There is a big purple elephant standing in the corner of the US healthcare system

In simple terms, IOM stated today that US healthcare sucks.  It is about time someone addressed the elephant in the room.

"In a lengthy report out Thursday, the IOM wrote that U.S. medicine wastes roughly $750 billion per year, permits tens of thousands of needless deaths and bungles its mission in ways foreign to other industries." -The Hill's healthwatch blog commenting on the IOM report released today

Lost in Translation

I recently had my first experience using a medical translator in order to communicate with a patient.  Actually, I had to use 2 different translators for 2 different patients in the same day.  One experience was relatively neutral, the other extremely frustrating as the entire conversation seemed to be lost in translation.

At the hospital I'm currently rotating through, the translators come via a speaker phone on a language line.  My understanding is that this has become the most financially affordable way to translate and also allows for access to an increased number of languages.   Speaker phone means distraction from background noise in a busy hospital, a lot of need for reputation, decreased clarity, and a lack of visual ques. 

The frustrating experience involved an attempt to gain informed consent for a necessary surgery.  Informed consent is already a complicated song and dance as it is a multi-step process with nuanced details that make little sense to someone without strong medical literacy.  [The predicament of informed consent can, and probably will, be a whole different blog post all together.]  Add in a speaker phone, translator without proper terms for female anatomy, and language without words for "laproscopic", and you have an ugly mess.  We spent an hour and a half with that patient and I'm pretty sure she walked away more confused than when we started.   She answered in the affirmative to statements of understanding and denied having any questions but her face said different.  I'm sure that I'm not the first to be frustrated with these experiences and I have no idea how to make them better, but I really hope that this conundrum progresses throughout my career.  Part of my interest in healthcare is to educate my patients and I certainly hope that I can learn to do better than what I experienced.

Role reversals

I spent Friday in the emergency room, as a patient.  A bad cold superimposed with some type of viral stomach bug turns out to be a pretty awful combination.  Particularly when the patient is a type 1 diabetic who can't stop vomiting.  The family med doc who I saw in clinic Friday morning decided that a shot of phenergan along with a trip to the ER for some IV fluids was exactly what I needed.  Turns out that I also needed some IV zofran to actually stop the vomiting, a chest XR to rule out pneumonia, phenergan and cough syrup to take home with me, antibiotics for sinisitus, and a weekend of sleeping to break the fever and kick this bug. 

I really don't understand why our patients seem to like the ER so much.  The beds are uncomfortable, the IVs sting, the hospital gowns leave little to be imagined... It was not my ideal way to spend a day. I am very grateful for the treatment I received though.  And that they respected my knowledge of my diabetes as that isn't a fun fight to have when sick.  I am also grateful for the classmate who spent the day in the ER with me and the others who have been taking care of me all weekend.  While I don't feel perfect, I definitely feel better.  Here is to hoping I have the strength to pull off a 30 hour ob/gyn shift tomorrow as I've already used up one precious sick day. 

Brenner's army

Based off of The New Yorker article that came off this year, PBS put out this documentary on "doctor hotspots".   I propose we start Brenner's army: doing the research to find hotspots in our own cities and towns and implementing programs to change it.  It is about time we drastically change the way health care is accessed and better utilize our finite and precious resources!

Think there is any way that I can arrange a research year under Dr. Brenner next year?

Interesting idea

The NYT opinion page posted a proposal to make med school free, and then charge for specialty training, as a way of increasing interest in primary care. The idea being fiscally neutral since the government already pays for all US residency; it would just mean shifting orders and priorities. Seeing as increased access to primary care lowers overall costs, this idea could actually end up saving considerable amounts in healthcare spending. It is a fascinating idea. The more I think about it, the more I like it. While a possible genius idea, the realist in me realizes that the fine United States government would never approve such a socialist plan, even if it would help to increase access to quality primary care and neutralize the ever-increasing-although-already-exorbitant healthcare spending.

Maybe I should just move to the UK? Or the Netherlands?

Living in the south is bad for women's health...

The National Women's Law Center in conjunction with Oregon Health and Science University published the "2010 health report card for women" today. This report card looks at all factors important to women's healthcare: access, family planning, abortion, wellness & prevention, policy, etc.

The first thing I did was to look up the state I currently live in: F. Then I looked up the states that surround me: F, F, F, F... The south (TN, KY, LA, AB, MS) = fail. While not at all surprising, it is beyond frustrating. We theoretically live in a rich country with access to some of the best healthcare in the world; except clearly not. Women should not be receiving inferior care based on their gender. Southern's should be at a disadvantage based on their geographic location. Aren't we all US citizens?

My very liberal view is that we need some serious healthcare care reform NOW. Bring on the universal care with a single payer plan! Bring on preventative medicine. Bring on health education. Better incorporate other professionals into a person's care plan: social workers, nutritionists, and the such. Integrate more reproductive health care into primary care. OR, I should just move to Canada, or England...

What is my role in all of this? How can I help to improve healthcare as a medical student? Should I be getting more involved in health policy? How can I better prepare myself to provider comprehensive healthcare in such a broken system?

"Letting Go"

Here is another amazing article by Atul Gawande. He speaks of issues that make us Americans very uncomfortable: end of life care. It is not surprising to anyone that a disproportionate amount of our health care spending goes towards those facing death; is it worth it? When do we say that enough is enough? While drawing concrete lines that such and such a procedure under x circumstance is wasteful doesn't seem so hard; it all changes when talking about a specific person. How do we create a fair, finically responsible and sustainable medical system? How do we do it while valuing each individual life as priceless? Thoughts?

My inner-anthropologist thinks that we need to come to terms with death being a natural, and sometimes even desirable, end to life. As doctor's we need to stop seeing death as failure on our parts, and need to start seeing palliative care as an alternative option. We also need to really listen to our patients, identifying what their true desires about end of life care and encourage them to share this information with their loved ones.

Broken, part 1

"Medicine used to be simple, ineffective and relatively safe; now it is complex, effective and potentially dangerous." -Cyril Chantler

This is the first part of what I am sure will be a many part saga; an epic about how broken the US health care system currently is. I say all of this with the caveat that a) I'm really not sure what would be better; b) if I did, I'm not sure I would know how to transform our current system to this new shiny, effective, and cost efficient system; and c) as imperfect as I know single payer systems to be, I support systems that acknowledge my belief that health care is a right. However, I am never really sure what to say when asked "how much health care is a right?"

Two things happened last week that made me think about how broken our system is. The first was a public health class on health care management. We spent 5 days sitting around a room, shooting for the moon with our ideas about what health care should offer. We then discussed authentic leaders, and how to use leadership to make these things happen. In 20 years it will not surprise me to see these classmates transforming the way health care is delivered; and with the ideas that were shared, I pray that these minds are able to make an impact much sooner than 2030.

Second, I received two e-mails. The first from a friend worrying that her birth control pills were fallible. This friend should have been educated about all the possible signs and symptoms that may present when put on the pill. The lack of premptive education caused needles worry, undue anxiety, and possible misstrust in the system. The fact that she came to me (a know-nothing medical student) instead of her clinician speaks to the inaccessibility of educational services. Second, another friend, with a history of asthma ended up with multiple time-consuming and stress-inducing specialists appointments because of follow-charts. She saw her clinician presenting with shortness of breath and heart palpitations which automatically sent up the red-flag for cardiac trouble. While this red-flag supports the effectivness of the system (along with the fear of malpractice litigation), no one took a time out to actually think about the situation. The fact that she's young, healthy, had a normal EKG in the office, and that her signs and symptoms were consistent with her asthma regiment. If this thought process had been followed, she would have been saved excess time, money, use of precious resources, risk of added interventions, and excess time before the necessary change in asthma medicine.

I may be a naive medical student. Maybe you don't agree that these examples illuminate some of the many issues with our medical system. But, even still, can you really say that our system isn't problematic? And should we settle for something so broken?