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The Ones that Emory Didn’t Save

It was with much fan-fare that 2 American aid workers were airlifted from across the world and brought to Emory University Medical Center where they began experimental treatment for Ebola. We hope for a full and speedy recovery for them and others like them who do God’s work.

But it appears to me that lost in this conversation are myriad others who need help but never get it. Right now, humanitarian work is being done all over the world, and in very dangerous places. These people  knowingly put their life on the line for others. Yet  tragically, some of them are injured or sickened in the service of others. But for them, the call from the CDC offering to med-evac them out never came. There was a girl, who died of malaria while in Kenya. Or the young man who was serving in Egypt. Or a myriad other aid workers who die while serving their fellow human beings.

Also at issue, and it needs to be asked, at what cost are we saving lives? Who decides who gets what may have been, all told, a hundred thousand dollar medical evacuation? Susan Grant, the Chief Nurse for Emory Healthcare, in an article for The Washington Post rightly downplayed the infection risk posed by bringing these patients here. She went on to say:

“The purpose of any hospital is to care for the ill and advance knowledge about human health. . . As human beings, we all hope that if we were in need of superior health care, our country and its top doctors would help us get better”

This statement brings to mind others that need saving. They don’t work in far away lands, they live here in the U.S, right across town, in fact. They don’t have fancy, exotic diseases.  Their conditions have names like diabetes, heart disease, hypertension, and lung cancer. Right now many of them are getting collection notices for their inability to pay from medical centers like Emory University. Others have been trying to get appointments at tertiary centers  like Emory. Only they’re told that their insurance is not accepted there, or their co-pays and deductibles will be more than they can afford.

How would Ms. Grant justify the incredible expense spent on this endeavor to those people? What would she say about the necessity of this experiment, a clinical trial with an N = 2? Could she really  tell those sweating in the Atlanta heat after their electricity got shut off that this was all really for their benefit?

I don’t know how to solve the ethical dilemma here. While I am hope for a cure on the one hand, I cringe at the highlight this places on those at the bottom end of America’s healthcare disparity gap. Perhaps someday in the distant future they can take solace in knowing that they didn’t suffer for naught. Because if they ever contract ebola, there will be a cure waiting for them.

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End of Life Conversations are Becoming End of Life Confrontations

“How Dare You!”

Life can change in a heartbeat. Most of us believe that our lives, our loves and all the that things that make us who we are is a gift from a higher power. One that can be taken away as swiftly as it is given. But somewhere in the shuffle of taking kids to practice, catching up on emails, worrying about bills, and the search for the perfect barbecue, it’s all too easy to forget the truth of life. The one truth. The one single thing that life guarantees each and every one of us. From the moment we take our first breath,  life makes to us but one promise. The promise that our life will someday end.

“Who do you think you are?”

For some of us, death comes after a lifetime of achievement, for others all too soon. For many it will be feared, for others it will be welcomed as their bodies wither away. But for more and more of us in our increasingly sterile and safe society, it is simply not to be thought of at all. An unwelcome stepchild locked tightly away in the attics of our consciousness. Like a demon in waiting, we reshape it, remake it, remold it, until it becomes an ever distant sunset that bookends a romantic dream of a life full of love, accomplishment, achievement.

“You have no right to say that!”

Until finally, that inevitable day approaches. A man or woman in a white coat tells you the terrible news that your loved one is passing away. That yes,  they are alive and can be kept alive, but there is practically no chance that they could recover. They will never go back to the person they were before.

“Where’s my regular doctor?” Continue reading “End of Life Conversations are Becoming End of Life Confrontations”

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5 Ways Healthcare Reform May Impact Medical Education

Guest Post by Ta’Rikah Jones

Unless Congress completely smothers the Affordable Care Act (ACA), its changes will shake healthcare to the foundations as millions of people gain access to insurance and expanded medical care.

The ACA’s goal is to move Americans toward a health insurance umbrella for everyone while striving to control costs and drastically alter the insurance industry. Potentially every facet of healthcare could be affected, from the doctor’s office to research labs. Changes could even reach into healthcare education.

The law will change the number of patients seeking care, how much doctors are paid and may make some med school students even more uneasy about school loans.

These are some ways the ACA may affect medical education:

1. More primary care

The law seeks to foster primary care and boosts Medicare payments to primary and internal medicine physicians significantly while lowering payments for subspecialty doctors. Also, payment and coverage for preventative care would rise along with primary care.

This could slow the drop in students who pursue primary care in medical school. For years students migrated into more lucrative subspecialties, leaving only a small percentage of students interested in general medicine.

The act also calls for expanding some scholarship and repayment programs for primary care doctors and expands nurse and primary care training.

Continue reading “5 Ways Healthcare Reform May Impact Medical Education”

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Lung Cancer Screening: Almost There . . .

In 2011 The National Cancer Institute published results from their study of low dose CT lung cancer screening of individuals identified as at risk for lung cancer. The investigators enrolled those between 55 to 74 years of age who had at least 30 pack years of smoking under their belt (number of packs per day multiplied by number of years smoked). These people were then randomly assigned to either a chest x-ray group or a “low dose” CT scan group, with 3 images over 2 years. There was initial criticism that the authors used chest x-rays as the control rather than “usual care”. However given that the PLCO trial, comparing chest x-rays to usual care, subsequently showed no difference between the two, this would appear to have been a sound strategy.

The study also received some well deserved praise, as it was the largest study of its kind, and demonstrated some very impressive findings, as detailed in the article’s abstract. The most striking findings were:

  • a 20% reduction in the risk of death from cancer relative to the control group.
  • a 6.7% reduction in the risk of death from any cause relative to the control group.

I cannot sum up how to you how astounding these results were/are to the medical community, specifically to those who are involved as patients, or in the treatment, diagnosis, support, research, and  fund raising of lung cancer. Continue reading “Lung Cancer Screening: Almost There . . .”

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Healthcare Armageddon 6: Medicare and Generation X

                                              I’m Talkin’ About My Generation.

**Update: Treasury has just issued its reports on Medicare and Social Security, the results making this article more timely and relevant than I had intended. Together SS and Medicare make up 36% of federal spending. The Social Security trust fund is predicted to run dry in 2033, while the Medicare hospital trust fund (for inpatient services) is slated for extinction in 2024. Link to the report here.


Over the past few months i have struggled with how to portray the recent changes coming down the pike for medicare, what with ACO’s, and  impending cuts due to mounting deficits and the ever increasing costs of medical care.  What viewpoint, I wondered,  should this blog take on these issues?
Should I take the role of the traditional physician-blogger, and share the viewpoint of the myriad other physicians around me who live with uncertainty about how to run their practices in the current fiscally deprived environment? Should I write about the constant worry about whether congress will extend the recurrent doc-fix or let the draconian cuts in reimbursements go through? Will I write about whether there will come a time when it will no longer be feasible to accept Medicare or Medicaid?

Continue reading “Healthcare Armageddon 6: Medicare and Generation X”

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The Squandering of Tobacco Settlement Billions

 

TO KEEP SMOKING!

Please enjoy this recycled oldie-but-goodie while I spend the next few weeks juggling a high case load with studying for the boards with taking care of two babies, etc. . .

Few things smell worse to me than the stank of a cigarette while trying to trying to load up on cholesterol via awesome blossom.  Perhaps one such thing is the beguiling tale of what perverse fate has befallen the gobs of cash money rewarded to state governments from Big Tobacco.  

This seemingly righteous pursuit was fought by brave attorneys general of 46 various states to regain money we dished out to pay the costs of Medicaid patients who, due to tobacco use, found themselves in various states of wheeziness and/or infarction.  So naturally you’re asking “why then did these same states more recently try to help Big T in getting a recent settlement against it reduced?”  Good question.  Read on. . .

Continue reading “The Squandering of Tobacco Settlement Billions”

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Snow Birds and The Unfulfilled Promise of Electronic Health Records.

Please enjoy this recycled oldie-but-goodie while I spend the next 6 weeks juggling a high case load with studying for the boards with taking care of two babies, etc. . .

The migration has begun. All over Michigan, the annual migration of flocks moving south is in full swing. And behind those flocks, the other annual Michigan migration is starting too. Our office is starting to see our winter ‘checkout’ patients before they migrate south for the winter.

Over the next month, I’ll see a multitude of patients come in to get ‘checked out’ and get paper prescriptions to take with them to Florida in case they find themselves under threat of missing a golf outing due to varying states of cougheyness and/or wheeziness. Many of them have physicians in Florida that they sometimes see, and occasionally they get hospitalized while down there. They usually come back with an impeccable tan, an extra spring in their step, and a story of their various physician visits and /or hospitalizations with more holes in it than your average disability application.  They also explain that any tests that I’m about to order have probably already been done by their physicians in Florida, and they’d like me to take a look at those records before I order anything. We then start the dance of trying to get copies of their charts, which goes something like this:

Records Requested:                                 Records Received:
Request for chart.                                                     Nothing                  

Second request.                                                       Nurses notes 

Third request..                                   Copy of diet recommendations.

This whole dance has started to make me wonder about my ardent support for the electronification of medical records, which is supposed to do for medical care what the invention of sliced bread did for a fledgling sliced deli meat industry. By now we’re all aware that the Institute of Medicine (which by the way, to me sounds like a made up name) tells us that a gazillion patients are unnecessarily being decapitated every day because physicians’ illegible orders for ‘allow decaf for patient’ are being misinterpreted by hapless nurses as ‘and now decapitation’. Electronic medical records, says the Institute, would successfully ameliorate the silent killer that is physician penmanship.
But how does this impact the care of patients who had treatment from another physician or medical system, whether it was across the country or across the street? Nada. If I want to see those high tech electronic records, it still requires that I talk to a person, those records must then be printed, then faxed. Because of this, many of these tests end up being duplicated, and because of the awesomeness/stupidness of medicare, it has continued to pay for the duplication of these tests even if it has only been days since the original tests were done.

It seems to me then, that adding electronic medical records to the current system is kinda like adding a microchip to an abacus. . . in the end all you get might be nothing more than a fantastically expensive Goldberg machine. To me the only way that electronification of medical records will ever be the revolution that it’s backers claim it will be, is when there is a high degree of compatibility between systems. This would allow patients’ data to be shared among multiple different records systems. It would provide patients greater mobility between medical systems, rather than being tied to whatever system their PCP happens to be in. That greater mobility in turn might place greater pricing pressure on different medical systems as they are forced to compete to a greater degree. So how exactly do we implement this? I don’t know. But I promise I’ll start thinking about it once I’m done faxing all these diet recommendations to Florida.

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Healthcare Armageddon 5: The Crux of the Problem

There’s a central theme running through many of these “Truth About Health Care” posts that I write. Whether it comes to medical centers putting out press releases that are nothing more than thinly veiled advertising, or drug companies trying to get physicians to write more prescriptions, it comes down to the fact that there’s a whole lot of competing interests out there trying to get a bigger slice of a shrinking money-pie. And the pie is about to shrink a whole lot faster. . . Continue reading “Healthcare Armageddon 5: The Crux of the Problem”

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Update: Lunch money Pharma spends on physicians

This post at KevinMD has blown up and is generating significant interest.

Since writing it I was contacted by CNN, they talked about wanting to do a series on America’s addiction to medications and what sounded to me like the various excesses of drug companies to try to get people to take those medications. They wanted me to comment on the various excesses of Pharma from a physician’s perspective. They were interested in hearing about all the things the drug companies give us, specifically,  free stuff, give-aways, trips,  golf outings. . . you get the point. I explained that I had no experience with such things, nor did I know of anybody who had, and probably was not the right person to talk to.  

I feel like in this discussion, we private practice physicians are guppies in a big ocean. The occasional office lunch amounts to essentially (excuse the pun) small potatoes compared to the influence that pharma has had on the opinion makers, and subsequently, in the drafting of practice guidelines (such as recent lipid guidelines or the use of activated protein C in sepsis). In this, the influence is insidious; it exists largely in rooms that are closed to the rest of us. The influence is not nearly as extroverted and obvious as CNN (and the rest of us) would like to see.  However, I agree with many of you that having drug reps bringing lunch into the office at the very least gives the impression of influence, and may not be a practice that we as physicians can defend much longer.  In retrospect, I wished I had agreed to the interview with CNN, only for the sweet irony of my interview being followed by a commercial featuring two elderly people sitting in bathtubs on top of a hill.  .  .