Monthly Archives: August 2009

There has been a lot of talk about health care reform over the past month: much of the information has been repetitive, not based in fact, or purely sensationalist. However, there have been some well-written and meaningful pieces that have emerged above the din. I’d like to highlight a few of them here:

August 9, 2009 – NY Times – Robert Pear and David Herszenhorn – “A Primer on the Details of Health Care Reform”

This is a relatively concise and unbiased article covering some of the main issues of the Congressional health care reform proposals. It might be slightly outdated, but it’s hard to tell what real changes, if any, have been made since Congress is currently on recess. Various pundits and politicians can spread rumors about changes until they’re blue in the face, but it won’t mean much until the paperwork is presented again.

August 23, 2009 – Washington Post – T.R. Reid – Five Myths About Health Care Around the World

This article was passed along to me by a friend of mine who is much more internationally aware and better traveled than I am. It provides a brief education about some of the most common misconceptions about health care systems in other developed nations including the prevalence of socialized medicine and the overall quality of American health care compared to other systems. There are, in fact, several systems based entirely on (regulated) private insurance that have better health outcomes than the U.S.

One point I have stated previously and am always glad to reiterate is that many people in America fail to distinguish between medical care and health care: the U.S. likely has the best medical training, technology, and physicians (at least, on average, the best trained), but medical care is only one component of health care. Health care incorporates medical care, nursing care, rehabilitation, social work and case management, payment and insurance, drug and biotechnology development, hospital and systems administration, and perhaps most importantly, patient involvement and responsibility. In general, it appears that liberals seem to find fault in everything but patient responsibility, while conservatives find fault in nothing else but patient responsibility.

August 26, 2009 – Blog “Mind, Soul, and Body” – Repost: Medical Care, right or privilege?

One of my fellow bloggers reposted a piece he wrote last year. Although I don’t agree with everything in the post, there was a passage that I felt was particularly meaningful:

There is a certain basic concept that we are beginning to forget in our society, the concept of common wealth. Way back in the days of print media, communities would pool their resources to build a collection of books we call a library. This was because information and education was felt to be mutually beneficial if shared. The poor can only benefit from learning. We all can gain more as a group, enriching the whole, than any of us can individually. This is a way the group can protect resources from individuals who would devour or horde them. It turns out that together we have much more than any of us could ever hope to acquire individually. This is the thinking behind public museums, national parks. These are something different than commodities. They are actual sources of well being. This is our true wealth, and it is shared.

The common wealth of America are habitats, ecosystems, languages, cultures, science, technology, schools, social and political systems, democracy. These are things often so basic we sometimes forget how much we have. They are things we all value together and are well worth fighting for. So is medicine a right, or a commodity dependant on resources and wealth? My answer has to be an unqualified yes, it’s both.

I believe, sincerely in the depths of my soul, our commonwealth has to include medicine. We need to protect it, not exploit it. I doubt any of us could calculate what exactly any of these things would cost on the open market. I think it is safe to say that taken together our common wealth’s value exceeds all we could ever own privately.

August 7, 2009 – Kaiser Family Foundation – Side-By-Side Comparison of Major Health Care Reform Proposals

Finally, if you want to actually be truly informed about the proposals being proposed by various sectors of Congress, here is a consolidation of the information currently available as collected by the Kaiser Family Foundation, a nonpartisan health information group. One thing you will note is that President Barack Obama has not proposed a health care reform plan: in many ways, it is very silly for people to keep referring to a single health care reform proposal as “ObamaCare.” It is definitely a worthy argument that President Obama could, or perhaps should, take a stronger role in directing health care reform, and a few members of Congress have asserted this. On the other hand, there are multiple plans currently being proposed, all of which have various advantages and disadvantages, benefits and flaws. Instead of reading a thousand pages of triple-spaced legal-ese (the Dingell-House Democrat bill H.R. 3200), this table is 44 pages long. A shorter version provides details on the Senate HELP committee and House Tri-committee proposals, the main proposals being debated currently. Educate yourself. “Fight the stupids.” – Maple Street Bookstore Bumper Sticker


Since I first started writing about converting my iPod Touch to a medical PDA early in 2008, the iPhone and the iPod Touch have become ubiquitous in the hospitals where I work. It would be an extraordinary challenge to walk through the hospital without spotting a nurse, medical student, resident, or attending physician tapping their fingers on the touch screen of an iPhone or iPod Touch. Much like the wooden wands carried by wizards and witches in the J.K. Rowling’s world of Harry Potter, these items appear indispensable and multipotent, making everyday tasks much easier (like converting Celsius to Fahrenheit or calculating Glasgow Coma Scale scores), augmenting the practice of medicine with rapid information access (prescription medication dosing, information on obscure syndromes and clinical signs), and occasionally saving one’s skin (e.g. putting together a rounds presentation with five minutes notice, not that this has ever happened to me).

Over the past year, my usage of these devices has evolved considerably. Here is an overview of how I am currently using my iPhone 3GS, in descending order of most frequent daily use:


iPhone: Although I miss Verizon’s superior network in the New Orleans hospitals where I work, the AT&T network seems sufficient in most locations except the operating rooms and certain central corridors. For better or worse, Tulane Medical School is not interested in providing its students with pagers, so my cell phone has been my primary means of communication with my team.

Text Messaging: My Stroke Service team and my Surgery teams were very avid texters – I probably sent and received at least 10-20 text messages each day.

E-mail: Everything regarding medical school administration and course administration revolves around e-mail, including first-come-first-serve picks for clerkship sites. Having constant access to e-mail has changed from an addiction to an essential condition of life.

Calculation and Conversion

Mediquations – There are many medical calculators available, but I have stuck with one of the original apps. The creator, a medical student, has updated the app frequently with many new equations, resulting in a fairly comprehensive listing that saves one the effort of looking up a dozen different scales or equations on the Internet. Some of the ones I use most often are: Glasgow Coma Scale, NIH Stroke Scale, Temperature Conversion, and the Modified Rankin Scale (you wouldn’t guess that I’m interested in Neurology, would you?).

ConvertBot – I picked up this app when it was free. Although several of the functions are available in Mediquations, I love the aesthetic of the app which turns my iPhone into a little robot with a touch wheel that can rapidly convert units for temperature, pressure, time, volume, speed, fuel, currency, etc. I guess it mostly has a spot on my device for its cool factor.

Writing Prescriptions

Epocrates Rx – Although I have not used the Medscape drug database yet, the Epocrates database is much more comprehensive than the Skyscape database which seems to lack information on adverse effects. One of the main disadvantages of the Epocrates Rx database on the iPod Touch and earlier versions of the iPhone was its speed, but the iPhone 3GS completely eliminates that barrier to effectiveness. Along with the Interaction Checker and Pill ID (pictures of the pills, and searchability by the patient’s description), Epocrates Rx remains an essential part of my medical PDA’s repertoire.

$4 Formularies – At this time, Target, Walmart, Kmart, Walgreens, Rite Aid, and CVS all have reduced price formularies that are very useful when prescribing generic medications for uninsured or underinsured patients. These are available at And as a reminder, the vast majority of scientific evidence shows that generic medications are as effective as their brand name counterparts. However, the manufacturing and monitoring processes are marginally different, and some doctors will still prefer that their patients use brand name medications for some medications that are difficult to manage (e.g. warfarin) in order to avoid introducing another confounding factor.

Searching the Tomes of Medical Knowledge

• Sabatine’s Pocket Medicine – I have the red binder-paper version of this useful resource, but I have filled the little red binder with so many of my own clinical notes that I was happy to find a way to reduce the clutter in my white coat pockets. Of all the books to have on the wards during clinical rotations, I have found this book to be the most concise and useful across the board (I used it extensively during Internal Medicine and Family Medicine, and it also proved useful for consultations during Neurology, Ob-Gyn and Peds). Five years from now, I still expect to be referring to this book (most likely on the tenth version of the iPhone).

Massachusetts General Hospital Handbook of Neurology – This one was a very recent acquisition through Skyscape, an old name in the PDA book-porting business. I also have this book in paperback but again was excited to reduce the load in my pockets. The best part of the Skyscape format is that the book’s text is searchable, allowing for rapid retrieval (which is so important to maintaining efficiency on the wards). However, the tables and diagrams are not easily resizable when they extend beyond the screen’s borders: it is possible to zoom in, but using the “pinching” technique on the iPhone/iPod Touch also resizes the viewing window (making this maneuver unhelpful). Nonetheless, Skyscape, under pressure from users, has provided the option of allowing one to purchase full texts at full price as opposed to 1-year subscriptions.

Wikipanion – Although I do not approve of using Wikipedia as a research resource (e.g. citing Wikipedia = poor form), it sometimes proves to be the fastest method to find obscure information with a reasonable degree of quality (i.e. concise and direct explanations) and accuracy. For example, what are you going to do if your attending mentions Gradenigo’s Syndrome during rounds? Or what if your resident is talking about something called “Salaam spasms” that sounds a lot like West Syndrome but you can’t remember if they’re related? Like Google, Wikipedia is still useful when you need to cast a wide net to capture a piece of information you’re not familiar with before figuring out where you can find a more reliable resource.

Eponyms – Like Wikipanion, the free student’s version of Eponyms has its uses, particularly when faced with an old-fashioned (or just ridiculously brilliant) attending who likes to use the original names for various diseases and signs. For example, when your attending talks about the Monro(-Kellie) doctrine, she’s not talking about preventing further European colonization in the Western hemisphere.

Diagnosaurus – This little app from Unbound Medicine is a great, zippy resource; I just haven’t had the pleasure of using it much yet. Unfortunately, this app arrived after my Internal Medicine clerkship where the process of differential diagnosis is revered and protracted for the sake of education. I suspect it will become very useful once again when I do my preliminary year in Internal Medicine.

Brushing Up on Skills

Instant ECG – This program from iAnesthesia is well-designed and beautiful: I love the examples of real ECGs they provide as well as the video visualizations of the various arrhythmias (somehow, seeing the rhythms drawn out helps me remember them). I don’t consult it often on the wards, but I hope to keep referring back to it so until I know the major arrhythmias by heart.

Pocket Medical Spanish* – This program is another one I want to use more but haven’t had as many opportunities to recently. I like that the program facilitates communication between doctors and patient both verbally and visually (with enlarged versions of the Spanish phrases). I think this will become more useful when I do my Emergency Medicine clerkship. [Note: This is one that I actually received for free from the creator. It has also been one of the more expensive medical Spanish apps.]

Netter Neuroscience Flash Cards – This program has Netter’s beautiful neuroanatomical illustrations, but I find that it doesn’t always have the detail that I desire. Nonetheless, it is a useful resource when revisiting neuroanatomy during visits to Radiology or from Neurosurgery.

Everything Else

Things – Combined with the desktop application, this program is a wonderful GTD (get things done) solution that helps me keep track of my long-term tasks (e.g. the millions of things I need to do to apply to residency, to prepare for my wedding, etc.).

Groups – I just recently discovered this contacts management program which has provided me with a much needed service: helping me remember birthdays. Its main functionality allows grouping contacts (from the iPhone’s built-in app) based on user-defined categories or through “smart groups.” One of the neat features of this app is that you can e-mail entire groups, making it much easier to remember to invite everyone to dinner, to organize meetings, etc.

Clock – I like waking up to music, and the iPhone’s app and speakers makes this luxury possible. Maybe it’ll make waking up in the call room for prerounds slightly more palatable.

Tweetie, Facebook – Well, I need some way to stay connected with world beyond the white walls of the hospital. By the way, you can follow me (and my shorter thoughts, observations, and rants about medicine and related topics) on Twitter at LesterLeung.

WordPress – The engine for my weblog! I have posted or written drafts a few times while traveling, and it makes it easier for me to approve and reply to comments.

Shazam – The name even sounds like magic. I mean, it runs on magic right? How else can it identify the songs playing on the radio or in stores? Inconceivable!

Pandora – A radio station that actually plays good music based on songs and artists I like? And actually does an amazing job of selecting a decent variety like a good mix CD? If that’s not magic, I don’t know what is.

NPR News – While I prefer to use Google News to provide a broad range of news sources, I like that the NPR News app has streaming audio that I can listen to when driving to and from work. Sadly, radio in New Orleans sucks. A lot.

Camera – Not that other phones don’t have cameras, but I love that the iPhone has so many options for data transfer from the basic iPhoto synchronization to various apps that allow one to upload photos directly to online social sites or photograph storage sites. And it records video. Vraiment whoa.

* Disclosure: I received Modality’s Pocket Medical Spanish for free as a tester. There are numerous medical Spanish apps available for the iPhone and iPod Touch, but this is the only one I have tried so far (and thus cannot comment on its superiority or inferiority to other products).

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).

Glancing across the headlines and tuning in to the sound bites of angry protesters, it is remarkable to witness the various demonstrations of the qualities that make us human. Unfortunately, these demonstrations often display the ugly sides of our nature: the twisting of truths into fear-inspiring slogans, the murder of Kansas abortion practitioner Dr. George Tiller, and the carrying of an unconcealed firearm to the President’s town hall meeting in New Hampshire (legal, yes, but is there any question of the message this man was trying to send?).

The subject of health care – tending to our sick – is called a “deeply personal issue” by some, but it may be more accurately described as a “deeply interpersonal issue”: our distant ancestors, the first humans, broke with thousands of years of prior evolution to abandon the doctrine of strict Darwinism (the survival of the fittest, every man for himself) to care for our injured and sick and thus achieve a different type of community existence. Who will argue with the brilliance of the past few millennia of sophistication, cultural and technological development, and vastly improved quality of life? In the process of healing and caring for others, humankind has learned to shed suspicion and fear in order to trust another to aid one’s return to health. And yet, although we might see ourselves as more evolved, more advanced, more free, many of us still tend toward our old habits: terrified of the involvement of others in personal matters (e.g. invasion of privacy), the need to dominate others in lieu of being overpowered (e.g. shouting down others), and the fear of losing that to which we are entitled (e.g. rationing).

Underlying the landscape of fear is the one thing as of yet unachievable by the American dream, the holy grail of our modern age: immortality. Our people, our society, is deeply afraid of death in all of its forms: we are unwilling to think of it, unwilling to face it, and unwilling to admit that it may one day visit us – our loved ones, our friends, our parents, our children, and ourselves. Is our species a victim of its own success in its everlasting quest to prolong life? Is death so unfamiliar, so foreign, a thoroughly unwelcome stranger in our lives? Coupling our deep-set suspicion of others, of authority, with the thought of discussing the topic of dying, we suddenly work ourselves into a frenzy over state-mandated euthanasia. Who would want to talk about dying? How can any discussion of death be benign? Such are questions asked by those who have never seen excruciating pain in the eyes of someone who cannot speak, someone suffering in a frozen tomb of a paraplegic body. Such are questions asked by those who have not reached a stage of life where they can imagine being satisfied with the years gone by, with a life lived as fully as one can ask for. Such are questions asked in a society where the process of dying is hidden and enclosed within four white walls and the fog of privacy. In our society, families talk about death about as much as parents talk to their children about sex. It’s not prohibited as in some cultures, but it’s not welcomed either. Perhaps no life is lived perfectly, no life has a perfect ending, but every story, every life has an ending. Is it too much to ask to allow those who wish for it to know what’s to come, to plan ahead so that the process of dying is not as prolonged or painful?

One of the most important roles of physicians is the role of the guide: we might not always be able to save a life, but we can guide someone through sickness and death, where most people fear to tread. We save lives when and where we can – and we’re usually very aggressive about it – but there are times when our life-saving techniques and technologies lead to more suffering and pain. There is no role for physicians in assisting or intentionally causing death, but there is definitely a role for physicians in advocating for a patient with respect to minimizing suffering and pain. Most people would agree that they wouldn’t want to live the rest of their lives on a ventilator, with a needle in the neck and one in each arm, with a plastic tube through one’s urethra and another into the rectum, and the lowest likelihood of ever leaving this state of existence while alive. Of all the people in the world who can comment on life and death issues, physicians are the only ones who know whether or not their methods and treatments can help a patient recover some quality of life, whether independent or supported. Who honestly thinks it is a good idea to discourage physicians from taking this role as guide, leaving patients to squander in confusion and despair in the last months or years of their lives without any direction?

We may imagine that we are invincible, that we are immortal, but our bodies are more fragile than we would like them to be. It is not without reason that it is common for medical students to go through a hypochondriac phase: how can we live life knowing the hundreds of debilitating mistakes we can make with each passing moment, the thousands of ways in which our bodies can deteriorate and fall apart? The most common and adolescent response at our disposal is also the first stage of the grieving process: denial (that we, and our loved ones, will die). Many of those making headlines today have reached the next stage: (irrational and misplaced) anger – at the government for trying to “get between me and my doctor,” at doctors and hospitals for trying to “tell my mom and dad that they won’t receive care at the end of their lives so that they can save money,” and at everyone else for “taking my health insurance away from me.” It may be a very long time before our nation, as a whole, comes to the last stage, acceptance: that we all must die, that death is not shameful, that dying is natural – some even argue for the “right to die.”

The human body is an amazing creation, but like all machines, it will eventually reach a stage when it is irreparable and unable to function meaningfully. Determining what is irreparable is in the hands of the doctor; determining what is meaningful is in the hands of the patient. Finding the overlap between these two is the purpose of end-of-life discussions. At this time, these discussions don’t occur frequently enough, and not enough patients have living wills or powers-of-attorney to clearly designate their wishes. What many people do not understand is that doctors are not required to “do everything”: a patient or his family may “ask for everything,” but physicians can proclaim life-preserving measures futile and discontinue medical support. There are, of course, measures in place to prevent this power from being abused, and furthermore, physicians are in the practice of saving lives: the default is to do everything. If a patient can communicate and is conscious and competent (e.g. not delirious, suicidal, etc.), there is no problem: he or she can clearly say “I want to live” or “I am ready to die” and we can continue to do our work either way. However, too often we enter situations where a patient temporarily or permanently unable to communicate is stuck in limbo in the Intensive Care Unit: unable to survive without aggressive (and either painful or uncomfortable forms of) life-support from ventilation, intravenous fluids and nutrition, etc. Out of habit, the children and spouses of these patients often want everything done to keep their loved ones alive – at any cost. Unfortunately, that cost is not only paid in dollars but also in pain and suffering for the patient.

The leap from providing Medicare coverage for end-of-life discussions between physicians and patients to euthanasia achieves a unique level of preposterousness.

“This provision may start us down a treacherous path toward government-encouraged euthanasia if enacted into law,” House Minority Leader John Boehner, R-Ohio, and Rep. Thaddeus McCotter, R-Mich. said in a statement last month.

As emphasized by the legislators and the Obama administration, this measure is designed to promote these discussions, not mandate them. End-of-life discussions between physicians, patients, and their families are important in ways that most people inexperienced with death fail to comprehend: the current process of dying can be very emotionally painful and financially expensive when the desires of family members do not match the desire of a patient who cannot communicate (e.g. comatose, delirious, severely aphasic, etc.). The most sensitive and caring doctors I have worked with (who happen to be excellent arbiters of end-of-life discussions and decisions) hate situations where a spouse or child pushes to “have everything done” for a patient, resulting in months or years spent in a twilight daze with tubes and wires in every orifice and exposed blood vessel. Some of these physicians have submitted to me the observation that when critically ill patients are able to communicate their wishes in situations where the physician and the patient both understand that he is unlikely to recover an independent livelihood (away from advanced medical and nursing care), 99% of these patients will choose a comfortable, quiet and not prolonged death (withdrawing support). The hasty decisions of the spouse or child, then, seem to draw more from a selfish desire to “keep” the loved one “alive” in any shape or form. These situations occur very frequently, putting enormous financial strains on the family (after the prolonged hospitalization) and the health care system (thus overall reducing services that could be provided to other patients). In many ways, the advancement of life support technologies and techniques has outstripped our country’s philosophical and cultural maturation regarding death: we still want to live forever, but we don’t know what life is.

End-of-life discussions, when occurring outside of the setting of an acute and critical illness, should not be rushed, but they should be emphasized. Given the extreme shortage of time that physicians are able to provide to patients and their families, a great deal of medical care surrounds activities that are billable. Adding a financial incentive to offering end-of-life discussions can make these discussions more of a reality when desired.

The most terrifying word at the disposal of those seeking to halt health care reform is “rationing”: it musters deep set fears of having what one has rightfully earned (whether by hard work or inheritance) taken away and divided amongst strangers. Unlike the hyperbolic rants against “socialism,” discussing rationing somehow seems more, shall we say, rational? Having grown up in an Asian immigrant family and now having two parents who vote Republican, I am very familiar with the sentiments and arguments against the “redistribution of wealth.” However, I find it troubling that many people still cling to a status quo that is increasingly less stable and less attractive than imagined.

If health care is not a right, then it is logical that it must be earned. In the present day, health care is acquired through health insurance, an indirect payer, as paying out-of-pocket it financial untenable for the vast majority of Americans (and others around the world). Health insurance is primarily acquired through two means: employment or government sponsorship (for select groups including the elderly, veterans, and certain at risk groups including pregnant women and children). Note that I did not say that health insurance is guaranteed for the poor: acceptance to Medicaid varies from state to state with some being more welcoming than others. Putting aside government sponsorship for a moment, it seems that acquiring employment is a worthy means of acquiring health care privileges: it is key part of the American dream to work hard and reap the benefits of financial and political freedom. However, not all employment offers health insurance benefits. Are some jobs, then, more worthy than others? Is it reasonable that a corporate executive receives insurance benefits but not a checkout clerk at Walmart? Well, maybe seniority and promotions including health benefits are incentives for people to work harder and advance up the socioeconomic ladder. How about this: does it makes sense that a storehouse shelfer at Pepsi receives great health benefits but not the same type of employee at Walmart? (If Pepsi or Walmart are reading this, forgive me if this information is outdated, but these were real-life examples at some point in the recent past.) Is the Pepsi employee’s work more worthy of health care benefits, or was she just smart enough to pick the right company? Progressing down this line of thought, why should anyone bother to be self-employed or work for a small company (your Mom & Pop outfit) that cannot afford to provide employees with health benefits?

The answer to that question is that many Americans are gamblers and risk-takers: they believe they can beat the curve. They won’t be the poor suckers who’ll get diabetes or have a heart attack or a stroke. Unfortunately, this degree of hubris and inattention to detail (e.g. neglect) is precisely what lands patients in front of me in the Emergency Department with their first experience of crushing substernal chest pain or hemiplegia (unilateral weakness). Three intensive care unit days and one regular ward day and tens of thousands of dollars later, they are sent home to recover, only to receive the most unpleasant surprise: the first step toward bankruptcy. (Health care costs are the leading cause of bankruptcy in the U.S.)

Returning to the notion of earning health care, it seems logical that better jobs should lead to better benefits. By that reasoning, doctors ought to have really excellent health care, right? Here is a highly educated class of elite professionals that has one of the highest base salaries among jobs that can be obtained without nepotism or inheritance. The medical profession is still one of the hardest and most competitive professions to enter. Why, then, do we have resident physicians-in-training (in some parts of the country) who have to take their kids to free clinics because their health insurance plans don’t provide adequate coverage for primary care visits? Why does a highly-accomplished clinician in poor health have to choose to work at a seven-day week job in order to maintain health benefits until age 65 (when Medicare kicks in) just to ensure coverage for high-cost medications for a chronic illness?

In reality, health care insurance currently provides inadequate protection against the rising costs of health care. Although health care costs can be reigned in to some degree, new and better treatments will almost always be more expensive (in order to support the research and production). Furthermore, the fear of rationing is irrational for yet another reason: it already exists (throughout the country, but worse in some places than others). I do not mean to improperly generalize the condition of New Orleans to the rest of the country, but the fractured health care landscape provides a glimpse at a future that the current health care systems could lead to without intervention:

• First, New Orleans has a severe shortage of physicians, nurses, and other health care personnel (therapists, social workers, etc.). Many current trends upheld by the current health care system would continue this depletion: the lack of emphasis on primary care, the paucity of protections against frivolous malpractice litigation, and the increasing numbers of uninsured and underinsured patients that pressure physicians into limiting their practices to “concierge” practices (seeing smaller numbers of higher-paying patients, thus limiting medical resources to the whole population).

I heard a quote on NPR this morning from a concerned conservative constituent saying “My friends in Canada tell me ‘Don’t you dare change your health care system to something like ours; it takes me 6 months to get an appointment!’.” Here, in New Orleans, a follow-up appointment with an Internal Medicine/General Medicine physician after a hospitalization at one of the public hospitals (where uninsured patients go) takes 6 months. A follow-up appointment with a Neurologist takes one year.

• Secondly, care for the uninsured in Louisiana follows an antiquated system that could be reemphasized again in other parts of the country if universal coverage is not achieved. Federal funding for Medicaid in Louisiana, instead of being directed toward providing individual patients with health insurance, is funneled into a large “safety net” system that fuels an expensive, inefficient series of public hospitals (a true “two-tiered system” where a majority of white, paying patients go to the private hospitals and a majority of black/Hispanic, uninsured patients go to the public hospitals). As more and more patients become uninsured or underinsured, they will be unable to afford care at more expensive private hospitals. Why is the care more expensive at private hospitals? I’m guessing that the billing departments are better able to recapture expenses via reimbursements and patient payments at private hospitals. If you don’t have enough money, why not just go to the public hospital and tell the hospital administration representative, “I don’t have insurance” and let the federal government pay for your hospital stay and medical care? In other words, private hospitals sometimes have more resources to do a more thorough “wallet biopsy” and have more effective means of discouraging or diverting uninsured patients to public hospitals (when they exist). If your wallet is particularly thick-walled, you can bet that they’ll take the time to sell you out to the collection agency. The same departments at public hospitals are likely more overworked and less likely to obtain reimbursement for the hospital stay from the patient than from the government if the government provides a relatively easy (or consistent) means of reimbursement.

• These changes within the New Orleans health care landscape has led to an extreme polarization of the system. On the one hand, you have public and academic hospitals with a steadily rising patient population due to increasing numbers of uninsured and underinsured patients. Rationing clearly exists here, especially regards to the establishment of outpatient care and specialized care (e.g. psychiatry, specialized surgery, etc.). On the other hand, you have a network of private hospitals that, in order to maintain financial viability and profits, develops a variety of methods to increase volume and expenditures (to be paid by insurance companies) by relying more heavily on expensive diagnostic testing, by calling for more (sometimes of minimal necessity or benefit) consults, by minimizing the duration of hospitalizations for complicated patients (who might otherwise stay for weeks or months at an academic or public hospital which might recoup only a small percentage of the costs), and by scrapping expensive, high-risk, highly specialized departments (e.g. organ transplantation). I recall my experiences with one patient my team followed at a public hospital who waited two months on the general medicine ward for a diagnostic surgical procedure that the stalling surgeon never performed despite a possible plan for aggressive treatment; I saw her two weeks later at a private hospital where she stayed for less than two days, received a “diagnostic” procedure, and was sent home without hope or treatment for her “complicated” condition. Which would you prefer to suffer?

Rationing already exists in the U.S. health care system: it just happens to people who are not picketing the offices of members of Congress. It is a reality that people are dealing with and increasingly greater proportions of our population will be subjected to this reality as more people become uninsured or underinsured. Current proposals for health care reform might not rid the system of the trend toward further rationing, but doing nothing will certainly worsen this problem.

Reflecting on my subinternship, I realize now that one of the areas of greatest learning was my exposure to the health care system from the perspective of a young physician in his first month ordering tests, writing prescriptions, and getting involved in the micromanagement of in-hospital patient care (and preparing for “disposition,” the patient’s immediate destination outside the hospital). In doing so, I have spent a great deal of time dealing with VA paperwork, striving to accurately document to maximize Medicare reimbursement (routinely less than expected), wasting time on hold on the phone while trying to schedule appointments for patients or reach nameless individuals with key details of the aphasic patient’s history, bargaining with nurses to fulfill the orders I wrote to keep deep vein clots from forming or delirium from settling on the mind of a sundowning patient, and struggling to work with patients straddling the thin line between impoverished despair and unpleasant death and to help them find a third (sometimes wispy and intangible) option. In this heart of darkness not emphasized on televised dramas or comprehended by patients and lawmakers accustomed to hospitals outfitted like four star hotels, I now pause to refine my perspective on the ways people would like to see health care changed:

Pay for Performance – While this idea makes sense to economists and those less inspired by the motives of doctors in pushing for expensive interventions, a pure Pay for Performance system fails to account for the patient factor. On the one hand, some patients are needlessly demanding in asking for pricey “fixes” to problems that might be managed more simply and inexpensively, or they might demand an MRI when a clinical diagnosis (based on a good history, a physical exam, and a handful of lab tests) is sufficient. On the other hand, some patients, for whatever reason, are not inspired to take ownership of their own health: they do not cooperate with nurses and doctors in the hospital and do not comply with their medications and therapies outside the hospital. This is particularly troubling to me: I find myself more at ease caring for a patient on the verge of death than a patient who has given up on living. How do you convince a patient to take his medications to stay alive and reasonably healthy when his life is miserable? Instead of trading one perverse incentive (letting patients be sick so as to treat them with more expensive means) for another (not treating the sickest and most miserable patients circling the drain), it probably makes more sense to find a compromise between Pay for Performance and Fee for Service systems that increasingly incentives measures taken to improve patient outcomes while allowing for wiggle room in actual patient outcome (owing to contribution of patients and other factors).

Government-run Health Care – I am not convinced that a single-payer system of health care is the right system for the U.S., but I tire of the conservative arguments that follow the “you don’t want the government to get between you and your doctor” line of reasoning. Someone recently pointed out to me this notion: currently, many patients with private insurance have entire companies (whose profits are built upon denying payment for medical services rendered to the patient) saddled between them and their physicians with virtually no protective measures in place. Is this truly better than having a government agency regulating the delivery of health care to a patient? Frankly, I don’t think either is desirable. However, government officials are elected and are supposed to be held accountable by their constituencies; who holds the insurance companies accountable for their actions?

The Doctor-Patient Relationship – A lot is said by many people about the doctor-patient relationship, but few people are willing or able to discuss its many dimensions adequately. On the one hand, the time spent between a physician and her patient in the examination room is as sacred and untouchable as the confessional. On the other hand, the relationship is a complex financial transaction filled with billing codes, hundreds of forms, and dozens of parties pointing fingers at one another as to who should pay the bill. The physician, whilst not officially a civil servant, nonetheless has an unusual amount of authority: he can hold someone against her will in the hospital or take extraordinary life-preserving measures in emergency situations. The relationship can be one of respect, trust, and admiration, or it can be antagonistic and doubting. Those who distrust and dislike doctors like to point to their God-complexes, even when those same doctors deny such notions of grandeur: what, then, does that say about how we view those who arbitrate our struggles with sickness and death?

In entering the modern age, I don’t think all physicians have fully adapted their approaches (or their mindsets) to present needs. A direct physician-patient relationship is a rare find: there is almost always a layer between populated by receptionists and nurses in the clinic and nurses, social workers, case managers, therapists, and hospital administrators in the hospital. These people are there for a reason: they are supposed to help patients navigate an increasingly complex health care system and help doctors provide medical care. However (and this might be disproportionately biased by my own personal experiences), what you do not do with your own hands cannot be said to be done with 100% surety. There is always room for error or defiance or questioning. The additional layer, the payer (i.e. insurance companies or the government), is just one more question mark or checkpoint between the doctor and patient. The notion of a one-on-one doctor-patient relationship is ancient history. The question, now, is whether the infrastructure surrounding the doctor and the patient can be improved and streamlined to emphasize improved patient outcomes, physician independence in medical decision-making and delivery, and universal coverage, all at the same time.

This cannot happen without physicians taking leadership roles in the days to come.

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