You have to be a pretty sadistic, greedy, mean-spirited, vile, wretched, and corrupt industry to overcharge the elderly and the poor (not mutually exclusive). But if anyone can be sure to sink to that level, it’s big Pharma!

Let’s see. You overcharge community health centers, which are already facing budget cuts, and trying to maintain the safety net in this country, taking care of the poor and working class of this country. And then, to top that, you raise the costs of drugs so that the Medicare prescription drug card discounts just maintain your current level of revenues! Brillant!

(And then you pay doctors $10,000 to prescribe your drugs .) If that’s not an industry that cares about the health of the population, I don’t know who does. I’m guessing GreaterRX won’t be covering these stories.

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The first in a series of things I’ve been meaning to write about: when one ethical value comes into conflict with another.

We have a bioethics class where we discuss autonomy , nonmaleficence , beneficence , and scarce resources , but I’m not particularly a fan. We can argue this hypothetical case studies presented in class, and see different perspectives, but in the end, the answer always seems to be “it depends on the situation.” It always seems like a cop-out.

In the last week of classes, however, we had a patient come speak to us about his experience as a smoker and lung transplant. The surgeon presented the patient’s history, and told us that there are significantly more people waiting for donor lungs than there are donors available. The patient told us he ended up smoking something like 120 pack years , and was supplemental oxygen for at least 5 years, and *still* kept smoking. The patient eventually stopped, and had one lung transplant. It was a bad pair of lungs–they failed within months–and so he was put back on the transplant list, and received a second set of lungs. (Nothing up to here really gets to me.)

The surgeon presenting the case told us the patient was on immunosuppressive drugs , to prevent the body from rejecting the foreign lungs, and then reminded us that, as a consequence, the body is much more likely to develop cancers and tumors when it is immune suppressed. The patient then told us how he knows he’s at higher risk for skin cancers, that his doctor has warned him, but he doesn’t listen–he just got back from a week in Cancun tanning all day long. Most of my classmates laughed; the surgeon did too. “What a silly, fun-loving, risk-taking patient! Ha ha!”

Maybe I was just in a peevish mood, but it totally rubbed me the wrong way. I mean, here we are, talking about lack of resources for other lung transplants–or hell, lack of resources in general–and we’re encouraging destructive behavior by laughing at it.

I *know* we can’t just tell patients what to do, how to behave, or what to eat. Maybe it’s my lack of experience with non-adherence by patients, but it just seems like totally ignoring the “justice” or “limited resources” ethical value.

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From new kid on the block Shephali comes some decent medical cartoons . Kind of hit or miss, but definitely worth the click.

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Y’know how you always hear about how patchwork and messed up the health care system is? As if you needed more evidence, Jacob has posted a perfect example of the system , as it normally works. My father (a psychiatrist, mental health extrordinaire) and his billing director plays this game day in and day out. Mental health benefits are notoriously messy.

Man, wouldn’t it be easier if everyone had health care coverage automatically? That you billed one entity for all services? That all providers were in the system? Naw. That’s just crazy talk.

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Like my previous Rock Bands , I present, for your literary pleasure, medical terminology that could be confused with Harry Potter spells:

* Status Asthmaticus
* Medial Lemniscus
* Olecranon
* Staph Aureus
* Eosinophilia
* Rhabdomyolysis
* Ipratropium
* Amiodarone

As always, feel free to add your own. If some of them don’t sound like it, try saying it with a teen British accent. You’ll see what I mean.

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Friends, readers, and family members that read this weblog and then call to talk to me about it on Saturdays:

By the power of Greyskull , I harness my pitifully small readership to please go vote for my classmate , Cheri Blauwet. She was just nominated for a 2004 ESPY, the ESPN athlete award. Unfortunately, the site only works in IE, and it’s been acting up; you may need to hit refresh to get the voting to show up. But please vote now !

And what the hell, since everybody else is doing it, I’ll throw in a Gmail invite if you vote and leave a comment saying hello!

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To hell with good intentions. Money. It’s what I want.

I think one of the most important things I’ve learned this year is that *money sets the rules.* I obviously had an idea of this, but it was really driven home today. So much that I’m not as against it as I was a year ago. There have been a number of experiences that have made me realize the power of money, mostly in influencing policy and regulations. As a student government representative, we had to devise a way to split up a very limited sum of money among 40+ student groups (how there are 40+ student groups in a school with 86 students per class shows you how overachiever we all are). The student government set the rules: groups only got X dollars per person for food, X dollars for copying expenses, for hiring speakers.

And at a reception for Dr. Sam LeBaron , the 2003 recipient of the Humanism in Medicine award, the Pfizer reps could not shut *up* about how great it is that _Pfizer_ can sponsor and promote such a great physician. Make no doubt about it–Dr. LeBaron is an amazing person and lives and breathes humanism, but the Pfizer reps made me sick to their stomach. The food and wine were nice, no doubt, but I could have sworn the reps were being paid per mention of Pfizer. The introduction went something like this:

bq(quote). Hi, I’m PeppyYoungBlondeWoman, and I’m from the Pfizer Pharmaceuticals company, in Pfizer’s Lipitor division. We at Pfizer are here today to present the 2003 award for Humanism in Medicine to Dr. LeBaron. Pfizer is so proud that Pfizer can be a part of this award; Dr. LeBaron is a wonderful man and echoes the values that Pfizer strives to achieve as well. Pfizer made a video… blah blah blah.

See? When you pay for the reception, they let you say what you want.

And most recently, I’ve seen the power of money when applying for a summer Med Scholars grant. My community health classmates and I wanted to do some program implementation with local community partners for the summer–our partners had identified a need for a new program, and we wanted to help them implement it. But the powers that be gave us a cold, quick DENIED. We had to do some sort of community research to be funded–implementation didn’t qualify for funding. We needed to do a survey and collect data. (Nevermind the fact that our community partners didn’t need surveys or data, they needed programs–that’s an entire argument unto itself.) The community health team did finally secure some money for us to do community work, but it was still frustrating. Our classmates choose to impact the field of medicine by doing research, to advance knowledge, test a drug or device, and because it’s research, they’re funded for it. But if I want to impact the health of a population by creating a program to provide patients with free medications to manage their chronic illnesses, it’s apparently not academic enough. No data. No rigor. Just helping patients. Again. He who holds the purse strings!

So. Let the money start rolling in. I still haven’t worked out how one attains wealth without being corrupted by it, however. And frankly, I don’t know that I’d be able to fight it myself.

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The last few weeks of school were literally a flurry of multi-colored pens on paper for me. Writing notes, then writing notes about my notes, then organizing my information differently, and taking notes on those notes. And I must say, I noticed a change in my writing style. I could easily get through a page of notes conveying facts and concepts without using verbs, and shortening nouns into abbreviations, acronyms, or just pulling out all the vowels from the word.

bq(quote). HCTZ -> ↑ Ca ²⁺ ↓ Na ⁺ H ⁺ K ⁺ @ distal CT; Tx: HTN; Tox: HyperGLUC

actually means

bq(quote). Hydrochlorothiazide increases calcium blood levels, but decreases sodium, hydrogen (acid), and potassium levels. It acts at the distal convoluted tubule, and it’s used to treat hypertension. It has a number of toxicities/side effects: hyperglycemia, hyperlipidemia, hyperuricemia, and hypercalcemia.

I can go on for pages and pages, with arrows, letters with circles around them. And anytime you see an “x,” it’s usually just an abbreviation for some word we have to write all the time, and prefer not to:

* Dx = diagnosis
* Rx = prescription
* Tx = treatment
* Cx = complications
* Chx = characterized by
* Sx = symptoms
* SFx = Side effects
* Bx = biopsy

And on, and on. I’m sure I’ve just barely touched the surface.

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I’ve been attending a mini lecture series on Medical Informatics, and some of the new technology coming up is pretty darn impressive. It seems almost ridiculous that the health care industry has been able to get by with paper records for so long–every other industry has adapted to technology. (Secretary Tommy Thompson of the Department of Health and Human Services likes to talk about how health care can change if grocery stores can , but I’d like to hope that we’re more cautious about getting our medical system right than we are our price checks on aisle seven.) Still, changes seem right around the corner: there are finally some good standards in place to let software talk to other software and other systems, and things are finally becoming platform-independent. It’ll be a rough change, but it’s already starting to happen, and based on the data I saw, it’s for the better. Note, of course, when I say “right around the corner,” I mean, in the next 5-10 years.

Dr. Paul Tang , CIO of Palo Alto Medical Foundation , gave us a look at their EHR system as well as their patient communication and interaction system, and I’ve got to say, they’re both pretty damn impressive. (Note I’m calling it an Electronic *Health* Record, as opposed to an Electronic *Medical* Record; the goal is to get people to think of it as their all-encompassing *health* status, not just their *medical* care. Yes, it’s semantics, but semantics shape the way we think. Ask any PR firm.) They use the EPIC system, which seems to integrate absolutely, positively *everything* in the medical world and turn it digital. A patient’s history and physical are in the chart, as well as all progress notes. All labs, complete with normal ranges, values, and explanations. Radiology (x-rays, MRIs, etc), too. Prescriptions are recorded, and refills can be approved with a click of a button and are digitally faxed to the pharmacy of the patient’s choice. Patient communication online is also integrated (more on that in a second.) And a summary of the visit is given the patient in paper form–the reason for their visit, the medications prescribed, their follow-up instructions, etc. And while the documentation is still as painfully intense as ever, the software has keyboard macros that fill in text for you as you type. And it’s customized depending on the illness, disease, or template: type “bl.” and hit enter, and if you’re describing a patient’s lung disease, it will fill in “blood-tinged sputum.” It will even make clinical treatment suggestions if the physician doesn’t appear to be following current best-practices.

And all this information is pulled from the same database for the patient. If you go to the Palo Alto Medical Foundation Online page as a patient, you can login and see your visit, and communicate with your doctor. And the same information that your doctor has given you regarding your disease is the same information you see on your screen. Even better–the medical jargon in the definitions is all hyperlinked to explain what “dyspnea” or “syncope” is. Or if you’re taking a new medication, he or she may ask you to follow-up to make sure you’re not having any side effects. You login, send a message, and your doctor can respond–securely. Dr. Tang is very cautious and conservative about privacy and HIPAA regulations, s, all the communication happens through the website, not via insecure email. The patient can even track his own lab data; if the patient starts taking a statin (to lower LDL cholesterol), he or she can graph the cholesterol level over time.

Dr. Tang says the feedback he’s gotten is overwhelming positive from patients, and although there was initial resistance from physicians, they’re starting to like the system, too. And according to multiple studies in medical informatics journals, doctors are more likely to practice medicine “better” (in more accordance with guidelines) with electronic health records than with paper ones.

As a computer geek, I was really impressed with the system, but several concerns still remain issues with me. First, can we really just template-ize medicine? Can a series of symptoms be put together in an algorithm and spit out a diagnosis? And be right every time? It seems like if medicine gets to the point where everything is just checkboxes and data, you might miss a diagnosis. Hopefully I’m wrong. And doesn’t this take some of the fun out of medicine? And what’s the point of having a doctor (or, ahem, medical student) learn all the side effects of drugs and all the complications of a disease if our software will tell them to us anyway, and have a better memory of them than we do?

Second, the digital divide . All this technology is wonderful, and well adopted by the well-to-do in country club Palo Alto, but it falls apart if you were to walk 50 yards to East Palo Alto, at the clinic where I’m working this summer. All the patient interaction requires a computer and an Internet connection, and frankly, that’s not available for many people in this country. If we’re going to be moving to a new type of administrative system for health care, we need to make sure everyone can access it fully, or else we’ll just be increasing health disparities even further.

But Enoch probably knows a lot more about this system than I do, seeing as though he kinda works at PAMF.

UPDATE : I’m getting a ton of hits from epicsystems.com from some address “weekly_news.asp;” I’d love to hear what you guys think about my post, or in what context it’s been posted. Please, comment!

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In the spirit of summer and pools and swimming, a quick little physiology lesson, since I just finished my exercise physiology and autonomic nervous system studies. Ever curious why you’re supposed to wait an hour after eating before you jump in the pool? When you start exercising, your body reroutes blood from your digestive system (which is activated by eating food) to your muscles. It clamps off a lot of your circulation from your stomach to the muscles you’re using. And when your digestive system still has food in it that it’s trying to digest, it needs blood flow to get the energy to digest it all. It’s not getting that flow, so it keeps working, without oxygen, and you get acid buildup because of it. And voila. Acid buildup equals pain, pain equals cramp.

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