June 25th, 2009 by DrRob in Better Health Network, Opinion
Tags: Democracy, Healthcare reform, Journalism, Little Guy, Medical Blogging, Politicians
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I was looking through an article in Time Magazine recently and came across an article about healthcare reform. It spoke of the daunting task ahead and went through a list of the people at the table in the process of creating change. The list included politicians, hospital corporations, pharmaceutical companies, insurance companies, and lobbyists from certain large special-interest groups. Notably absent from the list was physicians and “normal” patients. I commented about this in a conversation with Val Jones, MD, and she said: “If you aren’t at the table, then you’re on the menu.”
She’s right. Up to now, the interests of the people who matter most – the doctor and patient in the exam room – were largely unheard. Folks said they knew our needs, but they all had their own agendas and so often got it wrong (either out of ignorance or out of self-interest). Even the organizations that are supposed to represent my needs, the AMA and the specialty societies to which I belong, are not composed of folks who spend most of their time in the exam room; they are people who have either retired to spend their time in Washington, or are full-time smart people (they know lots about other people’s business). There are very few people at the table who regularly see patients. There are also very few who represent patients without a particular axe to grind (elderly, people with chronic disease or disabilities).
But healthcare is about what goes on in the exam room. The entire point of healthcare is health care; it is about the care of the patient. It isn’t about the business, the drugs, the delivery system, or the insurance industry; it’s about optimizing how the system makes sick people better and keeps better people from becoming sick. Everything else is a means, not an end.
But those of use who are in the exam room are soon to be served up on the menu for the sake of political gain and special interest clout. They may or may not have a good plan, and they may or may not have good intentions. But they definitely do not have an understanding of what really goes on and won’t be affected much by the decisions they make. They are serving up a dinner of food they don’t know about and they won’t have to eat what they cook. How can they make good decisions?
A step in the right direction would be to listen to bloggers. As opposed to the lobbyists and pundits inundating Washington, we actually do healthcare. The doctor and patient blogs on the web represent the interests of the people who are in the middle of the healthcare universe. This universe doesn’t have Washington DC at its center, it has the patient and those who care for him or her.
A good parallel is the crisis in Iran. There are reporters and politicians who say they know what it’s all about – and in some ways they do – but the voice of the people living in Iran are crucial to understanding what is going on. Why are there riots? Ask a rioter. Was there rigging of the election? Ask someone who was there to witness the process. The people who are on the ground should always be listened to. They don’t give the entire perspective, but getting a true perspective is impossible without talking to them.
Don’t just listen to me; I represent a specific point of view, and don’t represent that of patients or specialists fully. Don’t just listen to patient blogs, as they often don’t have a clear understanding of the business of medicine or the complex medical realities (although I know some of them do know an awful lot). We need to force ourselves to the table. We need to give perspective that has previously been invisible.
Blogging matters because it gives perspective that could never come from anywhere else. Blogging is the journalistic equivalent of democracy, giving the average person a chance to make their voice heard.
In July, a group of us medical bloggers will be going to Washington to do what we can to make our voice heard (thanks to Val Jones’ hard work). Maybe it won’t make a difference; but at least we won’t be invisible any more.
*This blog post was originally published at Musings of a Distractible Mind*
June 23rd, 2009 by Shadowfax in Better Health Network, Health Policy, Opinion
Tags: Baucus, Costs, Featured, Healthcare reform, Malpractice Reform, Medical Malpractice, Obama
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What a welcome headline to see in the New York Times:
Obama Open to Reining in Medical Suits
In closed-door talks, Mr. Obama has been making the case that reducing malpractice lawsuits — a goal of many doctors and Republicans — can help drive down health care costs, and should be considered as part of any health care overhaul, according to lawmakers of both parties, as well as A.M.A. officials.
Wow. Yay. Crisis over, let’s move on to something else now.
Or maybe not.
Senator Max Baucus of Montana, the chairman of the Senate Finance Committee, is expected to outline his proposal for a health care overhaul this week, and aides said liability protection for doctors is not part of the plan.
So, I’m guessing that Obama’s talk about supporting med mal reform runs about as deep as his comitment to gay rights. Which is to say that he’ll put out some happy talk about it to appease a necessary constituency but won’t twist any arms or spend any capital in Congress to actually make it happen.
Worse, the semi-concrete proposals I have seen don’t look like they’ll offer much protection. Jon Cohn at TNR links to a summary of a few options:
Win-Win-Win on Malpractice Reform? – The Treatment
Disclosure-and-offer programs, in which health care providers disclose unanticipated outcomes of care to patients and make prompt offers of compensation. Patients do not waive their right to sue by accepting the offer, but reportedly, few go on to file lawsuits.
It’s hard to see this as reform at all. Disclosures are nothing new any more, and it’s always been good tactics to make an offer of compensation if there actually was substandard care. I doubt this will be embraced by the medical community, since when you do a disclosure you’re basically giving a potential plaintiff a roadmap for their future lawsuit. You’re basically relying on their sense of decency to avert a suit, and how that fact can be altered I cannot imagine. Another commonly cited option would be to:
create a federal “safe harbor,” retaining the current process of adjudication but insulating physicians from liability if they adhered to evidence-based medical practices. For example, legislation introduced by Senator Ron Wyden (D-OR) in February would create a rebuttable presumption that care was not negligent if the physician followed accepted clinical practice guidelines.
Sound great, but good luck applying that standard. Consider Whitecoat’s trial, in which the case seems to be hinging on the fact that the got the right diagnosis and performed the right treatment, but he may or may not have done so in a timely fashion. Presuming there even exist “guidelines” for a particular condition or presentation, there are so many technical variables in the execution of the care under these guidelines that I don’t see how juries could be expected to put this into practice.
Consider a child with meningococcemia. It’s a no-brainer that a child with this deadly infection needs to be given antibiotics as soon as possible to have a chance to survive, and there’s probably a guideline out there that makes reference to “urgent” or “timely” administration of antibiotics. So, if a kid comes into my ER with a fever and petechiae and I don’t get the Rocephin in for, say ninety minutes, was that timely enough? Or maybe the kid didn’t have the rash on presentation, but at hour three of an extended ER work-up the rash is noted and then antibiotics are given? Or maybe I was too rushed, stupid or negligent to notice the rash and didn’t give antibiotics till hour three. My point is that it’s meaningless to say that “guidelines were followed” when it’s impossible to write guidelines that cover every clinical circumstance. Worse, if implemented narrowly, the “safe harbor” would offer very very little protection, and if construed broadly, it would make it very difficult to actually distinguish negligent care from good care.
The reason I’m spending so much time on this point is that this proposal has had explicit endorsement from Obama himself, his Chief of Staff Rahm Emanuel and his physician brother, Ezekiel Emanuel, and key legislators like Senator Ron Wyden. It sounds great, but it too is just “Happy Talk.”
The last option cited is the classic option of moving med mal cases to specialized health care courts of some variety. I’ve always thought this had great potential, but there doesn’t seem to be any political support for it and it would certainly be fought tooth and nail by the trial lawyer’s association.
So it’s looking more and more like health care reform, if enacted at all, will probably not include any meaningful or effective national solution to the ongoing malpractice crisis. Plenty of “Happy Talk,” but no action and no solutions. Not that I really expected any, coming from a Democratic President and a Democratic Congress, but hope does spring eternal.
*This blog post was originally published at Movin' Meat*
June 23rd, 2009 by Gwenn Schurgin O'Keeffe, M.D. in Better Health Network, Opinion
Tags: Healthcare reform, Lifestyle, Medical Education, Pediatrics, Pregnancy
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With health care reform being the talk of the week – a top priority for President Obama and for the AMA, who wants to be sure that America’s physicians are not just talked about in the reform process but included – I can’t help but wonder if the entire system will be reevaluated or if we will end up with just another band aid.
What worries me is that it’s not just the practical end of medicine that is broken. It is not just the billing end that is unhealthy. It’s not just the reimbursement and billing end that is broken. The overall culture of how we practice medicine is broken as well as the educational system in which and through which our next generation of physicians are being trained.
In this Spring’s issue of the Tufts University Medical School Alumni Magazine, my medical school Alma Mater, resident life style issues were at the core of their headline article. Reading the article, Pressure Drop, by Susan Clinton Martin, M.D., M.P.H, ’04, a pediatrics resident, I was at times propelled back in time to my pediatrics residency at the same institution in the early 1990’s have discussions with my adviser and residency director about whether I wanted to go part time. As I was in my junior year of my pediatrics’ residency and expecting my first child, this was not an easy decision to make and I had seen mixed results with other residents who had attempted this path before me.
In the end, I opted to not go part-time and for the reasons stated in the article for most residents not opting for this path:
1. longer length of overall residency
2. decreased pay and benefits (not ideal with a baby at home!)
3. resentment of colleagues for fear of extra work on their plates
4. lack of support of the program
The honest truth is all of these issues were at play back in the 90’s with me and my colleagues and still exist today. I opted to just forge ahead and deal with having a baby and being a full time resident. I don’t regret that decision. I had the support of some attending physicians and colleagues, friends, my husband and a wonderful nanny who a PICU (Pediatric Intensive Care Unit) Attending introduced me to. It wasn’t easy but is there ever a great time to have a baby in the medical profession? Let’s be honest – residency is one of the most challenging times for a physician and adding any stress to the plate makes it worse.
Balancing work and family is never easy for any career but particularly challenging as a doctor and incredibly challenging as a resident physician where you don’t control your time. Residency programs have rather rigid schedules and even the most thought through back up systems don’t accommodate the last minute life issues that can occur unexpectedly when you are a new parent and have a new baby at home. Residencies try to be reasonable when life issues emerge but it isn’t always easy and there is always some sort of “pay back”. Even when unexpected life issues emerge – daycare crises, infant illness, or a family crisis, it’s almost easier to find a way to get to your shift. That’s how intense the pressure is on you at the time. I recall seeing an Attending pregnant with her 3rd child in tears one day because some small issue had unraveled at home. I asked a mentor about it and she told me “You’ll see when your baby comes. Some days the pressure just gets to you. Just come talk to one of us. There are a few who understand and can help.”
Reading that Dr. Martin was brave enough to go part time was like seeing a rose among weeds. The benefit to her and her family was enormous. When working her “on” months, she can focus and feel less guilty, knowing her time with her family is coming. When she has her “off” months, she’s refreshed “emotionally accessible” to her family.
A recent study by Martin’s program director Dr. Robert Vinci showed that today’s medical students value part time options in residency programs, yet few residents are utilizing those options when they do exist and the majority of programs are still very traditional. According to the article, only 25% of US residencies have part time options with only 10% of residents in those programs utilizing the part time paths.
So, there’s a big disconnect in medical education between desire for better lifestyle and what is available, no different than what those of us who have completed our education and training have experienced within the health care system for years. While it’s discouraging that our caring profession doesn’t have a system that allows us to care for ourselves and our families, it’s encouraging that we are all finally speaking up that balance between work and home isn’t a frill but a necessity – even for physicians.
This is why it is so crucial that doctors at every level of today’s health care system not only have a voice in the health care system discussions under way but be the key players in crafting the new system. This is our career, our life’s work. We would never tell the Government how to do their jobs…what makes them think they call tell us how to do ours?
*This blog post was originally published at Dr. Gwenn Is In*
June 17th, 2009 by scanman in Better Health Network, Opinion
Tags: Abortion, India, Obstetrics And Gynecology, Radiology, Tiller
2 Comments »
Abortion and the intense debate about it in an otherwise enlightened (?) country was the topic of two of my earliest posts in this blog (this post and this one). I posted again when it looked like the debate was going to start in India. Thankfully, it died a natural death.
Those of you who follow me on twitter know that abortion has been on my mind following the sickening murder of Dr. Tiller. For the record, I didn’t even know that there existed such a doctor as he till I chanced upon news of his death. I refrained from writing anything here as I figured I had stated my views already.
Then I saw this post in my friend Dr. Val’s blog.
The abortion “issue” is such a hot topic that I have never written about it on this blog until today. I hope I won’t regret that decision but I felt it was appropriate to respond to this medical student’s essay – and the ~560+ comments that follow it – as a physician who has witnessed (but never performed) about 100 abortions. Let me explain.
Read the entire post at Better Health: A Third-Year Medical Student Discusses Her Views On Abortion In The Washington Post.
Also read the medical student Rozalyn Farmer Love’s post, My Choice, in the Washington Post.
I’m a third-year medical student at the University of Alabama at Birmingham. I plan to become an obstetrician-gynecologist. I dream of delivering healthy babies, working with families and supporting midwifery. But as part of my practice, I also envision providing abortions to women who need them. …
I agree that ending an unwanted pregnancy is a tragedy. When I advocate for reproductive rights, for choice, I don’t claim that abortion is morally acceptable. I think that it’s a very private, intensely personal decision. But I was stunned when one of my professors, a pathologist and a Planned Parenthood supporter, told me that decades ago, entire wings of the university’s hospital were filled with women dying from infections caused by botched abortions. It’s clear that women who don’t want to be pregnant won’t be deterred by limited access to providers or to clinics. And I believe that it’s immoral to let them die rather than provide them with safe, competent care.
The lines that affected me the most were…
I plan to choose a residency program that provides further training — a place where I won’t worry that asking to be taught to perform an abortion could somehow limit my future options. At the start of medical school, I was very careful about how I presented my pro-choice views to the faculty for fear that I could jeopardize my grades or hurt my chances for recommendations or of being accepted into a program run by any of the professors. This experience of treading lightly is unique to medical students in more conservative parts of the country, where opposition to abortion is widespread…
I was equally moved by these lines from Val’s post…
I initiated rapid sequence intubation with the assistance of the anesthesiologist, and then moved to get the ultrasound machine to visualize the uterus and its contents. Much to my discomfort the fetus was fairly large – and was moving around normally, even sucking its thumb at one point. I asked the Ob/Gyn resident why the fetus was being aborted since it didn’t appear to have any structural abnormalities. She responded that the mother simply didn’t want to have the baby, and had wrestled with the idea of abortion for a long time before she made her final decision. The rest of the procedure is a bit of a blur – with details too graphic to describe here. But suffice it to say that the resident performing the dilatation and curettage had a fairly difficult time removing the fetus through the cervix, and had to resort to eliminating it in smaller parts, rather than a whole. It was very sad and it took a long time to make sure that the uterus was fully evacuated. I decided that I couldn’t watch another one of these procedures.
All I can say to Val is: Do not visit any ObGyn procedure room or OT if/when you visit India.
I did not set out to write this to hand out that gratuitous bit of advice to Val. I wanted to highlight something else that she had written that caught my attention and raised some doubts.
In my opinion women should have the right to choose to have an abortion, but I’d hope that they also consider their right to choose to give their baby up for adoption as well. Some believe that an abortion is “easier” than giving up a baby for adoption – but I’m not so sure that’s the case from an emotional perspective.
I want Val and all those who share similar views re. adoption as an alternative to abortion to read this moving essay by Judy Brown in which she says When Abortion Was a Crime, I Would Have Sought One. Read the entire essay and pay particular attention to the two paragraphs at the end…
There are approximately 500,000 children in the foster care at any time in the United State — many of those children are adoptable, but will not be adopted — why don’t “pro-life” advocates step forward to adopt them now? Do they want the forced return to warehouse orphanages for still more unwanted children? Do they want women sent to prison for seeking an abortion, and doctors also jailed, when we already have a shortage of doctors in this country? And nurses jailed, when we have a shortage of nurses in this country? How much damage and destruction of life will they support to force the rest of us to subscribe to their “religous” views? I’ve never heard a so-called “pro-life” advocate answer those questions honestly. Making abortion illegal will not stop abortions, it will just stop safe abortions, as is the reality in the few civilized countries in which abortion isn’t legal, but their abortion wards are full to bursting with maimed women, and whose morgues overflow with dead women.
I agree with Val’s concluding paragraph that Rozalyn, the third year medical student may change her mind after witnessing or performing a few procedures.
Even in a country where abortion is a non-issue, I believe there are many medical professionals who are troubled by late trimester abortions and abortions-on-demand. I am one such. But the sad reality is that we are the minority here. I feel particularly sad because occasionally in my professional role as a diagnostic radiologist I am the cause of some of these wrenching cases of late trimester abortions. Some of them I can agree with, though they could have been avoided by earlier diagnosis and decision-making, like an anencephaly being diagnosed at 35 weeks gestation. But most are not that morally or ethically clear cut.
*This blog post was originally published at scan man's notes*
June 17th, 2009 by Gwenn Schurgin O'Keeffe, M.D. in Better Health Network, Opinion
Tags: Cell Phone, Features, Pediatrics, Psychology, Sexting, Technology, teens, Texting, tweens
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Cell phones are their feature are an ever growing topic in today’s families. It used to be that the hot button issue was whether to get the phone. Now, we have to deal with all the features: texting, Internet, camera…to name the tip of the iceberg!
Clearly we’re becoming a more mobile society with our cell phones taking over features previously reserved for our computers. A recent Nielsen Wire report confirms this observation showing that in Q1 of 2009 21% of cell phone owners used their phones to search the Internet, up from 16% in Q4 of 2008.
At the moment, digital plans are pricey so it’s easy to lock our kids out of their cell phone Internet access. However, not too long ago we said the same exact thing about texting and now we have affordable unlimited texting plans.
Given the impulsivity of tweens and teens and how difficult it is for us to help kids with appropriate Internet use on computers, do we want to open the door to having them have access to the Internet on cell phones? Once data plans become more affordable, should we let them have cell phone internet access?
Perhaps it would be easier to answer if asked slightly differently. How are our teens and tweens doing with the digital cell phone freedom they have right now? Given the rise of extreme texting and sexting, I’d say not so great. Before we open the door to new issues and digital freedoms they are not ready for, we have to help them more with the freedoms they already have – and are clearly struggling with. Plus, as parents, we are still sorting out the issues with the digital uses of technology our kids are currently using. Let’s sort those out first before we give the green light to other mobile freedoms that will certainly be more complex and harder to control.
If all goes well, data plans will remain unaffordable for a while longer so we won’t have to cross another digital bridge none of us are ready for.
*This blog post was originally published at Dr. Gwenn Is In*
