Today President Obama released details on the latest iteration of health reform.  CNN published an article on the new proposal here.

Before I begin my thoughts on the matter, let me say this.  I have a major problem with calling it health care reform.  Health care is not the issue.  People can say what they want about the insurance system and how we pay for health care.  Say what you will about the health culture and how people take care of themselves.  I would point to the data on cancer survival, where the US far outpaces any other country, as evidence that we know how to take care of sick people.

As for this latest proposal, there’s one major, major flaw that will do nothing to help the situation.  The plan requires everyone to buy health insurance in an effort to spread out the costs of the system.  It also prevents insurance companies from denying a person coverage on the basis of a pre-existing condition.  This is all well and good, except you have to enforce the insurance requirement right?  The latest proposal would eventually put the penalty at $695 or 2.5% of salary, whichever is greater.  This is lower than most insurance premiums.  There’s no incentive to avoid the penalty in favor of purchasing insurance.  The astute, and healthy, individual is free to save money by paying the penalty, then when illness hits, buy insurance, since the pre-existing condition won’t disqualify coverage.  This will increase the costs born by those that are using a greater proportion of the resources as companies are no longer off-setting those costs with young, healthy individuals.

To me this is like rearranging deck chairs on the titanic.  It’s trying to tweak what is consistently being called a broken system.  This won’t “bend the cost curve”, to borrow the phrase politicians like to use.  For the past few years, whenever this discussion comes up, I maintain health insurance should be more like car insurance.  Make primary care a cash-based business.  You don’t use care insurance to get an oil change.  You don’t even use it for more expensive maintenance like getting new tires.  Why should you use it for your annual physical?  Making primary care cash-only does several things.  It increases transparency in costs, physicians can compete for business and patients can choose the lowest cost.  It decreases the overhead of these physicians.  They no longer have to have an employee or service solely for the purpose of billing (and arguing with) insurance companies.  So much paperwork has developed for insurance purposes only.  Decreasing these headaches is what will drive more people into primary care instead of sub-specialties.

In addition to this, health insurance should be opened up across state lines and bought on your own accord, as you pay a premium associated with your risk, just like every other kind of insurance.  There’s no reason for the 40-year old triathlete in prime physical fitness to pay the same premium as the 40-year old obese smoker that’s had heart disease since 35.  Reward people for taking care of themselves.

Addendum: The Wall Street Journal on Friday published an article that delves into great analysis of the current plans circulating in progress.  It exposes some of the faulty arguments people use to say we need reform (not saying we don’t, I just disagree with a lot of the popular arguments) and shows how the current plans will not decrease spending, but increase it through a variety of misguided mechanisms.  Click here to read the full article.  Thanks to MedRants for posting this article on twitter.

FutureDocs has an excellent article on the IOM duty hour recommendations which will be coming down the pipe in the near future.  I won’t spend much space discussing it, but we really do have to ask ourselves the question, at what point is a tired but well informed doctor better than a fresh one who knows nothing about the case?

I recently had a discussion with a few friends about how our healthcare system works and what changes could improve patient care.  For the non-medical people I was speaking with, preventive care was a major topic.  They said the same thing that most doctors would say, which is that it seems cheaper to educate patients and steer them towards a healthier lifestyle than to wait until they develop the diseases that are a result of unhealthy choices.

None of this is groundbreaking stuff, however the second part of our discussion was much more interesting.  I explained that while many physicians incorporate preventive care and lifestyle modification into their practices, these are not things that are easy to bill for and as such they are not always a top priority.  I’ve heard many doctors, mainly primary care physicians, talk about the need to change the way doctors are reimbursed so that preventive measures becomes a larger component of patient care, but the fact remains that it is much easier to prove that you have provided a procedural service than an abstraction like counseling a patient.  So the barrier to changing reimbursement becomes how to quantify what sort of counseling is being done and also verify its quality.  In a perfect world we could be on a honor system and trust that when a provider says he has counseled his patient he has done so in a thorough and effective manner, but in reality the process of ensuring that this advising is substantive and effective is much more difficult.

So I pose the question to you the readers.  How can we accurately measure preventive counseling services in a manner that makes it feasible for payers to reimburse providers with confidence that the service has been rendered appropriately?  I’m curious to see what solutions others can come up with.

For the past year (or longer), the administration at our medical school has hammered home the idea that this year’s NRMP Match will be the most competitive ever, on a greater scale than previously seen.  It’s been a trend of the past few years that more and more programs are filling in the match with progressively fewer spots available in the scramble.  This year, however, the possibility exists for a greater jump in this trend.  Our class is the first to see the enrollment increase first recommended by the AAMC.  At our school, it was a 10% increase over the previous class size.  As my esteemed co-author already pointed out in a previous post, this increase in graduating medical students has not been met by a coinciding increase in residency spots.

There are many theories as to just how this is going to play out.  Will American or International medical graduates feel the squeeze?  Both are possible, some programs are traditionally IMG heavy, if AMGs are not applying to those programs, they will feel it worse.  However, it is believed that residency programs favor AMGs given an equal appearance on paper.  In that case, IMGs would feel the squeeze.  In the end, there will likely be a mix of the two outcomes.

Hit the jump for commentary on Internal Medicine, specifically.

Surprise, surprise, right?  TV shows aren’t realistic.  But why should this matter?  Because our country is increasingly sedentary and learns from what they see on TV.

Here’s the article, but here is a brief excerpt of the statistics:

“The study looked at the depiction of seizure care for all episodes of “Grey’s Anatomy,” House, M.D.,” and “Private Practice,” and the last five seasons of “ER.” The research will be presented at the American Academy of Neurology’s annual meeting in Toronto, Ontario, in April.

In nearly 46 percent of seizure cases, characters on these shows delivered inappropriate treatments such as holding the person down, trying to stop involuntary movements or putting something in the person’s mouth, the study said. The shows did show proper treatment about 29 percent of the time, and in the remaining 25 percent of the time, the accuracy of the portrayal couldn’t be determined.”

The disturbing part is that these shows all have medical consultants, so it would be easy to get it right. (Side note: How funny is it the American Academy of Neurology is having their annual meeting in Canada?)  Of course, the odds of your average person having to care for someone in the middle of a seizure, I would imagine, are pretty low.  Of greater concern is how something like CPR is depicted on these shows.  I started laughing once it was so bad.  The article even goes on to discuss this:

“There have been other studies showing that television medical shows do a poor job of portraying procedures appropriately and accurately. Of concern is one about cardiopulmonary resuscitation, or CPR, Sanders said. A 1996 New England Journal of Medicine study of “ER,” “Chicago Hope” and “Rescue 911″ found that in the episodes viewed, 75 percent of patients survived cardiac arrest immediately, and 67 percent appeared to be well enough to leave the hospital. In real life, long-term survival rates vary from 2 to 30 percent for cardiac arrest outside a hospital and 6.5 to 15 percent for arrests inside a hospital, the study said.

False depictions of CPR are probably more alarming than misrepresented seizure care, Sanders said. Normally, seizure care is left to doctors, who don’t get their information on treatments from television. But CPR is a procedure that lay people do learn how to do, and they might get false impressions from watching dramas, she said.”

CPR is something every lay person should learn.  While the statistics for survival are low, it is typically still the best hope, and CPR is not technically difficult.  You can learn in a half-day, if that.

And now the humor I promised in my last post.  Dr. Centor of DB’s Medical Rants recently linked to our blog.  He is on the faculty of the institution that brought us the following:

Today’s New York Times carries an article about the expansion of the US medical education system, with an additional two dozen schools opening or expected to open over the next several years.  While this increase in the number of medical school slots is needed, the article fails to address the other, likely more important, component that limits the number of US physicians; that is the number of US residency positions.

Once a student graduates from a medical school he is a doctor, however he is not able to enter practice as a physician.  To practice, graduates must apply to and be accepted into a residency program that will train them for an additional three years in whatever subspecialty they have chosen. Currently there are 22,427 PGY-1 spots, 23,343 US applicants, and 46,309 foreign med grad applicants.  This means that any increase in medical school enrollment will create increased competitiveness for residency spots, but no actual increase in the annual production of practicing physicians

These new schools claim that they will be more focused on educating primary care physicians, and while they may do quite a bit to encourage their students to seek primary care residencies, the type of doctor a student becomes is not determined by their medical school training, it is determined by their residency.  If the US wished to shift the proportion of physicians entering primary care, they would need to expand the number of training spots for family practice, OB/GYN, internal medicine, and general surgery, however even then, the graduates of those programs would be free to enter fellowship training to become subspecialists.

The article goes on to make a few other comments about expanding care with nurse practicioners and physicians assistants and while these providers are a useful tool, they are not a replacement for doctors and should not be treated as such.  Hopefully the AMA and other policy makers will soon address the real rate limiter in medical education and expand residency training positions so that we can finally see an increase in the number of practicing doctors.  Until then, we’re only putting a band aid on a much larger problem.

In my opinion, based on very little experience at this point, one of the most difficult things in medicine is telling a family bad news about their loved one.  There’s no class you can take.  No amount of role-playing with your classmates can prepare you for this duty.

I’ve been in the room several times, with residents and attendings, as the news is given, typically a newly diagnosed cancer that is already beyond treatment.  With internship and residency quickly approaching, I know my time is coming.  I find myself thinking about which techniques fit my personality.  I do think the most important thing is to be as comfortable as possible while talking to the family.  It does no one any good to be nervous and uptight when trying to put a family at ease.

Do I guide them towards the diagnosis or firmly tell them up front?  Do I wait for a few minutes after they have asked questions to see if they have more or do I promptly leave and let them know the nurse can page me if they think of anything else?  Did they understand?  What if they ask for advice on how to proceed?  Should they try for a cure or aim for comfort?

I’ve been on both sides of the discussion.  I know the answers to some of my questions, others will depend on the situation.  Then there’s the countless other questions that I can’t think of until I experience it.

There’s so much to medicine that has nothing to do with disease.  In my personal statement, I discussed the art and science of medicine.  Developing a style and learning the art will take just as much effort as learning the science behind what we do.  It’s a challenge, but it’s a big reason of why I chose medical school over other professions.  It sounds corny, I know, but I will forever maintain that it’s a fitting description.  Knowing how to talk to people is just as much of a skill as proficiency at any procedure.

Two serious topics for both posts, maybe next time I can be humorous.

32 days to Match Day.

To some who are reading this, the very question “does insurance matter?” seems absurd.  Of course it matters!  Right?  Well, maybe not, at least where mortality is concerned.

Megan McArdle of The Atlantic poses the question “How Many People Die From Lack of Health Insurance” in a recent column and the results may shock you.  The most reliable number of unexpected deaths correlated with lack of insurance is 20,000.  However it turns out the group with the highest mortality rate is not the uninsured, but rather those who are on government insurance programs.  This leads her to ask whether or not the factors that might predispose someone to being without insurance or on government insurance are not the same factors that might have a negative impact on health.  This is an interesting proposition and though I seriously doubt any politician in his right mind would ask that question, there probably is a link between behaviors that predispose someone to lack of insurance and poor health.

All of these arguments though are tangential to the question we should be asking.  The real factor that affects the quality of peoples’ lives is not whether or not they have insurance, but whether or not they have access to adequate medical care, which she sums up succinctly in this quote:

We don’t necessarily care whether people are marked by some survey as “insured” or “uninsured”; we care whether there is preventable suffering in the world.

The simple fact that is often overlooked in the healthcare debate is that insurance status is not really a marker of healthcare access; it is a surrogate marker and likely a poor one at that.  With free clinics and other charity programs, as well as those who have the financial means to provide for their own healthcare outside of the health insurance system, we should be asking ourselves whether or not we are looking at the right numbers when we debate the status of healthcare in our country.

McArdle argues that the best proof that insurance has no effect on mortality is the lack of any change in mortality rates at age 65, when all citizens become covered by Medicare.

To my mind probably the single most solid piece of evidence is this:  turning 65–i.e., going on Medicare–doesn’t reduce your risk of dying.  If lack of insurance leads to death, then that should show up as a discontinuity in the mortality rate around the age of 65.  It doesn’t.  There are some caveats–if the effects are sufficiently long term, then it’s hard to measure, because of course as elderly people age, their mortality rate starts rising dramatically.  But still, there should be some kink in the curve, and in the best data we have, it just isn’t there.

I will concede that there are likely differences in the quality of life and at the very least pure peace of mind between the insured and the uninsured.  However, the proposition of thousands of our neighbors languishing and dying because of lack of health insurance might in fact be nothing more than a red herring.

Not an expert witness

Over the past few years there has been increasing media coverage over the supposed “dangers” of immunization.  Scientific giants like Jenny McCarthy have taught us that excessive levels of mercury, aluminum, and other random elements on the periodic table are giving our children autism, decreased sperm counts, red hair, and an affinity for reality TV.  However, none of these great thinkers have ever been able to prove a causal linkage between immunizations and the supposed side-effects.  Further still, they have ignored the side-effect of not getting immunized, which is the danger of actually catching one of these diseases.

As it turns out Measles, Mumps, Rubella, Diptheria, and a host of other bugs are really quite dangerous and if you catch them bad things are likely to happen.  Which leads me to this story;  It turns out that there is currently an outbreak of Mumps in New York that is popping up among an unimmunized group of Hasidic Jews.  This should be a lesson to those who believe they can “hide in the herd” and avoid being immunized while still not catching any of the diseases.  In a world as interconnected as ours, the risks of being exposed to an unimmunized person are quite high, and if you yourself are not immunized, the chances of becoming infected are equally high.  The moral of the story is to quit listening to bleach blondes with IQs of 73 and get your children immunized… now!

Today’s entry will address Morning Rounds, which is perhaps the greatest sacrament in medical education.  It embodies all of the great traditions of medical education including patient care, pimping, and inefficient use of time, but not every rounder is the same.  Each attending physician has his or her own style, reflecting their own personality and views on the proper way of taking care of patients.  Below is a basic, but by no means exhaustive, listing of the styles I’ve encountered.

1. Gravity Rounds – Like a spiraling sky-diver these attendings prefer taking the elevator to the top and stairwells all the way down approach to rounds.  They are usually thorough in their patient care, but see no reason to expend any sort of additional energy in activities such as climbing stairs.  This method is fairly efficient and preferred by many teams after a hard call night.  The attending who adopts this method is sure to win a few bonus points from his team.
2. The Everest – The nemesis to the Gravity Rounder is The Everest.  Determined to stay on top of his cardio routine and convert his pudgy residents into true athletes, this attending will start on the lowest floor of the hospital and work his way up with stairwells only.  This attending is usually the type who prides himself on his own personal work out routine and will chide his residents for being unable to find time to run 5 miles a day regardless of the fact that the resident works 80 hours a week and spends his spare time sleeping and trying to read a page or two on how to treat his patients.
3. Pinball – The pinball rounder’s morning routine resembles an ADHD Squirrel on a sugar high.  Do you have five patients on the third floor?  That’s great, but let’s break it up by heading up to the seventh floor for a minute, then come back to three, and then maybe stop by the radiology department before we wrap up the orders on 352.  There’s no method to this rounders madness, just the impulse to “see an interesting exam finding” or “get the radiologists read on a film”.  A particularly cruel hybrid can be found when this attending also has Everest impulses and takes the stairs for all of these side adventures with some studies suggesting that this combination may be responsible for a five-fold increase in sudden cardiac death among residents.
4. The Surgeon – Stethescope?  What stethescope?  This attending can sum up all relevant physical exam findings with four simple letters “LGFD”, that’s right Looks Good From Door.  You want a cardiac exam?  Look at the vitals the nurse gave you.  Pulmonary exam?  He doesn’t look like he’s breathing hard to me.  If you want to lay hands on a patient you can go change the wound vac down in the SICU!  Now stop asking so many questions, we’ve got a  6:30 am case!
5. The Eternal – The preferred  method for some academic internal medicine docs, this method can stretch a simple “day 3 of 7 for IV antibiotics” into a long discussion on admission criteria for pneumonia, the relative advantages of PORCH scores verses other admission criteria, proper selection of antibiotic coverage, the antibiotic resistance rate of various bacterial species, incidence of IV site infiltration and irritation based on antibiotic coverage, and any other minutia you can imagine.  The residents better strap in for this one and bring a snack, because even if you only have five patients on your list, you won’t be done before 2 pm and there will not be a lunch break.
6. Zombie Rounds – Usually a form seen only when a team is post call, this pack of residents looks like the cast of your favorite undead flick.  Poorly groomed, with ties barely tied at their necks, they will stumble behind their attending in a daze only thinking of their next meal.  “Is this my patient… oh… I suppose I should present… he’s pretty sick, but I think he’ll be okay… anyone want a sausage biscuit?”  Don’t expect too much in the way of conversation from this pack.

If you know of any other major rounding styles feel free to leave them in the comments.