This week in the New York Times Week in Review, there is a column stipulating that we should pay doctors less.

I wholeheartedly agree.

If medicine truly is the profession that I believe it is, you should hear a chorus of doctors saying, “Fix this system, even if it means paying me less.”

(Read more…)

After seeing the movie SiCKO, I can’t help feeling like it taught less about health care specifically, and more about the need for greater awareness of the world around us. I’ve long been interested in how the U.S. compares to other countries in health and other indicators, but I must admit I felt a little duped by my country, my teachers, my education, after the movie. I’ve experienced high school, a college education (where I majored in International Relations no less), and years of graduate school — just to now receive my own lessons on comparative work hours, health care, and government services, through a MOVIE nonetheless.

I felt rage, I felt sad. What was my education worth? How could I know so much about the United States but so so little about the rest of the world? And how did the mainstream media and my education keep that information away from me? How do people in other countries know so much about the United States but here I am, not knowing that France has some of the most fascinating government social services, and gives citizens unlimited sick days (because they’re “sick days!” as one of the ex-pats there said in the movie, with a “duh!” attitude). How can we all learn from each other and share, if instead I’ve got my ears plugged up?

And then I read Ezra Klein’s “Why Michael Moore is Good for Your Health” in the American Prospect, and it made me feel a tad better:

The film is more radical, and more troubling, than he’d even imagined. Moore’s movie is only superficially about health care. It uses the subject — and also sick days, and vacations, and child care, and maternal support policies — as a way to critique unthinking American exceptionalism, to challenge the tautology that states that the way we do things is the best way to do things because … it’s the way we do things. The particulars of the account all add up to the larger question: Is the America we live in the America we think we live in, and the America we want to live in?

Every story, every tale, every vignette asks the same question: “Who are we?” Who are we that our fellow citizens have to decide which fingers they’ll pay to get reattached? Who are we that our hospitals push the ill and indigent into cabs, and drop them off, disoriented and clad in a paper-thin gown, on skid row? Who are we that we let insurers deny coverage to our neighbors because they are too tall, or have too many seasonal allergies? Who are we that we don’t guarantee paid sick leave, or vacations, or child care, leaving that all instead to the whims of employers? And most of all, who are we to have let national pride blind us to these better alternatives, and let moneyed interests and powerful lobbies construct a country that best serves their needs rather than ours?

Yes, who are we?

I’m hearing others reflect like this also, and it can only be a good thing. A nation of introspection, much needed. So — how else did the film SiCKO shake you up? Share your thoughts…

(cross-posted at Cure This)

Can’t say I was shocked to hear this, but Richard Carmona, the former Surgeon General, recently came clean about the censors coming from the Bush Administration on important health issues such like reproductive rights and sex ed. This is entirely in line and consistent with this administration’s politicizing of health, so consistently applied that we come to expect it. You wonder if Karl Rove will start planting personal attacks on Dr. Carmona like any of the previous administration officials who later criticized the President…

Some links:

Kaisernetwork’s coverage

Rep. Waxman’s excellent website on politics interfering w/ science in the Bush admin

(not sure how recently its been updated)

“Doc, I feel like I hit the health care lottery!” 

JJ is a 50 year old woman I have been caring for for 7 years.  She originally came to me with two ongoing work injuries stemming from being robbed and assaulted while driving a metro bus.  For 3 years we worked on these issues.  Then she got diagnosed with diabetes and a severe lipid disorder. 

JJ is unable to work due to the work injuries but made too much money from her disability payments to qualify for medicaid.  She applied for medicare based on disability and was repeatedly denied.  She could not find a lawyer to help her due to the lack of potential compensation.  With her new diagnoses, she needed multiple medications, glucometer and all the appropriate follow-up services associated with her diabetes and lipid problem.

She did everything I asked of her with respect to changing her diet and doing low impact exercise.  She cut down but did not quit smoking.  After considerable tinkering with meds, she wound up on atorvastatin, gemfibrazil, metformin, glipizide and pioglitazone.  The pioglitazone alone is 180 dollars per month.

She would come see me 2 or 3 times per year.  She has never had an eye exam and would get yearly glycohemoglobins and lipid levels.  This is what she felt she could afford.

She came in recently and made the above declaration.  She finally got on medicare.  JJ managed the paperwork maze by herself and it took her 3 years.  Now she can get her eye exam, regular labs, medications, diabetic education and even a mammogram.

It is no wonder she feels like she won the lottery.

Unfortunately, I have many JJs in my practice.  People who fall through the holes in the safety net and struggle to get any medical care.  I know there are other stories like hers.  

What do others do to manage patients in these situations?  Do we need universal health care!?!?!?!?!?   

Emily Yoffe describes in excruciating detail the adventures of serving as a standardized patient to medical students, to evaluate their physical exam skills. I remember the days of medical school when were evaluated in this way. It definitely was awkward, for both the medical students and the “patient”, but it was greatly appreciated. She shares some interesting stories in this piece:

Over the course of three days recently, I had 23 head-to-toe physicals from 23 second-year students at the Georgetown School of Medicine. I was the first person these would-be doctors had ever fully examined on their own. Some were shaking so violently when they approached me with their otoscopes—the pointed device for looking in the ear—that I feared an imminent lobotomy. Some were certain about the location of my organs, but were stymied by the mechanics of my hospital gown and drape. And a few were so polished and confident that they could be dropped midseason into Grey’s Anatomy.

Georgetown allowed me to be a “standardized patient”—that is, a trained person who is paid $15 an hour to be poked and prodded by inexperienced fingers, so that med students can learn communication and examination skills before they are sicced on actual sick people…

The concept of the standardized patient has been around for decades, but only in recent years have medical schools made training with them a regular part of their curriculum. I talked to a 50-ish physician friend about my experiences, and he said when he was in medical school and it was time for the first rectal/genital exam, the students were told to pair off and examine each other. “So, do you pick someone you like, or someone you don’t like?” he recalled. “Either way, it’s lose-lose.”

Now there are standardized patients trained for genital duty (they’re called GUTAs, for genitourinary teaching associates), but I signed up for something less invasive. Mine was the simplest possible assignment. I was to sit on the edge of a padded table in one of those awful, flapping hospital gowns, in a room equipped with recording devices in the ceiling. Each doctor had 30 minutes to conduct a standard head-to-toe physical: from my vital signs, to my nerve function, to my reflexes, etc. Then I was to go to a computer and check off whether they’d done all 45 parts of the exam (“Palpated for fremitus,” “Auscultated carotids”), and write my comments on their bedside manner…

Oh, it gets better. Check out the rest of her piece. Any thoughts on this concept of standardized patients? Any embarassing stories folks have to share?