I took creative writing courses throughout medical school and during my 3-year residency in family medicine. Although these often provided a much-needed outlet from the stress and intensity of long days and nights spent in one hospital or another, paradoxically I usually ended up writing about patients I'd met, or how I felt about doctoring in general. I wrote the following reflections during a creative non-fiction class that I took at Elizabethtown College (PA) in the spring of 2003.
**
Lancaster General Hospital doesn’t stand out from the air. Looking down from a twin-engine Cessna taking off from the Smoketown Airport on the outskirts of Pennsylvania’s Amish Country, the most noticeable features are the farms, the country roads connecting them, and a hundred or more churches. One might still imagine a midwife going from house to house delivering babies with nothing more than clean towels and a basin of water, or even (in the not-so-distant past) the old-time family doctor with his black bag of tools and potions.
My mother gave me one of those shiny black bags after my medical school graduation. The most I can say is that I’ve used it as a carry-on for weekend trips. Not once have I taken it to see a patient. But I did hold one of these bags years ago, from a retired mentor who had inscribed his initials on the gold-plated clasp. The leather was worn through in several places, and it smelled quite old and promised magic inside. The contents – a stethoscope, reflex hammer, tuning fork, and blood pressure cuff – were disappointingly standard, and the thermometer was electronic rather than mercury. The bag seemed to imply that there was no room in medicine for nostalgia.
Modern-day medicine is often hidden behind layers of technology and increasingly sophisticated ways of diagnosing patients’ ills without actually having to touch them. The other day I read a newspaper story about a robot “virtual” doctor who makes rounds with a physician assistant, wheeling into and out of rooms with a video screen showing the real doctor, hundreds of miles or more away. This, the author implied, is progress. The story also quoted a physician’s prediction that robots would “transform the delivery of medical care.” He went on to compare the efficiency of the traditional “laying on of hands” to a gas-guzzling 1950s Chevy.
We doctors are trained from day one to create and maintain the illusion that all of medicine is an organized enterprise, from the numbers of specialists assigned a case to the technology purchased and utilized, to every order we write and action we take.
It’s not. Usually, it’s chaos and disharmony and waste. ...
**
... which is why we need health reform now!
Saturday, September 26, 2009
Wednesday, September 23, 2009
Health care for illegal immigrants
Pay a little now, or a lot later. It's that simple. In a previous blog post about irrational health care bills, I wrote:
"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."
Unfortunately, it appears that the only issue in health care reform that both liberals and conservatives actually agree on is that illegal immigrants should be excluded from coverage. This is a terrible mistake, regardless of one's political or ideological leanings. If we hope to ever stop undocumented workers from using hospital emergency rooms as their primary source of (overpriced, poorly coordinated) primary care, then every person living in the U.S. must have access to an affordable family physician under health care reform. (Notice that I wrote affordable, not free.)
A recent article in Newsweek argues that insuring illegal immigrants could actually drive down the cost of medical premiums, since this population is typically younger and has fewer chronic medical problems than American citizens. Also, requiring all workers to be insured regardless of immigration status would reduce or eliminate the income disparity that currently makes it attractive to hire undocumented immigrants, rather than citizens, for certain jobs.
Yes, Rep. Joe Wilson is an idiot, but I actually hope he was right - health reform will be better off if President Obama was lying about illegal immigrants not being included in health care reform.
"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."
Unfortunately, it appears that the only issue in health care reform that both liberals and conservatives actually agree on is that illegal immigrants should be excluded from coverage. This is a terrible mistake, regardless of one's political or ideological leanings. If we hope to ever stop undocumented workers from using hospital emergency rooms as their primary source of (overpriced, poorly coordinated) primary care, then every person living in the U.S. must have access to an affordable family physician under health care reform. (Notice that I wrote affordable, not free.)
A recent article in Newsweek argues that insuring illegal immigrants could actually drive down the cost of medical premiums, since this population is typically younger and has fewer chronic medical problems than American citizens. Also, requiring all workers to be insured regardless of immigration status would reduce or eliminate the income disparity that currently makes it attractive to hire undocumented immigrants, rather than citizens, for certain jobs.
Yes, Rep. Joe Wilson is an idiot, but I actually hope he was right - health reform will be better off if President Obama was lying about illegal immigrants not being included in health care reform.
Monday, September 21, 2009
Primary care: no next generation?
My wife and I are both family physicians, 9 and 8 years out from medical school graduation, respectively. Principal and interest payments on our remaining combined six-figure student loan debt consume about 5% of our pre-tax income each year, and at our current rate of repayment, we could still be paying off this debt when our oldest child starts college. But after attending my alma mater's annual Alumni brunch in Washington, DC recently, I realized that today's future family physicians are much worse off than we are.
Consider these figures from a follow-up solicitation letter for scholarship donations: "Among the 155 members of the Class of 2008, 78 percent graduated with an average debt load of nearly $143,000. 18 percent graduated with a debt load that exceeded $200,000." These figures are hardly atypical for most private (and some public) medical schools. Given these grim numbers, it's a wonder that any medical students choose careers in primary care - the lowest-paid specialties being general pediatrics, family medicine, and general internal medicine.
In a 2008 letter published in the Journal of the American Medical Association, family physician-educator Mark Ebell, MD, MS demonstrated a near-linear association between median income and the percentage of U.S. senior medical students who entered a medical speciality - put simply, students go where the money is. And given their increasingly staggering debt loads, who can really blame them?
Consider these figures from a follow-up solicitation letter for scholarship donations: "Among the 155 members of the Class of 2008, 78 percent graduated with an average debt load of nearly $143,000. 18 percent graduated with a debt load that exceeded $200,000." These figures are hardly atypical for most private (and some public) medical schools. Given these grim numbers, it's a wonder that any medical students choose careers in primary care - the lowest-paid specialties being general pediatrics, family medicine, and general internal medicine.
In a 2008 letter published in the Journal of the American Medical Association, family physician-educator Mark Ebell, MD, MS demonstrated a near-linear association between median income and the percentage of U.S. senior medical students who entered a medical speciality - put simply, students go where the money is. And given their increasingly staggering debt loads, who can really blame them?
That's why I was excited to hear that the recently established University of Central Florida College of Medicine awarded full scholarships to its entire inaugural class of 41 students. Other schools may soon follow suit. Not surprisingly, UCF was the most selective medical school in the country this year. But will the absence of student loan debt result in this school ultimately training more primary care physicians? Only time will tell.
Does the type of birth affect postpartum health?
My first child was born surgically via cesarean section, while my second arrived naturally by what maternity care providers call a “normal spontaneous vaginal delivery.” Surgical deliveries are rapidly becoming the norm rather than the exception in the U.S., reaching a record high of 31.8 percent of all births in 2007 (the 11th consecutive year that this percentage has increased). In most communities, trials of labor after a previous cesarean delivery are actively discouraged, even though 76% of women who attempt them (including my wife) have successful vaginal births.
The rising number of surgical deliveries is troubling, given that more than three-quarters of first-time mothers in the United States who are employed during pregnancy will return to the workforce within their infant’s first year of life. In a 2006 study in the Annals of Family Medicine, Dr. Pat McGovern and her colleagues at the University of Minnesota reported the relationship between delivery type and measures of postpartum health 5 weeks after childbirth.
Participants were 817 employed women who gave birth to single healthy infants at one of three Minneapolis-St. Paul community hospitals in 2001. Study personnel telephoned each woman to conduct an interview that lasted approximately 45 minutes. The interviews assessed overall physical and mental health as well as typical postpartum symptoms, including fatigue, decreased interest in sex, back and neck pain, constipation, hemorrhoids, and appetite problems.
The authors found that women who delivered by cesarean section reported significantly worse physical health 5 weeks after birth than women who delivered vaginally, although mental health scores were similar between the two groups. This is important to know, since while surgical deliveries aren’t always avoidable, there are some simple things that a woman can do to reduce her risk (such as asking her obstetrician, family physician, or midwife what the practice's average c-section rate is and their most common reasons for doing one). If you want more information, I refer you to a website that pulls no punches with the facts about how to avoid an unnecessary cesarean.
**
Note: the above post is adapted from an article I wrote in the August 15, 2006 issue of American Family Physician.
The rising number of surgical deliveries is troubling, given that more than three-quarters of first-time mothers in the United States who are employed during pregnancy will return to the workforce within their infant’s first year of life. In a 2006 study in the Annals of Family Medicine, Dr. Pat McGovern and her colleagues at the University of Minnesota reported the relationship between delivery type and measures of postpartum health 5 weeks after childbirth.
Participants were 817 employed women who gave birth to single healthy infants at one of three Minneapolis-St. Paul community hospitals in 2001. Study personnel telephoned each woman to conduct an interview that lasted approximately 45 minutes. The interviews assessed overall physical and mental health as well as typical postpartum symptoms, including fatigue, decreased interest in sex, back and neck pain, constipation, hemorrhoids, and appetite problems.
The authors found that women who delivered by cesarean section reported significantly worse physical health 5 weeks after birth than women who delivered vaginally, although mental health scores were similar between the two groups. This is important to know, since while surgical deliveries aren’t always avoidable, there are some simple things that a woman can do to reduce her risk (such as asking her obstetrician, family physician, or midwife what the practice's average c-section rate is and their most common reasons for doing one). If you want more information, I refer you to a website that pulls no punches with the facts about how to avoid an unnecessary cesarean.
**
Note: the above post is adapted from an article I wrote in the August 15, 2006 issue of American Family Physician.
Saturday, September 19, 2009
Health and tort reform: it's not about saving money
Many good ideas that have been around for years have benefited from being included under the banner of health reform. However, the recent focus on the cost of reform has made it seem that only ideas that are guaranteed to save money are worth including in a comprehensive overhaul of the system. Viewed in this light, if critics of reform can make the argument that an idea isn't cost-saving, it should be discarded.
Frankly, that's one of the stupidest arguments I've ever heard. Almost everything worth doing in health care costs money. If our top priority is saving money, we should hand out free cigarettes and alcohol to minors and remove seat belts and airbags from cars, because early deaths from cancer, heart disease, and automobile fatalities would save the health care system billions of dollars in health care expenses for seniors in the long run!
As Dr. Steven H. Woolf of Virginia Commonwealth University argues in an excellent policy paper for the nonprofit group Partnership for Prevention, health reforms should emphasize interventions that provide good value, rather than cost savings. Mammograms and Pap smears don't save money (because most women do not have breast cancer or cervical cancer), but our society generally regards the prevention of late complications of breast and cervical cancer to be a good thing. Gym memberships and healthy food choices cost money, but since exercise and healthy eating prevent heart attacks in some people, most would agree that those costs are worthwhile.
Another good idea that's been taking a beating recently is tort reform, or putting limits on malpractice lawsuits that drive up the price of malpractice insurance, drive up overall medical costs through doctors who practice defensive (or in some circles, CYA) medicine by ordering unnecessary tests and procedures, and in some states have led to an exodus of specialists in high-lawsuit areas such as obstetrics and neurosurgery. Yet recent newspaper articles have asserted that enacting tort reforms would be unlikely to save significant health care dollars.
Although I think this point is debatable, it's another case where the answer really doesn't matter. Tort reform is a good idea, whether it saves money or not. It is ridiculous that the only way that a patient (or grieving family member) can obtain money to provide for someone crippled by a bad health outcome is to sue the doctor, whether or not the doctor was "at fault" or not. As a result, the vast majority (greater than 90 percent) of patients who probably deserve compensation for medical errors never see a dime, and those who do receive compensation after years of litigation end up giving much of what they win to their lawyers.
Health reform would benefit greatly from including tort reforms modeled on existing no-fault compensation programs, such as the National Vaccine Injury Compensation Program or the Virginia Birth-Related Neurological Injury Compensation Program. That way, patients who suffer medical misfortune would get the funds they needed for care, good doctors who made mistakes would be able to apologize without fear of a lawsuit, and aggressive malpractice attorneys would get exactly what they deserved: nothing.
Frankly, that's one of the stupidest arguments I've ever heard. Almost everything worth doing in health care costs money. If our top priority is saving money, we should hand out free cigarettes and alcohol to minors and remove seat belts and airbags from cars, because early deaths from cancer, heart disease, and automobile fatalities would save the health care system billions of dollars in health care expenses for seniors in the long run!
As Dr. Steven H. Woolf of Virginia Commonwealth University argues in an excellent policy paper for the nonprofit group Partnership for Prevention, health reforms should emphasize interventions that provide good value, rather than cost savings. Mammograms and Pap smears don't save money (because most women do not have breast cancer or cervical cancer), but our society generally regards the prevention of late complications of breast and cervical cancer to be a good thing. Gym memberships and healthy food choices cost money, but since exercise and healthy eating prevent heart attacks in some people, most would agree that those costs are worthwhile.
Another good idea that's been taking a beating recently is tort reform, or putting limits on malpractice lawsuits that drive up the price of malpractice insurance, drive up overall medical costs through doctors who practice defensive (or in some circles, CYA) medicine by ordering unnecessary tests and procedures, and in some states have led to an exodus of specialists in high-lawsuit areas such as obstetrics and neurosurgery. Yet recent newspaper articles have asserted that enacting tort reforms would be unlikely to save significant health care dollars.
Although I think this point is debatable, it's another case where the answer really doesn't matter. Tort reform is a good idea, whether it saves money or not. It is ridiculous that the only way that a patient (or grieving family member) can obtain money to provide for someone crippled by a bad health outcome is to sue the doctor, whether or not the doctor was "at fault" or not. As a result, the vast majority (greater than 90 percent) of patients who probably deserve compensation for medical errors never see a dime, and those who do receive compensation after years of litigation end up giving much of what they win to their lawyers.
Health reform would benefit greatly from including tort reforms modeled on existing no-fault compensation programs, such as the National Vaccine Injury Compensation Program or the Virginia Birth-Related Neurological Injury Compensation Program. That way, patients who suffer medical misfortune would get the funds they needed for care, good doctors who made mistakes would be able to apologize without fear of a lawsuit, and aggressive malpractice attorneys would get exactly what they deserved: nothing.
Thursday, September 17, 2009
The "single payer" should be you
When some people say that the U.S. should have a "single payer" health care system, they're generally talking about a system in which government is the exclusive payer of all health care bills. It's tempting to think that in such a system, the money comes from some magic place in the sky, but of course, it ultimately would come from higher payroll or other taxes.
If you take a broad perspective, though the U.S. already has multiple forms of single payer systems. Medicare and Medicaid and the Veterans' Health Administration provide health services that are directly funded by taxpayers. Employer-based and individual health insurers collect premiums from employers, employees, and individuals to create large pools of money that pay the health care bills of their members. In all of these cases, the "single payer" is, ultimately, you.
The trouble with all of these systems is that much of your payments (up to 40 percent in some cases) pay for administrative costs rather than actual health care services. But what if there was a way to cut out the middle men? The Seattle-based practice Qliance Primary Care has developed one innovative solution - charging a flat monthly fee for the full spectrum of primary care services. The practice offers "same or next-day appointments for urgent care, unhurried 30 to 60 minute office visits, 24 hour phone and email access to a physician and the convenience and cost savings of an on-site x-ray, laboratory and 'first-fill' prescription drug dispensary."
Previous medical groups that utilized this business model often charged exorbitant fees, leading critics to label them "boutique" or "concierge" medicine, available only to the wealthy. In contrast, Qliance's fees are quite affordable: from $49 to $79 per month. This fee, combined with a catastrophic health insurance policy to protect against unexpected ER visits or hospitalizations, is significantly less expensive than traditional insurance policies - which makes sense, since 100 percent of payments go directly to the practice rather than being filtered through insurance bureaucrats.
So why aren't there more advocates for a "single payer" health system in which the single payer is you?
If you take a broad perspective, though the U.S. already has multiple forms of single payer systems. Medicare and Medicaid and the Veterans' Health Administration provide health services that are directly funded by taxpayers. Employer-based and individual health insurers collect premiums from employers, employees, and individuals to create large pools of money that pay the health care bills of their members. In all of these cases, the "single payer" is, ultimately, you.
The trouble with all of these systems is that much of your payments (up to 40 percent in some cases) pay for administrative costs rather than actual health care services. But what if there was a way to cut out the middle men? The Seattle-based practice Qliance Primary Care has developed one innovative solution - charging a flat monthly fee for the full spectrum of primary care services. The practice offers "same or next-day appointments for urgent care, unhurried 30 to 60 minute office visits, 24 hour phone and email access to a physician and the convenience and cost savings of an on-site x-ray, laboratory and 'first-fill' prescription drug dispensary."
Previous medical groups that utilized this business model often charged exorbitant fees, leading critics to label them "boutique" or "concierge" medicine, available only to the wealthy. In contrast, Qliance's fees are quite affordable: from $49 to $79 per month. This fee, combined with a catastrophic health insurance policy to protect against unexpected ER visits or hospitalizations, is significantly less expensive than traditional insurance policies - which makes sense, since 100 percent of payments go directly to the practice rather than being filtered through insurance bureaucrats.
So why aren't there more advocates for a "single payer" health system in which the single payer is you?
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