$8,569.27

That was the bill for my wife's hospital stay during and after the delivery of our second child, a daughter, at a major teaching hospital in Washington, DC. It seemed extreme even to us (two family doctors who are used to navigating the byzantine, overpriced health system on behalf of our patients) especially since my daughter was delivered by a nurse midwife, without anesthesia or other drugs, and my wife labored in the hospital for only 2 hours and was discharged after less than 30 hours. Curiously, when we requested an itemized bill, the hospital could only account for $6562.47 of the tab, of which our health insurance (a program for federal employees) ended up paying $4352.32 and we paid $100.

I might use this absolutely true story as an example of the complete lack of transparency and common sense in health care costs, or as a morality tale about greedy hospital executives or cheapskate health insurers. But instead, I'd like to make two other points: 1) You are not the customer. 2) You're subsidizing care for the uninsured already, but in the worst possible way.

What does it mean when I say that you, the patient, are not the customer? For insured people, it means that medical bills are a complex negotiation between insurers and providers of care (hospitals, physicians, outpatient facilities, etc.), where actual costs mean very little to patients. Sure, my wife and I felt our hospital bill (which included mysterious charges such as a separate $163.90 "daily supply charge" on top of the $1115.00 daily room fee and $1074.70 "recovery first 2 hours" when my wife shivered under a cheap blanket, her lunch never arrived, and she ended up lunching on a reheated hamburger I purchased in the hospital cafeteria) was excessive, but what did it matter to us since our insurance was footing all but $100 of the bill? When we, the real consumers of care, are completely disconnected from what that care actually costs, most of us are inevitably tempted to request too much care, which hospitals and physicians are usually happy to provide but which does nothing to improve our health.

The other reality illustrated by our bill is the hospitals, like all medical institutions, already use insurance payments (your money) to subsidize care for the uninsured. When a patient without insurance and no other means to pay comes to the hospital to deliver a baby or in the throes of a heart attack, who pays? You do - in the form of higher insurance premiums that pay for artificially inflated bills.

This is why it makes no sense to advocate for limiting health care to U.S. citizens, or legal immigrants. Illegal immigrants get sick too, and they end up going to U.S. emergency rooms when their health problems become too serious to ignore. The high-risk premature delivery that could have been prevented by routine prenatal care, and the heart attack that could have been prevented by controlling blood pressure and cholesterol levels (which primary care does very well and cheaply, given the opportunity), instead become expensive, catastrophic emergency visits, which are charged to your hospital, and therefore your health insurance, and therefore, you. Immigration policy is an important and divisive issue, but it should be separated from the issue of public health and the health reform debate.

Heroic medicine vs. public health, part II

In the previous post, I described some hypothetical trade-offs that might need to be made in a health system with strictly limited resources, such as the British or Canadian systems, for example. Critics of those systems point out that the beauty of the U.S. system is that we can choose to pour in more resources whenever we want - and indeed, over the past 25 years, we have done just that. Spending on health care now accounts for about 17% of the gross domestic product (GDP), and with new treatments and technologies being added every year, that percentage has only been climbing. Not only do we spend more of our wealth on health care than any other advanced country in the world, since our GDP is far larger than any other country's, we outspend them by almost twice as much ($6600 per U.S. citizen vs. $3800 per French citizen in 2006, for example). Who's paying for that difference? You are, in the form of lower raises in salary and increased cost-sharing.

I've already mentioned many good things that we don't get for these immense amounts of money: free immunizations and other preventive care, primary care physicians for all, etc. But what else would we do with the billions of dollars we currently spend on "heroic medicine," such as inserting cardiac stents into 90 year-olds, keeping comatose patients on dialysis, using feeding tubes and artificial respirators indefinitely in patients with no hope of recovery?

Well, we could build more sidewalks. Or playgrounds. Public parks. Biking paths. These are the sorts of improvements that are designed to improve the public health - to encourage people of all ages to live healthy, physically active lives. In communities with the highest rates of obesity and diabetes, you generally won't find these sorts of improvements. So when certain members of Congress ridicule public health spending as irrelevant to health care reform, I'd like to invite them to take a look at the less touristy parts of my home town of Washington, DC. Let's take a look at the meager options some people have to make healthy life choices. Let them see exactly what they're trading off for the heroic technological interventions that do little to improve the health of my community and yours.

Heroic medicine vs. public health, part I

Grandma Smith is 80 years old, has chronic kidney failure, and requires dialysis three times each week to stay alive - treatment that she doesn't have money to pay for herself. A government-sponsored "death panel" determines that her life isn't worth what it would cost to continue her dialysis. This is the imaginary nightmare scenario that just doesn't seem to go away, even though its basis in the current health reform legislation is flimsy at best. No wonder so many people are outraged! Seen in isolation, this sort of callous decision seems to be emblematic of an unfeeling, bureaucratic health-care system that no sane person could possibly want.

But what if the trade-off for continuing Grandma Smith's dialysis was that we couldn't pay for yearly influenza vaccinations for 10,000 other grandmothers and grandfathers, protecting them from an infection that leads to death from pneumonia in thousands of Americans each year? Or what if paying for her dialysis machine, the technicians to run it, and the doctors to supervise it meant that your children didn't receive antibiotics for tuberculosis, or your community had to make do with inadequate water filtration? Balanced against the health of the public - that is, the health of countless others who are no less deserving - Grandma Smith's treatment begins to seem selfish at best.

Of course, health care isn't a zero-sum game. In fact, when dialysis machines were first invented, there were so few of them to go around that some municipalities formed committees who, much like the mythical Obama "death panels," determined which of their citizens with kidney failure would be able to go on the machine and whom would be left to die. The result was that eligibility for Medicare, which is primarily a government-run insurance program for the elderly, was extended to cover all patient with kidney failure severe enough to require dialysis, regardless of age. As a result, no person in the U.S. today goes wanting for dialysis.

But this is a double-edged sword. During my family medicine residency, I cared for a 45 year-old otherwise completely healthy man who, through an unlucky roll of the genetic dice, suffered catastrophic kidney failure and whose life was certainly saved by immediate access to the Medicare benefit. On the other hand, I've also cared for many other patients with irreversible brain, heart, or lung damage whose kidney failure was clearly part of the process of dying, and whose lives were merely prolonged ("saved" would imply that there was some purpose to continuing treatment) by dialysis while their loved ones avoided meaningful end-of-life discussions.

In my next post, I'll talk about the negative effects that spending on this type of "heroic" medicine has on the public health.

A "radical solution" to the health care crisis

If you have been reading this blog for a while, you may wonder where on the political spectrum I fall regarding health care reform. While I'll decline to reveal my major party affiliation for now to avoid possibly alienating half of you, I can say quite honestly that I consider my views of health care reform to be very non-partisan. What do I mean by this? I think that Democrats are right to believe that any health care system that continues to provide no insurance coverage, even for catastrophic events, to 47 million Americans will never be able to improve quality and control costs. I also agree with Republicans who believe that trusting the government (even though I'm a government employee) to efficiently manage the majority of the nation's health resources is a recipe for failure, and that in some ways government over-regulation of health care has led to unnecessary inflation in costs. On the other hand, I don't think that dumping another $1 trillion into an essentially flawed system will automatically deliver the long-term cost savings that we need, and I disagree with many Republican leaders who seem to feel that their "less government" philosophy means sticking with the status quo (for example, you can't favor less government involvement in health care and at the same time keep Medicare exactly the way it is).

However, until recently I've struggled to articulate a viable third way out of the health care morass. Now I don't have to. In a riveting piece in the Atlantic, titled "How American Health Care Killed My Father," business executive David Goldhill makes a convincing argument for a model of health reform that harnesses the advantages of market incentives while protecting the less fortunate and less wealthy. Far from being "radical," as the teaser paragraph describes it, his proposed solution makes more sense than anything I've yet heard out of the health care debate. Rather than trying to read the thousand-page bills currently winding their way through both houses of Congress, I recommend that you read this article instead to understand what's at stake and why reformers are probably moving in the wrong direction. The sections include:

1. Health Care Isn't Health (Or Happiness)
2. Health Insurance Isn't Health Care
3. The Moral-Hazard Economy
4. There's No One Else to Pay the Bill
5. The Government Is Not Good at Cost Reduction
6. Uncompetitive
7. Our Favored Hospitals
8. You Are Not the Customer
9. The Strange Beast of Health-Care Technology
10. The Limits of "Comprehensive" Health Reform
11. A Way Forward
12. $636,687.75

Goldhill concludes: "But let's forget about money for a moment. Aren't we also likely to get worse care in any system where providers are more accountable to insurance companies and government agencies than to us? ... Let me ask you to consider one more question. Imagine my father's hospital had to present the bill for his "care" not to a government bureaucracy [Medicare], but to my grieving mother. Do you really believe that the hospital - forced to face the victim of its poor service, forced to collect the bill from the real customer - wouldn't have figured out how to make its doctors wash their hands?"

Powerful stuff.

Does one drink a day help keep dementia away?

Although it’s clear that heavy drinking is bad for your health, some studies have suggested that drinking “moderately,” defined as up to two alcoholic beverages per day, may actually improve cognition (thought processing in the brain). In a 2005 study in the New England Journal of Medicine, Dr. Meir Stampfer and colleagues from Harvard Medical School examined the relationship between moderate drinking and measures of brain function in women age 70 years and older.

Women in the study completed six dietary questionnaires between 1980 and 1998, including questions about frequency and type of alcohol use. They were classified into three groups based on average daily alcohol consumption: non-drinkers (55 percent of participants), those who drank up to one drink daily (44 percent), and those who drank one to two drinks per day (5 percent).

Specially trained nurses, who were not given information about the womens’ drinking habits, tested their memory and cognition in telephone interviews between 1995 and 1997. While nondrinkers and women who consumed one to two drinks daily had similar cognitive scores, women who consumed less than one drink daily had higher average scores, and their risk of being classified as cognitively “impaired” was 20 percent less than that of nondrinkers. The type of alcoholic beverage consumed did not affect the results.

Given the impracticality of using alcoholic beverages in a randomized clinical trial, it is unlikely that we will ever know conclusively if any amount of alcohol is good for the mind, and if so, how much. The observational design of this study leaves open the possibility that women with better cognitive scores were more likely to consume moderate amounts of alcohol, rather than the other way around. It would be premature to recommend that women who are nondrinkers start consuming alcohol to prevent dementia. On the other hand, this study suggests that women who drink up to two alcoholic beverages per day will be no worse off, and may possibly fare better, than their nondrinking peers.

**

Note: the above posting is adapted from an article I wrote in the November 1, 2005 issue of American Family Physician.

My first experiences with end-of-life "care"

There's news today that the White House seems ready to strike reimbursement for end-of-life counseling sessions from the health reform bills in order to save it from critics who manipulated the concept into fictitious "death panels" staffed by cold-hearted bureaucrats who would decide "when to pull the plug on Grandma." That's a real shame. I hope that primary care clinicians and others will continue having these discussions with their patients nonetheless, because they are sorely needed - not to save money for the government and private insurers, but because without them, our grandparents (and our parents, and ourselves, for that matter) have little chance to die with dignity. (Strongly recommended reading: How We Die by Sherwin Nuland, a Yale surgeon's sober reflections that will poignantly dispel any myths you may have about how death occurs in the U.S.)

As a medical student, my first experiences with end-of-life care occurred in Bellevue Hospital in New York City, a 150 year-old institution famous for caring for the city's poor and being a rite-of-passage learning experience for generations of medical students. I inserted my first "chest tube" into a man from Thailand who spoke no English and was dying painfully from incurable rectal cancer. After we ran out of sites to place intravenous lines for his medication and intravenous fluids, a 1st year surgical resident inserted a "central line" for access directly into his neck veins, but managed to nick the top of his right lung in the process (a common complication of this procedure). In order to re-inflate his collapsed lung, I used what was essentially a large pair of sterilized pliers to punch through his chest wall (yes, it's almost as painful as it sounds to read) and force in a large plastic tube connected to suction. None of these procedures, incidentally, would have been necessary had this man chosen hospice care instead, but no one had ever bothered to find a translator to talk to him about it. So he lived the last few days of his life, as it turns out, alone and with a tube in his chest.

My second encounter with death was no better. For several weeks during my 4th year, I cared for an elderly woman who was dying slowly from metastatic colon cancer. Surgeons had removed most of her large intestine, but were unable to completely remove the cancer that had spread to her liver and bones. (This type of cancer, by the way, is almost completely preventable with colorectal cancer screening, the topic of a previous blog - but only 53% of eligible adults receive such screening.) After the surgery, her kidneys failed, and her wound healing was so poor that they were unable to close the surgical incision. Day after day I took a scalpel to the outer edges of the incision, carving away blackened, dead tissue; day after day I searched in vain for more sites to draw blood from her battered, bruised veins; and finally resorted to painful arterial punctures to get the laboratory tests that I was told we needed. Unlike my earlier patient, she and her family spoke perfect English; but she was essentially comatose and the family (who filled the sterile hospital room with flowers, balloons, and photos) seemed to never be around when the doctors were at the bedside.

On my last night on call at Bellevue, the inevitable happened - my patient stopped breathing, her heart stopped beating, and having received no orders to the contrary, we attempted to revive her. As I performed CPR for the first time on a real patient, I remember thinking how brittle her bones had become from the cancer, and how easily her ribs shattered under the weight of my chest compressions. The "Code Blue" team, knowing nothing at all about the patient, swarmed into the room, donning gowns and gloves inserting lines into every orifice. As we worked futilely to revive this dying woman, her bowels reflexively emptied one last time, soiling the sterile towels. We worked on her for twenty minutes, and when it was over, the room reeked of blood and urine and feces.

As the only person around who remotely knew the patient, I dutifully made the middle-of-the-night call to give the news to her sons and daughters. They sounded surprised, which shook me, since I understood metastatic cancer as a death sentence (which it is, but no one had explained this to them, they said). Sad to say, these events repeat themselves on a daily basis at hospitals all over America, where end-of-life discussions are pushed aside by misrepresentations, false hopes, and a technologically-driven, unrealistic, never-give-up mindset that pervades our broken health care system. How many medical students and doctors in training are, right now, learning about death this way? Will these be the medical professionals who attend to your loved ones when they reach the ends of their lives? Is this the kind of care you would wish for them?

Information on colorectal cancer screening

If you’re a man or woman over 50, chances are that you’ve been told about the importance of being checked for cancer of the prostate or breast. Finding some types of cancers at early stages (before they cause symptoms) may increase one’s chances of survival with proper treatment. What you may not know is that one in twenty adults will develop colorectal cancer (cancer of the large intestine) during their lifetimes. Even though this cancer is much more preventable through early detection than breast or prostate cancer, 57,000 people in the U.S. die from it every year.

There are three effective methods of screening for colorectal cancer: fecal occult blood testing (checking for microscopic evidence of blood in stool samples applied to specially treated cards), flexible sigmoidoscopy (visualizing the lower one-third of the large intestine), and colonoscopy (visualizing the entire large intestine, a procedure that is usually performed under anesthesia). The U.S. Preventive Services Task Force (USPSTF) recommends that all men and women undergo some form of periodic screening starting at age 50 and continuing until age 75, regardless of risk factors.

But what if you already know that someone else in your family has had colorectal cancer? In a 2005 article in the Annals of Internal Medicine, Dr. Glenn Eisen from the Oregon Health and Science University in Portland and Dr. David Weinberg from the Fox Chase Cancer Center in Philadelphia reviewed recommendations for screening patients with family histories of colorectal cancer and outlined recent developments in screening technologies.

If possible, your doctor will want to find out your affected relative’s age at diagnosis, location and number of lesions found, medical histories of second-degree and distant relatives, and a history of other family cancers. Most experts recommend beginning colorectal cancer screening at age 40 in patients with affected first-degree relatives, or (if earlier) 10 years before the relative’s age at diagnosis. In contrast to the multiple screening options available to average-risk persons, patients with family histories of colorectal cancer should undergo colonoscopy every 5 years. Newer screening technologies such as computed tomographic colonography (also known as “virtual colonoscopy”) and stool DNA testing have recently demonstrated promise but are not considered ready for “prime time” use, and are not covered by most insurance plans.

**

Note: the above posting is adapted from an article I wrote in the March 15, 2006 issue of American Family Physician.

Health care lessons from Astana

The city of Astana, the capital of the former Soviet republic of Kazakhstan, is well known to U.S. professional cycling fans as the team sponsor for Lance Armstrong and his rival Alberto Contador, who won this year's Tour de France. Earlier today I met two earnest physicians from Astana who are in the United States to learn about public health and prevention in order to inform their country's effort to reduce death rates from preventable diseases. Despite obvious differences in size, history, and demographics, the similarities between Kazakhstan and the U.S. in health policy are striking. Like us, they have concluded that promoting healthy behaviors such as smoking cessation, alcohol moderation, diet, and regular physical activity are the keys to improving the long-term health of their population. Like us, they are moving to enact health reforms to ensure that all of their citizens have access to screening tests and other preventive services. And they told us a story that could teach U.S. health care reformers a thing or two.

Several years ago, the government of Kazakhstan decided to made a major investment in modern health care facilities - primarily by expanding specialty clinics and hospitals. They focused on acquiring the most advanced diagnostic and treatment technologies and training specialist physicians in the use of those technologies. The result? Mortality and disease rates remained the same, or rose. Astana's health officials belatedly realized that their neglect of their country's primary care infrastructure made it difficult for people to access care, or have their care coordinated by primary care physicians. To their credit, they have diagnosed the problem and are moving aggressively toward a solution - including reforming their system of medical education to produce greater numbers of primary care physicians. In my opinion, Washington, DC would do well to learn from Astana's example.

Reform primary care first, and health care will follow

I mentioned in an earlier posting that fewer medical students each year are choosing to pursue careers in the primary care specialties (family medicine, general pediatrics, and general internal medicine). The reasons for the decline have been documented in other health-oriented blogs such as KevinMD, and are due to a number of factors, including an increasing income disparity between primary care and specialist incomes, the staggering array of conditions that primary care physicians encounter in a typical day at the office, insufficient funding for primary care residency training programs, and a basic research-centered medical education system that limits students' exposure to real-world community practices.

Most industrialized nations with efficient health care systems have roughly a 1:1 ratio of primary care to specialty physicians. In contrast, in the U.S., specialists outnumber generalists by more than 2 to 1, and with less than 15 percent of U.S. medical students choosing primary care careers in recent years, this imbalance continues to worsen.

As is probably obvious if you've been reading earlier posts in this blog, I very much support some form of health care reform that makes primary care available to all Americans. The current reform bills have all incorporated some variation of proposals advocated by groups such as the American Medical Student Association, including expanding the size of the National Health Service Corps (a program that rewards doctors who practice in rural and underserved areas of the U.S. by subsidizing their tuition or forgiving student loan debt), opening new independent, community-oriented medical schools, and preferentially recruiting college students with an interest in primary care during the medical school application process. All good ideas, but they won't be nearly enough to get us to the goal of 50% primary care physicians that will be needed in a transformed health care system.

Bigger, bolder steps are needed to attract medical students to primary care careers. Kevin Grumbach's post earlier this year in the Health Affairs blog summarizes what these steps - largely financial incentives - need to be. To this list, I add one more. For the past 5 years, I have taught medical students and primary care and preventive medicine residents at two universities where these disciplines are often underemphasized, and where my specialty - the essential cog in the wheel of any high-achieving health system - is openly degraded as not being prestigious enough for the best and brightest students. This perception can and must change before American health care can truly be considered to be "reformed."

Medicine and the not-so-free market

In the health care reform debate, some people argue that the solution to skyrocketing cost of health services is to encourage more "free market" competition to lower prices, rather than expanding public funding and controls. There is some value to this argument; generic drugs, which cost as little as $4 for a 30-day supply at national retailers such as Wal-Mart, Target, CVS, and Giant, have helped to take a bite out of many people's prescription costs.

Unfortunately, most of American medicine does not function like a free market or obey the laws of supply and demand. In an true free market, the supply of MRI machines would correspond to the number of scans that needed to be performed. In fact, MRI machines are huge money-makers for hospitals and radiology practices, which create their own artificial demand. Instead, the maxim uttered by Kevin Costner in "Field of Dreams" (If You Build It, They Will Come) applies. The more MRI scanners there are in a given city, the more MRI scans will be done, regardless of the actual need for this test. Every few days, I get a phone call from a private radiology unit in the DC area to "let you know that we have open appointments for today, just in case you need to refer a patient to us." While I'd like to think that I wouldn't order an MRI for something like back or neck pain unless it was really needed, same-day availability is awfully tempting to physicians and patients. (This also explains why there are so many more MRI machines in the U.S. than there are in Canada. It isn't that they have too few, it's that we have many more than we actually need.)

This practice isn't limited to Radiology, either - for examples of how the availability of procedures drives up costs related to heart procedures, see Atul Gawande's recent piece in the New Yorker. Build a cardiac catheterization laboratory, and more catheterizations will be performed. Build more hospital beds, and more patients will be admitted instead of sent home for treatment. For the past quarter century, a team of researchers at Dartmouth has been using data from Medicare to produce an atlas that documents wide variations in health resource utilization across the U.S. Not only have they found that where you live has everything to do with how much health care you receive, but there is no relationship between cost and quality of that care. So much for the free market!

Who are the uninsured?

If you're a fan of competitive cycling, like I am, you may have read Lance Armstrong's compelling memoir "It's Not About the Bike: My Journey Back to Life." A little-known fact is that soon after being diagnosed with a highly aggressive form of testicular cancer, Armstrong, having recently switched cycling teams, found out that his new sponsor's health insurance would not pay for cancer treatments because they considered his illness to be a pre-existing condition. Even though Armstrong was a wealthy world-class athlete, the cost of these treatments would have nonetheless rapidly depleted his considerable savings. Fortunately for him (and us), a personal appeal to his sponsor resulted in a quick reversal of the decision, permitting Lance to undergo arduous treatment, emerge a survivor, and win the Tour de France 7 straight times from 1999 to 2005 and finish 3rd in a comeback this year to raise awareness for his cancer foundation.

Most uninsured or underinsured Americans aren't so lucky. In contrast to public perceptions that the 47 million uninsured are either unemployed and destitute (and therefore actually eligible for Medicaid) or young, healthy people who choose to be uninsured to save money (see this recent Washington Times editorial), 3 independent national health surveys have found that 2/3rds of the uninsured are employed adults, more than half of whom earn less than 200% of the poverty level (less than $37,620 for a family of four in 2003). For example, although Wal-Mart recently came out in support of an employer mandate to provide health insurance, in 2006 they only provided insurance to 46% of their employees.

Physicians and storytelling, Part II

In 2003, while in my second year of family medicine residency, I wrote a personal statement for a leadership award that described the intertwining of my writing and doctoring ambitions into the occupation of a "physician-storyteller." I didn't win the award, but from my current vantage point, it still resonates. (This is the second of two posts.)
**

One story that I have found particularly compelling during residency is that of patients with HIV/AIDS. In July 2002, I did an elective rotation in Lancaster General Hospital’s Comprehensive Care Center, a Ryan White Care Act supported medical clinic. I was impressed at how the present-day management of HIV had become similar to that of other chronic diseases such as asthma and diabetes. Yet patients sometimes take their life-prolonging prescriptions sporadically or not at all. Curiosity about the reasons for these self-imposed “sustained treatment interruptions” (STIs) prompted me to join a fellow resident and attending in surveying our patients’ understanding of STIs and how it influenced their adherence to complex medication regimens. As part of this project, I personally reviewed the charts of nearly one hundred patients to collect information about past medical and social histories and am now involved in the analysis of this data. We plan to communicate our findings at the next Pennsylvania Academy of Family Physicians Research Day.

The service and research opportunities that I have enjoyed in residency would not have been possible without my program’s unwavering support and flexibility. That flexibility was severely tested during my internship year, when the program endured a crisis of change. The retirement of the only Program Director we had ever known, along with a decline in applications to family practice nationally and new resident work hour regulations, prompted the program’s most significant curricular revisions in a decade. As a member of my residency’s work hours committee, I became a tireless advocate for redesigning the intern schedule in a way that was more humane in terms of post-call duties but preserved the crucial educational value of those on-call nights. At the start of my second year, I and another resident formed an intern support group that meets monthly with a community preceptor to further bolster morale. These changes effectively reduced the burdens placed on current residents and made our program more appealing to prospective applicants. My positive experience in improving the working conditions of my fellow residents encouraged me to run for, and win election to, the position of Chief Resident. This year I’ve tackled several major administrative hurdles: scheduling for a block conference curriculum; developing an emergency plan for inclement weather days; and transitioning from a single continuity office practice to urban and rural tracks.

Of physicians, English professor Brian Ferguson-Avery wrote in JAMA: “Their years among the human animals have shown them futility, sadness, compassion, and the occasional hard-won triumph. As a result, they can better consider the big questions posed – and sometimes answered – in books.” I could not agree more. Although I have just begun my career as a family physician, my experiences in community service and resident leadership have melded with my writing talent to make me a better storyteller to my patients in every chapter of their lives.

Physicians and storytelling, Part I

In 2003, while in my second year of family medicine residency, I wrote a personal statement for a leadership award that described the intertwining of my writing and doctoring ambitions into the occupation of a "physician-storyteller." I didn't win the award, but from my current vantage point, it still resonates. (This is the first of two posts.)

**

I once believed that physicians belonged to just two types: the engineers and the storytellers. Let me explain. Physician-engineers scrutinize the human body and its components and recommend how to improve performance and extend shelf life. Physician-storytellers take a different approach. Instead of using hammers and slide rules, they ply patients with tales of struggles won and lost: for example, Johnnie Walker who couldn’t stay away from the neighborhood bar and died when his liver gave out. In place of diagrams, storytellers pester and cajole until pre-contemplation evolves into action, and they achieve the same – if not better – results.

Of course I now understand that the best kind of physician is both capable and humane. Yet I have always identified with the storyteller. In college, I combined a love of writing with a desire to make a difference in lives that I could not reach with a pen. I threw myself into volunteer work with children of all ages: as a Big Brother to Duy and Phuong, whose family had immigrated from Vietnam two years before; as a teacher at Martin Luther King, Jr. Elementary, where a fellow “ExperiMentor” and I conducted a series of lessons about the science of water; and as an SAT tutor in CHANCE, an after-school program for high school students who aspired to be the first in their families to attend college.

Although these interactions contained their share of inspiring stories, I was also driven to create my own. Along with contributing to an intercollegiate literary magazine, I wrote articles for and eventually served as Editor-in-Chief of the Harvard Science Review, a bi-annual popular science journal. In medical school, I helped to found a creative writing club and literary magazine Agora. During residency, I have taken evening classes in poetry and non-fiction at Elizabethtown College while writing medical articles for Central Penn Parent and American Family Physician.

Family practice called to me because I saw how the discipline’s emphasis on preventive health care allows physicians to shape patients’ life narratives. During medical school, I counseled teenage mothers on the importance of tamper-proof cribs and car safety seats. In addition, I spent Wednesday evenings at the Bellevue men’s shelter teaching residents about smoking and alcohol cessation. I’ve continued preaching the gospel of health maintenance in residency as a volunteer physician at the Water Street Rescue Mission Medical Clinic, where I add a dash of prevention to every spoonful of cough syrup. As a preceptor for a pre-medical program at Franklin and Marshall College, I advise future physicians that real-life medical drama isn’t always acute, and that success can be measured over decades as well as seconds. Last fall I became the program’s co-coordinator.

Why government-run health care can be good for you

Many politicians and television commentators are making "government-run health care" sound like a string of dirty words. I have a different view. To me, government-run health care makes me think about a patient I cared for during my family medicine residency - I'll call him Ed - whom I met while volunteering at a free clinic in Lancaster, PA. Ed was a well-educated man: he had a Masters in Divinity and formerly directed a nonprofit. But at that point he was just beginning to climb out from a disastrous time in his life, having fallen victim to alcohol and heroin addiction and losing his job, home, and family. A few months earlier he learned that he had diabetes, but having no health insurance or primary care doctor, Ed let his sugar level spiral out of control until he was hospitalized in a coma from diabetic ketoacidosis, an often fatal condition when the body's metabolism, unable to turn sugar into fuel, produces waste products that dangerously acidify the blood. Fortunately, doctors were able to reverse the process in time, and Ed pulled through.

Ed arrived at the clinic for his post-hospital follow-up visit the night I happened to be volunteering. I almost couldn't believe my eyes as I reviewed the laboratory results and hospital records he brought with him. He was lucky to be alive. Unfortunately, he had been prescribed several medications that, having virtually no income and living in a homeless shelter, he couldn't possibly afford. The clinic stocked some donated medications, but not nearly enough to supply Ed's needs for more than a few days - after which his diabetes would inevitably worsen until he would be back in the hospital again, or worse. Through a social worker at our hospital, I helped Ed apply for Pennsylvania Medicaid (health insurance administered by state governments with federal government subsidies), and was able to see him in my regular office.

I cared for Ed for nearly 2 years. During that time, we not only controlled his diabetes, but he was able to get back on his feet emotionally, spiritually, and financially, eventually moving into his own apartment and holding down a paying job as a counselor. That's what "government-run health care" can do. And if you're thinking that you'll never be stuck in a situation similar to Ed's, I'd ask you to consider what you would do if you suddenly lost your job, if you were disabled in an accident, or some other financial catastrophe happened to your immediate family or friends. The "safety net" isn't enough. Several national organizations representing primary care physicians recently came to the same conclusion; you can see their powerful message on the website Heal Health Care Now.