infrastructure in the world. With that, comes the freedom of flight.

Let’s keep this pioneering spirit alive.

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MIT Ground School, by Philip Greenspun, January 6, 2020. http://philip.greenspun.com/teaching/ground-school/

Discourse on Modern Medical Education

An interesting discourse has popped up recently surrounding medical education and its role in training physicians about social issues. Dr. Goldfarb argues that, “at ‘woke’ medical schools, curricula are increasingly focused on social justice rather than treating illness.” But his statements have met with pushback from other medical educators.

I think this discourse is fascinating to read, especially on the heels of a pedagogical course in which we examined how to teach writing, and recently implementing an aviation ground course on campus. There is so much more involved in teaching than I had ever expected, so this glimpse of the philosophy behind what medical students get taught is certainly eye-opening, but not surprising. What does surprise me, however, is the dynamic between modern educational thought and the hierarchical medical structure.

Todays world of medicine is filled with these dichotomies between old-age ideals and modern technological innovation. Specialties have become the norm for treatment, and no singular physician can adequately expect to treat the “whole person” as we might have imagined only 50 years ago. With increasing specialization, care has become fragmented. Increased fragmentation has led to patients bearing the burden of coordination.

The “professionalism” movement initiated in the 1990s had hoped to humanize the medical educational process and help develop physicians who were more than mere technicians.

Michael H. Malloy, M.D., M.S.

I do agree that tangentially related topics need not be given much time or dedication in an already packed curriculum. However, the underlying assumption that climate change, gun policy, and other social issues constitute as tangential betrays the point. Old school medical education gave rise to the current epidemic of overspecialization, so to continue the same pedagogical philosophy makes no sense. Todays physicians are encouraged to be well-rounded, socially aware, and empathetic. While scientific proficiency is vital for physicians, it should not come at the expense of forgetting that todays physicians treat people, not their symptoms.

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“Social Justice and Educating Our Physicians,” by Robert McLean, Michael Malloy, et. al., September 18, 2019. https://www.wsj.com/articles/social-justice-and-educating-our-physicians-11568830783

“Take Two Aspirin and Call Me by My Pronouns,” by Stanley Goldfarb, September 12, 2019. https://www.wsj.com/articles/take-two-aspirin-and-call-me-by-my-pronouns-11568325291?mod=article_inline

“Medical Schools Are Pushed to Train Doctors for Climate Change,” by Brianna Abbott, August 7, 2019. https://www.wsj.com/articles/medical-schools-are-pushed-to-train-doctors-for-climate-change-11565170205

Two Types of Fun

Recently, I saw a video by Ali Abdaal going over the lessons he learned throughout the year. The one that stood out to me most was the idea of there being two distinct types of fun. This put into words something that we all feel, especially when we reflect over the experiences of the past year.

Firstly, there is the standard enjoyable fun that everyone is well aware of. But the second type of fun is a bit less obvious. It’s the fun that requires work, and effort, before us calling it fun. Therefore it isn’t necessarily “enjoyable” in the moment, that is, while we’re doing it, but is later classified as fun when looking back.

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“15 Life Lessons I Learned in 2019,” by Ali Abdaal, January 7, 2020. https://www.youtube.com/watch?v=l3hOrfLuxU0

The Dilemma of Electric Aviation

The internal combustion engine has been around for about two hundred years, and to great effect. It has changed the world and made it a better place for many people. Yet, in its wake are the climate consequences of mobilizing an enormous swath of the population.

Today we’re seeing an explosion in electric vehicle technologies, and I am extremely excited for an electrified future. The advantages of electric propulsion systems for wheeled vehicles, including instantaneous torque delivery and greater longevity, easily outweighs the negatives. The improvements in fast charging have been drastic and the increase in range has negated the range anxiety that plagued early electric vehicles.

However, despite these advantages and improvements, I think aviation may well remain one of the last holdouts of the internal combustion engine. Aviation primarily uses one of two different types of internal combustion engine — the reciprocating engine, commonly found in general aviation, and the turbine engine, commonly found in commercial aircraft.

For short range trips, I admit that electric propulsion systems seem quite attractive. However, when looking at long distance cruising, which is paramount to commercial operators, the internal combustion engine still holds its own.

The reciprocating engine is particularly well suited to the demands of long distance cruising, especially when combined with a constant speed propeller. Running at peak efficiency essentially all the time means that the traditional issues that detractors bemoan, large and quick changes of RPM, are no longer relevant.

Because these engines need to be spinning at all times, ground vehicles need to utilize some sort of transmission and power coupling system to allow for slippage. Aviation, on the other hand, requires the propeller to be spinning at all times anyway (at least during flight and most ground operations after the initial set up procedures). Therefore, planes do not need to have a heavy transmission and are often simply directly connected to the propeller.

The near-instantaneous response times of electric motors is certainly helpful for pilots, especially during non-normal procedures such as stalls, go-arounds, etc., for most applications it isn’t absolutely necessary. Passenger aircraft would likely implement some sort of smoothing system anyway for comfort, negating the benefits almost completely.

The energy density of chemical fuels is unparalleled, with the exception of nuclear technologies. The energy extraction mechanisms used for nuclear energy are themselves quite bulky, completely negating any density benefits. On the other hand electric propulsion systems suffer from the exact opposite problem. Electric motors are lightweight, but the batteries are still heavy, despite the massive improvements that have been made in recent years.

The advancements in battery technology that are driven by innovation in the aviation sector will likely have an enormous impact on society as a whole. For that reason alone, I think pursuing electric aviation technologies is absolutely worth the effort and the increased funding that it deserves. This is an area where these developments may completely overturn the cost-benefit ratio and make electric aviation readily cost-effective despite some of the inefficiencies of the energy storage mechanism.

The electrification potential in ground based vehicles is more obvious. The benefits of electric motors are their extremely high torque, instantaneous response times, and independent wheel control (assuming 4 motors, one for each wheel).

I think off-road vehicles are even more suited, as having wheel-based motors allows for higher ground clearance. Likewise, buses and city vehicles as well, where weight is not really a huge concern, and electric charge stations are plentiful and can even by added to the bus stops themselves to keep the vehicles charged.

Because of these issues, I think that electric innovation will be primarily driven by ground-based transport, rather than by aviation. However, I would love to be proved wrong, especially as aviation becomes one of the largest emitters of greenhouse gasses. Reducing these emissions will be invaluable to increase the reach of general aviation reach in society, and I am eager for such a future.

This area, namely emissions, is where I see the largest potential for upheaval of the industry. As pilots and aviators, we probably contribute significantly more to climate change than others. Flying in small general aviation aircraft is inherently less efficient than flying in larger airliners. Allowing the public to pursue general aviation without contributing to the negative impact of climate change will be immensely beneficial. As a community, pilots are excited for a future where aviation can be carbon neutral.

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MIT Ground School, by Philip Greenspun, January 6, 2020. http://philip.greenspun.com/teaching/ground-school/

“Is it Wrong to Fly?” by Vox, January 8, 2020. https://www.youtube.com/watch?v=88Cd5H3kmXQ

Complete Ownership of Tasks as a Better Management Strategy

When I first read “Fairness in Housework Doesn’t Mean 50/50” in The Wall Street Journal, Eve Rodsky’s ideas seemed to perfectly take the abstract echoes from our subconscious thoughts and concretely place them into the context of the household – a backdrop that the vast majority of Americans can easily relate to. The tagline summarizes her argument concisely, “Happiness at home comes from each spouse owning tasks completely—not dividing everything exactly down the middle.”

I think that this is even more relevant in modern households. Todays elite, at least according to Daniel Markovits in “The Meritocracy Trap,” seems to run households in the image of a production facility, generating the necessary human capital to sustain the emerging meritocratic dynasties. In that sense, I now realize that Rodsky’s argument resonates with all aspects of management, from the household to large organizations, from small group projects for a class to whole teams of professionals volunteering their evenings to serve the community.

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“Fairness in Housework Doesn’t Mean 50/50,” by Eve Rodsky, September 20, 2019. https://www.wsj.com/articles/fairness-in-housework-doesnt-mean-50-50-11568989512

“The Meritocracy Trap,” by Daniel Markovits, September 10, 2019.

Point Yourself into the Wind

Last week, I wrote about the Goldsmith and the analogy to human struggle. That truly resonated with me. But reflecting on it, I remembered an early lesson from my flight instructor that had a similar message.

While taxiing to the runway, one one of my first flights, he told me, “Make sure you always face into the wind when taking off.” I look at life in the same way: the challenges and difficulties that we face in life are what lift us up high into the sky.

Why the Goldsmith Stokes the Flames

There is a historical element that, in combination with metallurgy and materials sciences, gives rise to the age-old practices of goldsmiths. Why is it that goldsmiths take precious metals and place them into the hot, dirty coals?

The goldsmith might retort, “I use the heat of the flames to purify the gold – to turn an imperfect piece into the most precious metal.”

Perhaps the glowing blaze of the forge, the rising embers from the ashes, the swirling heat that distorts our vision, represents far more. Perhaps the goldsmith’s retort is the answer to the primordial question, “Why do we struggle?” It is the flames of the coals that purifies the gold. Likewise, it is struggle and hardship that purifies the human soul.