Healthcare Reform

Sigh. I guess it's time to finally say something about this circus. About this distraction. About healthcare 'reform'.

The biggest thing I can say is that we're missing the point completely. The death panel debate is inane and shockingly uninformed and offensive, but it's really a shell game in front of closed-door deals that signal the true agenda of this bill and 'reform': window dressing for business as usual.

Obama, for all his rhetoric, looks to have sold the public down the river in order to mollify the big contributors, including for-profit hospitals, the insurance agency, and big pharma. How can I say this? Well, it seems obvious that he's agreed to limit contributions from the big players as covered by the NY Times and others. Now, conveniently the dialogue has shifted to co-ops instead of a public option; the 'death panel' idea has been dropped. The talk is about taxing health benefits, requiring people to buy insurance, and avoiding forcing drug companies into concessions on what they charge Medicare, all in the name of 'personal freedom'. These are all shifts away from what he said on the campaign trail, and away from meaningful reform.

The real show is going on behind closed doors. And if you're not outraged at that as a citizen you're missing the point. The big dogs are off making the real deal while we're busy yelling at each other like morons in 'town hall meetings'.

The real discussion needs to occur about the possibility of a single-payer, government run system. Unfortunately, with so much money and profit wrapped up in both politics and all aspects of media, it'll never happen. Does that help me as a doctor? Sort of. I'll keep making a higher salary, but I'll also be little more than a profit engine for corporations providing health care struggling to actually take care of patients. We'll still have uneven distribution of outcomes based on socioeconomic status, the CEOs of insurance companies and pharmaceutical companies and hospitals will still make enormous profits, and the president will get his speech. But, overall, very, very little will actually change except you'll be forced to buy crappy insurance.

What actually needs to happen is to get the monied interests out of the back conference rooms of the white house, and out of congress, and out of politics. When John Adams made his way to the continental congress before we were even a country, he had to do it for free, and he had to close down his law practice to do it. He did it because he loved his country, not for the bennies (which, for current congressmen and women, includes a great health care plan. Notice how they're not talking about giving that up). It's all about campaign finance reform and lobby reform, not health insurance.

Rat Poison

He finishes dinner with his wife, the first they've had in weeks as he's recovered from hospitalization. Both feel better. Renewed. Maybe a bit hopeful. His balance isn't what it used to be, he's still tired, unsteady at times. Weaker than he was. She finishes the dishes while he, complaining of being tired, heads for bed upstairs.

On the third step, he remembers something and, naturally, turns to go back down. His balance, though. Not what it used to be. He falls the three steps, foreward into the foyer. And weak; doesn't catch himself. His nose bleeds. And bleeds. Bleeds even after she holds pressure and calls 911, bleeds to the hospital. Bleeds with anterior packing.

By the time he stops bleeding with a postieror pack, he's intubated; mental status, airway protection, and all that. Multiple facial fractures are found. He's admitted to the ICU for a hopefully swift recovery. Opacity at the base of his lung is watched; perhaps he breathed blood. Hard to say.

By day 3 or 4, it's not hard to say. The lung fills in, the tube stays after the packing does. He spikes fevers. He doesn't wake up. Now 4 to 5 days without nutrition, fractured, infected, a tired body, issues layering on each other.

His wife knows that he wouldn't want all of this. Wouldn't want the tracheostomy, the feeding tube, the supportive care to see if he comes out of it. That's were we were. Stuck. Or, not stuck, because the family was sure of his wishes, and all of them agreed.

The Navy man who drove the boats for the landing on Guadalcanal had care withdrawn on the 4th of July. How terrible, you may opine. How macabre. But. The monitors were shut off. The tubes removed. His sons and daughter were there. His wife was there. They held his yellowed, bruised cool hands. Draped in a home blanket. They spoke to him, and we shut the door and the curtains, watching the monitor still on outside slow, and become more and more shallow until they stopped.

This is the situation the supposed 'death panels' were for. It was as good a death as we could offer for a good man. No bureaucrat showed up and told us we had to let grandpa die, nor would they if we had kept the 'death panels'. The family happened to know what he wanted, and because of that, we could let him go. What if they had been gone? What if they had disagreed? Weeks and months could pass, hooked up to machines and tubes, sustained, exactly as he didn't want to be maintained.

It's terrible when anyone dies. It's worse when they are treated with guesses as to their wishes. No one deserves guesses like that. The family is often asked to 'guess' what they might have wanted. Imagine, having to feel as though your decision will either end the person's life or lead to a full code and then the end of their life, not knowing if they wanted to leave quietly, or fighting to the last.

Pearls Before Swine

Which is more--twenty or thirty thousand, or fifty-nine?

The first is the approximate number of deaths over the last few years, per year, from 'influenza and pneumonia', one of the top ten killers in the country. The second, of course, is the number of deaths from the virus formerly known as swine flu, now known as H1N1 flu, which, though unreported, is also the antigen configuration that makes up a goodly portion of the seasonal flu. Now, I'm no public health guru, I'm just a simple resident. Somehow, though, those numbers call recent calls for global action into question just a tad.

We all love a crisis. Me more than most, apparently, since I picked a job where 'crisis' is part of the daily routine. We're good at it; we can pick a discrete enemy to fight.

I must say, though, that the reaction to this pandemic has been just a trifle ludicrous. Fifty-nine deaths? Really? Schools closed, flights diverted, billions of dollars, for fifty-nine deaths?

Not to mention the ED overload with people spreading whatever other gunk they had to each other in order to get tested for swine flu. Awesome. Sterling.

The public health departments actually did the job they were supposed to. They performed surveillance on a new threat and quickly tried to characterize it's mortality rate and epidemiologic characteristics. This work has to, by nature, be paranoid. It's the job of those of us watching and interpreting to avoid mass hysteria, and in this, we failed. I blame mostly the media, frankly, and Joe Biden for good measure as a proxy for elected leaders.

Oh, there's a new virus? Let's cover it for ten minutes of every hour of every day for weeks on end, close schools with no cases, and generally freak out as if the world is ending and make sure people know it COULD HAPPEN TO YOU AT ANY SECOND, especially if you happen to have Mexicans in your neighborhood or even in your time zone. Oh, wait, that's all of us.

Where are all these people for the ongoing threats we have to face on a daily basis? Where's the call for clean water worldwide? Where's the call for increased flu vaccination coverage, which is almost always woefully abysmal? Where's the call to stop diarrhea? Where's the call to actually, shock, have a helmet law or make drunk driving illegal to reduce accidents (no, it really isn't illegal, first time, in some midwestern states. It's a citation). Hmmm, must be too busy spraying down the playground equipment with powerful cleansing agents, because that will somehow stop the kids from sneezing on each other when they come back.

Seriously. Hissy-fit extraordinaire.

Non-Compliance

We have a guy right now that's got it all figured out. He has heart failure, and some sort of cardiomyopathy that keeps his heart from pumping well, and in order to treat this, we need to help him remove more fluid than he takes in, preferably rather quickly so he can re-equilabrate. Simple, right? So why does he roam the halls at night drinking tons of water from outside his room and stealing other people's food?

On the surface, it would seem mad, but deep down it displays the hallmarks not of madness but of mad genius. Each time someone tells him to be compliant, he says, oh, yes, I know, bless you, I'll do better. And then each night he goes and drinks more. A styrofoam cup filled with hospital ice here, someone's leftover milk carton there.

You see, if he's in the hospital, he has free TV, a comfortable bed with housekeeping, a nurse to help him take care of everything, and he gets to stay away from work because he has a decompensation of a serious medical problem. It's a five-star hotel with a craftmatic adjustable bed and an on-demand minibar of narcs.

The team this morning noted, accurately, that even if we discharge him he'll be back in the ED in a couple days 'feeling puffy' and wanting admission, so if we kick him out, he just becomes a problem a few days later for someone else.

Where's our out? Here's the mad genius part. He never openly defies anyone, and he never asks to leave. He says he wants to get better. This takes away the option of letting him leave against medical advice, one out for a troublesome patient. But he doesn't want to leave.

He's always pleasant to the attending and usually to the resident, and always agrees that his health is important, and that he has to save his urine so we can measure it and comply with the fluid restrictions ordered. Thus, we have no options we normally have with a defiant patient. We have no way to restrain or sedate him, or put a catheter in him to measure the urine output he refuses to save. We literally cannot force someone to get treatment unless it's an 'emergency', which, currently, it's not. Further insight can be gained through his one persistent request: a disability letter so he can get out of work. He knows the hospital gig is limited, even in the current climate. He has to have a long-term retirement plan. He's found the gravy train, and it's us. He's playing us. The team knows it.

Our system, for all it's good intention, facilitates this cycle. He has to be seen if he comes back to the ED even if we kick him out. We know if he leaves he'll just drink, do cocaine, and eat salty foods until he 'decompensates' again. I suggest a sitter to make sure he stays in his room, and I'm told that we don't have the staffing for it, because apparently it's better to just have him in the hospital for an endless amount of time. He's totally non-compliant but pleasant, thus we continue, night after night, him wandering the halls undoing everything done during the day. He's been here for almost 2 weeks, and another hospital before that, working on getting his disability in air-condintioned comfort, with top notch nursing staff and a team of dedicated doctors.

It's good to know that if we kicked him out and he got really sick again, there would be a wealth of potential legal advocates to represent his interests. It's great to know that our system supports this poor gentleman in such dire need. God bless America.

A Stye? Oh, wait, a hordeolum...That's an Emergency!

If you come in at 01:30 by ambulance into our ED with two months of eye pain that you just couldn't take anymore with no redness/swelling/discharge/eyeballpain/changesinvision/headache/fever/chills/nausea/vomiting and bumps on both eyelids that you haven't tried anything for, well, OK...no, please, tell your son who just got home from work that he doesn't have to come get you because we can call you a cab right after we dispense your tube of erythromycin ointment. Sure, no problem.

Oh, no, don't worry, we won't bill you for the cab or the ambulance ride or the visit or the eval or the ointment or the tissues. No, no. Thanks, taxpayers. You got this one.

Six shifts, I lasted, before I got mad about misuse of the ED. Not too bad. And remember, folks...85% of patients believe they have a true emergency, even if only 5% of MDs think so.

Is a Missing Lip an Emergency Condition?

The medblogs are buzzing about University of Chicago's decision to treat a boy attacked by a pitbull without surgery.

Shadowfax has posted multiple times, most recently here; WhiteCoat has picked up on it here; and Scalpel has replied with a vigorous, bracingly conservative ripost here.

These three and others have framed the question as an EMTALA violation; is this a patient dump, or not? Is it illegal, or not? I'm more interested in how it framed the plight of modern EDs. I don't think, from what I've read, that there was an EMTALA violation. The boy was 'treated', and although his cosmetic outcome may well have been better, according to Dr. Grevious (no joke) once mom carted him across Chicago for immediate surgery, I think UCMC has a case.

More interestingly, the question is how can overwhelmed EDs possibly respond to crushing patient loads, the loss of subspecialty coverage, the mandate to see any and all regardless of pay, and all of this increasing as more and more EDs close and the federal government that forces us to see everyone subsidizes less and less? This on top of California's recent court decision that legally prevents EM groups from seeking additional compensation for services rendered from the patient. From our perspective, what exactly are we supposed to do? Chicago was trying to dispo out people who don't need emergency care. That's OK with me; tons of people abuse the ED although they are overall the minority. I think they picked a horrible time to do it with this kid--but, then, maybe they did it on purpose. No plastics available? Fine. No subspecialty care? Fine. America, this is what you get from us, they are (possibly) saying. You get the care you pay for. And when co-pays in the ED are zero, medicare reduces payments towards zero, states disallow collection of fees, we all end up with...well, zero happy stakeholders.

It's easy for me to say I care about cosmesis and wound outcomes and I'll fix a lot. I didn't see the kid, it might well have been beyond me, and besides, I work in a pediatric ED sometimes with triple attending coverage and three or four residents for twenty rooms, and we still have visit times up around four or five hours. I can see UCMC's side, easy--even if I also feel for that poor kid who couldn't get his lip sewn after he was a chew toy for a pit bull. If we can't take care of that, we're in trouble. Maybe UCMC is just pointing that out to society.

You got an MRI for a stress fracture?

There's a new article in the NYTimes that talks about the error rate in MRIs. The article is written fairly well, but totally misses the mark. Why?

The story says that MRIs have variable quality based on who reads them--sure--and that if your MRI is read by someone inexperienced it might miss something. OK. Then it quotes someone from U Mass who says 'we don't miss things because we have a 3 tesla MRI and radiologists who only read musculoskeltal MRIs', essentially. I'm guessing on the 3 tesla thing but I'm sure U Mass has at least one, probably more.

So? So, the author had a new stress fracture. OMG! Get an MRI! Have it read by a specialist at an academic medical center! Or, take a plain film to ensure adequate alignment, and put your foot in a boot with close primary care follow-up. Good God. To be fair, she finally gets around to the idea that we rely on scans too much and should just talk to the patient, but it's buried at the end. No wonder we spend trillions.

Meanwhile people living on Indian reservations in New Mexico don't even have an ambulance within 30 minutes, let alone an Emergency Room.

The scariest part? It was the number 1 e-mailed article of the day. I guess I'll brace for MRI requests.

Shoot. Can't Vote for McCain.

And I sort of liked McCain, too. He seems honest, and straight-talking. But his health policy advisor apparently had this to say about the uninsured:

"anyone with access to an emergency room effectively has insurance, albeit the government acts as the payer of last resort. (Hospital emergency rooms by law cannot turn away a patient in need of immediate care.)

"So I have a solution. And it will cost not one thin dime," Mr. Goodman said. "The next president of the United States should sign an executive order requiring the Census Bureau to cease and desist from describing any American – even illegal aliens – as uninsured. Instead, the bureau should categorize people according to the likely source of payment should they need care.

I can't really even respond to this idea. Those who are mandated to be seen in the ED are not funded, for one, and basically saying that being seen in the ED is akin to insurance is a touch daft. Sigh. If only I had enough energy for a true rant, but alas, I'm too tired already. Too many patients to see. Where could they be coming from? I wonder. See the post on the Movin' Meat blog here.

No Hay Ganadores

An article in the NY Times today discussed the story of a TBI victim who was repatriated to his Latin American home for care after a stay that cost $1.5 million. Arguments from most people said that the hospital was dumping the patient, since their agreement to accept Medicare and Medicaid obligated them to care for this person.

The other unspoken mandate behind this story is EMTALA, which requires hospitals that have Emergency Departments to treat and stabilize patients with emergency conditions--in this case, two broken femurs, internal injuries, and a head injury. This mandate is poorly funded, as well.

Medicare payed $80,000 of the $1.5 million.

That's why I said no winners. What was the hospital supposed to do? No long-term care facility will take this patient that requires intensive rehab; their hospital, like ours, costs roughly 2K per night for an inpatient. Is that a good use of resources? The hospital shouldn't 'dump', but if emergency care is mandated then all of the downstream consequences must be mandated as well, including follow-up care, and, wait for it...reimbursed.

We have a serious discussion on our hands in this election. Do we change how we care for everyone regardless of insurance coverage in the ED, and continue to have these situations? Or do we stop seeing people without coverage? I vote for funding the current mandate because I love the fact that I see people regardless of who they are based on need. I don't love getting reimbursed at a 5% rate.

Entitlement

150 people in an auditorium, I asked the prof a question, and then pointed out when he responded that his explanation didn't match the book or some such 2nd-year med student snarkiness. I got, in response, a long, loud, diatribe about how we were the most entitled bunch of whining babies he had ever seen come through the school. I achieved enough notoriety that some smart fellow yelled out to tell the doctor, quick, as I went up to read my match day assignment.

I was hurt at the time; I had worked hard to get there--working full-time and completing pre-reqs as well while trying to see my newborn daughter every once and a while--and he was telling me I was entitled?

But now that I've seen more patients, and seen more of the system, I see that I was--admittedly a bit spoiled--but also just the last straw for an ID doc who was sick of people whining about wanting antibiotics, vaccines causing autism, people not doing their jobs and patients wanting more, better, faster, and cheaper.

Over at M.D.O.D., the posters have little, if any, patience left for the people we treat as a community, who think health care is a right, and that anything less than perfect, enjoyable care is not good enough. This goes in line with the 'quality' movement sweeping through health care based loosely on the six-sigma line of thinking.

I don't know yet how much this affects the field. I will note, however, that the ED I'm about to begin training at has all private rooms, with flat screens and cable TV in each one. I'll also note that they hand out consumer satisfaction surveys to patients. In theory, this may sound great. In practice, it worries me.

Patients are not customers. Putting cable TV in the rooms certainly improves the wait, I'm sure, but aren't we sending the wrong message? When we spent trillions on health care with only so-so outcomes, are flat screen TVs really where we should put our money?

I happen to favor national health care a la the system seen in the UK, the NHS. However, I also acknowledge that this is often advocated in a very indignant way, as if it is an injustice that we don't yet have it. I used to feel the same way. How can the US, which is so advanced and spends so much money, not yet have universal care? Being a schizoid combination of realism and idealism, I like the idea of universal health care, but having watched our government screw up a lot of other things--public education, welfare, land management, and so on--I'm pretty sure we'd screw up health care, too. Instead of decreasing idiotic subjective meaningless griping surveys, it would probably increase them, and JCAHO would metastasize, becoming totally inoperable.

We are becoming a nation entitled. They say it's bad parenting now to tell your children that there are starving kids in Africa that would gladly eat those carrot sticks, but isn't it totally true?

We should tell patients that, too. You just waltzed into this ED at 2 am because you need a refill on your Percocet and got seen within an hour while you sat in your private room and watched the Top Chef marathon on the Food Channel. You personally will not be charged for this visit because we won't be able to find you, and because I am totally exhausted you might even get some narcs out of me. Then, you'll complain how I wasn't compassionate enough on the survey the nurse is required to hand you, knowing full well that the parent of the pediatric resuscitation that went perfectly down the hall won't have the time or energy to fill out a survey because they have more important things to worry about. There are patients in Africa who would gladly take this level of health care.

It's nice going into residency being pre-jaded. At least I won't feel the pain of my ideals burning away.

La Raza, or, Am I Racist?

I just came back from Step 2, and, no, official oversight committee, this is not a blog entry about any details of the exam; I understand that such postings are forbidden.
At the end of our 4th year all of us now have to take an exam that is practical, called step 2 CS; we line up in our white coats, with our non-augmented stethoscopes, without or accessory brains (PDAs), and go in to see 12 standardized patients. In 15 minutes, we have to take a history, do a physical exam, and present our impression to the patient. Then we have 10 minutes to write a note with what tests we want to order. The whole thing costs over $1,000, which I think is a racket, personally. Who's idea was it to charge 4th year students, those whose loans have most likely run out, over a grand for a required test? At least they supplied lunch--cold cuts and pasta salad. That extra scone was about $450.

It's not a bad test, actually. But what I wanted to talk about today is a bit more interesting than details of cases. For whatever reason, there were four of the twelve standardized patients I had that were African-American. I think, having thought about it, that I treated them differently.

I didn't mean to, certainly. However, in the exam situation, it was with young, African-American standardized patients that I forgot, more than others, to tell them about tests I would consider routine in their situation. Perhaps I'm imagining things; or, perhaps there's something to the finding that minorities get poor health care even when you control for income. What was going on? Did I think them less likely to need the test? Did I consciously want them to have a missed illness? I'm sure not. Rather, it was likely my brain did what it did, distracted by the pressure of the test.

I've spoken about Malcolm Gladwell's books on the blog before, and his idea that there is a whole slew of assessments and judgments that occur the split second after you see or talk to someone is relevant. He calls it 'thin-slicing', and at best, thin-slicing in an experienced physician can allow for quick recognition of major illness versus stability. At its worst, however, it can be distracting.

So, because these folks were black, did I somehow make a snap judgment that caused me to order fewer tests? I think so. I think so because when I left to write the note, it was obvious the work up I wanted to do, and I put down those tests I hadn't described to the patient. For whatever reason, though, there was a gap between whatever initial judgments I made without thinking about it and what amounted to good, thorough care. Of course, now there are a maze of confounders--did I know I wanted the tests, but not explain them well because I was less comfortable on some level? Were they less forthcoming with me and therefore I didn't feel like they were acting as sick? Did differences in question style, language, and non-verbal communication make a difference? Not sure; I do know they had two-way mirrors for 'research', so maybe there's a way to find out.

Obama's candidacy for president has made clear that race is an issue in the US. I give us credit as a country for talking about it; there are lots of racists in the world and they often deny that they are much more than we do, as when a Korean student I met denied that there were any Korean homosexuals (I know that's not race but it's similar). The test makes me wonder just how much I'll have to watch myself for hidden bias. Better, I suppose, to see it for what it is and correct it--which is precisely what everyone has to do when their 'thin-slice' is inaccurate.

I remember a class in Mexico where we discussed race, and the class wanted to know why Americans were racist, why they locked the car door when Hispanic youths walked by, why they were so anti-immigration. I found myself on the block for everyone. It was disconcerting, but also enlightening; we have a constant choice to either ignore our own blind spots, or look into them. Hopefully, by doing so, I become a better doctor for everyone, not just the Scandinavian farmers I know how to relate to.

The Abercrombie & Fitch ED

Apparently Abercrombie & Fitch has donated enough money to a hospital in Ohio to get their name on a new ED and trauma center, and people are upset about it--saying that A & C sexualizes teens and it is the wrong message to send to people. The American Family Children's Hospital is apparently more palateable, as is the Nationwide Children's hospital. Hasbro and Mattel have branches.

Everyone's mad about A & C, similar to the ads that Benetton ran a few years ago, saying they are inappropriate. Interesting to juxtapose A & C with a new report that some 25% of teenage girls age 14 to 19 has one of 4 common STDs: HPV, Chlamydia, HSV, or Trichomonas. Any connection there? I leave it up to the reader.

The more troubling point is the number of EDs and Hospitals in the article that have turned to corporate funding. These aren't sports stadiums we're talking about; these are public resources. What does it say about us that the only way to fund a new ED is to turn to a clothing company? Especially given that patients are mandated initial stabilization by EMTALA, generated by the US Congress (yay!) Aren't we more worried that we depend on nekkid teenage models to pay for care?

Has anyone figured out how A & C sells actual clothes?

The Candidates on Health Care

Let's hope these two pictures don't start fighting.

I've learned some interesting things from the health care plans of each candidate, Hillary's and Barack's. Also discussed by Paul Krugman of the NY Times here.

Here's my favorite. According to Hillary's fact sheet, the average yearly health insurance premium for a family in 2006 was $11,480. Eleven thousand dollars! That's more than it costs to mortgage a house (well, a small one at least). In effect, every family in the US owns a second home--their clinic.

Is there a big difference between the two plans? Well, both mention creating something similar to congress's plan, the FEHBP. Both want to increase coverage of kids especially. Neither is advocating a true single-payer system. Both want to 'increase competition' between health insurance providers, whatever that means. Both want to replace Medicare's ability to get discounts from drug companies based on size, removed during the Bush administration. Both stress preventative health regimens and incentives for 'quality'. Both discuss electronic medical records. Otherwise, they seem similar with the exception of some differences below. In general, Hillary's plan seems much more detailed, with more references and more numbers. They kind of fit the personalities of the candidates.

Hillary plans $3 billion a year for implementation of electronic medical records, Barack $10 billion. I suppose that doesn't matter since Hillary pegs savings from EMR implementation at $77 billion a year, once up and running.

Barack mentions a new 'National Health Insurance Exchange' that will increase competition, but I'm not sure how. Hillary doesn't really address competition between health insurance companies, but does talk about restoring discounts.

Hillary talks about 'sensible' malpractice reform, basically a system by which doctors are held to 'transparent' standards with regards to error rates. Barack doesn't really talk about malpractice reform. This is a big issue in some states where caps on damage awards have recently been rescinded. I'm not totally sure it's a good idea to measure MDs on quality while ignoring the price-cap issue and the sheer cost of malpractice insurance in many states.

Hillary talks about a national research initiative to find best practices. A new 'Institute'. That sounds nice, I suppose.

Krugman and others believe that Hillary's plan will lead to universal coverage, through mandates that require people to buy coverage. But neither plan says anything about what 'affordable' or 'reasonable cost' means. Barack's plan pledges universal coverage for children, but leaves out those who don't want to buy coverage. Doesn't that leave them back at the ER again? Aren't those the very catastrophic injuries that cost so much?

In reality, there's no great way to compare these because they're both simplified and hypothetical.

The bottom line, for me? If there were a single-payer system, there would only be one place to send a bill, one place to worry about funding, and one place that, if federal, would be required by law to disclose where all the money goes. Don't we want that? Don't we think that if we spend trillions on health care we'll be able to pay our doctors, create short wait times, and still do research?

I guess in the end I don't see the appeal of the system we have now such that we aren't talking about a single-payer system. Yes, Hillary's plan seems a bit tougher. But both are incremental change to a broken system. Good luck with that, says my cynical side. Is there a better way, asks my pragmatic side. Maybe not.

Single-Payer Healthcare

There's a great entry here on the Canadian health care system from the Health Beat Blog, which seems apropos given our current political chance to perhaps make some changes.

I'm no policy expert. But I do know my own finances. In our wonderful system that operates in a free market, this is what happened to me as a father of one to three children, depending on when it happened.

When I had employer-based insurance, as is typical, I had to pay a premium for my family of between $200 and $300 a month. I couldn't switch plans once I had chosen one even though I wanted to--so much for free choice of doctors. Once I became a student, I had to either sign up for student health--over $500 a month with lots of co-pays--or use COBRA, an obscure system whereby the newly unemployed person pays the 'full' cost of their insurance which in my case was $575 a month but at least I had the same doctor.

I was unemployed, paying $575 a month. Awesome. This is the system we currently have. Lost your job? Here's an extra $500 a month in expenses.

18 months later, we were eligible for Medicare. Cost: $0. Choice of doctors: well, pretty much any. In fact, my access to academic providers went up substantially, and I didn't need prior authorization. Wait times were similar. I got to keep the same pediatrician for my kids and choose pretty much anyone for my own primary.

Advantage, big bad government system. In both choice and cost.

But surely, doctors are paid better in the US? So you wouldn't want a government system? Well, I currently have $175,000 in loans from medical school. Partially because there were no social services whatsoever, so I had to borrow money to pay for health insurance. EVEN WHEN I'M WORKING the cost of health care per month will rise again to between $150 and $500 a month depending on where I work (let's say the American South is not 'service rich'). Do I want a good salary? Sure, but only because I have so many loans because I had to finance both my own education and pay exorbitant premiums for health care (under COBRA, above) while I was a student.

Is there any hope? There is one notable institution that supplies free health and dental care to all its employees. What? A medical institution that gives free health care to all its employees? They must be going bankrupt! No, actually. They thought about going to a plan before. Just playing for care without the administrative cost was...cheaper. Golly.

Pretty obvious to me. Government plan: free, better access. Employer plan: expensive, less choice. And that's even without any static for prior conditions and all that garbage, or mental health which is not always covered, and so on.

Oh, right, taxes. Well, let's see. Taxes might be higher with more services, it's true. From where I'm standing, however, government health care saved me on average $500 a month. That's $6,000 a year. Now, I'm no expert on taxes. But according to Wikipedia on taxation (granted they may have a bias) that's more than a person making $40,000 a year will pay for their TOTAL tax bill. So for me, going to a government plan actually more than paid for my taxes the years I was eligible. In other words--government health care helped my true out of pocket expenses go down, not up.

I don't know if this convinces you. It does me. Leave aside the small observation that all other developed nations have universal coverage, and that the nations with the largest tax burden and therefore, the largest support network also have the best social indices: that fabled land, Scandinavia.

"Who are we to play God?"

I'm down to a post a month. Sorry. Things should pick up soon. Currently I'm taking a break from multiple choice questions contrasting various treatments for a rectocele, which, by the way, is caused by a loosening of the levator ani fascia, and results in the rectum encroaching into the vagina.

I have my doubts about my future career proceeding in uro-gynecology. Not that there's anything wrong with fixing such problems. Anyway.

OB has been hard to write about. But I figured it out reading an article in the NY Times about gender selection. The director of a prominent fertility center in the above article perhaps questioned a doctor's right to play God, but, interestingly enough, he was in support of allowing a patient to choose the gender of their child. He essentially said, if the patient wants to have a girl, who are we to play God and prevent them from making that choice? Clever, to turn the argument on it's head that way.


Aside from chuckling at the inversion of logic evident in such a turn of phrase, it got me thinking that doctors constantly play God, so to speak. Fertility is an obvious example. But every operation or intervention is essentially an attempt to monkey with the divine design of nature. Are we not playing god when we insert three or four instruments into someone's belly to extract a hemorrhagic ovarian cyst? Certainly we are not trusting to nature to sort things out. Certainly there is some element of intervention there.


And we would not have it any other way. The hubris necessary to even think of taking a person caught in a car accident, opening their stomach, and ripping out their bleeding spleen in a matter of minutes is a bit mind-boggling. Thank goodness we do it. If we weren't a bit hubristic we'd be paralyzed by indecision.


But what's the real difference between that and fertility other than speed? The person in the car accident may have made any number of questionable choices, just as some say fertility seekers and the doctors who treat them are on shaky moral ground. The trauma victim may have been a 21-yo, intoxicated, unbelted, ejected driver found on the scene of a multi-car accident unresponsive. In the absence of any recorded spontaneous resuscitation and splenic rupture repair in the field, I'd have to say, we're 'playing God' and altering the natural consequences of his choices.


So to say that fertility docs are somehow monkeying with God's natural order more than doctors in general is a bit false.


I don't actually support choosing a gender, and I think most couples who want the most expensive fertility interventions should actually adopt, since they often aren't using their own genetic material anyway. But that's my personal opinion, not my professional one. Let's face it, we're playing God all the time. Perhaps the real hubris comes when a doctor says, 'you may play God', and, faced with someone else, 'you may not'. Perhaps the very argument should be discarded altogether.

This one isn't sorted out yet, more later. Back to Burch slings and cystoceles.

NY Times Takes on Pharma

The New York Times has recently had two fascinating and, I think, accurate articles highlighting the relationship between doctors, health care, and pharmaceutical companies, in anemia treatment, and in antipsychotic use in children.

I posted once about problems with the use of antipsychotics, but this is a whole different issue. This is a major problem. It looks like doctor's groups in NY that were prescribing variants of EPO, which boosts red cell production and is thought to be useful in conditions like chronic kidney disease and chemotherapy, were receiving rebates from the pharmaceutical companies based on how much they gave patients to the tune of millions. Millions. Sounds a bit fishy. Getting rebates based on the drugs you give people.

Then, there's a second article about psychiatrists receiving payment from drug companies in Minnesota, which publishes such statistics unlike most states. It said the most money received by a doctor was over $600,000 in a year.

Now, I'm usually one to point out that doctors don't make as much money as CEOs, or business folks, or lawyers; in a recent book, Better, Atul Gawande pointed out that the return per year of schooling for doctors was on the order of 16%, as compared to almost 30% for business school. Still, we're not about to end up in the poor house as a profession. We should know better.

There's good evidence that these trips and gifts and, well, cold cash in bank accounts, influence prescribing practices. It seems obvious with enormous rebates, but it's true even of the pens and note pads. Ask your doctor about it. Go ahead. And check out a site that some doctors have started in protest, called No Free Lunch. It has just started a directory of providers who have pledged not to accept gifts from pharmaceutical companies.

Yes, we need drugs. Sure. But we don't need to be paid by the companies that make them. Sheesh. And we all supposedly took ethics in med school. I suppose it's easier for me; drug reps aren't allowed to visit UW physicians. I've never seen one.