Robert Whitcomb: Health-care beacons, Snowden, our big river

The Connecticut River at Orford, N.H. (See item at bottom.)

Much of American health care’s future can be seen in two synergistic kinds of institutions in Rhode Island.

One is Federally Qualified Health Centers (FQHCs). These facilities, set up around America, provide a wide range of free and insurance-subsidized clinical help for millions of patients, most of them low-income. The other is Johnson & Wales University’s spanking new Center for Physician Assistant Studies.

Consider the state’s biggest FQHC organization -- Providence Community Health Centers (PCHC). Its teams of physicians and other clinicians, such as nurses and nurse practitioners, work for what is the biggest single provider of primary-care services in Providence, with more than 35,000 patients. (I toured PCHC’s immaculate Prairie Avenue campus the other week, led by Merrill Thomas, its CEO, and Jane Hayward, the Rhode Island Health Center Association’s president.)

PCHC ‘s mission, it says, is to “provide neighborhood-based high quality and accessible primary medical care to improve the health status of the residents of Providence and surrounding communities regardless of their ability to pay.’’ FQHCs play especially important roles in inner cities and impoverished rural areas, such as Appalachia, where many physicians don’t want to practice, especially because of low reimbursement and so many difficult cases involving seemingly intractable behavioral-health issues.

Expanding primary care -- especially preventive care -- is essential if America is to improve overall health outcomes that are near the bottom of the Developed World while better controlling medical costs, which are the highest.

Whatever happens with the Affordable Care Act, the U.S. population’s aging (older means sicker); the daunting complexity of our health-insurance system; the permanent exit of many well-paying jobs; emigration to the United States of low-income people, and the decline of the stable, two-resident-parent family suggest that Federally Qualified Health Centers ought to play even bigger roles.

Of course, increasing the numbers of primary-care clinicians is essential for the long-term success of these clinics. Doing just that is the Johnson & Wales Center for Physician Assistant Studies, which has a beautiful building in Providence’s Jewelry District.  George Bottomley, its director, gave  me a tour the other week.

Its 24-month master’s program addresses the need to train many more non-physician clinicians who can perform highly professionally and cost-effectively some of the tasks now performed by over-worked (if highly paid) doctors. PAs are especially useful in getting patients to make the behavioral changes needed to prevent serious illness, in part because they can generally spend more time with patients than can physicians; many of the latter are more harried than ever because of onerous electronic-health-record duties and administrative pressures to boost patient volume.

J&W notes that PAs work in integrated medical teams to “provide diagnostic, therapeutic and preventive health-care services.’’ (By the way, the differences between physician assistants and nurse practitioners mostly involve some education details. They’re very similar professions.)

With physicians as supervisors, physician assistants take patients’ histories and perform exams; order lab tests; prescribe medications; diagnose illnesses; develop treatment plans, and counsel and educate patients.

No wonder that demand for PAs is surging. Forbes.com has listed Physician Assistant Studies as the “No. 1 Best Master’s Degree for Jobs.’’ The American Academy of Physician Assistants (AAPA.org) says that “demand for physician assistants and nurse practitioners rose by more than 300 percent in the last three years.’’

We’ll need Johnson & Wales PAs in droves in coming years as, technology, demographics and new cost controls continue to transform U.S. health care for all patients, especially in primary care, in which physician assistants will be at the forefront.

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Edward Snowden – as a Russian spy and/or as an arrogant but naïve narcissist-- has provided vast amounts of U.S. security information to Vladimir Putin’s police state, perhaps resulting in the death of agents working for us. And he has aided the Chinese dictatorship’s relentless cyber-warfare against America. Some hero!

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Last week we cruised the gorgeous Upper Connecticut River on a pontoon boat. Because it’s by far New England’s biggest river, on it you get a sense of what Mark Twain might have felt on the Mississippi. We yakked desultorily in the soft breeze about big projects we’d do – as if we were 30 years younger than we are.

Robert Whitcomb (rwhitcomb51@gmail.com), overseer of New England  Diary, is a partner in  Cambridge Management Group (cmg625.com), a healthcare-sector consultancy, and a fellow of the Pell Center for International Relations and Public Policy.

Blighted and bright college days

BY ROBERT WHITCOMB

(comment via rwhitcomb51@gmail.com)

A few weeks ago, I was chatting with a Dartmouth College classmate about stuff that happened when we were students in 1966-70. I mentioned someone we knew in common and recalled that he was in a certain fraternity.

 The guy I was talking with, Denis O’Neil, a screenwriter who recently published a part-memoir, part-novel of that period titled “Whiplash: How the Vietnam War Rolled a Hand Grenade into the Animal House,” politely corrected me; in fact, this person was in another fraternity.

Time has fragmented and mingled stories in my memory and those of others from that era, now almost half a century ago. One could argue that it was a tumultuous era, and thus it’s easy to get things scrambled, but most times are tumultuous and transitional. Mr. O’Neil makes much of the stress caused by the fear of being drafted and sent to Southeast Asia, but as bad as that was, it was much worse for young men in World War II. Whatever. We’re all the centers of our own universes, and we create narratives to explain ourselves to ourselves and others and to place ourselves in history.

Certainly, the huge size of the Baby Boomer generation, and technological and social changes of its young times, were dramatic, though I would argue that except for improvements in the rights of racial minorities and women, the transformations caused by the Internet (which increasingly looks as if it has made things worse for most people) have been much bigger than “Sixties” changes.

Still, it’s true that in that period one had the distinct sense of living in a discrete and vivid era, which actually began about 1966 and ended about ’73. People who lived in the “Roaring Twenties” — 1924 to the Great Crash of October 1929 — told me in “The Sixties” that they had had a similar sense back in the Coolidge administration. Youth is intense, and so the memories the now-autumnal people of “The Sixties” are intense, if sometimes erroneous.

From Mr. O’Neil’s book, which centers on fun, romance (not always fun) and anxiety, you might think that 80 percent of a male undergraduate’s time was spent drunk, seeking young women to have sex with and trying to get out of the draft. In fact, even for non-nerds who disliked what we then called “booking” — has the World Wide Web come up with its own equivalent phrase? — most of the time was spent going to class, studying and sleeping, not “raging” (the word for partying). After all, a lot of students wanted to get into good graduate schools and then fancy jobs. A lot did, and went on to become perhaps the greediest generation in U.S. history.

Mr. O’Neil was wise to have constructed his book at least in part as a novel, letting his imagination and telescoping of events provide a better story for the movies, a business he knows very well. If they do make a film of his story, I’d be interested to see how much of it gives a sense of the more humdrum aspects of college life for middle-to-upper-class late adolescents back then.

Probably not much.  The famous and often hilarious (and even witty) Dartmouth pranks memorialized in "Animal House'' (and Mr. O'Neil describes some corkers, including  a great train robbery of sorts) and the stuff described above offer rich material for a film.

Still, while L.P. Hartley’s line “The past is a foreign country: they do things differently there” is much quoted  people don’t do things as differently as they now might like to think  they did 45 years ago.

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I was working last week in Harrisburg, Pa., the capital of the Keystone State. While that recently bankrupt city has seen better days — for many decades, it was a thriving center of trade and manufacturing and is bounded by rich farmland — many of its old residential and commercial buildings are beautiful, and you get a sense that people in the region very much want the little city to come back.

Greater Harrisburg has more brick and stone houses than you see in New England, where most houses are of wood, but there’s the same sense of an almost European-style settlement pattern, with a tight city center and the countryside close by. More and more people there complain about commuting and some of the gentrification in parts of Harrisburg suggests that a lot of its aging population is getting tired of driving. Indeed, demographics may gradually undo, over the next decade, much of the social and economic damage done by developer-driven sprawl zoning.

And there’s still a lot of boosterism in Harrisburg: The small local airport is proudly called Harrisburg International Airport, with flights to Toronto providing the “international” angle. Perhaps poor little Rhode Island could use a little of what some might slur as Babbitry to help talk itself out of its inferiority complex.

Robert Whitcomb (rwhitcomb51@gmail.com) is a Providence-based editor and writer.