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.

Comments Off on This is Health Care?

Kevin, MD points to an AP story about over-the-counter cholesterol lowering drugs, and rightly argues that it’s all about money. “Savings for insurance companies, continuing profit for the drug companies.” I couldn’t agree more. Our pharm professor said there was an article in the British Medical Journal awhile back saying we should put statins in our water supply. How it would be great for the public.

So where’s the outrage? I can’t seem to find it. Physicians seem hell bent on medicating the public to death. (Maybe for good reason. Maybe they’re tired of prescribing exercise and a healthy diet and seeing 10% of patients trying?) Still, I can’t help but be bothered that we’re willing to prescribe pills for every man, woman, and child in this country at the cost of side effects and enormous increases in health care costs. We pay fast food companies to get us into this mess, and then we pay pharmaceutical companies to get us out of it. God forbid we pass some sort of law that encourages healthy eating. It works for smoking . Bad food is just as bad.

1 Comment »

Let’s cut to the chase: go see Super Size Me . I’ll follow with my normally over-verbose reasons, but seriously. Just go. Everyone in the US should see this movie. If not for their health, for a friend or family member’s.

I saw it last Saturday, and was totally blown away. It made me want to become a filmmaker. What a great way to reach and educate people. It does an excellent job of educating people about obesity and fast food in a fun, reality-TV type medium. Just what people want. (And if that’s not enough, Morgan Spurlock, the star, is blogging the interview circuit, too.)

The premise: a man eats McDonald’s food for a 30 days. And only McDonald’s food. If it’s not on the menu, he can’t eat it. Or drink it. He can only supersize the meal if they ask, and he has to eat one of everything from the menu by the time his month is up. He started out a pretty fit man, and got checked out by an internist, a gastroenterologist, a cardiologist, a nutritionist, and an exercise physiologist. I won’t spoil the ending for you, but he ends up putting on weight, and doing a fair amount of damage to his liver. Now, this is not 2 hours of film watching a man eat. It’s mostly education about obesity, diabetes, the fast food industry, advertising, school lunches, and American eating and exercise patterns. Did you know the McDonald’s salads with dressing have more fat that a Big Mac? Or that the large yogurt parfait with granola has more fat than the caramel sundae? Or how a Chicken McNugget is made? You will after this movie.

The movie does an excellent job of pointing out all the factors that are plotting against us; the advertisements, the lack of nutrition information, the power of industry. But it also notes that none of these things are going to change anytime soon, and if we don’t all work on them starting now, we’ll end up in a world where one out of three children born in 2000 in the US will eventually have diabetes. What a disgusting statistic.

2 Comments »

Blogborygmi thinks my Oreos bit was a little too paternalistic, and a little too idealistic. And again we get into the difficult, where-to-draw-the-line ethical quandary. Where does patient autonomy stop, and good health “paternalism” begin? I want to let patients be in control of their lives, and therefore, their health care, but will I try to persuade them to stop smoking? Sure. Is it paternalism in every case, if medical professionals simply have a greater knowledge, education, and experience of health and disease? Or is it bad medicine not to convince someone of a particular treatment?

I’m all for patients making their own choices. But why not (yes, ideally) change the structure of the system such that they’re coerced encouraged to make the healthier choice? Wonder why fast food burgers are so cheap? Beef subsidies. Why not structure the system such that salads and fruit are cheap? And oats? And whole wheat breads and tofu? (People might argue that these don’t “taste as good,” but if they were bought and sold in the quantities that Twinkies and Big Macs are, markets would create tasty options.) Why not tax bleached flour and corn syrup? People aren’t just horses that respond to carrots and sticks; I believe that many people will choose the “right” choice (in this case, the healthy one) as long as they’re educated about the choices, know the benefits and costs, and can acquire it at an equitable price. If we could provide healthy options at similar or lower prices (by subsidizing costs), I think you could change a significant number of people’s diets. Or support more local farmer’s markets? Or why not build more bike lanes and encourage bicycling with Clean Air Cash , like Stanford does? I’m just trying to make the point that there are structure- and policy-related issues that determine the way many people live their lives. From what food we buy to how our homes and communities are designed and built; from where our jobs are located to what our options are for recreation and entertainment on the weekends. A lot of these things are already set in stone, but that doesn’t mean we can’t begin to change them today.

Personal responsibility is in the mixture, too, but it’s absolutely worthless if people aren’t educated about the short and long-term effects food can have on their minds, bodies, and relationships. (Example: people that smoked in the early part of the last century didn’t know it was bad for you–some even thought it was good for them. Without the knowledge that smoking causes cancer, should they have been held personally responsible for developing lung cancer?) Children are especially vulnerable to advertising (and a lot of food advertising is aimed directly at them); what parent has time to let them know that those Chicken McNuggets aren’t so great for them?

Obesity is a complex problem, and I am but a lowly first-year medical student. So I’ll yield to a source of higher authority: The Institute of Medicine. From their report, Promoting Health: Intervention Strategies from Social and Behavioral Research ,

bq(quote). “It is unreasonable to expect that people will change their behavior so easily when so many forces in the social, cultural, and physical environment conspire against change. If successful programs are to be developed to prevent disease and improve health, attention must be given not only to the behavior of individuals, but also to the environmental context within which people live.”

1 Comment »

The Michigan House has passed a bill called the Conscientious Objector Policy Act; it would, in effect, give health care workers the right to object to treating certain patients on moral or ethical grounds. According to the bill text , health care providers at any health facility in Michigan can refuse to treat patients, as long as their condition is not life-threatening, on the basis of a provider’s “ethical, moral, or religious belief system.” He or she must provide the objection in writing to his or her employer. Interestingly, “a medical school… shall not refuse admission to an individual or penalize that individual” for issuing such an objection. However , you’re not allowed to discriminate based on any of the categories listed under civil rights (sex, religion, race, etc.), or “based on a disease or other medical condition.”

Michigan’s going to have a great time if this one gets passed. I’d love to be the medical student that refuses to treat patients when I’m having a bad week because I’ve recently converted to Christian Science , and in my new-and-improved moral framework, find it morally reprehensible to treat patients medically. (And I couldn’t be punished for it!) If you can’t think of any other loopholes, you’re not trying hard enough.

It’s a frightening precedent they’re trying to set–that you should be able to pick your patients, that it’s okay to pass judgment on them when they walk in the door. The consequences could be dire for rural residents, since many times there are no other doctors available.

Quick side note: this is obviously aimed at gays and abortion. But since the moral/ethical framework stuff is so loosely worded, couldn’t I refuse to treat anyone I wanted?

* I refuse to treat patients who smoke; supporting the tobacco industry is against my belief system.
* I refuse to treat patients who are hypochondriacs; not because they are hypochondriacs, but because they wash their hands so often. In my moral understanding, washing hands frequently is evil.
* I refuse to treat redheads; they’ve been marked with the red hair of the Devil.
* I refuse to treat people on Wednesdays; it is my day of rest.
* I refuse to treat the poor; I believe they should lift themselves up by their own bootstraps.
* I refuse to treat non-Christians; they’re not going to Heaven, so I find it ineffective to help them medically.

Do I think many physicians would do this? No. But it’s fundamentally against the medical profession, and the profession should fundamentally oppose it. If you learn one thing quickly in medical school, it’s that you don’t get to pick your patients. They come in all ranges of personalities, shapes, and sizes, but they’re here because they require your help, and well, the Michigan law just doesn’t mix well with that whole Hippocratic Oath thing. “First, do no harm,” is kinda tough to trump.

3 Comments »

We were talking about atherosclerosis in class today–blocking arteries that supply blood to parts of your body, like your heart. As most people know, it’s strongly related to how much LDL (bad) cholesterol you have in your blood. The cholesterol gets digested by cells in your body that congregate in your blood vessels, and block them off.

It’s really interesting the lines that people will draw between “freedoms” and health. You’re not allowed to commit suicide, and euthanasia’s also out. And you’re not allowed to kill other people, or hurt them acutely, either. But you are allowed to ingest things that will kill you, albeit slowly. You’re also allowed to sell products that will, if not kill you, at least leave you in a painful state of misery for your final years. I’m not arguing for right or wrong here, just pointing out some inconsistencies. We all do things that are dangerous, or at least bad for our health (from smoking to drinking to riding a bike without a helmet); it’s society’s job to decide how far we’ll allow things to go in that vain.

I was watching a special on PBS on “The Heart of the Future,” or some such nonsense, and there was an interesting interview with the head of cardiology at UCSF. He said something to the effect of, “If we could design a pill that would increase everyone’s HDL [good cholesterol] to 80 and keep it there, we’d elminate all the heart disease in this country.” I found it fascinating that he was willing to support a pharmaceutical cure to our country’s heart problems, but didn’t mention exercise or a healthy diet. While I’m sure he supports the latter measures, is taking a pill more acceptable because it’s so easy? Because it’s so convenient, or requires so little time? Or maybe because we practice defensive medicine–not in the malpractice sense, but in the sense of reacting to disease , instead of promoting wellness . Would patients be less likely to respond to a doctor’s prescription of “exercise and healthy diet” because it’s time-consuming, or because the gains are long-term?

Either way, I’m all for people being informed about their trans fats. And why not require package labels to provide pictures of the long-term effects? If you want an Oreo, you’ve got to see the consequences: a nasty, occluded coronary artery in the bottom, and a diseased, dead heart in the top.

1 Comment »

Friend and fellow med student blogger Chris McCoy alerted me to a bill that may have undercut the Match lawsuit — it essentially exempts the Match from anti-trust requirements. It apparently was quiet thrown on to the end of an unrelated bill, came out of committee, and was signed into law yesterday. Chris sums it up well–“blink, and you missed it.”

Comments Off on Match Lawsuit Undercut?

So I get an email today from Stanford’s media department, a kind of “Stanford Med in the News” thing. I’m skimming through it, and the last item lists me. What the hell?

It’s just a bit quote , and not the most important quote, if I could have picked, but whatever. I had emailed the writer, Bard Lindeman, last month about single-payer–he was a bit confused about single-payer versus the Federal Employees Health Benefits Program (FEHBP). I probably went a little overboard on the policy analysis (I sometimes forget not everyone’s not a policy wonk like me), so he picked a silly little opinion quote from me, but that’s fine.

The funniest thing–I had no clue I was being quoted. He at least could have told me!

PS: The article mentions Bob LeBow, a great physician with a great book on health care reform . If you’re interested in a basic book that will explain single-payer to you, without the policy wonk lingo, it’s the book for you. Sadly, Bob passed away last year after a series of complications due to a freak accident leaving him paralyzed from the neck down in 2002.

Comments Off on Coulda Told Me

Man, if you replace the word ‘marriage’ with ‘slavery,’ or ‘segregation,’ or ‘denying women the right to vote,’ it’s hard to tell if it was Bush speaking today or one of his historical likenesses:

bq(quote). “The amendment should fully protect slavery, while leaving the state legislatures free to make their own choices in defining legal arrangements other than slavery. America’s a free society which limits the role of government in the lives of our citizens. This commitment of freedom, however, does not require the redefinition of one of our most basic social institutions. Our government should respect every person and protect the institution of slavery. There is no contradiction between these responsibilities.”

And, just to finish off the point, a couple zingers from some pro-slavery arguments from the antebellum era. Sound anything similar to the speech today?:

bq(quote).. Speech to the Virginia legislature, 1832
Thomas R. Dew Defends Slavery

“It has been contended that slavery is unfavorable to a republican spirit; but the whole history of the world proves that this is far from being the case. In the ancient republics of Greece and Rome, where the spirit of liberty glowed with the most intensity, the slaves were more numerous than the freemen. Aristotle and the great men of antiquity believed slavery necessary to keep alive the spirit of freedom…In modern times, too, liberty has always been more ardently desired by slaveholding communities…”

” … and all who are white are equal in spite of the variety of occupation…And it is this spirit of equality which is both the generator and preserver of the genuine spirit of liberty.”

2 Comments »

… begins the headline at the New York Times . It appears that two business trade groups, the Manufacturers Alliance and the National Association of Manufacturers, have come to the conclusion that, big surprise, the manufacturing costs in the US are making it compete with other industrialized nations: Canada, Germany, Britain, South Korea and France, for example.

bq(quote).. Comparing wage compensation to total value added in manufacturing in several countries, the study concluded that the United States was more competitive than Canada, Germany, Britain, South Korea and France. But throw in structural costs – which add 22.4 percent to the cost of doing business in the United States – and American manufacturers’ costs exceed those of counterparts in Canada, Britain and South Korea. Even France, reputedly hostile to business, isn’t far behind.

How is it that the American economic system, thought to be far more friendly to businesses than the European system, has become a competitive disadvantage for American manufacturers? One of the main culprits is health care. And the solution may be something that has traditionally been anathema to corporate chieftains: bigger government.

After corporate income taxes, employee benefits are the second-largest structural cost for American manufacturers, adding 5.8 percent to costs, according to the study. In all major economies, paying for health care means a combination of public and private money. But in the United States, businesses pay a larger chunk than do their European and Asian counterparts.

In Canada, the private sector spends 2.8 percent of gross domestic product on health care; in the United States, the private-sector figure is 7.7 percent. And American private-sector spending falls disproportionately on big employers like manufacturers. Some 97 percent of members of the National Association of Manufacturers provide health care coverage for employees. In 2002 alone, General Motors, which covers 1.2 million Americans, spent $4.5 billion on health care.

p. Coincidence that this point was made here at Gross Anatomy yesterday? I think not.

1 Comment »