If Only I Had Known

Lately, I’ve been reading more and more medical blogs, and it has been interesting reading that of an Emergency Medicine resident who comments at length about health care coverage. While I sometimes find his writing to be dramaticized and overly cathartic (as amusingly demonstrated by both his comment thread fans and his passionate critics), he tends toward intelligent commentary and analysis of the push for universal health care. Furthermore, his stance is decidedly conservative, and I would likely find my future pursuits to only appeal to half of this country if I didn’t at least occasionally listen to perspectives such as his.

I’m still trying to figure out my own perspectives on what universal health care would ultimately mean for the U.S., and how it would best be implemented. While I don’t necessarily believe in single-payer systems, I do think that charity-based “safety net” health care should eventually be phased out (albeit at different rates for each region): New Orleans is the perfect example of a city that currently needs a safety net, but can benefit from setting a timeline toward mandate-based policies requiring and facilitating health insurance ownership/coverage for all citizens (as currently in the process of being implemented in Massachusetts, which is the plan Secretary Leavitt is trying to force on Louisiana at a time when it might not be feasible – the verdict is still out).

On the one hand, there is the notion that we need to reduce health care costs. This is reasonable, but it is based on faulty interpretations. It is commonly cited that the U.S. spends more than any other country on health care, but it doesn’t have the best outcomes or population statistics (life expectancy, infant mortality, etc.). This is partly due to health care inequalities (the life expectancy for one community of East Asian women in New Jersey is 80+, while the life expectancy of Native American men in another community in North Dakota is around 55). This is also due to the large investments that the U.S. places on discovery: research and development of new treatments and medical technology (of which the U.S. produces more than any other country). Furthermore, Americans (who do pay for health care) pay for convenience and excellence: we pay for shorter waiting times (minutes or hours for tests, imaging studies, and procedures instead of days or months), and we also pay for the most highly trained physicians (high profiles figures in other countries are often sent to the U.S. for acute medical conditions). Lastly, the U.S. is a big, heterogenous country: in some ways, it’s like 50 smaller countries. Health care, depending on your measurement and subjective perspective, can vary considerably from state to state.

On the other hand, there is some compulsion toward “providing” health care for all American citizens. Some say it’s a right and criticize our willingness to propagate health care disparities that uphold socioeconomic disparities. Others point to the swelling of Emergency Departments with uninsured patients and the notion that these patients drive up costs for everyone else. Others argue that a penny in prevention saves a hundred dollars in later acute care. Others (me) suggest that people aren’t nearly as productive toward society when they’re sick and disabled as they could be when they’re more healthy. These are just a few reasons – there are probably more I’m forgetting to mention.

It seems that things aren’t going to get any better if we do nothing. However, if we push for some rendition of universal health care, we have to do it in a way that actually solves problems. Panda Bear points out in his comment thread that improving access doesn’t necessarily result in better health, especially since improved access doesn’t equate with improved usage of health care resources. I completely agree. However, this information is weak support (at best) for the argument that primary care for the poor and uninsured is a lost cause.

Where I disagree is in the assumption that people cannot make the right decision (because they currently aren’t making the decisions to improve their own health statuses). My thoughts on this issue coalesced (in my post-exam, semi-cogent state) when I read shadowfax’s criticism of Panda Bear’s reference to poor people as “people who don’t think and plan ahead.” It is often stated (usually by conservatives) that people make bad choices, and accordingly, we shouldn’t go out of our way to help them. Instead, it is argued that we should only help those who help themselves (assuming that we, the doctors, are in the right position to judge this). What sense does it make to applaud people who can afford health care when they choose to seek health care and criticize people who can’t afford it when they choose not to seek care? That is the current state of affairs. Now, if everyone were hypothetically covered by health insurance, would it make any more sense to criticize those people who still aren’t seeking primary health care?

My argument: no, that does not make sense. Why? People make decisions based on varying degrees of acquired information, and information disparities are considerable. One example is with smoking. Everyone knows that smoking is bad for you, but they don’t know why. Most people think that smoking leads to lung cancer, but this is only one effect: tobacco use also dramatically increases the risk of heart attacks and strokes. Furthermore, people say, “I’m going to die of something anyways.” What they don’t realize is how much pain and suffering they might have before they die, or how prematurely they may die. Pain and suffering from: not being able to breathe, gangrene, blindness, pain and lack of physical mobility due to heart failure, not being able to sleep well because of fluid in your lungs, losing mental and motor faculties because of a stroke, etc. Sure, everyone dies: but who dies in their forties and fifties these days? Who wants to spend the last decades of their life trying to sleep with three pillows tucked behind their backs because they feeling like they’re drowning when they lie down?

The CDC/U.S. Department of Health and Human Service’s “Chartbook on Trends in the Health of Americans” shows extensive data indicating that increased years of education correlate with reduced prevalance of smoking. In 2004, 29.1% of people who didn’t graduate from high school or get a GED smoked, 25.8% of those who did graduate, 21.4% with some college education, and only 10% of those who graduated from college smoked. While this correlation isn’t a proof of causation, it does suggest that people with access to more knowledge may have more accurate health knowledge on which to base their decisions. It’s a problem of value: some people don’t know the true value of health care they receive or preventive measures they might take. If they did, they might make the right choices (or try harder to, despite other obstacles such as financial costs, difficulty in finding resources, etc.).

I’d like to recall my story some months back about the young mother with her little girl that had a high fever and a bad cough. When I first saw her, the first thought on my mind was that she could be a typical, angry, impudent, noncompliant, charity patient with a tendency toward making bad decisions. However, that interpretation didn’t stick: it was completely wrong. The young mother had been waiting in the ER for almost eight hours; there were other places she needed to be. However, because she was worried about her girl, she came into the ER, foregoing a day’s worth of pay. However, as she waited for the chest x-ray, her doubts grew as to whether or not her daughter was really that sick. After all, it probably was just a bad cold, right? When the attending physician came to berate her for considering leaving AMA (Against Medical Advice), she obviously wasn’t happy. This physician was essentially accusing her of child abuse and putting her little girl in mortal danger. When the attending physician went away, she turned to me and showered me with questions. What is this medication for? What was the chest x-ray for? Why? She had no idea that pneumonia could be lethal: that up to 20% of untreated cases of pneumonia result in death. The doctors needed to determine whether her girl had pneumonia or acute bronchitis, but she had no idea why she was waiting for so long: if anyone had explained it to her, the message didn’t get across until she asked me. Was this privileged or complicated knowledge that I was passing along? No. But without it, she or someone else in a similar situation could have made a very bad decision. What if she didn’t even come in the next time? We might have a little girl with a fractured foot who might limp for the rest of her life. Or perhaps something worse. Either way, we might take the overly simplistic action of blaming the mother for making bad decisions. But we would be wrong.

Later this week, I’m going to be riding a six-hour shift in an ambulance truck with paramedics. This ambulance ride program is required for all first year medical students at my school. Though there is relatively little diagnostic expertise I can offer (at the most, I can do a Tier One physical examination and perform CPR), I plan to arm myself with what knowledge I do have available to me at this stage in my training that I might be able to pass on to others. The program director left us with the words you so often hear from the mouths of patients, parents, and family members in so many Emergency Rooms: “If only I had known.”

A skeptic might suggest that this is just an excuse; that people do know. However, this is the view of someone who blindly doesn’t understand why people don’t have the information they need. I have always been interested and acutely aware of deficits in knowledge, their effects on how much people can achieve, and what measures may be taken to amend this shortage of knowledge. Perhaps it may be worth it for me to make it a goal to make sure that “If only I had known” is a phrase that is never used again in the context of health care. At least, as it is used now.

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