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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.

I recently encountered an article* in the February 15th issue of the New England Journal of Medicine about Medicaid and the various political machinations that have compromised this federal program. Remarkably (to me, though perhaps not to others who have a more cynical view of politics), the support and opposition to the continuation of Medicaid as a major priority for the federal government falls distinctly on party lines: the Democratic party voted unanimously against the Deficit Reduction Act of 2005 that would reduce spending on Medicare and Medicaid and limit the scope of eligibility for Medicaid coverage, and most Republicans voted in favor of the measure. Medicaid, unlike Medicare which is fully funded by the federal government, is a joint federal-state program, requiring extensive cooperation between both levels of governments. The division among governors about the state of Medicaid did not fall on party lines, but rather, many who favored reductions in spending for Medicaid aim to make the program “more manageable” without disenfranchising individuals covered by the program. As this time, states are still figuring out how to best approach their goals for Medicaid under these new federal restrictions and guidelines.

How do these changes to Medicaid, reflecting larger trends in health care coverage regarding the reduction of benefits and the emphasis on “personal responsibility” (i.e. cost-sharing), affect physicians and the practice of medicine?

1. Reimbursements for providing care to Medicaid patients will continue to fall. For a number of years, states have reduced Medicaid reimbursements for physicians using the Sustainable Growth Rate formula. The government sets an expected yearly expenditure for physicians’s services. If the actual expenditure is below this expected amount, payment increases. If the actual expenditure is above this expected amount, payment decreases. Accordingly, the Congressional Budget Office expects a total Medicaid reimbursement reduction of 25-35% over the next few years if physicians continue to provide the same services. Solution? One might suggest that physicians should order fewer tests and use less expensive therapeutic methods, but will patients accept this? In other words, will they accept the judgment of the physician (based on cheaper, but potentially as or nearly as effective diagnostic methods) instead of the results from a (costly) battery of tests?

2. Proponents of the DRA aim to limit benefits as well as the range of beneficiaries. – Medicaid actually provides coverage for some services often not covered by employer-sponsored plans, including mental health care, long-term care, and transportation to the health care provider. Accordingly, with the reductions in Medicaid expenditures, it is likely that these “extra” services will be the first to be cut through the potential lack of foresight from government administrators. Some might not view these services as essential, but a physician who is able to comprehend the extent of an individual’s many difficulties in accessing health care and maintaining a good health status might argue otherwise.

3. With the reintroduction of cost-sharing and provisions to allow the denial of health care services in case the patient cannot pay their share, do low-income patients stand a chance to getting adequate care? A 1986 law, the Federal Emergency Medical Treatment and Active Labor Act, required that hospital emergency departments must provide a medical examination to all patients encountered in their facilities. Previously, many emergency departments, particularly those in private hospitals, routinely denied care to patients who could not pay for services. Is the DRA reopening this Pandora’s box, and furthermore, subjecting the 60.4 million Medicaid patients to new risks of being refused care (as though they were uninsured patients before 1986)? Mr. Inglehart (the author of the NEJM Health Policy Report on Medicaid) suggests that physicians may be put in the gatekeeper role of making the ethically unsound decision to deny care.

4. The DRA provides states with the option of introducing “personal responsibility” requirements that can result in a beneficiary’s expulsion from the program if he/she does not adhere to them. While this sounds reasonable in light of a constant goal in medicine to help patients help themselves (especially through preventative medicine), this also sounds a lot like the Bush administration’s No Child Left Behind Act, a controversial educational reform measure that is notorious for its corruption, harmful overemphasis on standardized testing, and accentuation of problems through punitive responses to poor performance. That is, schools that perform poorly might need the most help (and need more time to bring about positive change), but instead, they are penalized with reduced funding. Would the same happen for patients under need federal-state regulations regarding personal responsibility for health care? Would the patients who need our help the most lose their eligibility? I find these provisions questionable given the likelihood that access to care will be increasingly more difficult to achieve for Medicaid patients with potential reductions in transport assistance and denied services with cost-sharing. Furthermore, physicians, again, might be put in the difficult position of determining whether or not a Medicaid patient is achieving these personal responsibility measures.

5. DRA proponents consistently press for regulations that limit enrollment into Medicaid, and thus, make it increasingly difficult for uninsured patients to acquire coverage. How can this possibly be a good thing? Why is one quarter of the aimed reduction in expenditures coming from Medicaid alone? Given the waning of coverage and eligibility for employee-sponsored health care coverage and the increasing numbers of working individuals and families unable to afford private coverage, how can these measures enacted by the formerly Republican-dominated Congress have a positive, or even just a neutral, effect on the problem of providing care for the uninsured?

Concluding Thoughts

From the politics behind Medicaid reform emerge the core principles of the Republican and Democratic parties, at least on a national scale. While the Democratic party urges the need for providing services to those who do not have the means, the Republican party emphasizes the need for self-determination and personal responsibility in guiding an individual’s success or failure. While I personally am on the left end of the spectrum, I am willing to consider the benefits and faults of all sides and even vote regardless of party distinctions. However, while I understand that fiscal responsibility and management of costs is essential to the overall welfare of our country, I do not believe that these cost-cutting measures should be at the level of the patient, or even the physician. Rather than reduce the services available for patients to acquire and physicians to use, why not reduce the costs of producing and distributing these services?

Dr. Paul Farmer and Partners in Health demonstrated to the world that the expensive treatment regimens for HIV/AIDS could be provided in a low-resource setting like Haiti. The cost to the patients? Nothing. With help from the William J. Clinton Foundation, Farmer showed that antiretroviral treatments (e.g. AZT) with an average annual wholesale costs of $10,622 could be provided for $577 per patient in 2002. By 2005, pharmaceutical companies would charge $719 annually for AZT, while the drug could be acquired generically for $281. While one might expect a drop in price for treatment when generic drugs are made available, would such a drastic reduction in price have happened without the advocacy of Dr. Farmer, Partners in Health, and the Clinton Foundation? I strongly doubt it.

What can physicians do? Besides being advocates for our patients in every way imaginable, we must find ways to push for reduced health care costs while also coordinating with our close allies to help individual patients. Health care technology and pharmaceutical therapies can be provided at significantly lower costs than they are currently, but it may take the passionate work and advocacy of physicians (and other patient advocates) to bring down costs and make expansion of health insurance coverage possible (and not at the expense of the health of patients).

* [The March 2007 issue of the Next Generation provides a link to this article without requiring an NEJM subscription.]

It is said that medicine is both an art and a science. Various individuals may emphasize one aspect over the other, noting certain insufficiencies in the training and practice of physicians. However, neither should be emphasized at the expense of the other: physicians need to maximize the efficacy of both their scientific reasoning and their interpersonal skills. Both are brought into question on the subject of Complementary and Alternative Medicine (CAM).

Both the “art” and the “science” of medicine are criticized by individuals outside the profession. Patients complain about their interactions with physicians: the brevity, the impersonality, and sometimes the questions left unanswered. Scientists complain about physicians and their lack of rigor in their methods of deduction, their extensive use of anecdotal evidence to guide practice, and perhaps with a degree of jealousy and incredulity, their confusion as to why physicians benefit from higher salaries and the reception of more respect despite their inability to adhere as strongly to the fundamental principles of science. These are all important to consider, although never to the point of excessive and unwarranted self-doubt. More damaging to the integrity of medicine, however, are not affronts from the outside, but rather, those from within.

The medical sects grouped under the broad categorization of “alternative medicine” have existed as long, if not longer, than allopathic medicine, also known as “Medicine”, “Western Medicine”, or more recently taking on the latest moniker, “evidence-based medicine.” Allopathic medicine rose to dominance over health care in America during the 20th century as a result of the discovery and allopathy’s (begrudging) acceptance of Germ Theory, the rapid growth of the hospital-medical school complex as the center of allopathic training and health care delivery, and allopathy’s assimilation of rival sects (to some degree) or destruction of rival sects through the political manifestations of licensure and medical practice laws. From the time Europeans first set foot in America to the acceptance of Germ Theory (i.e. that diseases are often caused by microscopic organisms) in the late 1800s, medical care in the United States was decentralized and dispersed across a variety of competing disciplines: practitioners of allopathy, homeopathy, osteopathy, botanical medicine, surgical medicine, and more. In other words, medicine was heterogeneous, and no one knew which was “better” or “right.” The years after the discovery of Germ Theory, however, shifted the concept of disease from having an environmental basis to having a microorganismic basis, and this scientific finding gave allopathy a distinct advantage over other medical sects. Importantly, there was a shift in the focus on disease symptomotology to disease etiology (i.e. the mechanism by which a disease develops). Allopathic physicians were now able to more effectively treat and cure diseases. With the power of important scientific findings, political clout, and good strategy (i.e. pairing up with laboratories and hospitals, and absorbing other sects to varying degrees, including surgery and osteopathic medicine), allopathic medicine became just “medicine.”

Along the way, allopathic medicine developed many important scientific tools by which to improve the practice and efficacy of medicine. Among these are the randomized controlled trial (RCT), the gold standard of clinical research, and newfound emphasis on evidence-based medicine as a primary means to guide practice (as opposed to anecdotal or experiential evidence alone as overriding or primary guides). While responsible for much of the progress medicine has made in improving the effectiveness of health care, the efficacy of mainstream American health care is more questionable. That is, we have powerful tools to treat and cure diseases, but these tools, for many reasons, are not always producing the desired outcomes of maintained or better health.

I am not yet in a position to comment extensively on these reasons, but I can identify a few. First, there is great disparity in the delivery of health care technologies and services to all Americans. Secondly, failures in either the practice of the art or science of medicine may not achieve desired outcomes. In communicating with patients, we sometimes miss important details in their histories or their observations. In determining diagnoses and treatments, we sometimes make mistakes due to poor scientific reasoning. Finally, a third reason is that some patients (and their physicians) find that conventional medicine has little more that can be offered to them: they are told that “There is nothing more we can do for you.”

During the summer of 2004, I worked in the Editorial Offices of the New England Journal of Medicine, obtaining early critical thinking lessons from the Editors, some of the most talented and experienced minds in the realm of clinical research. That same summer, I spent a few weekends with an alternative medicine practitioner, a martial arts instructor who began applying his traditional Chinese physical therapy techniques to perform qi gong treatments on patients who found themselves left with no more options available from Western medicine. True to form, I approached these experiences with both curiosity and skeptical analysis. The practitioner, an American-trained physicist by training, became curious in alternative therapies when friends began to ask whether his qi gong exercises associated with his martial arts instruction could be applied to medical problems. Over the course of several years, word-of-mouth brought dozens of patients to his doorstep. To name a few: a woman who previously had encephalitis and subsequently developed epilepsy, a baby with an untreatable fever, and a patient with Parkinson’s disease. I saw the first two, and heard about the latter.

1. The woman with epilespy had seen the practitioner a few times, and each time, she and her husband attested that she appeared to be having fewer seizures. She had been taking antiseizure medications, but she claimed that there were no noticeable reductions in symptoms until she started seeing this alternative medicine practitioner a few months later. (Did the medications have a long latency period before becoming effective? Were the medications ineffective? Did the qi gong treatments reduce the seizures, or did they have a placebo or complementary effect?)

2. The parents of the baby were very concerned: their doctor had given them medications to reduce the baby’s fever, but the baby’s temperature was not going down. After seeing the alternative medicine practitioner, the baby’s fever immediately disappeared and did not return. (What happened here? Again, was latency of the medication the issue? Or did the qi gong pracititioner have some effect in reducing the fever? I think a placebo effect is somewhat less likely here, since the baby probably would not have known what was going on.)

3. The story of the Parkinson’s disease (a disease marked by the progressive degeneration of motor function or muscle use) patient was the most remarkable, though must be approached with sufficient skepticism. A patient was brought in by her family: she was almost completely immobile and couldn’t talk. The practitioner allowed her to stay at his house for daily treatment. After a few days, she was able to move her hands. After a week, she could sit up. After a month, she was able to stand on her own and have enough coordination and strength to play catch with the practitioner.

These are anecdotes, and should not be considered sufficient evidence to advocate this method of therapy. However, there is compelling evidence to suggest a closer examination of the scientific basis for these healing and restorative effects. The practitioner actively and assertively tried to find researchers in Boston to study these forms of therapy as well as to identify a scientific basis for the phenomenon of qi. However, to this date, he has not had substantial success in recruiting the interest of researchers: even if they are interested, they aren’t willing to spend their time and money or risk their credibility in studying a topic far outside the realm of conventional medicine.

I personally have no intention of seeking to practice or incorporate complementary and alternative medicine into my practice of medicine: the current proposed applications for these very diverse therapies are not yet in fields that interest me. However, I do believe that CAM will be an important part of my practice. Why? It’s not that I would bring it to my patients; rather, my patients would bring it to me. As much as $27 billion was spent by Americans on alternative medical therapies yearly in the late 1990s, and this number has likely grown since then. There are many ways that I, as a future physician, could choose to approach the topic of CAM therapies: I could ignore them, I could discourage them, I could encourage them, or I could try and work as closely as possible with the patient to see how conventional and alternative therapies could work together.

Many patients are afraid to bring up the topic of CAM therapies with their doctors: they’re afraid of being berated and made to look stupid for choosing something that isn’t based in hard scientific fact, even if their personal experiences suggest that they are garnering benefit from CAM treatments. This is a very serious problem. CAM therapies are very heterogenous: some may be harmful if used to the exclusion of conventional allopathic medical therapies or they may even produce undesired side effects used in conjunction with those prescribed by their doctors. How, then, is it helpful if physicians turn a blind eye to alternative medical treatments or make passionately blunt claims that only an idiot would consider to use CAM therapies? Only a very bad doctor would be so callous as to fail to consider the reasons why a patient would choose CAM therapies over the advice of their doctors. By failing to consider these reasons and motivations, by failing to be willing to talk to patients openly about CAM therapies, we as physicians would only appear to be protecting our own financial interests. Science, one of the two pillars guiding medical practice, is an imperfect and constantly evolving construct. This is, in fact, the reason why science is so powerful: because unlike unflexible dogma (often connected to religion and faith-based concepts of disease), it can change. There was fierce controversy and debate during the late 1800s when Germ Theory was introduced, and many allopathic physicians refused to believe that microorganisms could cause disease. There was uncertainty then, and there is still uncertainty now about many scientific issues in medicine. For example, scientists and physicians alike do not know the mechanism through which many anesthetic drugs function: we have a rough understanding of the areas of the brain that are affected and the corresponding effects, but not enough to be considered “well-understood.” However, the use of anesthetic drugs are a standard of practice (although many surgeons once discouraged the use of ether, one of the first anesthetics, because they believed that hearing the patient’s expressions of pain was an important tool for guiding surgical protocols).

Rather than be bigoted in our approach by tenuously upholding “science” as our only guide for medical practice, physicians need to be open to the discussion of the reasons behind patient decision-making. Physicians, for so long, have long assumed that they are always right: this paternalism has both upheld the professional integrity of medicine and fractured the doctor-patient relationship. In most cases, physicians are right with respect to the science, but this doesn’t always mean that what we advocate is right for the patient. Just as physicians cannot decide whether or not a patient should live or die in the Intensive Care Unit (ICU) (i.e. a patient has the right to withold life support if he/she would die otherwise), physicians cannot decide what treatments a patient should have: only the patient can decide whether or not to accept the advice of physicians (except under extenuating circumstances, such as in emergent situations). The sooner physicians admit this to themselves, the sooner we can better communciate with patients about the decisions they make. This is especially important on the topic of CAM therapies: while some may be useful and may someday become standard practices, some may be very unhelpful or even harmful. However, physicians have no true credibility in discouraging the use of a particular CAM treatment until they are willing to acknowledge its existence, the status of research into that therapy, and the reasons why patients might choose this alternative treatment. Science cannot be used as a singular end-all to all discussions, lest we lose the trust of our patients. It is important, perhaps the most important guiding principle, but we have more than science at our disposal to help us treat our patients. If we believe that we only have science as a tool for helping our patients, then we are no better than some scientists with their lack of the ability to apply science to the real world, and most importantly, to real people. Where some scientists lack sufficient ability to interface between abstraction and reality in matters of life-and-death, we have chosen this profession because we can. We can understand people: their fears, desires, and motivations. Accordingly, we must not give up a chance to understand and help our patients because of our arrogant belief that our science makes us right.

My Minority

One of the big catchphrases passed around the medical community now is cultural competence, referring to the need to understand the beliefs and principles guiding patients and their life choices. Cultural competence is usually used in the context of mainstream American physicians serving ethnic and racial minorities. It occurred to me recently that I also belong to a cultural minority that has its own “eccentricities” and difficulties: New Orleans natives. During the past year, the city of New Orleans and its current and former residents have received a lot of media attention. For perhaps the first time, a great exodus of New Orleanians brought this city’s residents all across the country as refugees from one of the most severe natural disasters in recent history. Of course, this event may not compare to natural disasters elsewhere such as the tsunami that occurred not long before, but it was remarkable for many reasons, if only for the fact that America as a nation was once again faced with the opportunity to witness true suffering on its doorstep. Did we respond appropriately, and with enough compassion? Those are goals for any physician: to respond appropriately, and with compassion. As a nation, it’s easy to state comfortably that we did so in the wake of the September 11, 2001 terrorist attacks. I think the case is much harder to make with respect to Hurricane Katrina and its aftermath.

I don’t mean to point fingers or write at length about the many instances where we, as a people, failed. I do believe, however, that I have something meaningful to convey in speaking to fellow physicians-in-training like me: physicians must be individuals with great emotional wealth, both in capacity and generosity. We must use this ability to understand the suffering of others, to help ease that suffering, and perhaps even to help abolish that suffering altogether so that all that remains is the memory, hopefully one that can be erased with future happiness. I know that many of my readers are classmates of mine here in the city of New Orleans, and others are fellow physicians-in-training who are friends of mine who know how much this city has played a role in my life. To those of you, it should seem apparent why it would be important to know the character of the suffering of our patients. To others, this account might help remind you of the depth of suffering many around the world face every day, as well as the great opportunities that we as physicians will have to address this pain.

Here is my attempt at (as brief) an explanation (as possible) of how these people have suffered, and how this affects and reflects who these people are – my people, the people of New Orleans. I can’t offer any accounts of a miserable week in the Superdome, of rowing in a boat to help rescue fellow New Orleanians on their rooftops, or of experiencing the cold reception of Houston residents as a Katrina refugee. I can, however, offer a little perspective on how people think, what they believe, and how we can help ease their suffering.

My City

New Orleans may be seen as a city of the decadent, the lazy, and the destitute. It may also be noted for its great socioeconomic and racial disparities, its poor potential for economic growth, and its remarkably high murder rate and gang violence, all of which are intimately intertwined and codependent. It is an imperfect city, and so accordingly, are the people who call it home. They eat, drink, and party excessively, often with little thought for the future. And yet, despite all of this, why would I be fond enough of this place to call it home and these people to think of them as my extended family? I do none of these things in excess, nor am I fond of this city’s vices. I am, however, a person guided by love, and in my travels and my experiences from living in four different cities, I have found few other places in this world where the people live their lives so full of the energy generated by the love of a place, the love of a way of life, and the love of those around you willing to share this life with you. I’m not referring to decadence or lack of ambition or “the big easy” lifestyle that people associate with this place: instead, I find that as a whole, people here are more willing to find friendship and good in those around them, be they friends, neighbors, or new people in their lives, most of whom become fast friends. When people came back to New Orleans, against their “better judgment” and logical economic sense, it wasn’t because New Orleans is a great cultural center or an important port for Gulf trade and industry. These are all just excuses to be made to those who don’t understand. It wasn’t for these things that people came back: it’s for love, of the place and of one’s own people.

I went to college with three friends from high school. Although we were friends previously, we had our separate groups of friends in college and didn’t spend much time together. However, after Hurricane Katrina, when we resumed our undergraduate studies, we inexplicably gravitated towards one another. Without any word spoken, it rapidly became aware to us that there was so much we shared in common with one another, and there was little that we wanted more than just to be with others who understand what we’ve just been through. While others would ask us “Is your family ok? Did you lose anything in The Storm?”, it’s difficult for us to believe that any of them can really empathize with us and what we had been through. Though we asked the same questions to each other, it had a different meaning: we knew that we could understand one another because we spoke a common language and shared a common identity through the experience of having lived in New Orleans. It wasn’t exactly insulting to have others presume that they could possibly understand what we went through, but it was awkward and alienating, as though we were the new “Exhibit A” to be talked about but not touched. Others around us could show a degree of sympathy, but not empathy. Nonetheless, by most measures, we made it out well: two of my friends and I had minor damage to our houses, one of my friends lost his house due to flooding, and my father lost his job (placing my family in a very unstable financial state until he found a new one more than a year later). However, we were alive, none of us lost family members, and we have great prospects for resuming our lives with minimal impacts of the storm on our educations, careers, and social lives.

Understanding Suffering

However, when I look upon my medical school classmates, particularly those from other cities and states, I wonder if they can possibly fathom the extent of the suffering that other New Orleanians suffered and still suffer. How can they possibly understand what it would have been like to live for a week in the Superdome: sleeping on the stadium seats, the filthy-beyond-belief bathrooms, and the rumors and possible reality of rape and violence in the absence of order and authority? Struggling to survive in the Convention Center, completely overlooked and forgotten by FEMA’s leadership for several days? Or hitting even closer to home, could they imagine what it would have been like to have stayed at one of the hospitals or medical campuses during that terrible week, waiting desperately for the rescue helicopters to arrive while being shot at constantly by gangs, now equipped with stolen rifles and handguns, trying to break in? To those who don’t believe that Post Traumatic Stress Disorder is a serious medical problem, I invite you to live in a war zone, a world turned upside down, for a week. On top of that, stuck at the edge of existence, imagine hearing that the national government and the rest of the country doesn’t care enough about you to do all they can to help. Instead, they respond with hesitance, judgmental criticism, and half-hearted efforts. Once a city of love, it became a city of hate and hopelessness: hate of the betrayal felt as we were abandoned with our dreams of a beautiful New Orleans broken, and hopelessness as everything we once loved decayed into chaos so rapidly.

These are memories that most people would rather forget: the days when all of the problems we thought we had addressed reared their ugly heads and destroyed the self-image of the city. These are also things that the mass media was urged not to report on extensively, for fear that the rest of the nation would sour to the prospect of helping the people of New Orleans. When we were all in the same boat, how could some of us turn against one another? This was perhaps the most emotionally traumatic consequence of the hurricane, this manifestation of all our vices: having the gang war cycle of violence normally isolated to the gangs suddenly be turned on the rest of the populace in the moment of chaos and uncertainty. In particular, a number of young black men in gangs, having looted guns from a local Walmart, were said to have tried to “take over the city.” Some people might say that these troubled youths were simply gang members, not members of the same family that we belong to. Could that be any further from the truth? I hate the fact that even my mention of the phrase “young black men” automatically causes some people to subconsciously label them as “other.” I once found it remarkable that I had personally experienced more racism in Cambridge, Massachusetts than in New Orleans, Louisiana. I sometimes, perhaps naively, believed that New Orleans was a special place where people were actually trying to ease race tensions on a social level, and hopefully someday, on a socioeconomic level. And yet, race became an apparent issue in the wake of the hurricane, particularly since it became apparent that the relatively peaceful coexistence of races prior to the hurricane was more tenuous than some of us believed: it was dependent on the “good life” and good will of the people of New Orleans, but those suffered greatly. Likewise, the pains of the school system, the lack of stable employment opportunities, and the vicious murder cycle among gangs that were always here blazed brightly before us, now that we were awake from our complacent state.

I consider myself to have a vivid imagination, but even I can’t fully grasp the extent of the suffering felt by New Orleanians who lost homes and family members to the hurricane, let alone the horror faced by many New Orleanians trapped in the city in the wake of the storm. However, even if I can’t know the suffering in full, I can care about it and the people who suffer, with all of my heart, each time I encounter someone who has felt this pain – it comes naturally, because these are my people and I understand them, even if I don’t fully experience their pain.

Hard to Heal

For a long time, I was hesitant and uncertain about the prospect of returning to New Orleans for the first stage of my medical training. The inverted image of my hometown, turned upside down and ravaged, constantly visited me in both my dreams and waking hours, and thousands of miles away from New Orleans, I felt wave upon wave of despair and betrayal. A large part of me didn’t want to come back; it wanted to forget and cut ties and not take up the responsibility of addressing the great suffering I knew existed. Like so many who chose not to return to New Orleans, I didn’t want to face any more pain then I already felt. Furthermore, like many of my classmates, I wondered whether I was making a risky gamble to seek training at a financially-troubled school and in a city with a broken health care system. However, each time I cried myself dry, I knew one thing: that although I don’t expect to live in New Orleans forever, I didn’t want to leave the city with bitterness in my heart. There are some wounds that cannot be easily healed in a convenient context – another time, another place. I came back, with apprehension, but rapidly found many of the things I once loved to be intact. Despite the apparent devastation around us, I found that those who returned (from all walks of life, all socioeconomic classes, all races and creeds) still remembered what it was like to be a family, to have a warm and congenial degree of commonality, and they were also now ready to address those problems that tore our city apart. Each smile and sign of hope I see around me balances out each tear I shed in the days as I waited to hear whether my parents had made it out of the city alive amidst the gunfire, the days when I silently absorbed the vented bitterness and depression of my father, and the days I fought with myself over the prospect of returning to the place I had thought I would never get a chance to see again. I think I’m making good progress so far. I hope I can help others find redemption and healing in a similar way.

What Physicians Can Do

The example of New Orleanians and what they have suffered is a meaningful analogy to the role of physicians in the lives of their patients. We often bemoan the shortening of time given to each patient encounter (especially in private practice), and people often attribute this to a distancing in the doctor-patient relationship. I believe, however, that we can do better, regardless of the amount of time we have. The moment someone tells me they are from New Orleans, there is something I instantly know about them, and my heart immediately opens up to their suffering. I hope that someday I can react this way to the suffering of all of my patients, regardless of their backgrounds and identities. Likewise, I encourage all physicians-in-training to learn how to truly open their hearts and minds fully to the patient sitting before them: to address and treat the suffering as well as the disease, since treating just the disease would mean that we’re only achieving half of our mission. There’s so much to know about another person, but we cannot afford to be overwhelmed to the point of hesitancy, apathy, and inaction. I personally do not belong to any specific faith, but I do believe in a commonality shared by all people: we are a family, and we should try to understand and care about one another as we do with the friends and family we currently recognize as being our own. Perhaps in believing this, I belong to a cultural minority. If so, I hope that all physicians belong to this same group, and that all physicians-in-training aspire to be part of it.

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