Friday, July 30, 2010

Swing on the Spiral

Looking forward, while looking back and spinning while standing in place.

Term 2 - Genetics, Parasitology, Community & Preventative Medicine, Neuroscience, Immunology, and Physiology.

Yet, when I think back, I just remember the bright sun. I think this was the first term I really understood it's power down in the Tropics. Living on campus gives one a false sense of the island in many senses. The AC is on everywhere, all the time and since the buildings are relatively clustered, you really don't have to go outside for a long time to traverse around. Even going to IGA (the "supermarket") and the beach was rather restricted in Term 1 (my roommate had a car, so we'd wait until HE wanted to go) and I'd go in the evenings.
But living off campus showed me this other world of Grenada. I talked to more people from the Island, learned about the weather patterns and previous droughts (it was a bad one this time), found a market that has locally produced foods and snacks (local plantain chips!!), and generally started to get a sense of the people here. They are friendly, they like to have fun, and I think, if I were back home, I could pick someone from Grenada out after talking to them for a bit, just certain mannerisms and ways they speak.
You don't get that on campus though - it's essentially a giant resort. No pool though, and you can't go to the beach on campus(2 stars). And the Grenadians play two roles: Security & Maids - which gives a distorted lens of this island as dangerous and poor. Both of which belay the diversity on the island. I know because I felt that way living on campus!
One thing that now rings quite true was when my advisor, Dr. B, said during Anatomy lecture that he walked home after dark almost all the time, and never had a problem or felt unsafe.

Oh yeah, medical school. I wish I used a quantified self tracking tool to chart my feelings towards each course over time. Initially, I thought Neuro was awesome, but then at some point it got annoying, and then fluctuated back to alright with potential for interesting subsets. I was excited about Immunology, and, as previous posts indicate, grew frustrated with how it was taught but still liked the material. Physiology was always alright at first, but then it grew on me. And Dr. H was excellent - one of the best teachers here - even if he does watch Fox & Friends every morning. I've done diabetes research in the past so that was a known interest, but I was surprised to find myself really enjoying the Endocrinology section. Parasitology gave a great global perspective and showed how debilitating certain, entirely preventable, diseases could be. Genetics went by in a flash, I just remember many of the diseases were quite rare (as opposed to parasitology - interesting what society focuses on). Community & Preventative Medicine was not taken seriously by anyone, unfortunately, though I enjoyed it - but felt that the principles of the course needed better integration with the bulk of the material we learn in medical school.

Now Term 3 is coming to a close this week and the much rumored about Term 4 is making its presence known through emails and syllabus/handouts. Term 3 is a funky combination of what I'd say is Public Health with a good chunk of Psychiatry. We learned about Malpractice, the recent health care reform, epidemiology, ethics and evidence based medicine. These things are fresher in my head and deserve their own post - so they'll get one.

While Term 3 has progressed, I've also been writing a Review paper on Electronic Health Records and Health Social Networking. This supposed to be the last part of my Research Fellowship and now I'm struggling with whether to continue with a great boss and interesting research(I'm pretty sure he wants me to stay), or find somewhere else to learn new things. I want to learn about Health Impact Assessments and maybe also about mobile health tracking devices.... nevermind all the other potential opportunities out there I haven't checked out... I don't anticipate much time to do much of these activities this semester, but I am looking at a winter break that is, at this point, open. On top of that, my current position helps me pay my rent ... not something guaranteed with other opportunities...and I've published 1 paper so far, with a second one nearly will have to do some reflecting on this... any advice appreciated!

That is Medical School Year 1 (MS1) and I'm spinning in place in Term 3 , looking at MS2 and beyond. Sometimes I get sick of being so far away, on a hot little island. But then I saw a former work colleague's IM picture of the old Map Plotter (printer) spewing paper. That made me appreciate my decision to come to Medical School on the Spice Isle.

Wednesday, July 14, 2010

Facebook Debates: Conservatives on Healthcare

An acquaintance of mine from undergrad happens to be a Republican rep. in the NH State House. We shared a good discussion on the environment and animal rights (he's an animal loving environmentalist republican!) and have kept in touch via Facebook. He likes to foster debates on topics on his page and while most of his friends are conservative, there is some variety and occasionally a few insightful words are written. Recently, a discussion started up on healthcare that I spent some time participating in and wanted to present it here. It started when ND said that her her replacement hearing aids weren't covered by her insurance. Without further ado:

ND: Tell him to make it a national law that all hearing aids are covered by insurance for all ages in every state.

BL: Judges do not make law, only legislators can do that, however there are judges that seem to forget that thier job is to decide if legislation is constitutional and if the cases before them meet those standards...

ND: Okay! Thanks for letting me know :) I'm leaving my expertise in the science fields to build up on my political knowledge! It costs $6000 for a really good pair of hearing aids. I have had them since I was 3 and have excelled with them. But my 2nd pair (and current) are starting to dwindle. I can't afford a new pair. Technically, you are supposed to receive a new pair every 3 years. I have only had two pairs. I should be on my 6th pair. Insurance companies say they are cosmetic. How is that fair? This is why I'm fighting. They cover eyeglasses, so they should cover hearing aids. I'm pretty sure it violates the Americans with Disabilities Act by not providing coverage for hearing aids.

Me: ‎@Nicole - has your physician helped in any way with this? Have you tried your local Lions Club or Sertoma Clubs, they can sometimes help.

ND: Nope! Lions club = sub-par hearing aids for the elderly that were recycled. I need higher power and better quality because I'm losing hearing as I'm getting older. And I'm still in college, with hopes to go to medical school. But yes, I tried all of my options. Now I'm taking this to a state level because everyone who has hearing loss goes through this problem. Insurance companies think HAs are cosmetic and not really important. Why do people get insurance for eyecare? That's not fair. I don't want Grandpa's hearing aids. I want my own specially fitted to my needs and power level. I can't become a Pediatric Oncologist with mediocre hearing aids. If someone is covered for eyecare, I should be covered for hearing care.

ND: Oh and insurance covers VIAGRA?! But not hearing aids... Totally messed up.

Me: That sucks, as a medical student I am continuously shocked by the behavior of insurance companies and how their actions pervert the motivations of health professionals. The government is not blameless here either, but health care does not operate as a "free market", no matter how many may wish it to - it's a societal responsibility to take care of each other!!
On the bright side, your plight should provide excellent material for medical school essays and interviews ;)
Rep. Bettencourt - are you listening?

TB: ‎"Tell him to make it a national law that all hearing aids are covered by insurance for all ages in every state." = Everything that is wrong with this country.

Skip: You are right, John - it is not a free market - it is HIGHLY distorted by Govt spending AND regulation - both based on politics rather than proper supply / demand signaling.

Sure, we should take care of others - so John, how much are you willing to pull out of your personal pocket, or how much time are you willing to devote to PRIVATELY solve Nicole's problem? Or, like many, are you simply willing to be lazy and outsource YOUR responsibility (after all, you ARE part of society, right?) to politicians and bureacrats? Why is your FIRST response - hey, let Govt solve the problem?

Sorry, dude - THAT's the base problem that GOT us into this problem - expecting that Govt can solve all ills by taking more of what others have earned simply to give to others. Man up, dude

On the other hand, Nicole, if your contract with the insurance company IS what you say, then Govt SHOULD step in (via the courts) and enforce what has legally been agreed to. what does your contract actually say (vs what a bureacrat within the insurance company is telling you)?

Me: I think a little history lesson is in order here. Blue Cross/Blue Shield started as physicians and hospitals realized that their services, due to technological and medical advances, were becoming too expensive for people to pay for out of pocket. So Hospitals contracted with teachers (Blue Cross) and had them pay $6/yr for 21 days of hospital care if needed. By having everyone pay an affordable fee, they avoided a situation where anyone had to pay an unaffordable bill. Blue Shield developed from employers contracting with groups of physicians to provide care for their employees in a similar manner.
As these plans expanded throughout the country and involved more people, a type of rating called "community rating" was used - that is everyone paid the same amount regardless of their utilization. The young businessmen paid $300/yr (even though they use less) and the older coal miner also paid $300/yr. The elderly retired person paid $300/yr as well even though they used more than that... By charging everyone the same the Blue Cross/Shield were able to afford to cover their expenses. Yes the biz guy paid more than he used but by doing so he allowed the elderly to be cared for.

The relevant part of this for our convo is that after WW2, when these plans expanded greatly, the private insurance market (professional insurers, not physicians/hospitals) got involved. Now the private insurance guys see that the businessmen only use a small amount, so they decide to offer them a plan for far less - say $100/yr. At the same time, the private insurance didn't bother with the elderly or the coal miner - they cost too much cause they actually need health services!! Now Blue Cross is stuck with the elderly etc., being more expensive users and having lost their cheaper users, they have to charge more - suddenly the elderly cannot afford health insurance and neither can those at the lower end of the economic ladder.

Hence, the 1960's we have this situation and the govt steps in to provide Medicare and Medicaid to plug the wholes in the "free market" system. This creates distortions, of course, which are then attempted to be fixed by various means, but largely ignored.

So yes, the govt did create distortions, but it was going in to correct distortions that were already present in the system. It seems to me the notion of insurance needs to be reformed - the incentives of insurers need to be fixed to provide the baseline of care for everyone at an affordable price. And the incentives for physicians and hospitals needs to be realigned to providing the best care as well as the best outcomes on a population scale - not the most care to get the most reimbursements as is currently the practice (I need to read more how the recent healthcare reform attempts to fix this - been busy with medical school - but from what I understand it doesn't do much in this regard).

You pay out of your pocket through insurance to cover those in your insurance plan that cannot afford to pay out of pocket for the entire cost of their hearing aid or the entire cost of their Chemotherapy (which can be millions of dollars). Getting donations through your social network could never make up the money needed in catastrophes for the vast majority of people - that is why we have insurance. As a medical student, I donate my time to helping others (since I live off student loans, that is the best I can do currently). Taxes do a similar thing - a community that is facing a flooding disaster could in no way afford to rebuild without assistance from wider society (taxpayers in the state/nation). We enter into the social contract of insurance or taxes in order to provide each other with the means to live healthy lives and be cared for when we need it.

Medical care is not a consumer purchase - you can choose to forgo TV or buying new furniture - with medical care, your choices are sometimes life or death, but more often you are forced into substandard living (as is the case with Nicole and her hearing aid). If someone could explain to me how medical care fits the dynamic of a free market (even if it is to reference me to texts) I am listening.

Me: no responses?? Guess you free market types prefer to outsource your arguments to Rush...

BL: Nicole, just so you know, the NH state legislature has passed a bill that requires private insurance companies to cover hearing aids. But, it does not cover those who are on medicare or medicade. I guess it is ok to require private companies to cover but not the government. If anyone wants to understand why insurance is so expensive it is the government mandating coverage for non emergency or life threatning issues.

Double standard. BTW I wear two hearing aids and have had hearing loss since I was 5. So I understand the issue.

Skip: ‎@John - your example of BC leaves out 1 thing - the voluntary nature of joining at its inception. And remember, because of wage controls instituted by Govt, "bennies" were the only way that companies could attract better workers than their compeition - thus GOVT started this snowball-from-hell down the slippery slope - and NOT the free market. It then got codified into tax law as a right off for companies but not for individuals - skewing the marketplace more and more and really making insurance prohibitively expensive over time. Add to that the politican penchant for adding mandate after mandate after mandate simply because a few people decided they wanted THEIR costs spread over eveyone else. WHY should I have to pay for someone else's treatment for alcohol addiction when I myself am a teetotaler? I have now lost the liberty to choose a plan that suits me and my family - politicians have decided they know better than I what I need or want.

Medicaid was not instituted simply to "plug holes" - review Progressive history stemming from the 1880s Frankfurt school that basically states, in a 180 from our Founders, that Govt SHOULD be in charge of the details of our lives and not we ourselves. Socialized medicine (which Medicaid and Medicare are components thereof) is simply an offshoot of that, and Statists that believe that the State is the premier entity in American life (vs the Individual primacy of the Framers of the Declaration & Constitution) are basically turning the philosophical underpinnings of our society upside down and inside out.
I disagree with your basic premise - healthcare is neither a right nor should it be an entitlement - it is a service for which one should be able to contract freely between providers and consumers. Govt, however, has made this almost impossible with "rent seekers" doing their harm as well.
And as far as "donations through your social network could never make up the money", before Govt became so bit that it crowded out private charity (see Brook's research on the inverse relationship of expanding govt & private help) - that DID happen and happened well (see de Tocqueville, commenting on how people DID take seriously their responsibilities through VOLUNTARY charity (vs what is now FORCED charity via taxes).

Me: ‎@Skip - While it is true the tax environment for benefits helped inflate health costs (something I believe the recently passed HCR bill attempted to address, not sure how that worked out), it was one of many factors - you cannot ignore that as medicine advanced and life expectancy rose the cost of care became greater and is continuing to do so, with the greatest financial burden in the last years of a patients life - again, when they are least able to afford the care (hence, Medicare).

At the heart of your argument is that the rights and freedom of individuals becomes trampled by societal (in this case government at any level) intervention into health care. I would argue that the Founders ideals, as enshrined in the Deceleration of Independence, that everyone has an inalienable right to Life, Liberty and the Pursuit of Happiness has as a pre-requisite in modern industrial society: the right to health care. The burden of poor health destroys liberty, crushes hopes of happiness and, in emergency situations, denies your right to live.

You must remember there was a difference in times between what our society is today and what it was in the time of the Founders and even Tocqueville. Jefferson even said he would rather trust to nature than his physician when he was sick - and for good reason, there wasn't much anything modern about medicine in the 18th century or most of the 19th for that matter (at least the part Tocqueville lived to see) - this was before antibiotics, before vaccines(which provide life-saving benefits to all, when all decide to take them), before modern surgery, anesthetics, before MRI, CT or even XRays! Before the germ theory of disease was accepted - Physicians believed the "four humors" were the foundation of medicine well into the 1800s!!

In todays world medicine gives people the freedom to live productive lives contributing to society. In fact, The Economist recently ran an article describing how a nations intelligence, and thus their economic development, is held back by parasites and pathogens ( ). By not giving everyone the right to accessible, quality health care, we are denying them the ability to live their lives to the fullest - these costs end up coming back to the public through violence, crime, dependency and lack of productivity among other costs. And a part of that right is affordability, not forcing choices between medicine, rent and food.

In terms of charitable giving being inversely related to government tax burden, I would invite you to review the literature (and link me to Brook's research as I could not find his/her specific work) as from what I found through Google Scholar, charitable giving may or may not be elastic regarding taxes - there are many more factors that come into play such as cultural norms, religion, societal structure and stratification, how much people control the means of their sustenance and various other influences. The economics literature, as I see it, is not in the agreement you present. And while Tocqueville certainly had some interesting things to say in his "Memoir on Pauperism" regarding dependent classes of society, his arguments are not based on any empirical observation and are clouded by selection bias as well as his own upbringing as a member of the aristocracy (hence his tendency to think of a benevolent link through charitable giving to the poor and scorn the assistance of the poor through taxation).

Regardless of any relationship, and there may be one, it is irrelevant - the cost of health care is unpredictable and can easily overwhelm any individual and their social support systems ability to cope. This is one reason why we have so many people going bankrupt from medical expenses - there is a general lack of understanding of the intrinsic nature of healthcare in todays world needs to be financed by large groups in order for any one individual to afford access to proper care. The free market system cannot operate in healthcare in a proper manner for this and many other reasons (think about the asymmetry of information between physician and patient!). Also, in a "service" one assumes there is a choice of whether or not to even have the service in the first place - that is fundamentally NOT the case with healthcare ( unless you consider death a choice). Government, as the instrument of the People, has a role to play in this. What role exactly is up for debate, but by shirking our social responsibilities to one another we hold back the potential for all of us to live freer and more productive lives.

DMK: I have been a tool-fool since my first Erector set in 1946. As a retired contractor and Master Electrician, I have many, many tools that allow me to do work that is otherwise impossible, extremely taxing or can only be done in slipshod fashion without a special tool.

Government, too, is a tool of sorts. One that was compacted to provide protection from enemies foreign and domestic ~ to protect us from others who ignore our social contact and resort to violence, deception and fraud. Not from ourselves.

It is a tool of blunt force trauma, itself, and is the only agency we allow to initiate the threat or reality of force to achieve compliance. It has more the nature of a sledge hammer, chainsaw or front-end loader than a scalpel. Only disease itself has killed more people than government in command (and not always on purpose either).

The issue is not that health care is a great and wonderful boon, nor that it becomes more & more expensive as failing bodies require more. No one disputes that sudden but unexpected illness or accident can result in the need for very expensive medical intervention that can bankrupt personal or family finances.

The real question is what tools and postures do we employ to deliver this boon to the individual. It is one of cost, to be sure, but individual choice has a huge role to play as well. One size does NOT fit all. But equal rights under the law requires just that! Not to mention the daemon of lowest common denominators, the "Problem of the Commons" and, of course, the inefficiencies of bureaucracies immune to effective feedback. The sad truth is, health care is not a task for a tool that specializes in coercion. Ask any disabled vet about the VA.
(A personal disclaimer here. I am a vet who has used the VA and have a great respect for the wonderful Nurses and Doctors who helped me. The VA made considerable progress under George Bush, but still had to accomplish its mission with a budget that failed to provide all the needed resources that were routinely available in local hospitals.)

In short, Skip is correct. Free enterprise is the way to go if you are results oriented. History, both here and abroad, makes this plain.

Me: I lean towards evidence based medicine, that is, I like to see peer-reviewed documentation that a procedure or therapy works. Even in allopathic medicine, many things we do are based on past experience of "it works, do it that way" rather than actual hard-evidence of efficacy. For instance we learned about Tube Feeding for dementia patients this morning. Surprisingly, it shows no evidence of prolonging life, decreasing infections or increasing comfort. Evidence shows it may increase discomfort and result in use of restraints. My point is that what we expect from Reasoning about a subject (tube feeding prolongs life) may not be what actually happens in the real world.

Yes, government is a blunt tool of coercion at one level - but in a democracy that tool is - when designed properly - held accountable and can be tweaked as circumstances dictate. In a decentralized state/local oriented system decisions can be adjusted to local circumstances more easily. There must be a balance though of fundamental rights guaranteed to all vs. decisions devolved to the lowest level. With private insurance, our current model, it is difficult to ensure accountability for necessary coverage except through the use of government regulations. But please feel free to present evidence to the contrary.

But the conversation seems to be going into one of cultural philosophy and further away from Outcomes - what works the best to deliver the best care, afforably for all. At my core, I'm a scientist but as a physician in training know that not everything that works is proven, but I'll ask anyway: Can anyone present evidence or examples (peer-reviewed preferable) of free market delivery of accessible, affordable, quality healthcare in a modern day setting?

Me: by the way, this is a fun and enlightening discussion - glad to see it stay civil.

Sunday, July 11, 2010

Not Dead Yet

It has somehow been 2 months (!) since my last post, but I will be picking this up again soon... Term 2 concluded successfully and Term 3 is well under way. Had a busy, productive and fun break too... and plans to think about for the year ahead... more shortly after (or before) midterm on Friday.