A visiting professor from Georgetown University has spent the past week giving us an introduction to medical ethics. We started with the Hippocratic Oath and moved through the ages, passing Beneficence vs. Nonmaleficence, giving a nod to Modern vs Post-Modern theories on the benefit/harm discussion, ending with the conflict between Social Utility and Justice as methods of allocating resources. I nodded my head in agreement for much of the class, right up until the final topic....
As fas as we discussed, we came to define Social Utility as that method which produces as much "net good" as possible considering all affected, i.e. all of society. Justice was aimed at an "end-state pattern" of "good" distribution in a more equitable fashion. I fall easily on the Justice side of things. Justice may not produce as much net good, in fact it most certainly does not, at least in the short term, which is all many people can see. It takes much more effort, resources, and cost to benefit one patient who is severely ill than it does to bump a moderately well patient up to a higher quality of life. Once we factor in socioeconomic status, race, gender, and location of the patient (and possibly other factors) something else is discovered: the patients with the lowest quality of life regarding health tend to be poor, minorities, females, and in rural locations. In order to pursue a Justice social ethic in this case there must be a greater cost input. Social Utilitarians argue that this is pointless - we do less good by focusing on those in worse circumstances. I argue the opposite. Social Utilitarians, reframe the problem!
Autonomy came up again and again in class, and I feel it is at the heart of the issue, especially for Americans. To Americans autonomy is valued above all and has been tried repeatedly in the courts and is found to generally win. The individual rules. It seems to me that in order to improve the health of yourself the most, it would be to your benefit to start by eliminating communicable diseases. This practice is prevalent in veterinary medicine - treat the herd and eliminate disease for all instead of treat one case after case after case. To translate into human medicine this would require a switch from the individual mentality, to one considering the masses. To raise the quality of life for those worst off, would in the end benefit the rest of us.
Consider the case of tuberculosis. According to Medecins San Frontieres (MSF, Doctors Without Borders) 120,000 people die from TB annually. Nearly another half-million cases are diagnosed each year. The hotbeds now are in southern Africa and southeast and central Asia (1). Sure, that is far from America, but if we don't control the problem, how long do you think it will take to reach North America? What with international travel so easy and relatively accessible, how long do you think we can keep TB off our shores? What about Multi-drug resistant TB (MDRTB) and the even newer version, Extensively drug resistant TB (XDRTB)? They're already in the States, actually, just not as prevalent as in other countries. The cases of TB are on the decline in the Sates, but on the rise internationally. This is a great argument for Texans to seal the border, but I don't think that's going to happen anytime soon (nor should it). Do you think it's a better idea to eradicate disease now, for all those infected, and in doing so benefit yourself in the long run? I think so. This is the position of Justice, and Social Utilitarians just consider the long term outcome. Prevent pandemics now by treating those worst off and at risk (which yes, will cost more) and keep yourself safe and warm at night and not in fear of the next person who coughs on you.
1. http://www.doctorswithoutborders.org/news/article.cfm?id=4334&cat=field-news
Thursday, February 17, 2011
Saturday, February 12, 2011
Boredom
It's hard to imagine getting bored in medical school. Generally, I don't have time for it. Last semester, between a full course load including Physiology, Neuroscience, and Immunology, running two review groups a week for the term 1 students behind me, participating in an elective course on ultrasound technique, and starting a relationship, there was no time to procrastinate. Study time was serious, even if unfocused. Now, I find myself bored. I admit this hesitantly because I know in about 10 days, when term 4 begins, I will have no problem with boredom. I will long for the days when I took naps and slept before midnight. This schedule reminds me of my undergrad days.
It has been recently suggested to me that I get a project. I think this is a great idea. For now, my project will be to blog more often, but I am also trying to get myself to the gym more regularly and get involved with our SOM's branch of Physicians for Human Rights advocating for sustainable energy solutions on campus. We'll see how the projects go!
It has been recently suggested to me that I get a project. I think this is a great idea. For now, my project will be to blog more often, but I am also trying to get myself to the gym more regularly and get involved with our SOM's branch of Physicians for Human Rights advocating for sustainable energy solutions on campus. We'll see how the projects go!
Tuesday, February 8, 2011
Law School for Doctors, Take 1
Today in the first of eight hours of Jurisprudence, part of the Behavioral Sciences course at SGU, we learned about Doctors and Lawyers. The video below shows "Doctors" - getting ready to take off into the wild blue yonder to practice what we've spent so long learning.
Then, just as we're in flight, learning to get our wings under us, we encounter "Lawyers" as below...
Our lesson: don't get sued.
Then, just as we're in flight, learning to get our wings under us, we encounter "Lawyers" as below...
Our lesson: don't get sued.
Monday, February 7, 2011
Health Fair 101
A couple of days ago I had the opportunity to participate in an event put on by a student club of which I'm a part. The Humanitarian Service Organization (HSO) puts on a Health Fair out in the community of Grenada each semester. It's a relatively new club, so this semester's fair was only the second. A group of 20 to 30 students from the School of Medicine (SOM) and Masters in Public Health (MPH) programs set out on a bus around 1230 pm, a little late already because we had to wait for some students to get their coffee fix. On! On!
We were setting up outside a grocery store called, aptly enough, Foodland. The store manager had been nice enough to put up about five outdoor tents in a row on one side of the parking lot. There was a hodgepodge of chairs and a few tables. The Type A's immediately grabbed tables and the rest of us made do with chairs and benches. After some initial set up, we got to work. We were taking histories, blood pressures and blood glucose readings. We had a couple certified nutritionists set up ready to give counsel, as well as a few clinical tutors who've actually graduated medical school.
My first patient was a woman in her 40s. She was slightly overweight and refused to make eye contact for longer than a few seconds. She told me she just wanted to check herself because she has high blood pressure and diabetes. She was taking insulin and had done so that morning. By this time it was nearly 130. She had skipped lunch and told me that she felt weak. Her head was drooping and she looked ill. She knew her sugar was probably low, so I decided to skip the page-long detailed history, and get to the testing. Since we only had four glucometers I had to go track one down from where it was hiding on a student's table (no longer in the central location designated for the glucometer home). I gathered my supplies and tested her - her blood glucose was in the 40s mg/dl. If that number doesn't mean much to you, suffice it to say that she was about to pass out on me and go into hypoglycemic shock possibly. I saw the number and definitely failed my first test of keeping a straight face when something was going wrong. I rushed to the clinical tutors to ask them where I could get something sugary for this lady to eat. After ten minutes and way too much discussion, she was handed a juice box to get her through. I retested again another ten minutes later and it had significantly risen, about 65mg/dl, which meant she was almost in the normal fasting range beginning at 70mg/dl. I quickly moved her through the system so she could go home and get something to eat.
Foodland surprised us again when they took orders and made all the students and clinical tutors a sandwich. Around 230 I was getting hungry, but we had a stack of patients waiting in the heat to be seen. I didn't even consider eating. Unfortunately, some of my classmates did. While patients were waiting a large group of our understaffed health fair took their sandwiches and went to the other side of the parking lot, in the shade, to eat their lunch and talk. Every patient waiting saw their student-doctors taking a break to eat lunch. Many of the patients hadn't eaten lunch themselves because they came to the fair! It will be a shock for many of these same students when they are required to work 12 hours or more and get laughed at when they say "but I haven't eaten lunch yet!"
Almost everyone I saw that day either had hypertension and/or diabetes themselves, or had a family history of it. I saw one patient who believed she could control her hypertension with a cup of hot tea. I tried, and failed, to convince her that she really should be taking her medication, since her BP was now 145/100. I saw one man who was 85 and had been failed by his regular doctors. He described excruciating burning upon urination that had been happening for some time with no improvement. According to him his doctors hadn't done anything for him. He felt it was useless to talk about it anymore since nothing would be done. I saw one girl, nine years old, whose mother wanted her BP and blood glucose checked. I asked if there was any reason she suspected something wrong, but no, just wanted it checked. The BP was uneventful (I did get to utilize my "variety pack" of BP cuffs for the first time). When it came time for the blood glucose check it was another story... the way we were testing blood glucose requires a small needle prick at the end of a finger and one drop of blood. It is a small needle, but still it is a needle. The girl didn't want it done and basically refused. I said that was okay we didn't have to do it, we would just have to tell her mother that she decided not to do it. At the thought of that she decided to just do it. I realize now that this is the moment I failed my patient. She didn't want to do the test, and it wasn't medically necessary. She didn't look like she had Type 1 diabetes, and she didn't complain of any key symptoms. The mother wanted it done because it was free and available, and why not? Turns out the mother was also under the impression that I was going to blood type her as well. I could have explained the test better and when the girl refused, I could have gone to talk to the mother instead of making her do it...in the end we did the test and she barely flinched.
The Health Fair itself was a success; we saw many more people than they did last semester. I learned a lot about myself and about how I could do better when I interact with patients. This is a learning process. I somehow expected that I wouldn't mess anything up because I was trying to be so self-vigilant. Looking back I do see things I could have done differently. Hopefully these lessons will stick with me as I move forward.
We were setting up outside a grocery store called, aptly enough, Foodland. The store manager had been nice enough to put up about five outdoor tents in a row on one side of the parking lot. There was a hodgepodge of chairs and a few tables. The Type A's immediately grabbed tables and the rest of us made do with chairs and benches. After some initial set up, we got to work. We were taking histories, blood pressures and blood glucose readings. We had a couple certified nutritionists set up ready to give counsel, as well as a few clinical tutors who've actually graduated medical school.
My first patient was a woman in her 40s. She was slightly overweight and refused to make eye contact for longer than a few seconds. She told me she just wanted to check herself because she has high blood pressure and diabetes. She was taking insulin and had done so that morning. By this time it was nearly 130. She had skipped lunch and told me that she felt weak. Her head was drooping and she looked ill. She knew her sugar was probably low, so I decided to skip the page-long detailed history, and get to the testing. Since we only had four glucometers I had to go track one down from where it was hiding on a student's table (no longer in the central location designated for the glucometer home). I gathered my supplies and tested her - her blood glucose was in the 40s mg/dl. If that number doesn't mean much to you, suffice it to say that she was about to pass out on me and go into hypoglycemic shock possibly. I saw the number and definitely failed my first test of keeping a straight face when something was going wrong. I rushed to the clinical tutors to ask them where I could get something sugary for this lady to eat. After ten minutes and way too much discussion, she was handed a juice box to get her through. I retested again another ten minutes later and it had significantly risen, about 65mg/dl, which meant she was almost in the normal fasting range beginning at 70mg/dl. I quickly moved her through the system so she could go home and get something to eat.
Foodland surprised us again when they took orders and made all the students and clinical tutors a sandwich. Around 230 I was getting hungry, but we had a stack of patients waiting in the heat to be seen. I didn't even consider eating. Unfortunately, some of my classmates did. While patients were waiting a large group of our understaffed health fair took their sandwiches and went to the other side of the parking lot, in the shade, to eat their lunch and talk. Every patient waiting saw their student-doctors taking a break to eat lunch. Many of the patients hadn't eaten lunch themselves because they came to the fair! It will be a shock for many of these same students when they are required to work 12 hours or more and get laughed at when they say "but I haven't eaten lunch yet!"
Almost everyone I saw that day either had hypertension and/or diabetes themselves, or had a family history of it. I saw one patient who believed she could control her hypertension with a cup of hot tea. I tried, and failed, to convince her that she really should be taking her medication, since her BP was now 145/100. I saw one man who was 85 and had been failed by his regular doctors. He described excruciating burning upon urination that had been happening for some time with no improvement. According to him his doctors hadn't done anything for him. He felt it was useless to talk about it anymore since nothing would be done. I saw one girl, nine years old, whose mother wanted her BP and blood glucose checked. I asked if there was any reason she suspected something wrong, but no, just wanted it checked. The BP was uneventful (I did get to utilize my "variety pack" of BP cuffs for the first time). When it came time for the blood glucose check it was another story... the way we were testing blood glucose requires a small needle prick at the end of a finger and one drop of blood. It is a small needle, but still it is a needle. The girl didn't want it done and basically refused. I said that was okay we didn't have to do it, we would just have to tell her mother that she decided not to do it. At the thought of that she decided to just do it. I realize now that this is the moment I failed my patient. She didn't want to do the test, and it wasn't medically necessary. She didn't look like she had Type 1 diabetes, and she didn't complain of any key symptoms. The mother wanted it done because it was free and available, and why not? Turns out the mother was also under the impression that I was going to blood type her as well. I could have explained the test better and when the girl refused, I could have gone to talk to the mother instead of making her do it...in the end we did the test and she barely flinched.
The Health Fair itself was a success; we saw many more people than they did last semester. I learned a lot about myself and about how I could do better when I interact with patients. This is a learning process. I somehow expected that I wouldn't mess anything up because I was trying to be so self-vigilant. Looking back I do see things I could have done differently. Hopefully these lessons will stick with me as I move forward.
Friday, February 4, 2011
The Problem with Healthcare
At my school "Behavioral Sciences" is a loose term applied to several disciplines including human development, abnormal psychology, biostatistics, epidemiology, clinical ethics, and health systems. Recently we spent all of four days discussing the health care system in the United States along with a few comparative examples from other countries including Canada, Switzerland, Germany, United Kingdom, and Japan. Apparently eight hours of lecture about a system so complex as the US model is all the time we future physicians get. Not surprisingly, our system is the worst.
On the final day of lecture we spent one hour discussing the Patient Protection and Affordable Care Act, i.e. Obama's Plan. Some of the reforms discussed in class are good ideas - for those of us lucky enough to be insured, no denial of coverage due to preexisting conditions is a great thing. So is no recision of coverage. So is a cap on co-payments and out-of-pocket payments. If you're on Medicare and living in the Donut Hole of Big Pharma, you're still screwed. Sure, you get a 50% discount...so you'll stay right there, in the Donut Hole, for twice as long. You'll spend the same amount of money that you don't have to spend. If you're uninsured the state in which you reside is supposed to set up affordable exchanges so that you can purchase your own insurance. Some of these ideas are well founded and advantageous, but I think we've lost the plot.
I am a lowly medical student; but if you ask me, the place to start is at the bottom.
The Basics:
Physicians supply medical care. Why does what they do cost so much? By the end of my schooling, my loans will be a quarter of a million dollars not including interest. Let's call it closer to 300,000.00 by the time I pay some interest. It takes most physicians 15 to 20 years to pay off their debt. If going to school to be a doctor was less expensive, we wouldn't have to charge so much. Granted, some may still charge exorbitant fees, but that's where the government gets to cap prices. Make school cost less, decrease fees. Regulate state-funded medical schools and put a cap on tuition. Medical schools don't need that much money anyway. What supplies do we use? The internet, a few scalpels if you're lucky, the library and a coffee shop. That shouldn't be too expensive. Oh, you might have to cut administration fees. If physicians still charge too much, then let's just pay them negotiated fee-for-service like they do in Germany. Physicians love to get paid for every procedure they do, so let them keep that, just contract with the government on what each service can cost. How do we pay for hospitals - the government sets a budget and the hospital lives within that budget. Hospitals can compete for the rich who have bought Supplemental Insurance (see below).
Almost every doctor is a specialist or sub-specialist and there are no GPs left on the front lines. How do we fix that? Obama is trying by offering a 10% increase to physicians practicing family medicine in an area of scarcity. How about this to keep costs down: since a doctor's school is now heavily subsidized by the government, or even free, require that all newly inked physicians spend two years in a Federal placement practicing family medicine. Continuity can be ensured by providing physicians who stay on that 10% increase. Even if that's not your intended specialty, the time fresh out of school is before you've decided your route, before you've Matched to a residency. It's the perfect introduction to health care and it serves a great need. It's like Teach for America, only let's call it Health for America, or Doctors Within Borders.
Insurance companies drag us over the coals with skyrocketing premiums and unfulfilled claims. How to prevent this? Hmm, how about some Federal REGULATION? In Switzerland, insurance companies are required to be non-profit. Amazing! If insurance companies want to make more money, they can by selling Supplemental Plans that the rich can buy. That sounds like a great idea, or perhaps we could cap premiums along with co-payments. Perhaps we could start a real Federal Health Plan. People don't have to join -they'll be enrolled when they get their Social Security number at birth. Everyone can have a Personal Insurance Card, like they have in many other countries. The card allows the physician to access the patient's entire medical history while linked up to the national servers. This is how they do it in Taiwan. Everyone pays into it. Medicaid for the masses, paid for by the masses. Everyone is covered and everyone is entitled to walk into a GP of their choice when their throat hurts, or go to the hospital of their choice when something more serious happens. No long waiting times, which is a common complaint from those anti-universal healthcare.
Besides insurance costs and hospital costs (both taken care of now) the other big personal cost is pharmaceuticals. Well, watch out Pfizer, regulation is coming to your house! The only way we can guarantee access to life-saving and quality-of-life-improving drugs is by ensuring costs are affordable for all. This means a Federally imposed set of regulations on prices. Big Pharma complains that they won't be able to do any more R&D if we regulate their spending. To this I say bollocks! Big Pharma will always do R&D because it will always be in their interest to come up with new magic bullets. Perhaps which avenues they explore could be encouraged or punished via incentives and regulations, i.e. we really don't need any more Viagra, but we could use some multi-drug resistant tuberculosis research.
How to pay for this, because it's going to get expensive... a flat percentage income tax might work. Yes, the rich will pay more. But then again, they have more money with which to pay. If you're rich you can think of it this way: all those dirty homeless people you pass on your way to your 50th floor corner office won't be hacking and coughing all over you anymore! In the end, it serves your own health better to take care of everyone else's. And no, you cannot opt out. All of this money should be collected into one source, located Federally. The money needed to keep the system going comes from taxes. Yes, taxes! "Tax" is not a dirty word, it is the only way to universal healthcare. The Germans undertake "Concerted Action" twice a year in which employers, unions, doctors, hospitals, government [and insurance companies] meet to set fees by which all will abide. That sounds like a good idea too, and the American people should like that because they'll get a voice in the decision making process.
True universal healthcare in the United States is not possible through a State system. States bicker and have their own lobbyists to satisfy. The Feds need to rise above all this and put together a COMPREHENSIVE plan, that doesn't just plug holes with bubble gum. Our ship is sinking. It needs a complete re-haul before it goes down completely. Other nations across the globe have been providing healthcare to all their citizens for decades. We have the advantageous position to be able to pick and choose different approaches from a multitude of working plans. Let's not reinvent the wheel!
On the final day of lecture we spent one hour discussing the Patient Protection and Affordable Care Act, i.e. Obama's Plan. Some of the reforms discussed in class are good ideas - for those of us lucky enough to be insured, no denial of coverage due to preexisting conditions is a great thing. So is no recision of coverage. So is a cap on co-payments and out-of-pocket payments. If you're on Medicare and living in the Donut Hole of Big Pharma, you're still screwed. Sure, you get a 50% discount...so you'll stay right there, in the Donut Hole, for twice as long. You'll spend the same amount of money that you don't have to spend. If you're uninsured the state in which you reside is supposed to set up affordable exchanges so that you can purchase your own insurance. Some of these ideas are well founded and advantageous, but I think we've lost the plot.
I am a lowly medical student; but if you ask me, the place to start is at the bottom.
The Basics:
Physicians supply medical care. Why does what they do cost so much? By the end of my schooling, my loans will be a quarter of a million dollars not including interest. Let's call it closer to 300,000.00 by the time I pay some interest. It takes most physicians 15 to 20 years to pay off their debt. If going to school to be a doctor was less expensive, we wouldn't have to charge so much. Granted, some may still charge exorbitant fees, but that's where the government gets to cap prices. Make school cost less, decrease fees. Regulate state-funded medical schools and put a cap on tuition. Medical schools don't need that much money anyway. What supplies do we use? The internet, a few scalpels if you're lucky, the library and a coffee shop. That shouldn't be too expensive. Oh, you might have to cut administration fees. If physicians still charge too much, then let's just pay them negotiated fee-for-service like they do in Germany. Physicians love to get paid for every procedure they do, so let them keep that, just contract with the government on what each service can cost. How do we pay for hospitals - the government sets a budget and the hospital lives within that budget. Hospitals can compete for the rich who have bought Supplemental Insurance (see below).
Almost every doctor is a specialist or sub-specialist and there are no GPs left on the front lines. How do we fix that? Obama is trying by offering a 10% increase to physicians practicing family medicine in an area of scarcity. How about this to keep costs down: since a doctor's school is now heavily subsidized by the government, or even free, require that all newly inked physicians spend two years in a Federal placement practicing family medicine. Continuity can be ensured by providing physicians who stay on that 10% increase. Even if that's not your intended specialty, the time fresh out of school is before you've decided your route, before you've Matched to a residency. It's the perfect introduction to health care and it serves a great need. It's like Teach for America, only let's call it Health for America, or Doctors Within Borders.
Insurance companies drag us over the coals with skyrocketing premiums and unfulfilled claims. How to prevent this? Hmm, how about some Federal REGULATION? In Switzerland, insurance companies are required to be non-profit. Amazing! If insurance companies want to make more money, they can by selling Supplemental Plans that the rich can buy. That sounds like a great idea, or perhaps we could cap premiums along with co-payments. Perhaps we could start a real Federal Health Plan. People don't have to join -they'll be enrolled when they get their Social Security number at birth. Everyone can have a Personal Insurance Card, like they have in many other countries. The card allows the physician to access the patient's entire medical history while linked up to the national servers. This is how they do it in Taiwan. Everyone pays into it. Medicaid for the masses, paid for by the masses. Everyone is covered and everyone is entitled to walk into a GP of their choice when their throat hurts, or go to the hospital of their choice when something more serious happens. No long waiting times, which is a common complaint from those anti-universal healthcare.
Besides insurance costs and hospital costs (both taken care of now) the other big personal cost is pharmaceuticals. Well, watch out Pfizer, regulation is coming to your house! The only way we can guarantee access to life-saving and quality-of-life-improving drugs is by ensuring costs are affordable for all. This means a Federally imposed set of regulations on prices. Big Pharma complains that they won't be able to do any more R&D if we regulate their spending. To this I say bollocks! Big Pharma will always do R&D because it will always be in their interest to come up with new magic bullets. Perhaps which avenues they explore could be encouraged or punished via incentives and regulations, i.e. we really don't need any more Viagra, but we could use some multi-drug resistant tuberculosis research.
How to pay for this, because it's going to get expensive... a flat percentage income tax might work. Yes, the rich will pay more. But then again, they have more money with which to pay. If you're rich you can think of it this way: all those dirty homeless people you pass on your way to your 50th floor corner office won't be hacking and coughing all over you anymore! In the end, it serves your own health better to take care of everyone else's. And no, you cannot opt out. All of this money should be collected into one source, located Federally. The money needed to keep the system going comes from taxes. Yes, taxes! "Tax" is not a dirty word, it is the only way to universal healthcare. The Germans undertake "Concerted Action" twice a year in which employers, unions, doctors, hospitals, government [and insurance companies] meet to set fees by which all will abide. That sounds like a good idea too, and the American people should like that because they'll get a voice in the decision making process.
True universal healthcare in the United States is not possible through a State system. States bicker and have their own lobbyists to satisfy. The Feds need to rise above all this and put together a COMPREHENSIVE plan, that doesn't just plug holes with bubble gum. Our ship is sinking. It needs a complete re-haul before it goes down completely. Other nations across the globe have been providing healthcare to all their citizens for decades. We have the advantageous position to be able to pick and choose different approaches from a multitude of working plans. Let's not reinvent the wheel!
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