We finally got to this woman and my mentor looked at the file only to frown. He looked at me over his glasses and said "Let's go and see this one." Usually, I had gone in alone to take the history, take the vitals, and do some of the physical exam but in my excitement and my exhaustion, I was just curious about what this woman might have.

We walked into the room and there sat a middle-aged woman scratching at her arm. As soon as my mentor stepped in, she began to hurriedly explain what had happened. On her arm were circular lesions, some scabbed over yellow, others still open. She touched them as she talked saying "There are some bugs that bit me. You see these black dots [referring to the brown spots of pigmentation on her skin] - I tried to scrape them out at my dermotologist's office...they were burrowing into my skin. They keep on biting me. I didn't have these beforehand." At first, I was in disbelief wondering what kind of bugs could have caused these lesions. Then she said, "They're all over my towels, crawling around everywhere. They're on my arm too." and pointed at the brown spots on her skin. My mentor hurriedly reassured her that no bugs had bitten her and asked her calmly if she had been scratching her skin to which she hurriedly replied that bugs had did this to her. I looked at her face and noticed around her lips and mouth were white spots and discolorations. As we left the room, she continued to talk hurriedly about the bugs and wanting medication to make them go away. I went outside, shocked with my mentor afraid to verify what I thought was the problem. He wrote a prescription for flu-like symptoms as she was presenting with high fever and sinusitis. I looked at him and he looked at me simply saying, "Well, that was scary." And that's when I knew. She had done that to herself. She had scratched those lesions into her arms thinking that bugs were biting her. My doctor told the other doctor on call "to not get in any further and tell her to go see her primary care doctor." I was even more shocked. Were we just going to let her go? Hope that she would book an appointment with her primary care doctor? I sputtered out, "Why?" and to which he said "She needs her primary care doctor- In fact, her doctor is very good." I left after that patient, almost running out to my car only seeing her scratching her arms and her discolored lips frantically telling us about the bugs that bit her. I drove with my hands tightly on the wheel, knuckles white from trying to concentrate on the road and not think of her.

Who's responsibility was this patient? Was my mentor right in letting her go? Could he not have done anything else? If the patient actually goes to her primary care doctor, would that make this okay? I don't know. All I know is that tonight, she will be my last thought before going to sleep.

Here's a quote I hope that people will comment on that was made in regards to what we do when bad health care happens:
"Indeed, I suspect that our collective search for villians- for someone to blame- has distracted us and our political leaders from addressing the fundamental causes of our nation's health care crisis. All of the actors of health care- from doctors to insurers to pharmaceutical companies - work in a heavily regulated, massively subsidized industry full of structural distortions. They all want to serve patients well. But they also all behave rationally in response to economic incentives those distortions create. Accidentally, but relentlessly, America has built a health-care system with incentives that inexorably generate terrible and perverse results. Incentives that emphasize health care over any other aspect of health and well-being. That emphasizes treatment over prevention. That disguise true costs. That favor complexity, and discourage transparent competition based on price or quality. That result in a generational pyramid scheme rather than sustainable financing. And that - most important - remove consumers from our irreplaceable role as the ultimate ensurer of value."
- From "How American Health Care Killed My Father" by David Goodhill in the ATLANTIC Monthly Magazine (September 2009)
Full Article: http://www.theatlantic.com/doc/200909/health-care

I'm sure many of you have been on the edge of your seats waiting for my next entries...
To appease that, I have decided to resurrect my blog and actively maintain it by ensuring at least 2 updates per week if not more. So please continue to read and if you can, leave comments, thoughts, questions. Also, please berate me if I fail to update.

By tomorrow 9 am, there will be an entry on this come hell or high water.

Until then, make sure to wash your hands throughout the day and cough into your armpit when possible. :)

Yours,
Reshma

1. An amendment that would reinstate the ban on federal funding for the syringe exchange, cost-effective and lifesaving program that does not promote drug use and provides a gateway for primary health care for hard-to-reach populations. VOTE: NO! The ban was kept lifted!

2. An amendment to strip federal funding for Planned Parenthood programs. Planned Parenthood provides birth control and other contraceptives for millions of teenage and older women at reduced or free rates along with abortion, gynecological, and nursing services. VOTE: NO! The government will keep funding this necessary program!

HUZZAH! Thankfully, these amendments were not passed and federal funding is going to great causes.

In this post, I am going to attempt to explain the difference between the two types of health care reform being discussed right now: PUBLIC OPTION and SINGLE PAYER

The Public Option:

This is what President Obama has been recommending to Congress for the past months. This is the plan that is being created and voted on within the Senate committees and then expected to end up on the President's desk by October. This is the plan that is going to help achieve universal health care. So what is this health care crisis saving plan?

The Public Option has been created to work within the current health care system. It will create a government sponsored insurance option that will compete with the other insurance plans. As it will offer low premium prices compared to the other insurance companies, it will help to hold costs down. As this will be offered throughout the country, it will help those cities in which only one private insurance company is available to its employers and citizens. In this way, people who cannot afford health insurance will be able to purchase it at a very low cost or receive waivers. The government would be reimbursing the doctors and the hospitals to provide health care. The Public Option as written by the HELP committee will guarantee quality and affordable health care to whoever wants it. People who like their employer based or private insurance are welcome to keep it but others can opt into the Public Option.

Criticisms: The Public Option would place a government individual between the doctor and the patient (you might have heard this said by many Republicans and Fox News) and thus promote socialized medicine. The Public Option is therefore "unAmerican". It would also drive costs too low and thus cause other insurance companies to go out of business creating a government monopoly. The cost of this health care plan will be too expensive - estimates have been that of 1.5 trillion. However, there is a lot of preventative care to be taken into account that cannot be quantified. Estimates have shown that the cost of the plan will be $600 billion over 10 years.

My specific criticism: The Public Option does not guarantee universal health care. In fact, at most, at the moment, it will only provide to at most 20 million of the 47 million uninsured. This is because while the premiums will be low, there will still be premiums. And waivers cannot be handed to everyone who does not have enough money or any money at all according to the current Public Option. Also, the quality of health care will not necessarily be improved - clauses have been put in but no talk about funding being allocated towards quality of care has been talked about nor has the exact guidelines for quality been discussed.

Single-Payer

Single-payer would put everyone in a public health insurance plan. A single government fund would be set up to cover all costs of doctors, hospitals, and other health care providers. This would be radically different from private insurance in that there would not be any risk assessment of a pool to determine the rates of health care, but instead just a single pool of money to pay all those involved in health care. Coverage would be the same for everyone and there would be universal health care as everyone would be subscribed to the public health plan. In order to fund single payer, everyone would have to pay taxes which would be dependent on income. The US is the only high-income industrialized nation that does not have a form of single payer.

Criticisms: Single-payer would get rid of the capitalistic nature of our health care system. The government would have too much control of health care and thus, quality will be affected. Freedom of choice in health care would not be available and as a result, queuing would occur just as in Canada and UK where people have to wait months to get an elective procedure or experimental medicines. In addition, the government would play an active role in deciding what procedures are appropriate and what medication should be available to fit under the constraints of the the single pool of money.

My criticisms: Quality might be sacrificed for the idea of universal health care. Valuable procedures and medications that should go to the public will be rationed instead.

I personally would prefer single payer based on the fact that in other countries, it works. While queuing is an issue, people who don't have health care have to wait forever for procedures. In true utilitarian fashion, I support single payer but at the moment, the Public Option is on the table and health care is in a crisis. Around 14,000 people are losing health care per day and more and more people are unable to get the medical attention they need. Right now, the Public Option is a necessity to give health care to as many people as possible and the opportunity to create real health reform. It's details are being hashed out so much debate and input from organizations like AMSA, AMA, and more will be considered.

If I have your email address, I will be sending you emails to call/email your legislator (with scripts!) to push for certain amendments to improve access and quality of our health care system. Senators do not know the struggle of people who don't have health insurance or poor insurance as they have excellent government-sponsored health insurance. This should be the standard for everyone. We need them to know what's it like to not get the test we need when we're sick, what it's like to not go to the doctor regularly because we just can't afford it, and what it's like to watch a doctor or health care professional make a mistake because of the system. We need to let them know what we want. We are the reason they're in office and if denied our right (yes our right) to health care, then they shouldn't represent us.

HEALTH CARE FOR ALL NOW!

The World Health Organization published an article entitled "Benchmarks of fairness for health care reform: a policy tool for developing countries" (to read the entire thing which is awesome, go here: http://www.who.int/bulletin/archives/78(6)740.pdf) in 2000. The WHO developed these benchmarks to be used as a tool to gauge whether a health system works or not:

1. Intersectoral Public Health - Does the nation provide basic nutrition, housing, sanitation, clean water, reduced exposure to toxins, education and health education, and public safety? Does the nation have infrastructure for monitoring health status inequalities? Does the nation try to improve social determinants of health?

US: I'd say so for the most part. Out of 10, I'd give us an 7 - we need to work on those social determinants more and some places are better than others. And we have PLENTY of inequalities in health care.

2. Financial Barriers to Equitable Access - Is there universal health care? How many costs are covered by insurance?

US: Clearly, we don't have universal health care. And there are enormous financial barriers to equitable access....and equitable access doesn't really exist here. So I'll give a score of 2.

3. Nonfinancial Barriers to Access - Does geography, gender, or cultural factors affect one's ability to get care? Does discrimination based on gender, sex, religion, race, sexual disease and class exist in health care?

US: A black baby born in the same place as a white baby has higher risk factors for disease just based on their race. In rural areas, there are less doctors available. Medicaid patients are turned away from doctors routinely and while this is not a direct example of class being a barrier, it is indirectly. Score: 4

4. Comprehensiveness of Benefits and Tiering: Are all services affordable? Are things categorically exclusive? Has there been reform to give uniform quality of care?

US: All services aren't affordable as many Americans (47 million) cannot afford healthcare. Additionally, even the working poor can't afford healthcare and many services are not available to people who do have insurance and thus, have to pay out of pocket. Tiering is not a huge issue in the US but there are not uniform standards of care met throughout the country as of yet. Score: 5

5. Equitable Financing: Is financing by ability to pay for both tax-based systems or premium-based systems? For out of pocket services, is the burden shifted mainly to the sick and not the entire population?

US: Managed care is unique in that due to the fact that a certain company has the same insurance, the premiums are based on the community of workers rather than the risk of each worker. This is great for many employees as it drives premiums down. However, financing of these premiums is not by ability to pay but based on how many benefits you want. Out of pocket services are mostly shouldered by the person affected in the US and not the entire population. Score: 6

6. Efficacy, Efficiency, and Quality of Care: (Definitely my favorite benchmark) Is there a primary health care focus? Is evidence-based practice used routinely? Are there measures to improve quality?

US: For our health care system, this is a mixed bag. On one hand, physicians do try and use evidence-based practice and guidelines are set by this research. Many organizations exist that advise the government regarding the quality of care such as the Institute of Medicine, Agency for Healthcare Research and Equality, Public Citizen, and many more. Besides this, money is poured into the health care system to improve equality by providing experimental drugs and research grants, new technology, and other administrative costs. However, we have a shortage in primary health care doctors throughout the country. The amount of money we put into improving quality of care through new technology does not seem to cause an improvement in health care outcomes, especially when compared to other countries:

We are 37th in the world in terms of health care outcomes.
Score: 4

7. Administrative Efficiency: Are administrative overheads minimized? Is there cost-reducing purchasing for services and medications? Is cost-shifting minimized? Is there minimal abuse, fraud, and inappropriate incentives?

US: Administrative costs are the highest in the US compared to the rest of the globe - 3 times higher than industrialized countries with the lowest rates. Medications are much costlier in the US compared to our neighbors in Canada. Cost shifting is not minimized and is many times left on the patient.
Score: 3

8. Democratic Accountability and Empowerment: Are there public, explicit procedures for evaluating services? Is there transparency? Are there fair grievance procedures such as malpractice? Is there enough privacy protection? Do people feel empowered to debate and discuss health care and actively engage for change?

US: It has taken 30 years for reform to be revisited again and we saw in the 1990s how health care reform was killed by insurance companies and Republicans. This time, we are making a difference - services have been evaluated painstakingly and are being rethought. Malpractice is rampant and has driven many a physician out of service but malpractice can be a result of the interaction between the patient and doctor rather than the doctor actually making a mistake.

Score: 5

9. Patient and Provider Autonomy: ....you get it.

US: Score: 9 -- Patients have the right to any treatment they want as long as they have enough reasoning. Doctors can take a more paternalistic approach to medicine although this is discouraged but all in all, doctors and patients can do as they please.

So these are the 9 benchmarks. Do you think they're worth using to evaluate our own health care?

At AMSA, I am the Health Care Quality and Safety Intern which means I focus on trying to get medical students excited about not just health care reform in terms of access, but also in terms of quality. Just to give you an idea about how quality is being compromised in our health care system, we rank 37th in the world based on our health care outcomes. According to the Commonwealth Fund, the US ranks last among 19 industrialized nations when it comes to "mortality amenable to health care" or in other words, deaths as a result of preventable and treatment reasons. If a black baby and a white baby are born in the same city on the same day, the black baby is four times as likely to go to the emergency room for an asthma attack than a white baby and the black baby is twice as likely to die from it. Between 44,000 and 98,000 deaths from serious medical errors are committed by doctors every year - that's more than deaths resulting from breast cancer or motor vehicle accidents. Why is this? Why do we get so little when we put in so much?

To be fair, there are some really good things about the American medical system. Unlike other countries, we don't have queuing issues - people do not have to wait long periods of time to get an elective procedure or surgery or experimental medications. We also have more technology than any other country, as expected since we spend 16% of our GDP on health care. There are plenty of MRI units and CT scanners for everyone. We spend so much money on tests and technology to make health care better, yet we are still at the bottom of the list in terms of quality and safety.

Last week, during the AMSA Chapter Officer Conference, Dr. Robert Kocher, a physician who advises Obama on health care, stated that a doctor is 8 times as likely to use a CT scanner if they have it in their practice than someone who doesn't and that it does not really change the outcome of the patient. Money is continuously poured into new technologies and new drugs, but shouldn't money be allocated to actually improving health care?

This is why I decided to become an AMSA intern. I am like many other medical students trying to do my part in being apart of the health care reform movement, but even more important at least to me, is that the quality of health care for all becomes better. In the end, it will not matter that a bill is passed that ensures health care because there is still a huge chance that the new patients will be apart of the 98,000 victims of the system.

The key areas I am working on are resident work hours and teamwork. Teamwork may sound very general but in fact, it is very tied to the efficiency and safety of health care. Regulations has been put in by the Accreditation Council of Graduate Medical Education (ACGME) to limit resident work hours to 80 per week through 16 hour shifts. Many doctors have complained that these shorter but much safer shifts limit continuity of care and are dangerous for the patient. However, I think it is more important for the resident to learn how to communicate with his team and to develop techniques to shift over care to the next resident with minimal errors. Besides this, more errors are made my residents who work longer than 16 hour shifts as they tend to make more and more mistakes due to increased fatigue rather than residents who shift a patient over to the next resident on call. I am working on trying improve these "hand-off" methods and create guidelines to ensure patients are getting the best and safest care possible. Doctors shouldn't be scarier than breast cancer or motor vehicle accidents.

Below is an amazing article by Atul Gawande about health care costs and quality entitled "The Cost Conundrum". I encourage everyone and anyone to read it. Even Obama has read it and is taking advice from it.

http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande

I've also posted two pictures from a press conference last Thursday (July 16th) where the HELP Committee announced that it had passed its bill including the Public Option. The other interns and I wore white coats showing our support for the bill as it is intended to provide universal healthcare through a new government plan with very low premiums that will compete with the other existing insurance plans. I'll explain what's been going on with health care and my thoughts on it in the next post.

These are phrases that I have heard almost every day I have been working for the American Medical Students Association as a Health Care Quality and Safety Intern (or the short form- Better Care Intern). It's been an interesting summer as I have this amazing opportunity to be a witness to not only a huge organization while being apart of it, but I am also a witness to a huge change that is about to happen....or at least, hopefully a huge change. A change in a field that I am on the precipice of entering. Health care reform is a shift for me from background in physics and math, but definitely a welcome shift. Besides last summer in South Africa, never have I been so engaged or immersed in a field so complex and so encompassing.

Before this summer, if someone would have asked me, "Do you think health care is a human right?", I would have looked at them strangely and vehemently said "Yes, of course." Now, during the summer, I still would have said "Yes" but it would be a yes with an understanding that our country, the country who spends the most amount of money in the world on health care more than even China which has 1 billion people compared to our 300 million and has universal coverage, does not think that health care is a human right. That it is a privilege to be earned by those who earn. That health care is a business, a now uncontrollable economic force. And high quality health care- well, that is a luxury only few can realize.

Maybe I'm being naive or too idealistic. But I can help cringe when I hear stories of many who do have access to health care having difficulties getting proper treatment or being turned away from doctors when they are at the worst. And I cannot help but wonder what someone does when they don't have health insurance and realize that even though they may be so ill that they can barely survive, that going to the doctor is not an option. If having reactions to these situations is called "naive", then wouldn't we rather have naive doctors or naive lawmakers or naive insurance companies?

And so being overwhelmed and troubled but wanting to help as much as I can, I am resurrecting this in hopes of putting everything I learn this summer and beyond into perspective. I don't want to lose these thoughts nor do I want to remain stagnant in my understanding of the what's happening right now. I also want those who are closes to me to read this and understand what I am doing here on a day to day basis and why I am. Soon I'll be surrounded by classmates who will have the same goal to become a physician. I want to hear from not just my fellow future doctors, but also my friends, my family, and people who will have to deal with this issue everyday. One day, I won't be just the doctor - one day, I will be the patient. In medical school, I can only hope that I will not forget that fact.