Disappointed
In 2008, I drove to New Hampshire and knocked on doors all over the state. I wrote letters to my hometown newspaper in Pennsylvania, arguing that electing Obama would improve our healthcare system. I flew to Washington for the Inauguration. Since then, when friends have argued that Obama should be bolder, I was the one who defended him. This is a conservative country and progress is slow and hard, I would say. Yes healthcare reform should have gone farther, yes the stimulus could have been bigger, yes we need a better financial regulatory law, but the direction of the country, at the very least, was right.
With his offer to cut Medicare and Medicaid, Obama has changed course dramatically. This represents not slow progress, but a giant step backwards. Paul Krugman has explained the negative effect that the Medicare cuts would have. I mentioned recently why I oppose the Medicaid cuts. Here I just want to express my disappointment. We need a President who is willing to stand up for the safety net and explain the vitality of these programs to the American people—not one who starts by offering deep cuts.
The past weeks have made me rethink my defense of Obama. The Republicans clearly think he’s a pushover in negotiations. What if it’s because he has been all along?
On Medicaid Cuts
I didn’t protest when we invaded Iraq: I watched the news with disapproval and detachment from a college dorm room. I don’t even remember the day when the Bush tax cuts were passed. Tonight I’m wishing I had joined the people in the streets.
Events in Washington are highlighting the choices that societies must make about how government raises and spends money. President Obama has put Medicaid on the table, offering up to $100 billion in cuts to healthcare for the poor. This will do real harm to some of the most vulnerable Americans.
Medicaid cuts will be invisible to many. Having spent the last year working at a public hospital, I can imagine the impact that they will have: less preventive care, delays in treatment, a greater burden of illness and more medical bankruptcies. People I care about will lose their access to health care.
The popular rhetoric would say that I want to spend without thinking about the consequences. No—I care about a balanced budget. I only wish we had our priorities straight.
One of my best friends from medical school is spending the coming year in Liberia working for Tiyatien Health, an organization dedicated to rebuilding that country’s health system after years of conflict. They use a community health worker model that draws on the work of Partners in Health. He’s documenting his experience on tumblr. Check it out:
msyj:
Open Road (Sinkor)
Made it to Monrovia, Tumblr and all!
The trip was significant for:
- TSA identifying my stethoscope as a possible threat to national security
- Mixed feelings about the large, and loud, groups of volunteer missions aboard my flight to Ghana
- Ghost plane (40 of 300 seats filled) from Accra to Monrovia
- All the memories of tropical developing countries coming back through sights, sounds, and smells
- Realizing the adapter I brought doesn’t have the ground I need for my laptop charger. D’oh.
Responding to comments about social media and medical school
The reaction to my most recent post on KevinMD has been strong. I’ve had posts there that I thought would be more controversial, but the topic of social media in medicine has drawn a lot of commentary. Perhaps I shouldn’t be surprised that online health professionals like discussing what health professionals should do online.
The comments are diverse. The response on Twitter has been very positive. In the brief Twitter style, people have shared the link with: “Agree!,” “Great post,” “Time to get with the program, doctors,” “Go where the people are!” and other supportive remarks appended. Via email I have received several responses from medical students who thanked me for writing the post and agreed with the sentiment. Two people have written to invite me to physician social networks that are in beta testing.
The response on KevinMD has been, for the most part, much more critical. One family doctor talks about how social media has helped his practice and reports that “older docs are losing potential new patients to the younger docs with an internet presence.” Beyond this, though, almost all the comments find fault in my post. It seems to me that the comments hit on two big issues: an adoption issue and a professionalism issue.
The adoption issue is highlighted by the commenter “saynotosocialmedicine.” Regarding the possibility of interacting with patients online, he writes,
“I love tech but if a patient wants my opinions, let her make an appointment for a face to face encounter, the only thing for which I can get paid.”
Sharon Bass adds,
“There are already too many things I am required (by insurance and the government) to do for which not only am I not paid but must do to get the pittance that they will pay. I have about had it and am this close to becoming a cash only office.”
This is a common refrain among physicians. Whether it’s adoption of electronic health records, building more comprehensive services for patients or doing any non-billable activity, many physicians say “that’s not what they pay me for.” They are right, of course. In most places we don’t pay physicians to do what would really be best for patients. ACOs and medical homes will hopefully start to change this, but I’m not entirely sympathetic now. When doctors in the 95th percentile of earners nationwide say things like, “they don’t pay me enough” to improve patient care, I can’t help but be disappointed: wanting to improve healthcare delivery was one of the principle reasons I came to medical school.
The Pager
On our first day of the Cambridge Integrated Clerkship, every student had a pager on their desk. We knew they would be there—the central idea of the clerkship was that students could be reached at any time when our patients came to the hospital. Still, it seemed to me a strange and antiquated device, only slightly less odd than a typewriter or rotary phone, and it was hard to imagine carrying the pager for an entire year.
At first it was novel. Wearing a pager on my belt was a sign that I had arrived in the clinical world, that the first two years of classroom work were over. When I put it on my nightstand, it was a pleasant reminder of the responsibility that my work demanded. As a group, we learned which ringtones we liked (I prefer the obnoxious loud beep, a sound that can’t be confused with a cellphone receiving a personal call) and how to carry the pager when out of the hospital (I was among the last of the students to realize that I should move the pager to my pocket at social events). We learned the etiquette of paging (always include name, role and return phone number) and the nuances of the computer program that allowed us to be notified when our patients came to the hospital.
Then the pages started to roll in. There was the daily 7 AM barrage of pages, as the hospital system alerted us to patients who had appointments that day. There were predictable pages throughout the morning, letting you know about unexpected visits: pediatric patients with ear infections or moms-to-be who had moved up their appointments. And then there were the truly urgent pages, the pages that would change your life for the next several days. These included pregnant patients in labor and patients who were seriously ill. It could be worsening heart failure or emphysema, a small bowel obstruction, appendicitis or an overdose that brought my patient in. I would come early and stay late to help care for them and to round with the obstetrics, medicine or surgery team. These were tremendous learning opportunities: we could often help the inpatient teams with the past medical history and they would teach us clinical medicine. I developed close relationships with many of my patients because I came to the hospital when my pager told me to.
Do global payments work?
“I don’t care who is paying for healthcare—what matters is how we pay for it.”
This is the hopeful argument that I made in a conversation with a friend less than a year ago. The friend was trying to convince me of the cost-controlling merits of a single-payer model and I was trying to argue that it was less important to have a single insurer to control costs (notwithstanding the obvious benefit for access and equality), than to move away from the fee-for-service model. Align the incentives in such a way as to discourage over-spending and… voila, reduced health care costs!
It turns out I was wrong. Or at least the Attorney General of Massachusetts thinks so. In a report released yesterday (pdf), Martha Coakley’s office puts forth a harsh critique of global payment in Massachusetts. Her staff found that global payment arrangements have actually been more expensive than fee-for-service plans and have contributed to the growth in healthcare costs. True, these plans are early in their existence, but they don’t look as promising as I once thought.
The problem isn’t that payment reform itself is a bad idea, it’s that it doesn’t address the unique factors that have led the U.S. to pay twice as much for healthcare as other developed countries. In our private insurance system, factors like prestige and market share are the principle determinants of what health care organizations charge. In a market where no one knows the true value of the product, all of the private actors have incentives to increase costs—and they do it based on market power.
Louis Menand and the Purpose of Medical School
There are, according to Louis Menand, three different ways to understand the value of higher education. In his recent article in the New Yorker, he assigns numbers: Theories 1, 2 and 3. Theory 1 is that the purpose of higher education is to sort members of society to their appropriate roles. In this mode of thinking, college is an extended and demanding audition for employers who need more than a standardized test to determine who is appropriate for a job. In Theory 2 the purpose of college is to expose the young members of a society to ideas and values that make them better citizens in whatever careers they decide to pursue. This is an essentially democratic philosophy of higher education. Theory 3 argues that advanced societies have a number of technical roles that need to be filled and that higher education should provide students with the skills to fill these roles. As Menand points out, this argument underpins the Obama administration’s current push to strengthen community colleges. The article is well written and thought-provoking and it suggests the challenge of similarly trying to articulate the purpose of medical school.
Of Menand’s theories, Theory 3 is the most obviously applicable to medical education. Medical school prepares students to fulfill a societal role, namely the delivery of medical care. The advent of so-called “mid-level providers,” nurse practitioners and physicians’ assistants, has challenged the notion that medical school is the only route to this special role, but, in many ways, society still grants medical school graduates a privileged place in the delivery of healthcare.
Theory 3 begs the obvious question: what are the skills that one needs to be a physician? This is where much of the debate in medical education circles occurs. As an example, I vividly remember a disagreement between a family physician and intensivist, both of whom are prominent medical educators. One felt that medical student evaluations in a particular context should be weighted toward cultural sensitivity and interview skills with the other feeling that they should focus on mechanistic understanding of pathophysiology. Another example is the debate about when suturing skills should be taught and if every medical school graduate (consider a psychiatrist) even needs to know how to suture. Do doctors need policy, public health and health systems skills? The debates rage because of the amazingly diverse work that physicians do. Still, equipping people with the skills to care for the ill seems to me like one of the noblest goals of medical school.
Link: Wellness Rounds
I just came across this blog by Dr. Mary Brandt at Baylor College of Medicine. She shares health and wellness tips for busy medical students, residents and physicians. Check it out for some ideas on staying healthy when your schedule is constrained. It’s a nice reminder about the need for (and possibility of) balance, even when free time is short.
Are pit crews enough? Here’s what my health insurance costs:
These are the rates for my student health insurance coverage for the coming year. I’m newly married, so my spouse and I will be enrolling together. That means that the total cost of health insurance for our family of two will be $7,522. Even though I’ve been paying $3,000 a year for my own insurance, $7,522 inspired some sticker shock. Our care is pretty heavily “managed” in this plan, allowing only three appointments per year outside of the University Health Services, so this seemed particularly expensive to me.
But the truth is that $7,522 for two people is probably below average. Health costs are rapidly approaching $20,000 a year for a family of four. In our case, though, we don’t yet have the benefit of an employer covering 60% of those costs.
That we find ourselves at the financial mercy of our healthcare system is a small irony since I am a part of that system. Knowing that average health care costs have doubled in the last nine years, I am worried about how much our insurance will cost next year. I have heard many prominent physicians say that it will fall on my generation of doctors to address this problem. So what does the future hold?
Some are hopeful. Atul Gawande’s Harvard Medical School graduation speech was about the potential that working in teams, like pit crews, has for improving health care and reducing costs. I agree with him. My friend and classmate Ian Metzler wrote on the The Health Care Blog this week about the need for education, improved clinical judgement, decision-support, institutional leadership and payment reform to help make care less expensive. He is also right.
But will all of this really “bend the cost curve?” What makes us think that these savings won’t simply lead to higher margins for providers, health systems or health insurers? Until we address the enormous cost of a private insurance system, either through stricter regulation of insurance premiums or through a public health insurance plan, we’ll have a limited impact on costs.
We also have a deep problem in our national consciousness. Too many of us, including myself before medical school, proceed with the notion that medicine should be able to fix anything and prolong our physical health indefinitely. We are willing to try obscure and expensive treatments with marginal benefit. As a society we have to accept the limits of what medicine can do. We need to come to better terms with our mortality and the inevitability of physical break-down and emotional loss.
For a long time, I wanted to believe that our problem with healthcare costs could be solved with technocratic expertise. But the fact is that our problem is deeply political and cultural. Young doctors need to realize this: working in teams like a pit crew is a start, but what we really need is to change the direction of the race.
Green space and well-being
There are many things to love about Cambridge, Massachusetts. Cambridge Health Alliance, the city’s public health system, which takes care of a diverse and underserved patient population is high on my list. Memorial Drive is near the top too. I have been riding my bicycle home from Boston along “Mem Drive” this past week and I’m rejoicing that it’s there. Just a few minutes from my house, it’s a bike path along the Charles river, where I nearly forget that I’m in a major metropolitan area. I love watching the crew teams row along the river, and there are bridges scattered along the ride that access many parts of downtown Boston. What a joy it is to live here!
It turns out that I’m not the only one who feels this way. There are a number of studies that look at the connection between green space and well-being. Jolanda Maas and colleagues, for example, found a compelling link between the percentage of green space within 3 kilometers of a person’s home and self-reported health. The labels on their graph below are a little difficult to read: the Y axis is the percentage of people reporting that their health is average, poor or very poor, and the X axis divides them into groups based on the percentage of space within 3 km that is green, according to a land use database (pdf).
This included people living in urban, suburban and rural areas. They found an even stronger correlation between green space and health when only urban areas were included. Importantly, the authors controlled for socioeconomic status, which has a strong role in determining whether people live in neighborhoods with more or less green space—this represents the effect from the green space alone!
