The Chicken and the Egg

When intelligent discussions about politics ensue, the fundamental basis of the discussion is always a question of human nature: it all comes down to how we see the people we are not, “the others.” Conservatives bemoan the creation of a welfare state, and they worry about the old adage about the hungry man. If you keep giving the man a fish, he will never learn to care for himself independently and will forever be a beggar (of course, conservatives in this country don’t really care much about teaching the man how to fish either). Liberals tend to have a wider, more diffuse set of reasons for helping the hungry man, but for them, it is always a question of mercy: for whatever reason, whether self-serving or mutually beneficial or truly altruistic, that man needs the help we can provide.

At face value, the conservative argument seems more compelling and solid. It is simple and logical. Conservatives hate the idea of their tax dollars going to pay for the next box of cheap wine that the bum on the corner is hustling for. Unemployed. Homeless. Dependent. Worse still, perhaps, are the thousands of Americans who could work, but are instead “gaming” the system through “disability,” perpetual “self-inflicted” impoverishment, etc. (These words come straight from the mouths of 15-year-old, Polo-clad teenagers at my high school responding to the question “Would you pay more in taxes for this? Why or why not?” posed by a history teacher.)

However, this fundamental argument lacks an understanding of the impact of sickness, and it is weakly supported by the conveniently muddled “chicken and egg” structure of its argument. Which came first, the poverty or the welfare system? In other words, knowing that there are people who abuse the welfare system, would the same amount of poverty exist if there were no welfare system to perpetuate it? Would providing more welfare worsen the problem or help it? If the government pays for health care for poor people who get sick, would those poor people keep themselves suspended perpetually in poverty to keep reaping the system for benefits? The answer: it doesn’t matter if the chicken or the egg came first. The solution: eliminate one of them – in this case, eliminate the burden of disease on the impoverished, those who cannot afford private health insurance.

Unlike other burdens of poverty, sickness is pervasive: it affects the mind and its ability to concentrate on working hard and keeping things together, it affects the will to keep fighting for a better life it affects the body and its ability to handle the stresses of labor and discomfort, and more practically, it affects the number of days we work, the type of work we can do, and our performance each day and in trials for career advancement. If you don’t have your own home, you can still try staying with friends or relatives, share housing with roommates, or stay in public housing or shelters. If you don’t have a car, you can still ride public transportation (sometimes) or try to find work close to home. However, if you don’t have health – the basic ability for the body and mind to function normally in our society – then you are subject to the greatest disadvantage and means for disqualification from standard routes for financial stability, independence, and success.

If only our society can remove the inequity of health care disparities, then maybe we can finally come a great deal closer to achieving the equality of opportunity our forefathers sought to promote and protect (and take seriously the typical fallback conservative criticism that people aren’t working hard enough to help themselves).

Filed under: Apollo's Experiences, Improving Medicine, News Analysis

Big Man on Campus

Now that I am one week into my senior year of medical school, I can say with some confidence that feels quite different from my experiences as a (lowly) third year medical student. It is a great pleasure to work with third year students: not only is it enjoyable to teach and feel like one is helping someone else, but it is also gratifying to see how far we have come in developing clinical skills and a nascent ability to survive Medicine. The emphasis changes from surviving the wards (and the requisite clerkship exams for each specialty) to thriving as a young doctor. I am currently spending four weeks on a sub-internship, a trial where the fourth year medical student takes on the role of a first year resident with matching responsibilities, in my field of choice: Neurology. Clinical instructors often use the acronym “RIME” to represent the four stages of a medical student’s evolution: reporter, interpreter, manager, and educator. Most of a third year medical student’s responsibilities and expectations involve accurate reporting of history, physical examination findings, and laboratory and imaging findings as well as the development of clinical diagnosis skills (interpretation). Now, as a fourth year and a sub-I, I’m taking on more responsibilities as a manager (making treatment decisions and requesting studies) and an educator (teaching students, and occasionally residents, with less experience in a particular area).

On a personal note, I’m enjoying revisiting my field of interest after a one year absence and solidifying my fund of knowledge. I’m more confident now in my examination skills, assessments, and gut feeling. I’m also developing confidence and comfort in the notion that sometimes I know more than an intern and sometimes second-year residents: they’re not necessarily far from my present state of knowledge. Maybe next time I’ll even be confident enough when I hear someone with more experience than me ask “Which side?” when discussing an anterior communicating artery aneurysm to respond, “What do you mean? There’s only one.”

Filed under: Apollo's Experiences, Improving Medicine

The Battle Continues

The stage is set for major health policy reform, but there is no clear solution in sight. Part of the problem is that there is no one issue that explains all of the failings of America’s health care system: it is described as a “systems problem” exacerbated by malpractice litigation, decreasing health insurance coverage, decreased incentives for physicians to enter primary care, increased utilization of emergency resources, and many other factors. Having completed my Family Medicine (primary care) and Internal Medicine (hospitalist medicine) clerkships, I’m more aware now of the considerable ideological differences between primary care physicians and specialists. For example, the way physicians handle scientific evidence varies greatly. Many physicians in academic centers and hospitals are willing to change their practice of medicine based on a single, well-designed ground-breaking study. However, primary care physicians are much more conservative in their changes: while it may seem that they are “outdated,” they ideally focus on making changes based on a broad base of evidence (many studies over several years) to minimize costs and maximize effectiveness. In other words, PCPs don’t care as much about “expert opinions” and new discoveries and instead focus on what appears to be repeatedly proven truths.

There are great merits to both schools of thought, and American medicine benefits from having this dichotomy. It is clear that there is a problem with primary care in this country, and most people consider it to be a shortage of primary care physicians. However, I’m discouraged by the proposals that varies policymakers, physicians, and others make in an effort to solve this problem. For example, some propose increasing primary care payments at the expense of specialist payments. While this seems honorable to reassert the value of “cognitive” specialties (e.g. medical care based on actually knowing your patients and individualizing their care rather than medical care based on delivering specific treatments), it doesn’t seem sensible to “lower” the value of specialist care: after all, it’s the specialists that drive discovery and research (developing new and better treatments, discovering new knowledge on how to better treat diseases, etc.). Furthermore, there’s a shortage of specialists in many areas of the country (i.e. distribution is an issue). Others propose requiring medical graduates to do a year or two of primary care before starting their residencies. This proposal makes very little sense to me: what happened to the notion of “continuity of care?” It would not necessarily help patients to inject a fresh supply of young and inexperienced medical graduates into communities only to have them leave a year or two later (after seeing their patients maybe 3-5 times). Lastly, the AAMC is requesting medical schools to increase their enrollment of students by as much as 30% with hopes that this will increase the total number of physicians that can enter primary care specialties and practice in underserved areas. While this will likely help to some degree, this doesn’t change the incentives contributing to the current problems.

Some people seem to be bothered by President Obama’s focus on health information technology as an initial centerpiece of health care reform during his term, but this I do not see this as a fault. If anything, health information technology is low-hanging fruit: the lack of interoperability between electronic medical record systems and the continued reliance on paper documentation is a frustratingly backwater problem (e.g. reliance on fax machines, errors made based on poor handwriting, time wasted in documentation, etc.). There are many hospitals and communities in which electronic systems are very functional and useful, while there are also many others where it has been poorly implemented. Laying the groundwork for a more functional, national intranet makes sense with respect to reducing the long-term costs of overutilization: much the way medicine is practiced (e.g. ordering tests and interventions) revolves around finding information (that may already be available in older records and is not volunteered or remembered by the patient). While eventually all of the other issues will need to be addressed, I don’t think it is a problem starting with a relatively more straightforward issue.

Filed under: Apollo's Experiences, Improving Medicine, News Analysis