I’ve said a lot of goodbyes over the past few weeks–classmates, old friends, family, exes, and now you, my dear readers. (Yes, yes, say it ain’t so!)
I started this blog almost 5 years ago (wow) to document the process of becoming a doctor, write about health policy, explain medicine, and provide an outlet to process and reflect on the things that I experienced. By all possible measures, I’d say it was a success.
The further I got into medical school, the harder it was to remember or understand what it’s like to be a patient–in terms of the knowledge and the experience. It’s hard to remember what it’s like not to know what a drug does, or the pathophysiology of CHF, or when a patient is ready for discharge. I think this is one of the biggest challenges we have to overcome–becoming doctors by definition requires us to enter a different space than our patients, yet we still must communicate and explain without trying to over- or under-simplify.
And along the way, I guess another goal was to show people that doctors are simply fallible humans that are, in the vast majority, trying their best, but are prone to the same flaws and errors and mistakes that all of us are. It just sucks that our mistakes have much bigger consequences. I will always strive for perfection in my practice of medicine, but know I will never achieve it. I wish more patients would realize this.
Thanks for all the comments, support, criticism, and linkage over the past 5 years. This book of my life is over, but who knows, you may see me again. My goals right now are to hit residency with a running start, learn New York, meet friends, find some love along the way, and if I find that I still have time to blog, perhaps I’ll be back. It’s been a great 5 years!
(I’ll be moving the archives over to http://www.grahamazon.com/over/ in the next week or so.)
Good Afternoon Dean Pizzo, family and friends, colleagues, The Guy Who’s Totally Uploading This To YouTube Right Now, The Undergrads Who Heard There’s Free Alcohol Afterwards, and of course, my fellow classmates, the Graduating Class of 2008,
Britney Spears once famously said, “Hit me baby—.” That was my ORIGINAL version of the speech. You weren’t supposed to hear that. Awk! Ward! Blarg. Wow. Uhm, okay. Let’s just pretend that didn’t happen.
Hannah Montana once famously said, “We. Need. Single-payer national health insuran—.” Okay fine, she didn’t. But, I’m kind of known for ranting about health care reform, so everyone probably thinks that’s what I’ll talk about today. But don’t worry. I won’t. Today, I would like to talk about something that’s been bothering me: name-calling.
During medical school (and my entire life) I’ve answered to just about any variation on the theme: Graham, Graham Cracker, Grahamazon, Grahambo, Grahamakin Skywalker, “Hey you,” Kilo, Graham Stain, Graham Positive, Graham Negative, and even, as one attending who didn’t care to learn the names of her students called me, “a medical student,” with the same tone one might use to ask, “Could you hand me a pen?” Man, I’m really going to miss medical school!
But lately, most people have been calling me doctor, and I’m not sure if I like it. Sure, people have said it all throughout medical school, but I always had sufficient grounds to correct them: “No no, not yet, I’ve still got 6 more months to go,” or “Gosh, I wish, but I still have to pass my boards!” But lately, I haven’t had a leg to stand on.
It’s almost as if I don’t want Graduation Day to be here. But too late now. Change happens. Today, we’re becoming doctors.
I remember at orientation an upper-classman saying that we probably thought becoming a doctor was a noble, selfless act—but any of you in the audience can easily vouch for how selfish it can be. We have demanded your patience, love, understanding, compromises, and support for all these years. So up front, I want to say to each of you, from all of us up here, I am sorry. But I promise to do better next time. Not to forget slash have to reschedule: your birthday, our anniversary, the dinner reservations we had, or that trip to Mexico.
But truly, we could not have made it this far without you. Not to get all Mr. Rogers on you, but to us, you are special. You are why we are dedicated to this: because our patients have their own families and friends like you. You are the selfless ones…not us. So from the deepest reaches of our hearts and souls, thank you so very, very much. Today, we celebrate becoming doctors as much as we celebrate you.
I guess I really worry about how the title of Doctor defines you. How it changes you. That I’m becoming a little bit more Doctor Walker, and a little bit less Graham. Sure, the title affords me some prestige and privilege—for example, complete strangers will now feel totally comfortable whipping out their strange moles at dinner parties—but at the same time, it makes people see me as primarily—or only—a doctor, not as a son, brother, partner, computer nerd, or Trader Joe’s enthusiast.
Maybe this is how it’s supposed to be. Maybe that’s the purpose of the title. To remind us and others of the Oath we take, or that patients’ needs are to come before our own.
But if becoming a doctor will change how people view me, there are several values I’ve learned here at Stanford that should get to represent me, too. And I have numbered these values, as I am going into Emergency Medicine, and have a short attention span. Oh, and just a sidebar: The next time you want to complain about your hospital’s Emergency Department, please remember that we’re probably getting distracted by… oh, I don’t know, coding patients, big traumas, (mumbling) bodily fluids being flung… at… us, or… … shiny… things.
Sorry. Back to my values:
Number one: I will continue to use objectivity, without forgetting the subjective.
Medicine is an art grounded in science. I’ll do my best to know the studies, the data, and the pathophysiology, and try to apply them objectively.
But I won’t forget the patient. I’ll listen. I’ll be compassionate. I’ll try to keep social context, “chief concern,” and patient perspective in mind.
And number two: I promise to ask questions, and on occasion dare to admit: “I don’t know.” And thank you to Stanford for encouraging this—in Gil Chu’s class, where we weren’t allowed to leave until we had collectively asked him 10 questions; with Dr. Wolfe, who teaches students to admit their own “Areas of Ignorance.” We are a generation of physicians who are unfortunately (or fortunately) still human. We are not gods. We still make mistakes, and we still don’t have all the answers. But, hopefully, we’ll know where to find them.
Number three: Don’t mess with the pancreas. Or, in the famous words of master pancreatic surgeon Dr. Norton, “I’m tellin’ you, don’t mess with the pancreas! You gotta believe me!”
And number four: I promise to be involved. Whether it’s researching, teaching, advocating, or volunteering, I will remember that health and medicine are often advanced and affected more by time spent outside a hospital than within one.
While passing clerkships and boards and memorizing facts may make us doctors today, it’s our values that will drive us to become great doctors, like the many we have met here at Stanford. Because the great physician is dedicated to the truth, but also to patient. She is a scientist, but also a healer. He tempers prognosis with hope. I think Kurt Vonnegut sums up medicine’s curiosity and compassion better than I ever could: “We are here to help each other get through this thing, whatever it is.”
So, today, fellow classmates, this is it, for better or worse. When our patients call us doctor, they’ll finally be right. (How scary is that?) While our profession may change how we see the world, or even how the world sees us, we must keep a part of ourselves the same. That part—our goals and our values—is what has gotten us to this point, up on this stage. You can call me Dr. Walker now, but I promise to remain just Graham. I’m too proud of each title to be dropping either anytime soon. Thank you.
I know it’s been pretty non-existent posting lately, but I’ve been busy seeing friends, wrapping up my med student life, and trying to get ready to start my residency one.
Congrats to all my classmates and fellow new doctors across the country. What a feeling.
So I had a wonderful trip to Guatemala overall. I learned a ton of Spanish, saw some great sights, and all.
But then the very last 5 days of my trip, spent in Antigua, Guatemala, were terrible.
(Warning, graphic description ahead.)
After eating a salad (I know, I know, I should have known better) in Antigua (very touristy, and I assumed that meant safe), I was puking. The next day I spent in bed rehydrating. The next day I felt a bit better. The next day I had overwhelming nausea, only controlled by around-the-clock dramamine (an antihistamine). Then finally the next day I went home.
I continued to feel sick for the next 5 or so days after I was home. About two days ago I got an appetite back and finally feel better.
I finished a 3-day course of Cipro, took an albendazole to de-worm, and a 4-dose course of tinidazole (anti-microbe, anti-amoeba). Apparently tinidazole isn’t approved in the US, as a compound similar to it causes cancer in rats. Whoops.
But I feel better. Finally. After 10 days of hell. And I’m 13 pounds lighter, down to 139, the lightest I’ve weighed since I was 19. (Eternal optimist that I am, I now get to eat whatever the hell I want to try to gain weight. Yum.)
Also: take any American who thinks this country is a terrible place (I was not one of them, I’m just sayin’), send them to a developing country for a month, and they will come back the biggest Patriot.
I’m incredibly thrilled and honored to have been nominated by my graduating classmates to give our Commencement Speech! Thanks for everyone’s support, I’ll do my best to say something profound, and if not that, entertaining.
Random thoughts that I’ve got to get out from the developing country that is Guatemala. And for me to rationalize wasting time on the internets, it’s in Spanish (and then English).
Primero punto: la polucion. Respiro muchas fumas de carros y autobuses todos los dias, y la polucion no ayuda mi asthma. Estoy tosiendo con un tos seco. Ugh.
Dos: necesito una escopeta. Todos la tienen aqui… en las escuelas, las farmacias, el centro commercial… increyible. Es mas por la espectáculo que uso, pero es un poco difficile a comprender.
Tuve un obsecion con mis intestinos por esta semana. Es completamente mejor ahora, pero al comienzo de la semana, un sonido pequeno de mi estomago me preocupe mucho. Tuve mucho miedo de problemas gastronomicas, pero ahora soy fatalista.
1st issue: the pollution. I’m constantly breathing fumes from cars, buses… it’s awful. My cough-variant asthma is in full effect.
2: I need a shotgun. Everyone here seems to have them. At schools, pharmacies, the mall… it’s incredible. It seems like it’s more for show, to scare people off than for actual use, but I still don’t really get it.
I have had a ridiculous obsession with my bowels this week, but now it’s better. I swear, the tiniest gurgle from my stomach would send me into a panic. I’ll still eat safe (no street food), but otherwise I’m giving up. I hope I don’t get anything, but it’s probably out of my control.
Voy a esperar de subir archivos algos photos si yo puedo.
I’ll try to upload some photos if I can.
(Feel free to correct mi espanol si quieres… escribo a computadora muy rapido!)
I hope you’ve enjoyed the series and it’s made you think a bit about health care, health policy, and how difficult it is to come up with solutions to our health care problems. I appreciate the civil discussion and debate, and continue to welcome any other feedback!
A few topics I wanted to cover but didn’t have time to:
Science education - If we want our patients to understand medicine and the science behind it, they need to understand (and accept) the basic tenets of science — randomized studies, for example — and perhaps that’s where we’re failing. People seem to have a miraculous ability to accept the science they have chosen to believe (antibiotics for bacterial infections, germ theory) while ignoring rigorous science that doesn’t fit with their world view (thiomersal is not responsible for autism).
Patient Autonomy - Has it gone too far? By asking patients or their decision-makers to decide, “Do you want to keep trying failing treatments or terminate care,” perhaps we’re putting too much decision-making in the hands of a person who clearly doesn’t want to feel responsible for “pulling the plug” on their mother (who would?)? While no one wants to die or wants a loved one to die, is it fair to other people who have a better chance of hope of recovery to take up a hospital bed to treat a demented 95 year-old man who won’t get any better?
And many more!
On that note, it’s been a pleasure writing about my journey through medical school, and I appreciate everyone who’s joined me and supported me along the way.
I’m heading to Xela, Guatemala (aka Quetzaltenango) tonight for two months with Asociación Pop-Wuj to do some intensive Spanish and medical Spanish training (as well as seeing their cigar-smoking saint, Maximón, and hiking and exploring) before heading back to be in a friend’s wedding. I likely won’t be blogging much, but hey, who knows. Since I now have an official job as a doctor (scary), I’ll be wrapping Over My Med Body up in time for Graduation in June. Stay safe and healthy and I’ll see you on the flip side!
Throughout this series, I’ve documented just some of the big, elephantS in the health care room that truly concern me as a physician, patient, son, brother, citizen, and person. I’ve suggested abstract and theoretical policy ideas for how they might improve things, while providing very little practical information on how they might be implemented (tax hikes, law changes, policy changes). Because I’m skeptical that any of them would ever happen in today’s health care environment.
We need a single-payer for all the reasons I’ve stated in the previous post. But we need a single-payer even more to provide some sort of direction in this damn train wreck of a health care non-system in America. Pick almost any issue I’ve mentioned–or haven’t–that concerns you, and ask yourself if you think it’ll go anywhere without some sort of organized plan or director at the helm.
As I said at the beginning, the goal of a country’s health care system–and note, we talk about a country’s health care system, because the whole country’s population is affected by it–should be to make its citizens the healthiest they can be. Right now we have a system that maximizes profit; this coinflip sometimes comes out with also optimal healthiness, but often it couldn’t care less if it makes its patients healthy. Case in point: the Hepatitis C outbreak in Nevada at a colonoscopy center, where 40,000 people may have been exposed to hepatitis and HIV because staff were re-using syringes to save money. Or the woman who finally sued and beat the pants off Blue Shield of California because they dropped her coverage when she started chemo for her breast cancer. (Sick people cost money!)
We currently have a system where each health care player is trying to pull the system in a different direction, and it really leads us to gettiing nowhere, fast. The private health insurance companies certainly have no interest in bigger national goals, since they for the most part don’t have huge national markets. 30% of people change health insurance each year (no surprise when people change employers so often these days). So it’s no wonder that the HMOs aren’t interested in having comprehensive preventative care or an electronic medical record: long-term benefits of long-term programs aren’t ever seen by these companies–their patients have gone to another HMO!
There are a ton of perverse incentives in our current health care system, and at least in health care, it’s worse for all of us. Hopsitals currently advertise that they have the best heart centers, the fastest ERs, etc.–hoping that they can make more money and often just keep themselves open (rightly so: what good is a closed hospital to its community)? So hospitals have invested heavily in profit-making centers–heart centers, new scanners, etc–while providing fewer resources to other more broadly-useful services like primary care. But since there’s no one at the helm analyzing the data saying, “Wow, this community could really use a new rehab unit, since it has a very high number of returning Iraq war vets,” no hospital has any reason to build a rehab unit–unless they can make it profitable. Again, money/profit is a top priority, not health care needs.
And when hospitals aren’t able to compete, they close. And hospitals over the past 30 years have typically closed in the poorest neighborhoods (which often have the sickest patients). So then these patients are now without a hospital and without a doctor. Which eventually makes it worse for all of us.
People Want Reform.
Look, take a gander at any recent poll on health care, and you’ll see that people recognize that this system is in trouble. Whether it uses the words “single-payer” or “national health care system” or “significant change,” significant change is going to happen. It’s just what kind of change. And as I’ve said before, if we don’t take an active role as the nation’s health care providers saying what we think is best for Americans’ health, some system worse than what we can even imagine will fall into place.
It’s not just the uninsured that are voting in these polls–it’s the insured, too. And I believe for people with insurance to put their faith in a new system, it has to offer them something better than what they’ve currently got. And that’s why I’ve made the case for single-payer: it would provide some level of leadership and direction for our health care system, and, because of that, I believe would drastically improve our health care system.
Why Would It Be Better
Better health service, policy, and epidemiological research. We could use some nationalized system to collect anonymous data to see how people do with condition X or treatment Y. Currently a lot of this data is confined to the Medicare or VA populations, which are often not good representations of the entire populations.
Doctors would have more time with patients. Currently so much time is spent with paperwork that doctors spend less time with patients, and have less time to keep up current data and research in the journals.
All the reasons stated above, including people never going without health insurance. I find it interesting that we can be frustrated with Medicare’s “never events” at an institutional level, but don’t apply that same perspective to individual patients. In a perfect world, should no one at a hospital fall and break their hip? Sure, but it’ll happen, no matter how hard we try to stop it. Similarly, should people never get sick when they’re uninsured? Sure, but it’s going to happen, and should they be forever punished for it? I don’t think so.
Single-Payer Won’t Solve Everything Throughout this series, I’ve presented a number of concerns for this health care system, without really mentioning “single-payer” as a solution, because it alone is not. Health care financing alone will not solve all the problems of health care in this country, but it will be a big step in the right direction. With a single-payer system there would motivation to fix the health care system, as we would have a publicly-financed system whose goal is to optimize our health care system in every way possible.
I don’t buy the argument that “all government is bad.” There are certainly good laws out there, and certainly bad ones. The No-Call List law has been amazingly successul; the NIH is a government organization that divides up billions of dollars a year for medical research; fire and police departments keep us safe, and libraries provide their communities with access to books and information. I certainly don’t believe that any of these would be greatly improved by privatizing them and adding a profit component.
Would single-payer (or any big health care reform change) cause massive changes in our health care system? Absolutely, but I believe to solve or improve many of our health care problems we need massive change. Massive change happened when we gave women the right to vote, or decided that segregation wasn’t acceptable, but I’d argue we all now view these things as fundamentally improving society.
Many of you I’m sure will not be convinced by my arguments. That’s fine. But if that’s the case, it’s your job to come up with a better answer that also has the ability to address the other issues this country is facing besides just paying for health care.
(For example: ED docs love to bitch about EMTALA and people taking ambulances because gas is expensive, but I have yet to see other reasonable ideas for solutions from them.)
You knew it was coming, my single-payer post. It’s a nice wrap-up to the series. (I figured since I was agreeing with KevinMD and Panda so much I had to do something.)
I could make my argument for single-payer in any number of ways, but you’ve probably already heard them:
Human dignity. Everyone should have health care as a human right. That people deserve health care, and as a wise family practice doc from Idaho wrote, the uninsured pay for their health care with their dignity. That almost all of the uninsured and underinsured are hardworking, tax-paying people who either make “too much” money to qualify for programs for the poor like Medicaid or don’t make enough for their employers to also provide health insurance. Or that health insurance is often way too expensive for their families, or even if they bought health insurance, it wouldn’t cover their major problems, like their kid’s asthma (sorry, pre-existing condition).
We the taxpayers and insured are already paying for the uninsured in the form of higher taxes, higher insurance premiums, and longer waits for our own health care (remember, we’re all connected). Since we’re humane enough to have EMTALA and not let people die on the streets, people are going to get some level of care, no matter how poorly planned, poorly organized, or terribly chaotic it is. We might as well just pay for everyone and get a better bang for our buck, no? Isn’t that the American way, to at least get a good deal?
Economic growth is seriously stunted by our current non-system. Why did the Jelly Belly factory cross the border? To get cheaper health care costs in Canada. (True story.) In our global economy, take a look at any American industry and you’ll see our health care costs stick out like a sore thumb–and this makes American companies have higher costs and are therefore less competetive. US automakers currently pay more for their employees’ health insurance than the steel to build their cars (which is why renowned health care economist Uwe Reinhardt refers to the American car companies as health insurance providers financed by selling cars).
Many people–especially potential small business owners/entrepreneurs–simply forget any aspirations they have of starting their own business because of health care costs. If you quit your job and lose your health insurance and then get sick, you’re screwed. So there’s an incentive to stay in a job one hates, no matter how unproductive the worker is, because it provides them with health insurance.
We already ration care. Many people cite a valid concern that single-payer would lead to ominous “health care rationing.” They do not realize that we already ration care: based on ability to pay, not health care need.
Single-payer will save us money. Take a look at any proposed health care scheme, as many economists have in multiple previous studies (California Health Care Options Project, The Vermont Single-Payer Study, The Maryland Single-Payer Study, Massachusetts Health Care Studies, and Maine’s Single-Payer Microsimulation. Just to be clear, these analyses were done by The Lewin Group and Mathematica Consulting, two economic analyst groups. Not single-payer supporters), and you’ll see that single-payer is the only one that provides health insurance to everyone while actually costing overall less. It does this by doing bulk-purchasing of products, just like you do at Sam’s Club. It also majorly simplifies administrative overhead–think of the billions spent on duplicate forms a doctor has to process from the thousands of health plans out there–and the costs of increased health care usage are still absorbed in the savings. (I’m not about to deny that Medicare has paperwork requirements, but they’d be one set of paperwork requirements only.)
Like I said. Probably really nothing new if you’ve ever read any single-payer stuff on the Internets or my blog in particular. But I’m here to propose a different, and much more important reason we should adopt single-payer. We can’t afford not to.On To Single-Payer, Part 2
My classmates and I had an incredibly successful Match Day, most people staying at Stanford, a record number heading to Boston, and others going to UCSF and New York! Time to celebrate!
I’ve always found it curious that we spend so much research and clinical time and money on drug treatment, debating which antihypertensive is best, or which chemo combination cures the most people, but quickly gloss over the requirements to get a pill in a patient’s mouth. To take one extreme, consider the following thought experiment: say a researcher develops a cure for cancer and HIV (yes, at the same time!) but that each pill costs $5 million. While the theoretical efficacy of the drug may be 100% at providing a cure, its practical efficacy is near 0%: without money (or more generally, access) for this pill, it cures no one.
Study after study after study has shown that a lot of people skip their medications, and in the US, this is often due to cost. You take someone and say, “Hey, here’s $100, do you want food for the month or medications,” and funny enough, they choose food. Certainly there are other reasons that people do not take their medications–and these affect people in all countries–but patients in the US are much more likely to cite cost as the main reason they do not take their medications.
A few reasons this doesn’t really make a whole lot of sense:
We pony up and pay for the acute consequences of poorly controlled chronic diseases already. Let’s take my oft-picked-on disease, diabetes. If someone needs a foot amputation, or they need dialysis because their kidneys have shut down, we pay for it. So we wait until they’re super sick and then require a huge investment in resources, but before that, they’re simply out of luck. How is that a good financial investment? How does that minimize costs in our business-run health care world?
We pony up for acute care which we know saves lives, but not the chronic follow-up care which we know saves lives. If someone has a big heart attack, we throw an insane amount of resources toward that patient: emergency room staff, we often call in a team of cardiologists to go open up a clogged artery, and operate expensive machinery in the process, because we know it may save his or her life. But we take that same patient at discharge, when we have similar data saying that a drug like a beta blocker may save his or her life after having a heart attack and don’t provide the same resources to the patient, even though the beta blocker is a much cheaper intervention.
Yes yes, acute issues are by definition more immediate and often more life threatening, but if we’re providing resources, shouldn’t we provide them on some logical, rational basis or principle?
I’ll touch more on this in some of my concluding posts (which are coming up) but at the very least we should be providing better medication access to patients who have known indications for said drugs. I’ve seen uninsured patients with urinary tract infections who can’t afford their antibiotics and have simply returned to the ED with pyelonephritis (a kidney infection due to an untreated bladder infection) and require IV antibiotics and a hospital stay. It makes no sense for any player in our health care system: the patient, the nurse, the doctor, or even the health insurers, who’re getting billed more from hospitals because the hospitals have to care for the uninsured. We should all be angry, frustrated, and annoyed at yet another example of our health care non-system which, at the end of the day, costs us all more in time and money.
I applaud Wal-Mart, Target, et. al for making a huge list of their generics $4. It certainly makes things much more affordable for many people.
America loves to medicate its problems away. Can’t sleep on a plane? Take a pil. Nervous? Take a pill. We want to be in control of our bodies to the nth degree: we’re too busy to be sick, just give us antibiotics that may or may not work; we shouldn’t be fat, just give me a pill to make it all better. We get to have our coffee any way we like it, so why shouldn’t we get to have our bodies however we want them, too?
The problem is that pills don’t work that way. Our pills are, for the most part, chemicals that muck with cells’ pre-existing hardware often by altering how a certain protein interacts with another. But because all our cells generally contain most of the same ingredients, our pills end up poisoning other unintended cells, causing collateral damage. (This is why chemo kills cancer but has such severe side effects: it works by killing cells that grow rapidly, as many cancers do, but other body cells grow rapidly too–the hair, the gut, the immune system–and so these cells die too.)
It would be much cheaper for society–and healthier–to prescribe “exercise” or “a healthier diet.” Often this is what we physicians do prescribe, but our patients do not (and often cannot) follow through. Exercise, diet, and other things that can have a major impact on health are often lumped together as simply “lifestyle,” and are often viewed as individual preference and choice. It’s often easier to simply prescribe a drug (even though we realize that lifestyle changes would be much prefered). The Happy Hospitalist often rants about this–how much money would we save if people just ate healthier and exercised instead of taking pills?
Well, people should eat better, have less stress, and exercise more. Duh.
Some of this might be improved by better city planning and social policy: encouraging walking and public transportation, changing our farm subsidies around to encourage cheaper produce and more access to it.
But the larger social change (and therefore, less likely one) is changing our lifestyles. If you want people to eat better and exercise more, you have to give them more time to do these things. In the short run, sure, it’s easier to medicate the problem away. But in the long-term, I think healthier lifestyles beat polymedicated Americans anyday.
Again, this would require massive changes in our culture and society. To lose our obsession on material goods and consumerism, to realize that taking care of ourselves should take priority over a nicer car or more stuff. To have a greater distribution of wealth. But I illustrate this “solution” more to suggest how difficult it might be to make inroads in this prescription mania in America than anything else.
Primary care in this country is dying. There are fewer available primary care doctors in this country, as more and more physicians either go directly into specialty care or choose a specialty after completing one of the primary care tracks (internal medicine, pediatrics, family practice, obstetrics and gynecology).
Why is this a problem? Primary care is the foundation of a health care system. Most problems and illnesses most people have can reliably be treated by a primary care doctor. When Iran wanted to develop its health care infrastructure, for example, they asked a family practice doctor to fly over and work with their medical leaders, not a urologist or cardiologist. If you don’t have primary care in your health care system, you end up way overpaying for unnecessary specialist care (think of sending a person to a urologist if they have a urinary tract infection instead of going to their family doctor, for example). You also can’t effectively triage people and get them to the right doctor. If someone is short of breath, do you send them to the cardiologist, the pulmonologist, the allergist, the rheumatologist, or the infectious disease doctor? Lose primary care and you lose the basis for your medical decision tree.
And it’s not just that physicians aren’t going into primary care, it’s that primary care doctors are often actually stopping practicing primary care. They find there are other ways they can make better money (or lose less money). When you see this in a health care system–that DOCTORS are quitting medicine, for whatever reason–think bad, bad health care system future.
Why is this happening? A number of reasons, but I’d argue it depends on who you ask:
Primary care doctors: Money. All about money. Low reimbursement rates for seeing patients (especially compared to specialists who get paid much more handsomely for procedures). Long hours, relatively low pay compared to your colleagues. Lots of paperwork.
Medical students: Time. All about time. 15 minutes to see each and every patient, no matter how sick they are? No matter if they’re crying for the first five minutes of it, or if they walk in having active chest pain and you need to get them over to a hospital via ambulance right away? 15 minutes even if they’re asking you to fill out 5 forms that take 5 minutes each? That makes no sense. (Primary care docs certainly care about time, and medical students certainly care about money, just illustrating two of the big issues for primary care today.)
I’d like to discuss each of these issues–money and time–a bit further, because I believe they have wide-reaching consequences on our health care system (since, as we said above, primary care is the foundation of a health care system):
Money. While you might just say, “Well duh, doctors, like everyone else, want more money,” it’s more significant than this. We pay doctors a certain amount based on what they do. Medicare sets these amounts, and most insurers use Medicare’s rates on which to base their own. The way that we pay physicians today, doing is rewarded much more than thinking is. Extreme example: A doctor who performs a surgery is paid much more than another doctor who sees a child for a rash and knows the rash will soon go away, since it’s just a virus. An even more real-life example: a physician gets to bill for a more complex visit (and better-paying one) by prescribing a medicine over not prescribing one. We wonder, “Gosh, why do patients always want something done–a blood test, a study, a scan–when often watchful waiting is the better choice for the patient?” Culture is certainly to blame, but perhaps so are doctors. Patients have learned that more (tests, studies, scans) is better because more is better: for physicians’ pocketbooks. There’s a clear incentive in the system for doctors to do more, so perhaps patients have just learned that more is better by watching us to begin with. (See this NYT article for a perfect example of “more is better.”) I’m not suggesting doctors do this consciously, or that this is the only reason, just one that should be considered as it has drastic consequences for health care costs and unnecessary procedures that unnecessarily place patients at risk.
Time. Borrowing this point from the Panda Bear: when doctors only get 15 minutes to see a patient, you leave them no choice but to start referring a patient out to specialty care when often the diagnosis just requires a bit more time to sniff out. A few more questions to come to the right one. But instead, in this system where each patient only gets 15 minutes of a doctor’s time per visit, everything is referred to a specialist (who often either gets a bit more time to see each patient, or at least is just dealing with one single issue). Can any adult medicine doctor manage someone’s heart failure leg edema? Sure! But put the heart failure in a 75 year-old with glaucoma, dry skin, lung cancer, diabetes, and peripheral neuropathy, and it’s no wonder someone might say “Hey, go see a cardiologist about your leg swelling, I’ve got enough other problems to fix.” This not only leads to increased health care costs from unnecessary specialist care, but also leads to patient confusion (why am I seeing ANOTHER doctor?). I just read some study (can’t find it) linked somewhere saying that most specialists get referrals from primary care doctors without ANY documentation of why the patient is being refered? Perhaps there’s no time for the primary care doctor to write up the referral?
One can look at concierge medicine, which I discuss here and here, as symptoms of this lack of time and money problem. Thanks to Roy Poses for this analogy.
In typical Over My Med Body style, I think we need to address the root concerns identified above: time and money. Lack of primary care affects us all. (We Are All Connected.) I’m probably going to piss off both primary care doctors and specialists with my suggestions here, so please, leave your two cents on how these ideas might be improved.
Money: The simple answer is “pay primary care doctors more.” I believe this should be at the expense of specialists, meaning that the gap between specialists and primary care doctors’ incomes should shrink. Primary care is an incredibly challenging field–one of the most, in fact–and doctors should be better-compensated for practicing it. Perhaps, as well, they should be rewarded for good long-term outcomes for their patients.
Another idea I’d like to float down the river: pay primary care doctors per hour, like lawyers, instead of per patient, with minimums and maximums based on a patient’s comorbidities. So if a patient takes 15 minutes to see and 5 minutes to document, and another 5 minutes to arrange a CT scan for, the doctor gets paid for all 25 minutes (currently they only get paid for the 15 minute visit). All other doctors would still only receive payment for the 15 minutes to see a patient. I’ve suggested this idea before–pay primary care doctors for their paperwork–and I think it would pay primary care doctors better, allow them to provide better care for their patients, and encourage more medical students, residents, and other already-trained doctors to go into the field.
Time: Simply, doctors need to be given more time to see more complex patients. With the 15 minute system we’re in today, I think it has had the effect of trimming the fat from the patient visit, but it leaves little to no room for patient complexity or severity of illness.
I do think also that there are plenty of primary care options that should be open to nurse practioners and physician assistants. There are lots of circumstances where a patient needs to be seen by a doctor, but if the diagnosis is viral upper respiratory infection, why not allow a physician assistant to reassure a patient? I have trouble seeing the other side of this argument.
Medical students spend an average of $139,000 on medical school in the United States, while other nations provide either fully-funded medical school education or at least greatly subsidized medical education. When you add in the costs of an undergradate degree (which is often either not necessary for other countries’ medical school admission or again tax payer-funded), it’s not uncommon to have medical students starting residency in $200,000 of educational debt.
Often medical students also need to purchase or own a car in order to work at the multiple hospitals which will comprise their clinical training. This adds significantly to their expenses (as they have to take out separate car loans at higher interest rates than most of their student loans, and any car loan debts they have get subtracted from their eligible financial aid amount as well). In order to match in certain specialties, students may have to apply to 50 or more programs and interview at a huge number of them. This enormous amount spent applying, booking flights and hotel rooms and meals on the road can easily add up to $10,000 — and unless the student has $10,000 sitting around, it all goes on the credit card, at an even higher interest rate.
Because interest accrues immediately following graduation, even a low interest loan at 2-3% grows quickly when the principal is $100,000 or $200,000.
While these are just numbers on a piece of paper for most of us medical students (translation: I can’t really fathom owing $200,000, so I just pretend it doesn’t exist), we understand it well deep in our financial souls. Most medical students would be lying if they said this doesn’t at all cross their minds when they consider a specialty and future salary. Being in the hole $200,000 is a gigantic Sword of Damacles that scares the crap out of me.
As I’ve said before, i would much rather have medical school be free (read: tax-payer financed) and either have an expectation of:
making less money after residency or
required service time to the taxpayers who financed my education
Maybe we make it a choice. You can choose to pay full price, or pay no price, with either a guarantee that you make less money for life or have required service time for the country.*
I know the government has made unsuccessful attempts to do this in the past by essentially providing too little of a sudsidy for physicians; I would recommend improving this strategy by altering tuition reimbursement based on specialty need and location served. (For example, a primary care physician working in a rural area might be reimbursed 75% of tuition per year, while a pediatrician in the Bronx might be reimbursed 60%.) Perhaps physicians who continue to practice in these settings might receive bonuses for 5 years served, 10 years served, etc. (Yes, I realize the military does offer some programs like this for tuition reimbursement, however it is not available to some physicians *ahem, me* because of don’t ask, don’t tell.)
* Many medical training programs in other countries already require their trainees to essentially complete a medical internship in a rural or underserved area of their country where they are the doctor for the entire community; only then can they go on to specialize in surgery, radiology, obstetrics and gynecology, etc.
Black Monday (today) is the day that medical students find out if they matched at all. (Just got my email, I did!) If not, they have to go through The Scramble. Good luck to everyone, and if you have to Scramble, hang in there. I’ve been told that it’s best to see if you can find a friend to help you send out CVs and stuff while scrambling.
HIPAA is like the Transportation Safety Administration’s requirements that everyone take off their shoes and only carry a quart of liquids and creams: it apparently makes us feel safe and protected, but really just it’s all a big pony show that wastes everyone’s time.
The idea of HIPAA’s privacy rules is this: health information is private. It’s nobody’s beeswax besides yours, your doctor’s, and whoever’s agreed to pay for your care (insure you). And I agree. It is nobody’s beeswax. But it’s so bogusly enforced that it just creates headaches. As I’ve said before, I could easily walk into any hospital in the United States, and dressed appropriately, start reading anyone’s paper chart. Guaranteed. So, see, your health information isn’t private. It should be, but it isn’t.
HIPAA also prevents information from being shared between physician and patient easily electronically. HIPAA lists 18 items that must be protected and cannot be included unless the information is transmitted securely. (Note to bloggers: this is why I change everything about my patients if I write about them: saying anything more specific than what state you’re in is Protected Health Information!) Patients clearly want the ability to electronically talk to their physicians; my generation of physicians would certainly want this as well. Quick question, or side effects of a medication becoming a problem? Want a list of your medications? Want lab results emailed to you? Want your physician to email you an appointment reminder? No no no no no. Instead, we have systems where your doctor sends a message to you in a system with ANOTHER username and ANOTHER password, and it’s a big headache. Even if it’s not that bad of a system, you don’t have access to the messages on your own computer. It’s not like an email that you can just go back and find the message.
What’s even more ridiculous is that HIPAA doesn’t apply to anyone that’s not providing health care or paying for it. So neither Google nor Microsoft even have to comply with any of these requirements, so they’re more free to make information exchange happen than your own physicians!
Make HIPAA opt-outable easily. Maybe this is already common thing, but I haven’t really seen it anywhere. A simple form: I hereby authorize Dr. Walker to unsecurely email me with my: ___ Medications ___ Lab Results ___ Diagnoses to blah@blah.com, and waive my right to HIPAA security protections.
Also: pay doctors for email consults. When in doubt, the physician should always bring the patient in, but it’s a waste of both the physician’s time and the patient’s for questions like, “I feel better, do I need to finish my antibiotics?”
Be consistent with privacy rules. Either require all hospitals to go electronic so that data is behind a password (although one could certainly argue that it’s even easier to steal more data more quickly electronically) or don’t be so damn ridiculous about privacy standards. Also in exchange, provide a more standard protocol to streamline the reporting of stolen identities and stolen health records.
New Zealand is the only other country in the world that allows direct-to-consumer marketing. Those Lipitor ads, the Mucinex boogers — they don’t exist outside of those two countries. The pharmaceutical companies claim that their advertisements provide important educational value to patients. “They can learn about diseases they might have!” the companies say. I say humbug.
Patients learn nothing from these ads, besides seeing ridiculously attractive, healthy-looking, active people pretend to have any number of diseases. I’ve said it before–if the companies were truly interested in educating patients, they would teach them about any number of topics that many patients do not understand. Instead, they hawk products half the time and quickly ramble a list of side effects with the other half left.
Remember–the Pharma corporations are responsible to their shareholders, not the public. Their goal is to make more money, by selling more pills. They do not “educate patients” because it’s good for patients. They “educate patients” because it’s better for their bottom line. Do we not trust physicians to make accurate diagnoses that we need patients to ask for Lipitor?
Ban direct-to-consumer advertising.
If not that, make the field “direct-to-consumer educatisng.” 95% of your advertising time teaches the public how scientific studies work, or what a cardiac stress test does, or why antibiotic resistance is a problem and why doctors don’t like to give out antibiotics liberally, or why CT scans aren’t always a good idea, or why vaccines are safe. There’s an almost limitless number of topics physicians are repeating over and over to patients. In the last 5 seconds, you get to flash your drug logo. “Brought to you by Pfizer.” Put out or get out.
A number of services like HealthGrades and RateMDs allow patients to rate their doctors. Most of these ratings are based on things like “ease of scheduling an office visit,” “Wait time before seeing the physician,” or “Helps patients understand their medical conditions.” Fair enough things to grade a physician on.
A number of services like Medicare’s Hospital Compare or Cal Hospital Compare allow patients to compare hopsitals based on a set of standard “quality indicators” for things that we know will help patients do well — things like making sure patients with heart attacks get the right medicines or treatments in the right amount of time, or giving older patients pneumonia vaccines. Not only are hospitals publicly evaluated on these indicators, but Medicare is considering paying hospitals (and doctors) based on standard indicators. This is know as “P4P” or “Pay for Performance.”
However, physicians and hospitals rightfully argue several things:
You’re only going to get the extreme patients to evaluate you (and often the unhappy ones
The unhappy patients will have the opportunity to publicly say how terrible the doctor is, but because of privacy rules, the doctor or hospital cannot comment or defend him or herself
There is too much emphasis on bedside manner and convenience, and not enough information on outcomes — “How Good A Doctor Am I?”
Even if there is information on outcomes (like in the hospitals’ cases) if this determines payment or discourages future patients because of a bad rating of outcomes, the physician will be much less likely to risk treating a very sick patient, who will likely have a bad outcome no matter what
These systems also ignore where a hospital operates or where a doctor works — hospitals with large populations of poor patients are likely to be sicker than hospitals in affluent areas. Academic hospitals which often care for many incredibly complex, sick patients might be compared to relatively straightforward, simple patients at another hospital down the street.
Medicare has run a trial of this P4P stuff, and it’s been written up in the New England Journal, called Pay For Performance: At the Tipping Point. Let’s look at the some of the outcomes — they took hospitals and either paid the hospitals for their quality improvements, or told the hospitals their outcomes would be publicly available online:
Now, some might say, “Wow, look at that, if you pay people for doing better on quality, they get better!” But the keen observer would point something else out: “Wow, even if you don’t pay people, but make results publicly available, people do better, too!”
Folks (and by folks, I mean doctors and hospitals), this stuff isn’t going away. If you don’t have patients blogging about their encounter with you by name, it’s only because they’re in their 20s or 30s and are young and healthy. (I happen to be friends with one Dr. Gilbert, who is mentioned on the Stanford Hospital Yelp page as the Stanford ER’s McDreamy.) Seriously. The personal evaluations about you are coming, whether you like them or not. It’s in our best interests to argue for the best, most objective and accurate standards. If you’re one of the people that says “Medicine is a business above all,” (I’m not) then fine, but look at every other business in the US: it’s getting revolutionized, criticized, and evaluated online.
We don’t need less transparency, we need more. And the only way we’re going to get there is by having more data.
Physicians and hospitals should certainly be judged by if they’re taking good care of their patients. That means a lot of things: patient rapport, having a “good experience” (whatever that means), but more importantly, outcomes and guidelines. These are, however, guidelines, not rules. It should be simple and straightforward for the hospital or physician to not follow a guideline: if the patient’s heart rate is already 40, they shouldn’t be getting a beta blocker, which slows the heart rate, for example.
For physicians: do patients want the gruff surgeon who’s the best, or the one who’s pretty good but is kind and nurturing (I swear, there’s nurturing surgeons out there)? This data will soon be out there–but in subjective form. “I saw Dr. Green and two weeks later, my cancer had metastasized!” We need accurate, fair standards to examine how we’re doing as doctors, that take into consideration things like patient complexity and compare apples to apples.
For hospitals: I think a lot of the P4P and outcomes and quality indicators stuff for hospitals is worthless for the public. Hospitals get patients for primarily two reasons:
The patient comes to the hospital’s ER and gets admitted.
The patient has a particular doctor who has admission privileges at Hospital X, so the patient gets admitted to Hospital X.
Patients, when sick, do not launch a web browser and see which hospital was more likely to give an ACE inhibitor to its diabetics. They go where their doctor tells them, or barring that, wherever is closest or where they’ve had a good experience before.
P4P and Incentives
One of the big concerns in P4P is “how do we define good, and how do we reward that?” Do we pay the doctors who are really crappy, but then start to improve, while ignoring the docs who are already outstanding? Both? Neither?
For physicians: It’s a little frustrating that we would have to pay physicians to practice appropriate medicine, instead of expecting them to simply keep up with modern medicine, no? Isn’t that what CME requirements are for? I’m not talking about the cutting edge, latest-issue-of-NEJM stuff, but stuff that we’ve known for 10 years? ACE inhibitors, beta blockers, aspirin?
For hospitals: It’s a bit more complex to improve indicators in hospitals, because there’s so many different steps involved to coordinate successes, so hospitals should be rewarded handsomely. But hospitals shouldn’t be competing for patients. They should be competing with other hospitals. Perhaps we create “reward funds” for 3 hospital types: community, academic, and county. And hospitals compete with each other for “most improved,” “best indicators, etc,” — again, apples to apples hospital comparisons. Each 6 months, the top hospital in each category gets a reward that gets split up between the hospital and its staff; this would create innovation between hospitals, everyone trying to do better a job. And let’s say the winning hospitals have to give away their secrets to “best pneumonia vaccine rate” to everyone else.
Perhaps for the next 5 years, we start with carrots. If you’re either improving or continuing to do a good job (as compared to your equals), you get a bonus. 5 years after that, if you’re not improving, or doing significantly worse, in comes the stick, with some sort of punishment.
(Look, I’m well aware that the indicators aren’t always practical or the best, and they certainly need to be improved drastically, taking into account the differences between community and academic medical centers, etc, but the evaluations and ratings are coming. I’d much rather setup a system that is created by health care providers and reasonably fair than be evaluated by the subjective masses whose opinions are often muddied by sad, tragic bad outcomes.)
Just got my scores back, less than 3 weeks after I took it. Success!
(Note for the test makers: scoring and standard deviations aside, the computer should tell you immediately after the test if you did well enough to have essentially ‘automatically’ passed, and that your final score will be sent to you.)
Fear of malpractice lawsuits with supposedly growing payouts in a litigious society have led doctors to leave states with high malpractice premiums, lobby to enact non-economic damage caps (”pain and suffering”), practice “defensive” medicine (order generally unnecessary tests that they would not generally order except to prove disease X is not present, even though it is usually vanishingly rare). These are concerns because malpractice premiums the doctors pay in many states have skyrocketed.
There’s reason to believe, however, that perhaps there aren’t growing payments or settlements in medical malpractice. Let’s take a look at this Public Citizen report on MedMal trends:
So the payouts aren’t bigger, and there aren’t more judgments or settlements.
But doctors are instead seeing plenty of lawsuits filed. Even though 4 of 10 are dismissed because they are groundless, the accusation that a doctor performed malpractice costs more than just time and money; it takes a mental and emotional toll on the physician as well. No one likes to get sued, of course, but physicians have dedicated their lives to helping people, and have gone through enormous personal sacrifice to do so. And even if the suits are being thrown out, the media publicizes big payouts, making recall bias a problem as well. Even with all that said, only 1-in-8 damaged actually sue, if you can believe it.
Perhaps, however, doctors aren’t effectively disciplining their own. The same Public Citizen report shows only 1/3 of doctors with 10 or more malpractice payouts against them were disciplined by their State Medical Boards:
And so, as I said, doctors have lobbied for damage caps. As this GAO report suggests, it may be working to slow premium increases. This report also suggests that in many of the “problem states” with high malpractice costs, doctors are either leaving the state or leaving a particular practice because of costs, leaving both Emergency and Newborn care at risk. A rural Pennsylvania hospital no longer has an Orthopedics department because their orthopedists left. This is clearly not satisfactory for the patients this hospital serves.
Another problem–when and if a case does make it to trial, it simply turns into a he said-she said, in a Battle Royale of expert witnesses. Plaintiffs’ bring in doctors paid to argue their side of things, and defendants’ bring in doctors paid to argue their side of things.
We can take a look at other countries. But first, we’ve got to look at our whole health care system. We as physicians have to look at a system where if we make a mistake, we’re making a mistake in a system that provides for little support for the patient to which it happened. That if you are negligent and cause a grave disability to another person, that person is sure shit out of luck. That until they’re 65, that grave disability is not just a disability, it’s often a major personal and financial liability. Because it’s now become a pre-existing condition. And at that point, without any guarantee that the problem or its complications–that you caused, mind you–will be paid for, of course people are going to sue sue sue! If a 30 year-old patient loses his health insurance tomorrow, he’s got a good 35 years of extra health problems to pay for. (And mind you, the patient knows his or her lawyers are going to take over half the settlement, anyway.)
But patients need to pony up, too. People should be compensated for malpractice, but not bad outcomes. Americans must realize that death is part of life. That, for the most part, doctors are slowing death and prolonging life. If we weren’t here, their loved ones would die without our life-prolonging treatments that we’ve spent so long to learn. Surely this low bar should not be the standard we hold ourselves to as physicians, but there needs to be a way to quickly nip classic “adverse outcomes” lawsuits in the bud. There are certainly cases where it’s murky, but there are plenty of cases where a bad outcome or known risk is brought to court. I’m sorry, patients–I know you’ve come to expect perfection from your physicians. But we are unfortunately all too human to live up to that standard. Bad things happen. If 5% of people die from surgery X, you could be one of them. This is why sometimes doing less is more.
And this is why I support a no-fault medical malpractice system. (This Slate article is a good start.) “No fault” is how malpractice works in a bunch of countries–and even how specific types of malpractice problems (bad birth outcomes) are handled in a few states. No-fault systems are great for problems like we face in medicine–that we try to avoid them as often as possible, but they admitedly happen. (They also take most of the money that currently goes to lawyers and gives it to patients that truly deserve it.) Quoting the Slate article:
In Sweden, when a patient suffers avoidable injury, whether through gross negligence, such as a botched surgery, or through a more understandable but avoidable mistake, such as a misdiagnosis or medication error, the patient—usually with help from the doctor’s office—fills out a form requesting compensation. That request, along with relevant doctor and hospital staff reports, gets reviewed by an adjuster who decides whether the injury might have been avoided had treatment differed. If the claim passes that hurdle, a panel of legal and medical experts considers it. If the panel decides the injury rose from avoidable error, the patient is compensated. The award varies according to the nature of injury, the degree and duration of the patient’s disability, the expenses incurred, and other factors; it may also include compensation for pain and suffering. The entire process usually takes less than six months. Patients who feel unfairly denied or undercompensated can appeal, but they cannot sue. The system is funded by premiums charged to regional organizations of medical facilities and physicians. These premiums are substantially lower and more stable than malpractice premiums in a tort system.
Such a system would generate more claims than does our present malpractice system—indeed, compensating more of the injured is part of the point. The system would save money, however, by eliminating punitive damages and legal costs. The legal and administrative costs of our present system (lawyers’ fees, court costs, paid experts) account for 60 percent of the estimated $24 billion the malpractice system consumes each year. A no-fault system would cut that to 20 percent or 30 percent, roughly doubling the money available for the injured.
Another option, which seems to be more bureaucratic (but have more precedent in the US) would be health courts, where malpractice cases would go to a specific branch of the Judicial system and cases would be heard by groups of medical experts, who could more objectively decide what is malpractice and what is bad outcome. (There are separate tax courts and patent courts for these specific types of complaints.)
EMTALA, the law that requires ERs to evaluate and stabilize everyone who shows up, is a good law. (There went half my readers right there.) If you’re still with me:
I would argue (as would the writers of EMTALA) that we are so advanced a nation that patients should not be dying on the streets because of their inability to pay for emergency medical care. The problem with EMTALA is that it provides too much potential for abuse. This is the fundamental art of social policy — how do I put together a rule to maximize its use for its intended purposes, yet minimize the opportunities for abuse and loss of personal freedoms for whom the rule applies? (Note: unfortunately many policy makers do not seem to follow or care about this. They trust lobbyists to do this.)
If you were to look online or eavesdrop in a doctor’s lounge, likely “abuse of medical resources by certain patients” would be near the top a frequency-of-complaining list. However if you were to look at how much, in reality, these patients actually cost the system, it would be a tiny percentage of that compared to the truly sick. So it’s more a matter of wasting a doctor’s time and energy — these patients are truly draining: they frustrate physicians and nurses greatly.
The other problem is that EMTALA is an unfunded mandate. This means that hospitals are required to follow the rules of EMTALA no matter what the cost may be to the individual hospital.
Often it depends on why the patient is there — which often is near impossible to discern in the first place. Others are straightforward: hypochrondriacs? Easy. Refer to psych. For drug seekers (note: boy would these patients be easier to spot a mile away if we had some sort of national medical record), make sure they’re only drug-seeking, and get them out.
Others seemingly have nothing better to do. While I’d argue that perhaps job resources, education, and opportunities in the long term and for future generations might be a better solution, I’ll stick to health care for now.
If we want these patients to either stop seeking care altogether (not good to alienate people from the health care system, I’d argue, see my other posts in this series) or start seeking more appropriate care, then we’ve got to use our carrots (rewards) and our sticks (punishments) to lead the donkey.
Maybe we just need to offer better options. For some patients who simply don’t know any better, and for whom a stern lecture by a doctor isn’t going to educate them, they just need another place to go besides the Emergency Department. For these patients, we should be supporting our community health centers for after-hours clinics. They’re usually just as well-placed and located as hospitals, they provide more appropriate care settings at much lower costs, and they would also get a patient tied in for follow-up at the clinic, maybe even start seeing a physician on a regular basis. These after-hours clinics should be funded, like EMTALA (see below).
For other patients, they need a stick, as the niceities of education and better options simply don’t appeal to their finer sensibilities. Two possibilities here: perhaps it’s three strikes out at the olllld ballll game. Once a patient has been seen for non-urgent care (which would obviously need to be defined) three times, they no longer qualify for EMTALA at the hospital. If they return, they get a vital signs screening by a triage nurse, and barring no abnormal vitals or other gross, obvious issues, they are turned away. Another possibility would be charging a patient for non-urgent issues. We say, “Sure, we’re happy to evaluate you,” but if you are not even urgent (remember, you’re at an Emergency Department), you’ll be charged. (Note: this latter option I don’t support if there are no other options for these patients, which is why I think we should offer after-hours clinics.)
Finally, funding. A colleague of mine likes to say that a heavenly program can be hell if not funded appropriately, and maybe this would lead to a chain reaction of EMTALA fixes. If the federal government (read: taxpayers) had to start paying for EMTALA care (note: we already are, in the prices of higher costs to subsidize unreimbursed care), we would immediately see the true costs, and take actions to fix it. Currently, it’s all just buried in inflated prices and percentages of costs and losses in hospital account ledgers. Either way, EMTALA care needs to be funded. Some states are trying to partially fund this effort by passing certain taxes, but a national source makes more sense, since it’s a national law.
(Note: “Repeal EMTALA” enthusiasts are either kidding themselves, heartless, or living on Mars. If you believe that Emergency Departments in the United States should check for insurance in the ambulance bay or require a funds verification before they see a septic patient or one after a bad car accident, like they do in India, you might as well stop reading. We’re not going to see eye-to-eye anyway. For-profit hospitals would have no problem doing this, and it’s unethical and immoral.)
A young, healthy person very close to me called me last night with “a fever and pain on [his] right side.” I had my diagnoses 1 thru 10 (appy!) by that first sentence. He had possibly the most classic story for appendicitis I’ve heard yet in my career. Luckily he was already at the Emergency Department, waiting to be seen by the doctor and was stable and fine, except for all the pain that had migrated over the past hour to McBurney’s point. (I called him this morning, appendix now gone, and he’s already passing gas and doing great.)
But the fact that I was very close to him made the phone call a little uncomfortable to me. Sure, I have plenty of friends that call for medical advice, and almost always it’s “Boy, sounds like a virus, but I’d follow-up with your doctor,” but this time it was different. I knew that by giving him the diagnosis of appendicitis, I was putting him under the knife, and it gave me pause. It made me question myself, in a good way. “Is this really appendicitis? Is there anything else it could be that I’m missing?” This is the good side of subjective medicine–that we should try to perhaps apply this level of questioning and hypothesis to all our patients. Thinking to ourselves, “Gosh, I’d really hate to put my friend under the knife, I really want to be sure I’m right on this one,” and apply this standard to all our patients.
So I did my doubting, asked a few more questions, and felt even more convinced. He then asked me, “Well, should I demand a CT scan?” and again I thought to myself, “Boy, I’d really hate to be wrong on this and risk an unnecessary surgery, maybe he should get a CT scan anyway,” and subsequently realized the flip side of subjective medicine: practicing incorrectly because I care about a person and don’t want to put him at risk. So I thought some more, and turned my friend into any other patient, and realized I wasn’t applying the same standard — and it’s often cases like these, with celebrities, VIPs, relatives — where we apply a different standard, and they often get much worse care than if they were just a regular Joe.
The key is that fine line: treating each patient as if you know them and care about their well-being with the same regard you have for your loved ones, but not doubting yourself so much that your judgment is blurred in the process.
(Yes, duh, I obviously ceded everything to the ER doc and surgeon who evaluated him, saying I would trust their opinion over mine, but I certainly considered the situation as if my friend was in front of me. The story was so classic, the surgeon took him up around midnight, sans CT scan, and took out the big white worm. Also good to recognize that a CT is note harmless, as it exposes patients to radiation.)
So I come across this link for Stewart Uniersity: New Scotland International School of Medicine, which is apparently a “new medical school” and is somehow just down the road from Stanford. Funny, I’ve never heard of it. So I delve a little deeper, and my “sketchy”-dar (similar to gaydar) starts to go off. As I delve a bit deeper, I’m even more concerned for students and potential applicants (has scamming moved to medical schools now?). Let’s investigate the general info first:
Right off the bat, the school claims to be “the #1 leader in US medical education.” Them’s some big balls you got there, Stewart.
“Stewart University is the first medical school to open west of the Mississippi in the past 45 years.SM” Okay, fine, got me there — we need more doctors!
Stewart University is an International School of Medicine. Our curriculum is the standard allopathic (MD) degree discipline. The accelerated 16 month MD degree curriculum completes the basic science courses in first four semesters.
The World Health Organization (WHO) requires recognized MD degree granting programs to be at least 30 months in length. The Stewart University MD program is 34 months in length for a student with normal degree progress.
So they’re somehow an “International Medical School,” operating in the US. While the WHO may recognize an MD program as one with 30 months of teaching, I’m pretty sure the AAMC and other licensing bodies require a 4-year medical school, no?
2 years and ten months total program length
3 starting classes per year: January, May, September
No MCAT - NOT required for MD licensure
No Bachelor’s Degree - NOT required for MD licensure
No Minimum Undergrad Credit Hrs -NOT required for MD licensure
No AMCAS Application, Apply Directly via School Website
No Age Limit
Provisional Admittance - for those without prerequisites
Equal Admissions Process for All Applicants
Immediate Admissions Application Review
Okay, it is freaking awesome that you wouldn’t have to take the MCAT. But really–you don’t even need to go to college? No Bachelor’s Degree?
I love the handy Tuition Comparison Chart. Wow, if you go to Stewart University, you save a whole $9,000 a year over Stanford or USC. And you receive, according to the chart, a Curriculum with “Equivalent books and instruction as other Calif Med Schools**”. I had no idea.
On further inspection: It’s called Stewart University because most of the university is run by The Stewarts! William Bullock Stewart, Sr. is Provost Emeritus, his son, William Bullock Stewart, Jr. is Provost, and his son, William Bullock Stewart, III is Chancellor. The Board of Advisors, Ronald S. Steward, Rosemary E. O’Hara, and James T. Stewart are all of the Stewart clan as well, as well as the Marketing Illustrator.
“The Basic Science phase includes didactic instruction (and may have cable television instruction available also).” Where are they getting the bodies for anatomy? Are they even allowed to have bodies to dissect if they’re not accredited?
The Clinical phase of the curriculum is intended to be conducted at various U.S. Veteran’s Administration hospitals around the United States and Caribbean Island locations. This affords great flexibility to the student, particularly those on active duty or mobilized, to perform clinical rotations in military treatment facilities and tertiary care military hospitals around the world.
I guess this is how international medical students do it.
And the kicker, buried in the text: “For-profit institutions almost always have to wait 2 years after starting operations before they are eligible to submit an application for accreditation.” Oh, well there we go. You’re a for-profit medical school. I was guessing I’d find that somewhere. So you can teach, and provide the same training as any other California medical school, and take a cut as profit? Color me skeptical.
There’s also a blank but present page on Known Falsehoods, whatever that means.
It all leaves me pretty darn puzzled, ’cause when you Google the school’s address, you end up with A Postal Annex Store in Los Gatos, California — no medical school listing — and I’m pretty sure the Postal Annex isn’t Federal Land.
Sure, some of these features go along with some of the features of the Caribbean Medical Schools — but an accelerated curriculum, with almost no requirements for admission, and a campus that appears to be a mailbox in a Mailboxes Etc. store? Stay away, pre-meds, stay far, far away.
(I know my tone in places is snarky or sarcastic, but in all seriousness, I think there are reasons that American medical schools require things like the MCAT, admissions essays, and letters of recommendations. Mainly those being that as an MD you will be responsible for people’s lives, and it’s not something you should be able to just “sign up and do ’cause you feel like it,” which seems like the gist of the marketing campaign of Stewart University. I’ll admit I don’t know a whole lot about the Caribbean medical schools or licensure process in the US for IMGs, but these groups at least seem more interested in putting out good doctors than just somehow skirting around the requirements to get an MD through a loophole.)
Update: I just spoke to a man who answered the phone, who was very confrontational when I asked “Where is the school located?” He started rambling about how ValueMD and StudentDoctor have been harassing and stalking people from the school. He admitted the address on the website is a PO Box, and said the school does not release the address or location of the school until an applicant has been accepted. (”Fine by me,” I said, “But it seems a little weird that a medical school wouldn’t be visitable or even map-able.”) He then noted that “members of Al Queda have been in contact” with the school, and the school had to file a “400 page document with the FBI” because of this. Yowsers.
I’m watching Baghdad Hospital: Inside the Red Zone, an HBO documentary about one of the major trauma centers in Baghdad, where they’ve gone from mainly doing appendectomies to daily shrapnel extractions and penetrating trauma explorations. Their blood bank so frequently runs low that they take a patient’s ID card, and someone must go to the blood bank in the patient’s name and donate blood to get the ID back.
Perhaps the Red Cross or hospital blood banks should use a similar tactic: there’s always a good 100 people (at least) waiting in the surgery waiting room or the ICU waiting area who are visitors or family of a patient. Why not ask them to donate blood? They’re not doing anything else, they get free cookies, and they’ll be repaying the donation someone else made to ensure that blood is available for the next person who needs it. How about it, Mr. Levy? You always seem open to trying new things.
(The film is incredibly depressing, and the images gruesome: children getting bilateral chest tubes and DPLs because they don’t have film for xrays; doctors taken hostage and killed. I can’t imagine the stress of the staff and the patients there.)
When we last spoke, we had just finished our application and were patiently waiting for…
Secondaries
Secondaries come in all shapes and sizes. Some schools have big long lengthy sections, others have a few quick questions. Be sure to save anything you submit (which is usually online now), as other schools are likely going to ask you similar questions and you can make it work, a la Tim Gunn.
The key in secondaries is to give schools something new about you, or something that you just touched on but would like to develop further (often the former is easier to do based on the question). Like I said before, the faster your turnaround on the secondaries, the faster you can hear back about an interview usually. I think I gave myself maybe a
