EPtalk by Dr. Jayne 3/23/23

People are always asking me how I’m reacting to various things in the news. I was saddened last week to see that Pear Therapeutics is searching for ways to remain viable. They were one of my favorite finds at HIMSS22.

Unfortunately, I don’t think frontline physicians really understand what Prescription Digital Therapeutics (PDT) products are and how they differ from recommending that a patient just download an app. PDTs have to be approved by the US Food and Drug Administration before they can be marketed for patient use. Pear has treatments for substance abuse disorder, opioid use disorder, and insomnia that are clinically proven to provide benefit to patients.

For the technology to make it to patients, however, it has to be prescribed by a licensed clinician, and many clinicians are simply overwhelmed. It’s challenging to get them to learn about new drugs, let alone entirely new paradigms. If someone knows about PDTs, they have to identify appropriate patients, then prescribe the solution. A prescription transmission goes to the PDT company, which then has to fulfill it. In Pear’s case, by providing an access code that allows the patient to download it from Apple or Google Play.

Once the patient begins using the tool, the clinician receives notifications through a prescriber dashboard and can monitor patient progress. It’s not unlike prescribing a medication. The intervention still requires monitoring and follow up by the prescriber, and patient adherence can be an issue. I hope Pear Therapeutics finds what they’re looking for and can continue the good work that they are doing.

I also received some questions about the potential for telehealth use to mitigate the unfolding tragedy in pediatrics, namely, the increase in all-cause mortality for children in the US. A research article published in JAMA last week looked at the increase in child and teen deaths that began pre-pandemic but worsened during last few years. The largest increase in pediatric mortality in 50 years is being led by injuries, which include motor vehicle accidents, overdose, homicide, and suicide. All of them were on the rise prior to 2019, with suicide being on the rise as early as 2007. Even children from ages 1 to 9 had increases in death rates. Infants younger than 12 months were the only ones spared. The article summarizes some of the racial disparities that accompany the rise in mortality, with non-white children being the most impacted.

When talking with people about potential interventions or solutions, everyone says “telehealth” as if it’s a magic bullet. Although telehealth can reduce the burden on families who are trying to get their children help — through easier access, reduced driving, etc., — the reality is that there simply are not enough therapists to go around. Social workers and others who deliver telehealth therapy are leaving the field at an alarming rate. Policy makers need to go deeper and look at the causes of increased mortality. Nearly half of the increase in 2020 was related to firearms deaths, which were the leading cause for children aged 1 to 19 years.

The article points out that nearly all the gains that have been made in pediatric longevity over the past few decades are being erased by “bullets, drugs, and automobiles.” So much for improving outcomes with asthma, vaccine-preventable diseases, premature birth, and the like. I continue to come across parents who bury their heads in the sand about what is going on with their children and who seem shocked when the physicians caring for them suggest that they need to talk to their middle schoolers about sex, drugs, and guns. Frankly, by middle school, it’s a little late for a lot of that, depending on who your kids run with, but as family physicians and pediatricians, we’ll keep trying. We can throw some telehealth at it as well, but it’s a much bigger issue than the majority of people understand.

Several people have also asked for my reaction to “The Match,” which is the National Resident Matching Program. It’s the multi-month mating dance where medical students try to figure out where they will continue their training through internship and/or residency, and where training programs figure out who their workforce will be for the next several years. There were some huge shakeups in Match data this year, with emergency medicine taking a serious hit. It was bad enough that the American College of Emergency Physicians and other organizations issued a joint statement about the specialty’s prospects. It cites “workforce projections, increased clinical demands, emergency department (ED) boarding, economic challenges, the impact of the COVID-19 pandemic, and the corporatization of medicine, among many others” as reasons leading students to choose specialties other than emergency medicine.

I’m not an emergency medicine physician, but I’ve spent the last 17 years of my career practicing alongside EM physicians in the emergency department and high-acuity urgent care settings. The specialty has been absolutely dumped on during the last three years. If you don’t know what ED boarding is, that means that when there aren’t enough beds in the hospital to admit new patients (usually because of nursing or other staffing shortages), those patient stack up in the emergency department. Depending on the facility, often the emergency team has to care for them. Sometimes it’s bad enough that patients are even discharged from the hospital after a multi-day stay without ever going to a regular room.

That’s not what EM physicians signed up for, and it’s not their particular skillset. When primary care practices shut down due to COVID, everyone went to the ED and the urgent cares. Some physicians were seeing 80-100 patients each shift, while other physicians shut down. It was brutal, and the things we saw were horrific. The moral injury from having to ration care still haunts many of us. The sense of powerlessness that most of us felt for weeks grew to months and into years with little relief. Some of us are still coping with the symptoms of post-traumatic stress disorder, and a lot of us have left the profession.

For those frontline healthcare IT folks who have been trying to support the emergency department through all of this, you’ve seen it and understand why students don’t want to choose a career in the emergency medicine trenches. Thank you for your patience and compassion when we were frustrated day after day and the technology seemed like just one more thing causing torment. For those of you who haven’t seen this, or who haven’t been a patient lately, the downstream effects of this Match will ripple through our health systems for years to come. Ultimately patients will continue to bear the brunt of the mess that is the US healthcare system.

Would you encourage your child or loved one to pursue a career in medicine? What about healthcare technology? Leave a comment or email me.

Email Dr. Jayne.