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Monthly Archives: March 2007

Although the 2008 presidential election is a year and a half away, universal health care coverage has already risen to the top of the domestic agenda in the eyes of a majority of American citizens. According to a March 2, 2007 article in the New York Times, a recent NYTimes/CBS poll found that an “overwhelming” majority of those polled indicated that the current health care system in the U.S. needs a “fundamental change or total reorganization.” 64% believes that the government should guarantee health insurance for all, 27 percent believes that it should not (remarkably, this number has changed since the early 1990s when 56% believed the government should guarantee health insurance for all, and 38% did not). 25% of the pollees with insurance claimed that a household member had foregone treatment or testing because insurance would not cover it as compard to 60% without insurance (foregoing treatment due to the out-of-pocket cost). Amazingly, 60% (including 62% of independents and 42% of Republicans) were willing to pay more in taxes (with 50% saying that they would pay as much as $500 more annually and forego later tax cuts). There was “overwhelming support” for the renewal of the Children’s Health Insurance Program, and 84% would like the program to be expanded to cover all uninsured children.

This poll, and similar polls by ABC News and USA Today, all indicate that most Americans want universal health care coverage, and this desire extends across party lines. (I tried searching for similar polls by Fox News and other more conservative news sources, but found none; either my search was not thorough enough, or these news sources are afraid of reporting results that concur with this notion.) However, there is no consensus agreement on how universal health care coverage should be provided. In the NYTimes/CBS poll, 38%think the current mixed payer system is the best system, while 47% would opt for a government-run health care program (i.e. “single payer” system). As one might imagine, this growing majority that favor a government-based approach has stimulated considerable criticism and passionate resentment from select members of the health care community, be they health care providers or health care policy makers.

Training in a health care environment that has very conservative private practitioners who deny or limit care to Medicaid patients and academic hospitals supporting a large safety net system as well as many free clinics, I can’t quite tell whether these very vocal dissenters of universal health care coverage are large or small in number. Being in New Orleans, it is very clear that the need for universal health care coverage is great, particularly since stable and sufficient employment is scant, and there is a large population of low-income working families and individuals that cannot afford private health care plans. It is quite difficult to separate the subjective from the objective, however. I understand the personal frustrations that many PCPs, ER physicians, and others face when dealing with “freeloader” patients, but I find it objectionable that health care providers would readily accept the role of judging who should or shouldn’t receive health care.

On the one hand, the notion of rationing medical treatment and supplies seems logical, given the high and rising cost of health care and the scarcity of sufficient insurance coverage for large segments of the population. Similarly, rationing and encouraging personal responsibility for health would prevent people from demanding “freebies” and would place an upper limit on demand for health care. However, instead of placing restrictions and corrective measures on the least empowered segment in this relationship (i.e. the patients), why not address the problems at the level of health care costs and insurance coverage? Pharmaceutical companies, biotechnology companies, and insurance companies provide valuable services, but those services are only as valuable as they are usable. For example, what value does a health insurance plan have if the insurance company refuses to pay for end-of-life and nursing home care, betting that the patient will die before the insurance company can be held responsible? What value do drugs have when patients who need them cannot afford them? Why might a particular medical instrument cost thousands of dollars and be single-use, when the device could easily be much cheaper and reusable?

I recently posed this question to a fellow medical blogger:

Out of curiosity, which of these do you think comes first?
- the Federal government reducing reimbursements for Medicaid?
- increases in the costs of treatments (pharmaceuticals, biotechnology, etc.)?
- private practices limiting the number of Medicaid patients they see?
- Medicaid patients, having difficulty finding physicians that take their coverage, showing up in EDs looking for non-urgent care?
- Medicaid patients neglecting preventive measures and primary care?

Medicaid seems to cause much grief, particularly since it is an expensive program and its beneficiaries are often characterized as being “freeloaders.” Those who do think universal health care coverage is undesirable seem to think that a new measures to extend coverage to the uninsured will function similarly to Medicaid, despite the fact that most of the currently uninsured are hard-working, low-income families and individuals (i.e. what some call the “middle class”). Nonetheless, they properly identify that costs and demand will tend to increase to meet or exceed the budget allocated to a program. That is, as much as I and other health care providers argue that people are not at fault for their illnesses, there nonetheless is a need for people to be held accountable for their health status to some degree so that there are incentives to adhere to preventive and primary care health recommendations.

Accordingly, though there are supporters and critics of universal health care coverage (and even more disagreement on the specifics of how universal health care coverage should be accomplished), it seems that many people have too short an attention span or too narrow a perspective to truly address the interrelated problems facing U.S. health care today. In order for there to be a true solution, there must be corrections at all levels and coordination between the effectors of these changes. I do, however, believe that the best coordinator for these changes is the federal government, despite the heterogeneity of health care provision across states. Insurance, biotechnology, and pharmaceutical companies are multistate and international entities that cannot be properly regulated at the state level alone, and federal regulation by the FDA is currently weak. At this point in time, here are the changes that I believe must occur in order for our health care system to be optimized:

1. Pharmaceutical and biotechnology product costs must be reduced. Although R&D costs are high, they could be considerably lower if these were done in smarter, more cost-efficient ways. Advertising costs should be minimized (i.e. Direct-to-Consumer), with better exposure of products to physicians and patients through trustworthy and regulated information sources. Some medical instruments should be made resuable after proper safety testing is performed.

2. Universal health care coverage must be provided. I don’t necessarily think a single payer system is a good idea. I don’t think our current system is perfect either, but it has the theoretical benefit of having market forces compete to provide better services. However, anyone who claims that market forces are working is grossly misinformed, given the monopolies that many health care insurance providers have in their respective regions of dominance.

3. Health care insurance monopolies must be broken up and regulated. Health care insurance coverage is continually being reduced, in part, due to the fact that many companies have virtual or true monopolies in their coverage areas. Without competition, patients and physicians suffer for lack of benefits and reimbursements.

4. Medical tort reform has to happen. Physicians necessarily have to overspend (i.e. provide more testing and services than necessary) through the practice of defensive medicine due to the litiginous behavior of some patients and the ambulance-chasing tactics of personal liability lawyers. In order for physicians to provide care in the most cost-effective manner (i.e. lowest cost, highest efficacy), there have to be much greater protections for physicians from malpractice lawsuits. These suits should not end a physician’s career with a single event, especially since it takes more than a decade of training and hundreds of thousands of dollars invested into that training to produce that training professional health care provider. Malpractice lawsuits are doing a great disservice to U.S. health care.

5. With newly provided protections from malpractice lawsuits and better service provision-reimbursement matching, physicians must practice more cost-effectively. This goes without saying. According to studies by the Government Accountability Office, however, only a small percentage (approximately 2-3%) of physicians actually overtreat and overspend for Medicare patients. This may be different for privately-covered patients, however.

6. Patients must learn to take personal responsibility for their health care, no matter what their current or projected health status is. This can be achieved through education and incentivization. It’s not an impossible task. Measuring it is not as simple.

As for the title of this post, I reiterate that I find it disturbing that physicians would readily allow themselves to judge whether or not their patients deserve health care. Some policy makers are pushing for this, by requiring personal responsibility measures to be determined by health care providers as to whether or not a particular patient is adhering to the plan (i.e. should he or she be removed from the plan?). I think this is incompatible with the mission of physicians to provide medical care in a nonjudgmental manner, an approach that is essential to the maintenance of the integrity of the practice of medicine. In a way, those who do readily judge are Social Darwinists, believing that those who don’t take care of themselves don’t deserve to live. However, it’s very difficult to tell the difference between who doesn’t take care of themselves because they can’t and who doesn’t because they don’t want to. One analogy for this is a medical expedition to climb Mount Everest that studied physiological changes in the physicians and climbers who were part of the team. Interestingly, one of the physicians recounted his experiences, and the deterioration in his perception and judgment. At one point, he thought, “Oh, this slope looks like I can just slip and slide down it, nice and easy.” This was a well-educated physician, and he nearly killed himself. Just as staying at high altitude can drastically diminish mental performance (which has also been shown in studies where climbers have been quizzed periodically as they ascend a tall mountain), how can one expect people to always make the best decisions for themselves when they are sick and suffering? I think any physician who didn’t get that message in medical school is not providing the best care they can for their patients.

For those of you who haven’t heard my joke already, I think it would be quite amusing if I chose to become a pulmonologist so that I could introduce myself as “Dr. Lung” (since “lung” is the closest English approximation for my last name). It’s one field that I’m quite interested in, and one that I feel quite passionate about. Accordingly, I find it distressing each time I discover that a colleague or friend of mine smokes tobacco.

I hardly ever say anything, because I don’t wish to be judgmental. There’s no question of intelligence, or even of being informed (of the many adverse health risks directly correlated with tobacco use – drastically increased risk of cardiovascular disease, emphysema and chronic bronchitis aka Chronic Obstructive Pulmonary Disease, lung cancer, asthma, and much more). These are people that I personally like and for whom I have a great deal of respect and admiration. And yet, I find it troubling that I am not sure whether or not to address the issue of tobacco use among fellow medical students and physicians. I do not have the same degree of responsibility (or at least, I do not yet feel that I do) to provide care and advice to my colleagues as I do with my future patients. Furthermore, on a public health scale, my arguments are stunted because most of my colleagues who smoke don’t do so in public but rather only do so in the privacy of their own homes or in public, recreational spaces that allow smoking (and also, where they are unlikely to be wearing their white coats). For this, I am quite grateful, especially since it gives an asthmatic like me the choice to leave when my airways are feeling tight.

I feel much more comfortable, in the context of myself as a physician-in-training, to talk to patients and others who might seek medical advice about smoking with a much more clear cut approach and sterner tone; in these cases, someone is asking me for advice, and I can help inform them or point them to the health care providers who can provide the right advice. However, with colleagues, it’s much harder. While I am an advocate of self-policing and extensive critique of ourselves and our colleagues in the practice of medicine, it is uncertain what approach is best to take with respect to lifestyle choices. People do all sorts of things to themselves that are harmful, and others that are considered harmful but for which the evidence is much less strong in comparison with the plethora of evidence connecting tobacco use (of any type) with disease. In the end, not knowing what to do or what to say, I just feel sad because I see people I care about knowingly bringing harm to themselves.

While I try to maintain a consistent attitude in promoting smoking cessation without calling out my colleagues on their choices, I realize that this attitude cannot effectively address future suffering on the part of people in my field. To me, this poses a serious challenge to preventive medicine and the basic tenets of public health: if we, as physicians, are so willing to acknowledge that we are “just human,” how can we ever hope that other people will ignore our example and take active measures to maintain their health in every way we can imagine for them?

Because I’m always happy to review:
- Smoking: the leading preventable cause of death in the world, with approximately 5 million directly-linked deaths per year (i.e. respiratory diseases such as COPD and lung cancer), and contributing to countless more given the greatly increased risk for cardiovascular disease (ischemic heart disease, or myocardial infarctions/heart attacks, is the number 1 killer and cerebrovascular disease, or stroke, is the number 3 killer). (according to the World Health Organization)
- Smoking causes 90% of lung cancers, and lung cancer is the leading form of cancer death for both men and women in the United States. Smoking accounts for approximately 30% of all cancer deaths in the U.S. (as it also causes other cancers besides lung cancer).
- Smoking is the cause of 90% of COPD cases.
- Smoking increases the risk for developing coronary artery disease by 2-4 times, and doubles the risk of stroke.

From a study in the Annals of Internal Medicine:

Smokers were much more likely to die between the ages of 40 and 70 than nonsmokers. Just 9% of women who had never smoked died during that period of life, compared to 26% of women who smoked 20 or more cigarettes per day (heavy smokers). The difference was even greater for men: 14% of those who never smoked died in middle age, compared to 41% of the heavy smokers.

The more people smoked, the more likely they were to die in middle age. There were no significant differences in lung cancer deaths, or deaths from other smoking-related cancers, in men and women who smoked.

There was one piece of good news from the study. Quitting at any age lowered the risk of dying — but those who quit in their 40s fared better than those who waited until their 50s or 60s to kick the habit.

The CDC conducted a study between 1995 and 1999 that indicated that adult male smokers lost an average of 13.2 years of life and adult female smokers lost and average of 14.5 years of life due to smoking

Finally, as a final note, smoking’s many adverse effects accounts for 1 in every 5 deaths in the United States each year (approximately 438,000). “More deaths are caused each year by tobacco use than by all deaths from human immunodeficiency virus (HIV), illegal drug use, alcohol use, motor vehicle injuries, suicides, and murders combined.” Ironically, this correlates with the statistic that approximately 1 in 5 (20%) of Americans smoke.

End Note: Although it sometimes may not seem so, particularly with my predilection for critical analysis, I’m not a judgmental person. And certainly, I don’t believe that lifestyle choices and behaviors are signs of flawed character. Nonetheless, I do wish that I could find reason to speak, and that others would find reason to listen.

Dear friend,

I may never know what compelled you to make this choice,
to expose yourself in a most private and intimate way
to me, a stranger, let alone a hundred or more like me.

I can only imagine who you were in life, what character of soul
you carried within this vessel, a testament to your existence
and your success at making it so far.

In life, there are many ways we can share ourselves,
whether through our minds, our bodies, or our spirits.

In your time, you may have shared all of these, or none of these.

And yet, there was a moment when you decided to give more,
and in doing so, empowered me, and many others, with new knowledge
so that we could do more, and do better, for others who suffer.

In that moment, you felt something that we all feel,
whether we are aware of it or not -
that we are all human beings, that there is commonality between us,
that when you strip away superficial distinctions, we are all the same.

For you, no selfish desire to have your image preserved indefinitely
As you are laid to rest.

What others might have seen as a sacrifice
You saw it as the last gift you could give,
And I am grateful to receive it and prepare to pass it on.

To you, a teacher whose name I will never know,
I thank you for this knowledge and this ability to fight disease.

To you, a fellow human being,
I thank you for your bold statement of commonality, that we are united as one people.

To you, a kindred spirit,
I thank you for this early, powerful reminder that since we are all from the same stock,
we must do what we can to help one another recover
from those unjust causes of suffering.

You have my thanks, and now please accept my promise
to pass on this knowledge and your final message.

Rest in peace.

Today, we had our Cadaver Memorial Service, a very well-orchestrated and emotionally moving event, in honor of those who donated their bodies to medical education and the training of new physicians. In addition to an invocation, scripture readings, and two musical performances (including an a capella version of the song “For Good” from the musical Wicked), six speakers (including myself), one from each Anatomy lab, reflected on our experiences with the cadavers in the Gross Anatomy course. Remarkably, without prior consultation, we all reflected on shared themes: gratitude, awe at their wealth of spirit, and respect for our anonymous teachers.

Leaving the service, I realized that for me (and hopefully my colleagues), this gratitude and respect extends not only to the donors and our course instructors, but also to patients whom I have had the privilege to learn from during this past year (and during my pre-medical school experiences). Whether consciously given or not, patients who seek care at teaching institutions give a meaningful and valuable gift to its students. I find it very encouraging that I, and others, will aim to honor those gifts during our training and our careers.

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