What is it like to be a leader with every major health organization in Buffalo? A person to ask would be Dr. Margaret Paroski. A neurologist by training, Paroski started at the VA Medical Center, followed by the Buffalo Psychiatric Center, Roswell Park Cancer Institute, Kaleida Health and Erie County Medical Center, all while serving as a faculty member at the University at Buffalo School of Medicine. As she celebrates 40 years in medicine, Paroski has taken on a new challenge: Chief Medical Officer for Catholic Health Partners.
"At the end of the day, the heart of health care is going to be the doctor and the patient sitting down and talking to each other, and I don't think anything is ever going to replace that," Paroski said.
With nearly 1,000 physicians, Catholic Medical Partners is the largest practice association in the area. Paroski said CMP is trying to get patients better coordinated care in whichever practice works best for physicians.
"One of my priorities is getting to meet all the practitioners that CMP represents and say to them, 'What are the biggest challenges that you're facing? What are the things we can help you with?'" she said. "Studies have actually shown that physicians in private practice are happier because they value autonomy, and one of the things that CMP wants to do is preserve that choice."
Today a patient can receive care in a primary doctor's office, a specialist's office, an Emergency Room or as an inpatient, and if there is no "warm hand-off" and coordination among the caregivers, it creates more problems.
"There are so many handoffs in health care now that you don't have your one doctor who took care of you as an outpatient, that took care of you as an inpatient and basically was on-call 24/7," she said. "Now it's multiple physicians that are seeing you. If they don't communicate effectively, that's where mistakes get made."
So she is looking at things like new electronic medical record software that would flag gaps in care, like screenings that need to be done; contracting with pharmacists who can help manage at-risk patients, like those on multiple medications; while serving a new patent population that seems to want everything now.
"It used to be when a patient had a question, they called in. You wrote it down on a little pink slip of paper and we got back to you in a couple of days when we had time to chat," Paroski said. "Now patients are inputting something in a patient portal and are annoyed when they don't get something back in 15 minutes."
Another area Paroski expects more focus is telemedicine. She said a lot of times patients need to speak with a provider to manage their condition, but an in-office appointment is not necessary or possible. She said even older patients are technology-savvy enough these days.
"Even us grandparents know how to FaceTime our grandchildren. You master those basic techniques and I think we'll be seeing a lot more telemedicine practiced and a lot more effectively than it has been in the past," she said.
Health care was not as technology-based when Paroski entered medical school 40 years ago, and women made up only a third of her class.
"We were still breaking ground, but my mother-in-law, Jackie Paroski, had graduated in 1949, when there were only four women in the class, so the saying, 'You've come a long way baby' seemed to be there for us in the '70s," she said. "They were far less politically correct, though, so you had to get used to the male attendings calling you 'honey' or 'sweetie.' Many of my colleagues were outraged at that, but I used to say, 'Oh, no, my name is cupcake' and they realized, 'Oh, wait a minute. I shouldn't be talking like that.'"
Paroski interviewed for her residency when she was eight months pregnant with her daughter, in an era when there were no work-hour rules for residents and interviewers could ask lots of questions that are no longer legal.
"On one interview, the first words out of the interviewer's mouth were, 'You're not gonna do that again, are you?'" she said.
She informed the male interviewer she was planning to have more children and ended up taking a different residency, at UB, where the Chairman of the program said nothing about her "glaring pregnancy."
"He said, 'Young lady, you can drop a kid every nine months for all I care, just show up for work' - and he was true to your word," Paroski said. "I would be walking out with a wash basin full of bottles of breast milk. The world was not particularly supportive of nursing mothers in medicine at that time."
Her mother-in-law served as a role model, as did her father. They were both physicians. She said that type of support system "made a huge difference." Even while splitting her time at the VA and ECMC, women were in the minority of administrators.
"But I was one of those folks when I didn't see something done the way I thought it could best be done, I tended to be quite vocal about it, and when you open your mouth, I ended up being volunteered for things," she said.
"So without consciously going after administrative positions, I found people were willing to give me the job if I was willing to put in the work hours."
That also applied at the Psych Center, at the time a 650-bed inpatient facility that had been cited for quality of care issues. Paroski said it had a lot of psychiatrists, but not much of a Department of Medicine. Paroski was one of the people brought in to better the situation.
To help round out the Department of Medicine, she brought in her father, a cardiologist and Chief Medical Officer at the now-closed St. Francis Hospital.
"So I ended up being my father's boss, which was pretty sweet," she said. "It was great to have the roles reversed!"
The VA, at the time, was a huge inpatient facility, as well. Paroski said neurology, alone, took up about 40 beds and it was a very different time for what was allowed as an admission.
"We used to be able to admit people for malaise and keep them for 14 days. Now the hospital experience is very concentrated and most of the people in the hospital are really sick," she said. "The level of acuity of how sick people are in the hospital now is just overwhelming."
Paroski said physicians are always trying to predict who will be the next really sick people, to hopefully prevent conditions like hypertension and diabetes from progressing into more serious illnesses.
"U.S. health care has become phenonenally expensive and you can't spend the same dollar twice, so it's important that we utilize the healthcare dollars we have in the most efficient and effective way," she said.
One issue getting a lot of health care's attention these days is opiates.
Paroski said the Opioid Epidemic meant doctors had to take another look at their prescription habits. New York State also stepped in to require every prescription for a controlled substance be verified through the I-STOP monitoring system, limit the number of pills allowed in a first prescription and require physicians take a three-hour training course on opiates management
"So a lot of this is out of the hands of the individual practitioner, but I think that we are trying to be very responsible in our prescribing habits with this new information," she said, "and we have to be sensitive to the fact that we have a whole group of people with chronic pain who are on opiates and you can't just say, 'Oh, we're not gonna prescribe them for you anymore.' You have to either responsibly transition people to another medicine for their chronic pain or work with them to stay on their opiates responsibly."
Some doctors will not prescribe the drugs because they are just too much hassle. The same goes for medical marijuana. Within CMP, Paroski said DENT Neurologic Institute is a leader in Upstate New York. It manages some 7,000 patients on medical marijuana, but there is still much more research to be done: on its effectiveness and side effects.
"When thalidomide came out many years ago and women took it for morning sickness, it took them four years to figure out that that drug was linked to babies being born without arms," she said. "If something that obvious took that long to figure out, you can imagine how many years it's going to be when we really know what medical marijuana does or doesn't do."
She said physicians also need extra help managing high-risk patients, especially as Erie County's population is one of the oldest in the United States.
"We're also looking at getting our members a service that has pharmacists that will help manage high-risk patients that have 10 different prescriptions, to look at whether we can reduce the number of drugs that they're on, help us manage drug interactions, help us manage patient compliance with medications," Paroski said. "It really does take a village to take care of a patient these days."
All this is taking place within a society that seems to want everything right now.
"It used to be when a patient had a question, they called in. You wrote it down on a little pink piece of paper and we got back to you in a couple of days when we had time to chat," she said. "Now patients are inputting something in a patient portal and are annoyed when they don't get something back in 15 minutes."
Paroski said that demand of "wanting it now" has led to tremendous use of emergency rooms, when an ailment would be better and less expensively addressed by a primary physician.
"A lot of people come to the ER because they don't have a doctor or don't know where else to go, but honestly, the ER utilizers more often turn out to be the people who have a physician. They're coming during hours when their own primary doc would be available," she said, "and when you ask them, 'Why are you coming to the Emergency Room?' the two answers we most commonly hear are 'Because I can pick what time I go' and the other thing is the Emergency Room is one-stop shopping."
Otherwise, one doctor could order blood work, but the patient has to go somewhere else to get it drawn, she said. A CT or MRI may be ordered, so an appointment at another facility has to be made for that - after the test is approved by the patient's health insurance, of course. Then there is the wait for the results and perhaps making another appointment to get them.
"So I've had many a patient say to me, 'I go to the ER. I get everything done at once and I'm done and I don't have to get all these insurance authorizations,'" she said. "I think if insurance companies made it easier to get the care without the preauthorization, they might not be going to the Emergency Room as often. Most physicians would like to be the ones making the medical decisions."
If physicians have difficulty navigating through all this, what advice would Paroski give patients? She said the only thing that can be guaranteed in health care is change.
"The best advice I can give a patient is to take responsibility for your own health. Go and see your doctor, get all your preventative care. If there are areas of lifestyle that you have control over, that you can modify to decrease the severity of a disease or your risk of getting a disease, take ownership," she said, "and then partner with your doctor if you do have an illness, so that you're taking the most responsible care of yourself. All of us can meaningfully impact our health care and it's important that we do."