Monthly Archives: November 2008

My clerkships in Pediatrics and Obstetrics & Gynecology have afforded me a glimpse into areas of medicine I had not spent much time exploring before. In particular, my view of medicine has always been centered on the experience of the ill, suffering patient. However, these two fields have shown me another side: the treatment and health management of patients who are well.

In Pediatrics, especially in the outpatient clinics, the vast majority of the patients were described as “well-nourished, well-developed” children. On those clinic days, most of my time was spent playing with kids during the physical exam (some seem to love stethoscopes), terrorizing healthy three-year-olds with otoscopic inspection of the ears, or determining which vaccinations were needed to help these children catch up after interruptions in health care due to Hurricane Katrina. The kids that were on the inpatient service were similarly remarkable in that most of them bounced back from illness very quickly while only a relative minority were committed to extended stays. Those young patients who did have to stay in the hospital for a long time were very sick and sometimes had superimposed difficult social situations and had to be in the hospital for months (or even a year or more).

Thus far in Obstetrics & Gynecology, I have found a similar situation: the patients are generally quite healthy. Most of the Obstetrics patients are young women in good health proceeding down relatively routine courses of pregnancy with regularly scheduled visits and sometimes the ability to plan for events in the near future. Some doctors and medical school instructors joke that pregnancy is one of the most common and oldest “diseases”: if so, it is the one for which we have a detailed account of its natural history. As a male junior medical student, I have often found myself during these early weeks of the clerkship in the situation where there is relatively little that I know beyond the knowledge of a multiparous mother (one who has given birth multiple times) about the experience of pregnancy and its complications or beyond the knowledge of a postmenopausal woman about the changing predictability of the behavior of the female ovaries and uterus.

However, I suspect that the absence of a great burden of disease (on a routine basis in general practice) in these two fields is replaced by the price of social catastrophes. How can we best respond?
• During my ten days in the PICU, I frequently visited the crib of a baby whose mother, a cocaine addict, could not properly care for the baby. Although at the age when most babies develop stranger anxiety, he always looked up at me and every other nurse and doctor with affectionate eyes and a throaty, tracheostomic giggle of greeting, a testament to both the lack of a consistent caretaker and the love showered upon him by the “Mother Hen” within each of us. Though unspoken, I think we were all determined not to let this baby fail to thrive for a lack of affection.
• As a pediatrician, how do you deal with clear displays of bad parenting? I have encountered parents who repeatedly shouted at their children to “shut up,” publicly embarrassed or simply annoyed by the noise disturbance. At what point is it a sensible and useful expense of time and energy to intervene?
• It is hard to underestimate the impact of a positive test for a sexually transmitted disease (STD). Without even considering the life-threatening nature of HIV, the common diagnoses of Trichomonas vaginalis infection, gonorrhea, or chlamydia bear an unpleasant social stigma and insert a sharp wedge between a woman and her sexual partner (usually a boyfriend or husband). These infections, in almost every case, can only be passed sexually (not from a toilet seat or clothing), and they implicate either the woman or her partner in an act of infidelity. Telling patients bad news with regards to fatal or debilitating disease is very difficult, but these diseases usually attribute no blame: many people view them as matters of chance, and we as physicians sometimes propagate this mentality by speaking about “odds” and “risks.” However, to see a woman almost instantly burst into tears upon hearing the diagnosis of a sexually-transmitted infection is heartbreaking, for both the patient and the physician who is not yet hardened to the sight.
• I observed a dilation and curettage procedure performed on a mother of advanced maternal age who previously had a spontaneous abortion (miscarriage). This time, she and her partner tried in vitro fertilization (IVF), yet their efforts yielded a fetus without a detectable heart beat. After waiting for the “products of conception” to be expelled from her uterus for several weeks, the patient and her obstetrician decided that it was time to throw in the towel and remove the conceptus surgically. Before the surgery, as I waited with the patient in the preoperative area, I wondered about the feeling of alienation that patients must feel as they lie on a stretcher with nurses and doctors engaged in a wall of conversation around them that does not include them. For better or worse, I told her that I was sorry to hear that this attempt (at pregnancy) did not work. She gave a sad smile and a shrug. After the operation, in the postoperative area, I saw her wake up in tears, the façade of strength and reserve no longer necessary to uphold.

In other fields I have experienced, disease is simply disease: the worst thing you can do is die or continue living in extreme suffering. However, Pediatrics and Obstetrics & Gynecology carry a heavy emotional burden with each abandoned or abused or neglected child, with each miscarriage or stillbirth, and with each diagnosis of an STD. Pediatricians do seem to draw strength from the innocence of their patients, and obstetricians find joy in bringing new life into the world. Are these joys enough to help us deal with the pain?

Tonight may mark the beginning of a better future or the continuation of a downward spiral in the fortune and well being of the American people. The two presidential candidates offer drastically different pathways toward change in the health care system. The merits of each plan may be debatable, yet the greatest concern I hear from the mouths of a vocal handful of resident physicians and medical students has little to do with health care reform: instead, they are concerned with income tax. Some resent being “in the same tax bracket as Donald Trump,” while others find disgust in the notion of a welfare state. To those who believe this, I offer this challenge:

According to an analysis done by the nonpartisan Tax Policy Center on the tax plans of the two candidates, families with incomes up to $603,402 (99% of the population) will see a reduction or no change in taxes from the current level. Given the current level of physician salaries (most ranging between $100,000-$300,000), would you still be sufficiently opposed to a tax increase for the top 1% of income such that you would vote against a candidate actually willing to address health care issues?

It is clear from his policies that McCain has little to offer for American health care, let alone other domestic concerns. For most of the past century, America’s health needs has subsisted on a combination of employer-based health insurance that gives employers tax credits and the government-based (“welfare state”) Medicare and Medicaid programs. For the first time, a presidential candidate (McCain) wants to remove the incentives for employers to provide health insurance and replace health care plans with an insufficient tax credit: he seeks to reduce demand for health services by making patients keep track of their own health care bills. This runs contrary to the efforts of physicians, public health professionals, and policy makers toward improving preventive and primary care: the odds are currently stacked against the routine provision of preventive care to patients, and making patients pay for their health care bills out of pocket will further weaken primary care. The idea of “catastrophic health insurance” is attractive for a population of optimal health, but anyone with familiarity with the dual problem of increased out of pocket payments and increasing health care costs experienced in other countries understands the inapplicability of this idea at this time.

Obama’s health care plan is far from perfect, but it offers guidelines for improvement, and more importantly, room for expert participation:

Electronic Health Information Technology: Obama plans to spend $10 billion per year over the next five years to develop a standardized electronic medical records system which will help with quality measurements, reduce medical errors, and reduce costs from redundancy (e.g. reordering the same or unnecessary tests after transferring a patient). It is absolutely essential for physicians to be involved in the process of developing such a standardized system as it is partly due to the lack of adequate physician participation that we have disorganized, expensive, and user-unfriendly EMR systems. Here is a push from the top for a standard approach: all we need to do is say what we want.

Disease Management Programs: These programs are designed to aid patients in managing chronic diseases by providing information, reminders, and cost-effective services to coordinate care. Unfortunately, these are services that should be provided by physicians who are sometimes failing to routinely provide them, often due to time pressures imposed by their practices or their payers. My step-mother, a physician, is a staunch opponent of these programs for she believes that they disrupt the physician-patient relationship and lack coordination with a patient’s physician. I agree with her reasons for opposition, but I do not see these programs as necessarily evil: I believe they are a product of a lack of communication and coordination that we can improve upon.

Pay for Performance: Medicare and a newly formed health insurance exchange would both use P4P measures to incentivize better care rather than increased volume of care provided. Currently, the measures are variable in quality, and again, this is an important area for physicians to participate with respect to refining performance measures to match medical and health care quality!

Address health care disparities: One of the more complicated issues in medicine is the fact that people of different races and backgrounds get different types of health care for not entirely known reasons. In keeping with the our professional code, it is important for physicians to constantly strive for equality and just practice in medicine.

Address malpractice: Obama’s plan intends to reduce malpractice insurance costs for physicians by strengthening antitrust laws. This will help, but I think that physicians can help address patient safety and improve the patient-physician relationship (goals of the Obama plan) by setting up better methods of screening and evaluating malpractice cases (e.g. health care courts or panels) and delivering more, smaller compensation payments to those who need them.

Cheaper drug prices through importation, Medicare price negotiation, and forbidding anti-competitive measures: We want cheaper drug prices for our patients. There are enough reasons and issues that might hinder a patient from adhering to a medical regimen, and we don’t want cost to be one of them!

Reduce catastrophic expenses: Obama’s plan intends to have the government assist employers in providing health insurance to their patients by reimbursing them for catastrophic health expenses. The current estimate is that five percent of American patients account for 49% of expenses each year (although that five percent isn’t necessarily the same people from year to year). I’m not certain how Obama’s administration will cover these costs, but it is important for physicians to make sure that costs are not cut from other important health care provisions to address this issue.

Establish a National Health Insurance Exchange: In addition to the overall benefits of reduced paperwork, portability and simplified enrollment, having a good national plan (in addition to other private offerings and Medicare and Medicaid) can help reduce the amount of uninsured or underinsured patients with the promise of guaranteed eligibility: patients with preexisting conditions, often screened out by insurance companies who don’t want to pay their health care costs, won’t be penalized for being sick.

Health Care for All Children: It is shameful that the country with the most advanced medicine and the greatest potential for political, social, and financial freedom is unable to provide healthcare for all of its children and young adults. Obama’s plan includes a mandate to provide health care for children under 18, expansion and support for the safety net programs Medicaid and SCHIP, and better options for young adults up to age 25. In the past, physicians (pediatricians) reversed standard practices and stepped forward to protect children from child abusers and sexual abuse. It is time again for physicians to advocate for America’s children to give each one a chance at being a healthy, productive member of society.

Preventive health care: Obama’s plan seeks to address preventive health care at multiple levels, from individuals to schools to employers to cities and states. In order to properly address health care and medical issues, this vision requires experts. Who will step up to the plate and provide the information and leadership to make this happen?

For a long time, the large infrastructure of insurance, health management, and pharmaceutical/biotechnology companies have manipulated physicians and lulled them into a false sense of security and autonomy. Some physicians cling to the notion that they are able to practice independently from the influence of these powers and that if they fight health care reform (from the “big bad government”), they will retain what little autonomy they have left. This is a delusion, and failing to address the larger problems in health care will further weaken the role of physicians as independent operators and leaders in health care and in society. For the first time in recent history, a future President is offering a compelling vision for a better future that is neither unilateral nor drastic in the intensity of change. Instead, we have before us a picture of a path toward gradual, thoughtful reform. It is our job to bolster its strengths, correct its flaws, and do what is best for our patients and ourselves.

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