Matthew Holt has a few posts about Jay Parkinson, MD’s medical practice in Brooklyn, which is cash based and all digital and electronic–electronic medical record, online chats, video chats, emails to patients–totally awesome. I love the practice style.

My main concerns? Two things: he’s stealing all the easy work from people, and while I’ll admit I don’t know much about preventive medicine residencies, how much training does he really have in treating adults, when he did a pediatrics residency?

On the first point: he will only see adults age 18-39. If you look at adult preventive health care guidelines for people 18-39, it’s really mostly blood pressure checks and physical exams, with an occasional cholesterol check and pap smear and STI check for women. After kids, 18-39 year-olds are the healthiest group of people there are. For the most part, their main health problems consist of viral illnesses and substance use. Are there sick 18-39 year-olds, sure, but they’re the vast minority. Bottom line: 18-39 year-olds are, for the most part, incredibly easy to care for. Do they need to be seeing a doctor, sure, but man, low-hanging fruit.

My second concern: adults are not big children. The majority of a pediatrics residency is spent taking care of very sick babes and children. (Or seeing them in clinic and learning all the rashes and viral syndromes that most kids get seen for, the milestones, the vaccines, how to talk to parents, etc.) The closest you come to adults in pediatrics are adolescents that come in for physical exams for school for the most part. But you certainly don’t see adults, besides the occasional 18 year-old who wanders in and hasn’t changed doctors yet. Maybe this isn’t much of an issue, since taking care of these patients is pretty straight-forward, but still, it doesn’t seem like the training fits the job description.

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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:

1. making less money after residency or
2. 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.

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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.

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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 [email protected], 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.

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These terms are often thrown around as synonymous, when they clearly are not. Someone’s, or some society’s health takes into consideration the freedom from illness, disease, or injury (actually from the Germanic meaning “wholeness”). Health is impacted by genetics, stress, violence, diet, laws, living standards, and health care, to name a few.

“Health care” is the interventions we perform on individuals to try to keep them healthy . Economically, “health care” is resources spent on health: not just monetary resources, but time, energy, workforce, etc.

Health insurance is a way to pay for health care . The theory behind insurance is this: big, bad, expensive things can happen to you at any time. Your house can catch fire. You can get into a car accident. You can get cancer. We pay for insurance to decrease this risk–that we pay into the system now so that it will bail us out later . The more people in this system, the better. If there’s only two people, and one gets robbed, there goes a lot of the other guy’s money! But if 100 people are in the system, there’s 99 people’s money left to even out the risk.

The goal of health policy is to make the population as healthy as possible.

The goal of health care policy is to make the health care system — only one part of the determinants of health — as “good” at divvying up limited health care resources as possible. (Lots of ways to define good. I define it as going to those who most need them.)

I would love to see a population whose health is so darn good that we wouldn’t have to worry as much about health care. Health alone could be its own blog, so I’ll simply suggest a few ways that we might be healthier, without even messing with health care :

• Reverse the subsidies for vegetables versus meat. Wonder why a salad costs more than a Big Mac? It’s not that cows are cheap. It’s that government subsidizes.
• Walking instead of driving. Afraid as Americans we screwed the pooch on this one during white flight and suburban sprawl of the mid-20th century. One of many reasons I prefer the city.
• Create a more equal society. It should be no surprise to anyone that the poor are the earliest to die and are the most obese. When your food options are canned foods or McDonald’s, the game’s already against you.

I illustrate these points only to remind you that if your goal is to make people healthier, there’s many, many more avenues that might be far more effective (and far far cheaper) than optimizing or fixing the health care system. (We just like to argue about it because it’s the most accessible and well-understood by us.)

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(No, I’m not going to get all Kumbaya on you.) Listen:

We’re all in this thing together, whatever it is. That “limited resources” bit you remember from Econ 101? It applies to health care, too.

Look, the lesser argument has been made many times over, by the likes of Paul Farmer and other radicals who have fought battles in Infectious Disease: that if we don’t control infections in one population, they spread to other populations and make us all sicker. That if we don’t treat multi-drug resistant TB in Haiti, Peru, or the prisons of Russia, then we Americans will be fighting the MDR-TB here at home. (Similarly in the infectious disease world is the fact that vaccine “herd immunity” is becoming less useful, as our international lifestyles put us into contact with people who were born outside the US and never got measles vaccines, for example, and may be contagious.)

But the greater argument for our interconnectedness is this: that by allowing whole swarms of people (often but not always the un- or under-insured) to go without necessary chronic care and necessary follow-up, they eventually become sicker and more complex. And this, my friends, creates problems for all of us. Because sicker and more complex patients require more doctors and more time and more hospitalizations. And more hospitalizations that take more time, because sicker and more complex patients have more things that will go wrong with them.

How does this get back to you, oh-self-concerned one? Because when there’s more sick patients, there’s less time for you , when you’re sick. Some say that patients will get worse care and will be seen slower in the Emergency Department. While this may be true to some extent, triage — the sickest people to the front of the line — often takes care of much of this. But because there’s simple more people (quantity, not necessarily quality), your mom with the broken hip is seen slower, and fewer minutes are spent on her since there’s more patients total. It’s no wonder hospitals are stuffed to capacity.

So take a system with sick people, discourage them from seeking primary care by:

1. having them pay for primary care when they themselves often don’t see any benefit from it and
2. discourage doctors from going into primary care by making it a nightmare of:
   • paperwork
   • referrals
   • tons of complex, sick patients to be seen in 15 minutes and
   • little pay compared to other doctors

And you’ve got what we have today: any number of people who are sick, complex, and take up tons of time, energy and resources. And no matter how you spin it, it ends up creating worse care for us all.

We as doctors tell our patients to do certain things to stay healthy — and often pay more money to buy these pills – when often patients don’t see one lick of good from our recommendations. All they see is a lower blood pressure number, and money out of their pockets for expensive pills. (That is, until they stop taking their pills, or have a really bad consequence of their disease, then they see it.) Throw in any number of health care and physician scandals in the past decade, and it’s no wonder they’re skeptical.

In order for us to receive better care and to fight the constant ambulance diversions and hospital overflows, we’ve got to ensure that people take care of themselves. And that starts by removing the barriers to self-care.

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Really great and interesting YouTube clip of a woman who is in a wheelchair due to multiple sclerosis being able to walk and interact in Second Life.

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US and NZ sittin’ in a tree, K-I-S-S-I-N-G.

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.

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Even before the 80-hour work week, shift work was part of a physician’s and resident’s training. Now, it’s just more prominent. Residency programs have adapted, introducing night teams for their patients, various types of “floats” (night, day, root beer) who take over for a resident–or often an entire team of residents–when one set must go home because of hour restrictions.

In some ways, this is a good adaptation — and even if it’s not, it seems to be staying. I don’t care how tough and hardcore you are, you wouldn’t want a sleep-deprived resident ( equivalent to an intoxicated resident ) making health care decisions about your mother, let alone operating on her. (Having alcohol while on call or in the hospital would be a major violation, but sleep deprivation is inherently part of the system. Funny.)

In other ways, shift work is bad for patients: I know Mrs. Jones much better than the colleague I’m signing her out to, because she’s told me her whole story, her emergency contact, and how to reach her daughter’s cell phone if the first three numbers don’t work. Thoroughly complicating this issue is hospital overcrowding, especially in the ED when patients can be waiting for beds for days, and end up being handed off to a new physician every 8 hours. This knowledge differential between my colleague and I — he coming on shift, me going off shift — somehow must change, because the shift work world isn’t going to. Younger physicians are wanting shift work.

We know that most errors come about through errors of communication and often during shift changes. We KNOW that.

We owe it to our patients that we safely and correctly do hand-offs. We should be relying on a system that is designed to minimize communication errors, prioritize information and patients, and eliminate ambiguity while being as efficient as possible.

I’m not exactly sure what this system looks like. Maybe it means that we have some computer system that somehow collects important information about the patient and puts together a summary based on the electronic medical record.

I certainly know when I come across a piece of information that I know will be vital to sign-out, but sometimes I struggle at signout to remember it. Maybe it means that we carry around voice recorders and make memos to ourselves.

Maybe it means that we follow a cue from the nursing playbook and devote an hour to “shift change” in the name of patient safety. We review the patients in order of severity or likelihood something will come up, and in an order of importance: Patient Name, Age, Admission Diagnosis, Code Status, Active Problems, Active Plan, Anticipatory Guidance.

Maybe it means we teach physicians about conditional orders, and allow them to be carried out even if the physician is signed out. Things like:

IF 
	(Troponin #3 = Normal AND
	Social Work Note AND 
	Dispo = Complete AND
	Patient Has Outpatient Medications Ready AND 
	IV is out) 
THEN 
	(discharge home)

I’m not a communications expert, and I’ve fallen too far down the rabbit hole to probably even see where my own communication errors are. Perhaps that’s the problem right there — we don’t even know when or how we failed. Maybe the first step is to discuss it happening: along with M&M, how about a communication version? W&W? Words and Warnings?

As I’ll repeat throughout this series: if we as physicians don’t step up to the plate and do something about it ourselves, someone else will. And often that “someone else” isn’t caring for patients and doesn’t know what they’re doing. Being proactive about this stuff will help us in the long run.

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About the shortage of primary care , which I’ll be discussing — and with similar recommendations to Kevin — later in my series. Way to go Kevin. Another point we can agree upon.

(Kevin is right; as a medical student, we can see the writing on the wall and do the basic math.)

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