It’s sacrilege to not want to be the OR if you’re a surgeon, or a wannabe.
I’m guilty of it this rotation. Not only am I not actively seeking out the OR, I’m attempting to avoid it. And today, spending the day in it against my wishes, I’m peeved.
My disdain is multifactorial. Some of the reasons for avoiding scrubbing in are personal and beyond discussion here. But, in part, the fact is I’m tired of general surgery. I want to be a neurosurgeon and if I never see the inside of an abdomen ever again I would be beyond comfortable with that. Even agreeing that any operating time is good learning experience I can’t shake that sentiment.
Toss me anything with a neurosurgical faculty, an osteoma or a shunt or a trauma crani, and I would be there with glee. But I just cannot shake my distaste for what I’ve been doing over the past seven months or for what I had to do today.
Despite my own misgivings about scrubbing in, I can’t understand future general surgeons refusing general surgery (or its subspecialties) cases. I faced such today.
There was a single OR running today with four cases.
There are five residents on my service. It is highly over staffed. Four of the residents want to be future general surgeons. I’m the lone outcast. One was on call, I understand him not wanting to drive across town to scrub in. That left three others, all of whom are seeking to impress the faculty, to garner a good evaluation from this rotation. I’m alone in having my evaluation bear no impact on my future. I’m alone in not wanting to be a general surgeon. And yet I was sent to scrub in.
My response was frank annoyance, hardly professional, but I figure hardly misplaced in full.
It’s true I’ve managed to avoid the OR but for a handful of times and left the responsibility (and may I opine, privilege) to the general surgery wannabes on the services. I imagine them figuring I needed to shoulder my share of the ‘scrub in burden’. But what a ridiculous notion. The fact general surgery residents figured scrubbing in as a burden; essentially refused several general surgery cases out of what I can’t help but call laziness is bizarre and worth criticism.
My own avoidance of operating experience is something of laziness although my reasons on this particular rotation, as I said, are complex. But if anyone could be afforded an excuse for such it’s myself; with nothing at stake on this rotation unlike all the others.
And while throwing ones fellow residents under the bus is something of a shameful act I have to ask about today, “What the hell?”
The one guy with the most legitimate (at least I feel so) excuses for not going into the OR is prodded in so everyone else can take a lazy breather?
There’s something gut wrenching about being an intern in July. You’re a ‘doctor’ in name but there’s nothing magical that happened when they handed you your degree.
But that’s all a sidetrack. The fact remains that being a new doctor is not without some butterflies.
Every once in a while however you do something of effect. Opportunities to truly help patients often arise from the fact that as an intern I’m probably the physician who lays eyes on our patients the most.
I was two weeks into my intern year when I first ‘caught’ something with a patient. I was in the Surgical Intensive Care Unit. Late one day the ENT resident caught me to tell me about a post op patient they had put in SICU admission orders for. I can’t remember what he had had done but he had been a tough intubation and didn’t have an air leak when they were done with the procedure. So they kept him intubated and ventilated and dosed him with some steroids.
On a ventilator, of course, he was going to require an ICU bed.
I went down and visited him in the Post-Anesthesia Care Unit. There was a good chance he was going to spend the entire night down there as there were no ICU beds open. At that time he was hanging out. I put in some standard ICU orders, talked briefly with his wife, wrote a note and headed back up to the ICU.
About two hours later I get a call from the nurse in the PACU that the patient is agitated.
Something made the experienced nurse caring for him sit up and take notice when this patient began to pull at his restraints, rather than just turning up his Versed drip. As such I probably shouldn’t be calling this ‘my’ catch.
In anycase, I get down there and the guy is tachycardic on the telemetry monitor. I’m an intern so my modus operandi is to order every test in the book for every little thing and I’m already thinking about a PE protocol CT scan with this guy. But first things first, the nurse and I get an EKG. I’m admittedly surprised at how classic it looks.
The EKG Looked Something Obvious Like This
I remember MONA, call the cardiology fellow, fax over the EKG, call my upper level, call the ENT resident and the patient ends up in the cath lab with a clot pulled from his LAD.
The patient ended up in the MICU and I’ll be honest I don’t know how he ended up. Hopefully well. For me, this patient taught me some valuable lessons; he taught me to respect what the nurses have to say about patients, to lay eyes on patients whenever there’s any change. Things I need to keep in mind as I get along in my residency.
I’ve been working some hours of late as my fellow intern is taking vacation and there really wasn’t afforded anything in the schedule to mitigate that. Not to get all ‘I walked uphill in the snow both ways to get to school each day’. I know residency used to be something tougher. Maybe.
While I haven’t gotten into the operating room I’ve gotten some cool procedures, gotten pretty proficient at chest tubes and pigtails and generally had a pretty good weight towards actual patient care this rotation considering the bureaucracy of medicine that falls to residents at academic centers. So don’t number the above as a complaint.
[zdvideo height=400 width=500 theme=gray border=no]http://www.youtube.com/watch?v=qdH2hX0WmPU[/zdvideo] One Way To Avoid All This…
But the amount of time I’ve spent at the hospital has got me thinking about the way the ACGME polices residency rules. So much centers on self reporting. And there’s huge pressure to not report violations. When residency programs get in trouble with the ACGME there are consequences for the residents. A residency program shutting down can be disaster for residents. You could be searching for a new program, leaving a program you love, maybe even switching specialties or moving across the country.
The medical community does some to help in situations when programs are lost. In many specialties other programs traditionally give preference to those residents who have lost their spots. And the ACGME and most RRCs are helpful in giving residency programs exceptions for extra residency spots when programs shut down. In reality those concessions and that assistance are small potatoes.
Scrambling for a new spot that has funding for you, moving, acclimating to a new environment is major trauma. That is assuming you even get ahold of a new position.
There are major incentives for residents to keep their programs in good standing, including to lie about their hours worked.
Now I’ve never lied about my duty hours. And I can’t say I know directly of anecdotal episodes of categorical residents lying about their duty hours to protect their programs but you have to believe it happens. It is just not something that will ever be spoken to. If the ACGME wants residents and others to self report violations; if truthful reporting is going to be the centerpiece of review then it needs to give residents more protections. I’m talking about an extreme shift. I’m talking about emergency funding for residency spots when programs run into trouble, about guaranteed spots for residents whose programs fail including about requiring all programs to agree to participate in helping to take on displaced residents, about relocation expenses.
I’m thinking program violations for all sorts of things must be vastly, vastly, vastly under reported. ACGME policies don’t have a lot of teeth when weighed against the future of your training.
Life as a healthcare provider is privileged. You get to see a lot of humanity. The good, the sad, the humorous.
Probably two weeks into being a physician I had to push neostigmine on a patient. Neostigmine is a powerful cholinesterase inhibitor that among other things causes…significant bowel contraction. Which is why I was using it. My patient had come into the trauma ICU following, literally, a nose bleed. Early onset dementia had left the patient in a nursing home and following a fall at that nursing home no one had been able to stop his epistaxis. Down in the ER they had literally stuck foley catheters deep into his nostrils and inflated them to apply pressure and stop the bleeding.
Typically Doesn’t Go In The Nose
He had a lost a lot of blood and had a lot of comorbidities and was at high risk for rebleed and so he ended up in the ICU. Easily, supposedly the least sick patient in the trauma ICU.
He had significant deconditioning on presentation and likely had some generalized ileus. Being in the ICU and further bedridden didn’t make his condition better and his belly started to grow. A KUB sometime into his stay showed a pretty significant generalized ileus without evidence of obstruction. Enemas and other efforts didn’t do a lot to decompress him. So my resident sent me in to give the patient neostigmine.
Neuostigmine isn’t always a benign drug. ‘Side effects’ include bradycardia and, that persisting, arrest. So my resident had me go into the room to administer the neostigmine with a syringe of atropine should I require it. The rest of the team, in a telling move, stood outside peeking into the room; they feared the consequences of rapid bowel contraction.
I slowly push the neostigmine and I stand there, vigilant, grim waiting to have to urgently give the atropine if needed. I’m tense. I’m a two week old doctor and my resident has made this out to be a serious medication.
Suddently my patient starts with, “I have to go. I have to go. I have to go.”
“Okay, sir, we’re getting you a bed pan,” I say. It does nothing to temper my poor demented patient, “I have to go. I have to go. I have to go.”
The nurse runs out of the room to get a bed pan; an admitted oversight for everyone involved in this endeavor. “I have to go number two!”
“It’s okay, sir,” as we slide a bed pan into position. “You can go if you need to.”
I’m watching his heart rate on the monitor and then the patient starts throwing in a new phrase. At first I think he’s saying, “I hate you.” But as I strain to listen it’s clear, “I hate poo. I hate poo. I hate poo.”
I almost lose it. Sitting there with atropine in hand should this patient have a crisis and brady down, I have to turn around and walk to the corner trying to stop myself from laughing.
I refuse to call it unempathetic; there was something endearing and worth a non-condescending chuckle about what we were putting this man through to treat him and help him. It’s the humanity of practicing medicine.
My last residency interview was a couple of days ago. I’ve rarely been so relieved to be done with something. Walking out after hours of being holed up in a hospital conference room and of talking with faculty and researchers, I felt a real big weight leave my shoulders.
Interviewing for any job can be stressful. Residency interviews may be on a whole different level.
Residency has been caricatured by shows like Grey’s Anatomy and Scrubs. It is that time in a physicians life after they have graduated after they have graduated from medical school and gotten that M.D. after their name; when they are getting training in a medical specialty.
Can’t Wait For Graduation Day & The Diploma
But getting from where I am now, to where the characters of Grey’s Anatomy are requires navigating the residency interview and match process. It isn’t quite like any other job search out there. Although most of my interviews were get-to-know-each-other type of affairs I was, at times, ‘pimped’ on clinical scenarios, asked to read CT and MRI scans, and even had my dexterity tested. All more than fair. But except for select technical jobs – say engineering or computer programing work as examples – not exactly the type of oral test most job applicants face.
Those type of clinically relevant questions are important and not wholly unique. What may be more unique and grueling is merely the length of the whole process. Last year, in the specialty I’m trying to enter, the average medical student went on more than 14 interviews. Like for in many job interviews, each residency interview is a full day, often a multi-day affair. 14 job interviews is a lot. Perhaps more telling, it isn’t unheard of to talk with 15+ individuals at a single interview.
Let’s say the average number of faculty you interview with at any program (this is specific for the specialty I’m trying to enter) is 7 or 8. Let’s say 7.5. That seems like a reasonable number from my experience. If you went on 14 interviews you would’ve talked with more than a 100 people by the time the interview season was over.
That’s answering the same questions 100 times. That’s asking the same questions 100 times. That’s the same small talk 100 times.
Don’t get me wrong, it is important. This is your future as a graduating medical student. This is their future as a program. And the interview is often a very narrow window to get a feel of where you want to spend the next several years of your life. But boy, I think everyone can imagine how draining such a process could be.
And you do get such a small window of what programs are like. If my future was working in a cubicle, I could get at least a sense for the day to day mechanics of a corporation, of it’s bureaucracy, of what a typical day is like during a couple of days of interviewing. Residency interviews can rarely afford you that. Ten applicants, crammed into a day of interviewing cannot go spend time down in the clinic or go scrub into the operating room or round with the residents.
True, many programs, especially in some of the surgical specialties, encourage ‘second looks.’ They encourage interested applicants to come back and see how their residency program runs in a real day situation.
But there’s another kicker with that. The entire interview process, including any potential second looks, is largely self funded. Applicants applying to competitive specialties and going on many interviews can easily spend upwards of ten or fifteen thousand dollars. That is borrowed money and in actuality will end up costing the applicant much more than that.
It’s an investment in your future of course and so I think most applicants take the debt with grace. And most medical students are used to debt; another $10,000 is just something to shrug at…unfortunately. Still, it is a little eyebrow raising.
I’m done though. Now I merely wait. You see, the final difference between interviewing for residency and your typical job interview is that residency programs don’t really offer applicants positions.
Unlike interviewing for that cubicle job, there was no chance I was going to walk out of a residency interview and a couple of days later get a call offering me a position.
Instead, all applicants and residency programs are bound by contract to go through the residency match.
Applicants have to rank the programs they interviewed at. Residency programs have to rank applicants they interviewed. It all goes in a mysterious box and out comes the results, telling you where every applicant ended up (if they matched at all). In reality the algorithm used to match residency applicants to residency programs isn’t too complicated. Why it is done this way is a matter of history. The match is certainly not without it’s detractors; but that is for another post.
At the least, the match makes for a trying wait. From now until match day is approximately 2 months.
My interviews though are over. That sounds like an excuse for a celebratory beer.
When a medical student graduates as a physician they go on to residency. Such a time in a physicians life has been glorified by shows like Scrubs and Grey’s Anatomy.
My Goal Is To Be Like J.D. During Residency
Residency is a grueling apprenticeship. In the American and Canadian model it probably represents one of the most time consuming apprenticeships on earth. Residents play a huge role in patient care and several years ago the question over resident errors when they were tired led to rules which restricted how much residents could work. Technically residents are not supposed to work more than 80 (or in some cases 88) hours a week; averaged over four weeks.
Questions of compliance, especially in the surgical specialties, remain.
While the new recommendations do not reduce overall working hours for residents, the report says no resident should work longer than a 16-hour shift, which should be followed by a mandatory five-hour nap period.
The committee also called for better supervision of the doctors-in-training; prohibitions against moonlighting, or working extra jobs; mandatory days off each month; and assigning chores like drawing blood to other hospital workers so residents have more time for patient care.
Okay, to be fair, it is a better report than some of the working drafts that were leaked. Initially it looked like the panel was going to propose that the 80 work week be reduced to a 56 hour work week. That would’ve truly been insane.
Yet still, the Institute of Medicine panel has very poor perspective on what they’re delving into.
There is a very sound argument that surgical residencies are the most time consuming and that neurosurgical residencies are the most grueling of the grueling. I want to be a neurosurgeon. I’m not going to get pumped up and claim that I’m hyped about the long work hours. But they’re necessary.
The prospect of mandating restrictions on resident work hours in a neurosurgery residency is dangerous. I actively oppose both the current work hour restrictions and the new proposal from the IOM.
As I said, the IOM panel has a very poor perspective. It is difficult to degrade the efforts of a panel composed of such esteemed individuals but consider the following: nearly half of the panel is non-physicians and the panel included just one surgeon (an otolaryngologist).
A panel in which eight of seventeen members are not physicians and in which only one of the members is also a member of a surgical specialty; the specialties to be most effected by the recommendations (if implemented). I cannot believe, even with all the credentials of the panel members and the ‘exhaustive’ input the panel solicited, that anyone is taking this study seriously. It is laughable for a group to be making such recommendations without the first hand experience to bolster their voices.
The AHRQ, who commissioned the report to be done, had this to say,
“The Institute of Medicine study provides the clear evidence to prove what we have long-believed is true—fatigue increases the chance for human error,” said AHRQ Director Carolyn M. Clancy, M.D. “Most importantly, this report provides solid recommendations that can improve patient safety, as well as increase the quality of the resident training experience.”
First, while resident fatigue promotes errors so do “hand offs.” Hand offs occur when you turn care of a patient from one resident to another. As you can imagine, restricting resident work hours increases the number of hand offs. By some estimations the panel did not adequately weigh such risks to patients.
“The IOM committee, in making these recommendations, has failed to adequately consider the key patient safety issues – the considerable risks associated with too many patient handoffs and lack of continuity of care in complex neurosurgical disease or injury cases,” remarked AANS President James R. Bean, MD.
A significant percentage of resident physicians report that patient handoffs – transfer of responsibility for a hospitalized patient from one resident to another – contributed to incidents in which harm was done to patients. The study, published in the October 2008 Joint Commission Journal on Quality and Patient Safety, identifies situations in which problematic handoffs are more likely to occur and factors that may interfere with the smooth transfer of crucial information.
“Our findings suggest that patient harm from problematic handoffs is common,” says Barry Kitch, MD, MPH, of the Massachusetts General Hosptal (MGH) Institute for Health Policy and Harvard Medical School (HMS), lead author of the study. “In fact, problematic handoffs may be as significant a source of serious patient harm as are medication-related events.”
Second, the changes will limit the experience resident physicians get. In complicated surgical fields such can be an actual detriment to future patient care. Neurosurgery residency, for instance, is already up to eight years in length. There is nowhere to go to extend the length of time you spend in residency. And so neurosurgery residents are literally getting less training than before the work hour restrictions, as the AANS/CNS/SNS press report points out,
Additional restrictions in resident work hours will also create a new generation of surgeons with reduced surgical experience and expertise due to less exposure to complex surgical cases and direct patient care. “Unless the residency training period is extended considerably, residents in neurosurgery will receive 25 to 50 percent less training than residents received prior to 2003,” stated M. Sean Grady, MD, Charles Harrison Frazier Professor and Chairman, Department of Neurosurgery, University of Pennsylvania and current ABNS chairman. “One could reasonably ask whether any patient would choose to be treated by a neurosurgeon who receives half the training of today’s practitioners.”
Third, residents are cheap labor. That’s just honesty. Plenty of teaching hospitals in part actually need residents to make the system work. These are, often, full fledged physicians working at a fraction of their real earning potential to further their training. They’re cheap. Restricting their hours can significantly raise the costs of health care. Back to the New York Times piece,
“We know there is a cost to this,” said Brian W. Lindberg, a panel member and executive director of the Consumer Coalition for Quality Health Care in Washington. “If we’re enabling residents to have sufficient sleep, someone has to cover care during those periods. We also believe if you look at the totality of the recommendations, there is the potential for efficiencies in the system and savings from reduction in errors and harms. In the long run, it won’t cost as much as one might estimate.”
Plenty of other stakeholders, besides those groups representing neurosurgery, think the IOM has jumped the gun. The American Association of Medical Colleges tip toed around the issue but had this little rebuke for the report,
If the current duty hour limits are modified, it will be important to consider the impact of potential changes on other members of health care teams and the effect on patient care.
Putting the 2003 ACGME standards into practice has been a complex undertaking. The planning and implementation of any further changes will require significant time and resources.
The Institute of Medicine report holds no force of rule. Instead it is a recommendation for the actual self governors of medicine, namely the ACGME, to change the rules. Let’s hope that the ACGME is smart enough to simply ignore it.
A Print Anti-HIV Ad Campaign By The French Group AIDES
December 1st is World AIDS Day. You should go and make a pledge, not of money, but a promise for effort. Look for some small thing you can do to battle the spread of HIV.
President Bush, of course, spoke today of the plight of HIV/AIDS. And he took some credit for something the United States should be proud of in PEPFAR.
Five years ago, only 50,000 people with AIDS in sub-Sahara Africa were receiving antiretroviral drugs. Today, thanks to the emergency plan and to the generosity of the American taxpayer, that number is nearly 1.4 million. Think about that, over a five-year period of time the number of people in sub-Sahara Africa has increased from 50,000 to 1.4 million thanks to the American taxpayer. Around the world, another 6.7 million people with HIV/AIDS have received compassionate care, including 2.7 million orphans and vulnerable children. Tens of millions have received prevention — prevention messages based on the proven principles of ABC, which is Abstinence, Be faithful, and use Condoms.
Here is hoping that the United States has the will to continue its commitment to those living with HIV in Africa even as resistance sets in, even as the very effort the U.S. is making in getting AVRs to sub-Saharan Africa increases life expectancy and the costs that go with it.
PEPFAR is something, one of the few things, Bush should take proudly as his legacy. It was an impressive commitment of American resources.
HIV is the great infectious disease of my lifetime and I am certain that the possibility of me seeing it eliminated in my lifetime is very real.
In 1862 an American Egyptologist was far from the war that was engulfing America. In that year Edwin Smith bought a manuscript from an Egyptian collector in Luxor. A prolific collector of Ancient Egyptian manuscripts and finds, Smith was, apparently, never the less not the most gifted translator. He held onto the manuscript for more than forty five years, until his death in 1906 and in that time was not able to make substantial progress in translating the papyrus. At his death his daughter donated the papyrus, and other parts of her father’s collection, to the New York Historical Society.
In 1920 the Historical Society brought on the famous Egyptologist James Breasted to translate the papyrus. His completed translation was published a decade later.
What he translated was pretty fascinating
The papyrus is a medical textbook. Its clarity, conciseness and organization are remarkable for a medical treatise of the time. But perhaps even more impressive is its presentation of incredibly accurate physical examination and anatomical findings; along with rather reasonable treatment options.
It is also the first real neuroanatomical study. The document is broken up into forty eight cases and is an incomplete copy of a previous work. Of the 48 cases, 27 deal with head trauma and another 6 with spinal trauma. In presenting these cases the papyrus is the oldest surviving document to describe the sulci and gyri on the surface of the brain, the meninges, and the cerebral spinal fluid.
Breasted Translated This Hieroglyph As The Membrane Covering The Brain
Title: Instructions concerning a smash in his skull under the skin of his head.
Examination: If thou examinest a man having a smash of his skull, under the skin of his head, while there is nothing at all upon it, thou shouldst palpate his wound. Shouldst thou find that there is a swelling protruding on the out side of that smash which is in his skull, while his eye is askew because of it, on the side of him having that injury which is in his skull; (and) he walks shuffling with his sole, on the side of him having that injury which is in his skull…
Diagnosis: Thou shouldst account him one whom something entering from outside has smitten, as one who does not release the head of his shoul fork, and one who does not fall with his nails in the middle of his palm; while he discharges blood from both his nostrils (and) from both his ears, (and) he suffers with stiffness in his neck. An ailment not to be treated.
Treatment: His treatment is sitting, until he [gains color], (and) until thou knowest he has reached the decisive point….
Gloss: As for: “He walks shuffling with his sole,” he (the surgeon) is speaking about his walking with his sole dragging, so that it is not easy for him to walk, when it (the sole) is feeble and turned over, while the tips of his toes are contracted to the ball of his sole, and they (the toes) walk fumbling the ground. He (the surgeon) says: “He shuffles,” concerning it…
This appears, per many people’s interpretation, to refer to a closed skull fracture; with a pretty interesting description of some occular motor palsy and an ipsilateral lower extremity paralysis. Of the cases dealing with neurotrauma, they break down like this,
[The neurotrauma cases,] according to our present day terminology would be classified as follows: two compound linear fractures; four compound depressed fractures; four compound comminuted fractures; and one comminuted fracture without external wound. The symptoms and signs of head injury are given in considerable detail. Feeble pulse and fever are associated with hopeless injuries and deafness as well as aphasia are recognized in fractures of the temporal region.
James Breasted attributed the original treatise to Imhotep, the “Father of Medicine.” Such attribution would put the original work (of which the Edwin Smith Papyrus is clearly a transcription of) a 1000 years earlier. That would mean that these description of the brain and its coverings and the cerebrospinal fluid and all these detailed examination findings were recorded more than 5000 years ago.
I was pretty negligent with this blog during the election cycle. I didn’t even live blog the election as I did the midterms. And I certainly didn’t give the focus you might expect to the prospect of health care reform under both Presidential candidates.
That doesn’t mean I wasn’t paying attention; it just means the interview trail and the fourth year of medical school are weighing a bit right now.
But now we have a new President following an historic election. This is a President I happily admit I voted for despite some reservations about his plans to reform health care in this country. It’s important though to take a look at what those reforms may look like with the Democrats soundly controlling both sides of Congress and Barack Obama in the White House.
To be honest I have significant doubts about the possibility of ground shaking health care reforms occurring any time soon. The big hurdle is the economy. A massive shake up of how the U.S. finances health care is going to have significant launching costs; no matter the generous CBO estimates you read about any specific plan. In the current environment trying to cobble together a coalition to pass such costs, a challenge any day, is an even bigger hurdle. As well, we should be honest, despite polls showing the public’s interest in health care reform as a domestic issue, it likely to be pretty low on the agenda in Washington come January. Such is the state that Bush has left the country in. I also imagine some infighting amongst the Democrats themselves is inevitable. Various Democratic players already have a whole host of disparate plans they’ve introduced into the House and Senate over the years and since Obama’s election even more are coming out of the woodwork. I’ll get to some of those in a second. As well, the Party in power may be a little bit different but the major parties opposed to change continue to put money in the pockets of Blue Dog Congressmen and conservative minded Democratic Senators.
Still, I wanted to give a look at two things. First, what dream reform may look like for some Democrats (even if it turns out to be unpragmatic). Basically take a look at some of the plans for reform out there. Second, what may be more modest, but realistic goals for health care reform.
Much attention was focused on both candidate’s health care plans during the election. Obama’s ‘Plan for a Healthy America‘ got summarized by most major news publications, as well as some health care policy think thanks and health policy publications. The New England Journal of Medicine gave both campaign’s chances to editorialize their health plans and Obama’s campaign turned in this. The major points being:
“Through a national health-insurance exchange, people without employment-based insurance or who work in small businesses will have a choice of private insurance policies at rates similar to those offered through large firms. To promote competition among insurers, we will also give patients a new public-plan option, providing the same coverage that is offered to members of Congress and their families.”
“All insurance companies will have to take everyone, regardless of medical history.”
“My plan calls for investing $10 billion per year over 5 years in health information technology.”
“I will invest in programs, including loan repayment, training grants, and improved provider reimbursement, to give young doctors incentives to enter primary care.”
The most substantial reforms laid out in the Obama plan , financing wise, were the federal government entering the private insurance market, the regulation of health insurers to force them not to exclude people based on pre-existing conditions. and a pay-or-play mandate for employers of a certain size. The latter of these gets no mention in the NEJM piece.
Not entirely radical proposals but still not cheap. The costs of the full implementation of Obama’s plan has been put as high as $2.1 trillion over the first ten years of the plan’s life.
It greatly increases the federal regulation of private insurance but does not address the core economic incentives that drive health care spending. This omission along with the very substantial short-term savings claimed raise serious questions about its fiscal sustainability.
This is certainly legitimate criticism. Obama’s plan would eventually almost certainly drive private insurers from the market and leave people with fewer options. Depending on the level of subsidization the government extends to those trying to buy insurance you may see mixed benefit in the affordability of insurance for families and questionable gains off the uninsured rolls. While true, specific provisions for controlling the seemingly unsustainable rise of health care costs may not be as overtly prohibitive to Obama’s plan as Health Affairs makes it out to be. Despite rising costs private insurers truly continue to reap record windfalls.
Don’t get me wrong, I’m not using ‘insurance company profit’ as a bad word. I personally believe we should let the current system lie. But, the point remains there is a discrepancy between what the insurers pay out to cover increasingly costly health care in this country and what they pull. Therefore, there is a margin for a federal plan working in the private market to succeed in. Such a plan would be significantly more efficient (in terms of bureaucratic costs) than any current private plan. Another boost to the margin.
So while there’s some validity to Health Affairs criticisms, it isn’t all disaster.
Other criticisms of Obama’s plan are of the more typical conservative variety. The American Enterprise Institute has been particularly critical, firing even since Obama’s election.
It’s easy to laugh at the AEI right now. Despite their stated mandate the AEI boasts far less libertarian thinking than say The Cato Institute or The Hoover Institute. The American Enterprise Instute really is more of a neo-conservative front. And after the disaster of the Bush presidency, which AEI visiting scholars and fellows helped shape, it will be hard for serious thinkers in Washington not to take the Institute’s proposals with quite a larger grain of salt for the next twenty years or longer. I say that without hyperbole. Policy wonks travel in small circles and such circles reliably don’t function as meritocracies. Your future success in the world of think tanks and political posts often has less to do with your credentials than who you know. Yet still, having an AEI Fellowship on your resume counts for something significantly less than what it did even four years ago. And their credibility counts for something less as well outside their own kind.
It’s easy to pick and prod at some of the ridiculous points Dr. Gottlieb makes to try to bolster his claim. It’s fun as well. Here’s what AEI has to say,
Obama has…championed a “comparative effectiveness” agency–styled after the United Kingdom’s National Institute for Health and Clinical Excellence (NICE)–that would conduct reviews and studies on the clinical and cost effectiveness of drugs to inform central rulings on which patients should be eligible for a new treatment.
NICE’s real mission is to protect the British health care budget. Since 2000 it has denied patients the ability to use the newest cancer drugs–by my count, in 226 different indications for which American insurers and Medicare currently pay and for which the National Comprehensive Cancer Network says there is “high-level evidence” or “uniform consensus” of clinical benefit. Cancer survival rates in the United Kingdom are substantially lower than in the United States, and the gap continues to widen.
This is a little bit terribly misleading. For one, the U.S. detects cancer at a more prominent rate and, more to the point, at an earlier stage. The prevalence of money making tests makes sure of that.
And while instinctively that might come off as a “good” thing, that isn’t always the case. Early detection also probably artificially inflates those five year survival statistics. What I mean is that, from that early point of detection of course cancer patients are going to survive longer.
But the biggest rebuttal is that despite UK’s lower five year survival (whether NICE is responsible or not) the fact remains that the United Kingdom’s universal health care contributes to their society’s impressive end health outcome measures. And across those measures they beat the Untied States (here and here and more).
No I’m not debating my long argued stance that things like life expectancy at birth and infant mortality are both: difficult things to actually measure at times and also the product of multiple etiologies, not all of which can be influenced in a physician office. But, it remains that health care access is important these kind’ve utilitarian health outcome measurements and the United States’ figures aren’t so impressive.
The point is, if you want to improve the health of the United States by quantifiable figures then improving access is a key (as I recently argued).
How Democratic health care reform may shape up, if it truly does, is still a bit nebulous.
While interesting no one currently living with HIV should run to their physician expecting for this to be a viable option. As a British ‘expert’ commenting on the case put it,
“The problem is most people with HIV live in sub-Saharan Africa and this is hugely expensive, you have to find a matched donor, and it’s a pretty severe and painful operation.
“So it’s going to be an option for very few people.”
Finding a donor is the key hurdle. When someone has leukemia one of the options is to kill off all of their hematopoietic stem cells which are making the leukemic white blood cells. Then you replace them with the progenitor cells from someone else. Such is what a bone marrow transplant is.
To make it clear even though HIV infects T Cells, a type of white blood cell; you are not clearing the viral infection by doing a bone marrow transplant.
Instead, in this particular case, the patient got a bone marrow transplant from a donor whose white blood cells are resistant to infection from the HIV. For years people have been aware about mutations in the genes that code for specific proteins on the surface of T Cells and these mutations appear to confer resistance to HIV infection. These proteins on the T Cells appear to be used by the HIV to gain entrance to the cells. Think of them as door handles, as one piece I was reading described it.
The most prominent of these proteins is CCR5. Theoretically, and as it apparently worked in this particular patient’s case, if you could replace the T Cells of a patient with HIV with cells who had the “misformed” CCR5 protein then the infected patient would now have resistance to HIV infection and the virus in his body (depending on the serotype) would no longer be able to enter and infect his white blood cells.
A novel idea which appears to have worked in this case. This patient needed a bone marrow transplant for his leukemia and so they found a donor who also had the CCR5 gene mutation and, apparently, “cured” the patient of both of his diseases.
Unfortunately finding a bone marrow donor for a patient is already difficult. Like in all transplants specific antigens have to match up. But to make it tougher only about 10% of the world’s population has the CCR5 gene mutation. You have cut the available pool to search for a bone marrow donor by 90%. Already bad odds have just gotten terrible.
Beyond the costs and the novelty, finding donors for huge numbers of HIV infected patients is simply not feasible. So, bone marrow transplant will likely never be a realistic “cure” for the vast majority of those suffering from HIV. It does however, as the story says, raise the profile of studies on gene therapy to grant those already suffering with HIV a mutated CCR5 gene.
I truly believe that a “cure” for HIV is within our grasp. Bone marrow transplant simply isn’t going to be it however.
