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Tuesday, May 31, 2005

Reason To Consider Opthalmology

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From Grand Canyon National Park

Quality of Care

Trying to understand and anticipate where medicine and the business of medicine will be in four years when I graduate or 3 or 7 or 11 years when my residencies are complete is difficult. The fact is just from the experiences I have had I almost certainly understand the current state of medicine (both private and academic) better than the majority of medical students matriculating this fall. Yet the fact remains I'm not a doctor. Yet :)

As such my view is limited, and so some of my favorite posts from the blogs I read involve discussions of business issues on which I'm fairly naive.

Medrants has dedicated significant time not just bemoaning and discussing the state of medicine as a business but also looking at the reality of the future and opining on ways that doctors can prepare for it and change with the times.

Two topics I have enjoyed and which he has discussed at length are pay discrepancies between specialties and how it effects residency choices for med students and pay-for-performance in which physicians who meet certain quality indicators and have better patient outcomes may receive better compensation. In the post above he discusses the problems with defining what shape and form these quality indicators will take in the future.

The Uninsured & Universal Healthcare: Support (Part 2)

In this second post on the uninsured and the potential for universal healthcare, I discuss the pragmatic realities of our current healthcare system, other countries' universal healthcare systems, and the incredible lack of understanding amongst the American populace about the differences.

I will not try to sugar coat the first issue, despite my opposition to universal health coverage. Study after study has concluded that the uninsured do not receive the same standard of care in this country as the insured do. Emergency care is obviously available, but ERs and county hospitals are poor treatment centers for chronic illnesses and the likes which, along with un- or late diagnosed major diseases such as hypertension and cancer, account for the increase in mortality seen from the insured to the uninsured.

Here is an article on an Institute of Medicine study on the issue.

What is surprising is that, in surveys, the majority of Americans with insurance believe that the uninsured receive healthcare similar to them in the form of 'safety-net' features such as county ERs.

Still, despite this perception, support for a universal healthcare system continues to grow, fueled largely by the increasing costs of medical care. Some polls such as this ABC/Washington Post poll from 2000, have found support for a single payer government run healthcare plan based off the Medicare model at above 60%.

This support, as ABC notes, is conditional, dropping below 40% if waitinglists for non-emergency care are part of the new universal healthcare system. They almost certainly would be.

Despite this apparent dissatisfaction with having to wait for care under a universal healthcare system, a plurality of Americans (nearly 40% in this ABC/Washington Post poll) think that Canada's healthcare system is better than the United State's. This despite the Canada's incredible notoriety (like with most universal healthcare systems) concerning waiting times for care and doctor patient ratios.

In my mind, Americans seem to put a premium on the timeliness (and thus in some cases quality) of their care, but have little concept that both would most likely suffer in under universal healthcare. There are benefits for universal healthcare, it would raise the overall quality of healthcare for all by providing the currently uninsured with coverage. There are costs for universal healthcare as well, in terms of choice of providers and in the case of the performance of non-emergency procedures.

Tomorrow I throw out the most important arguments to consider when thinking about fixing the uninsured 'problem'. Is there an inalienable right to a certain standard of healthcare? Does such a right trump a right to property and privacy (if such rights exist)? What is the nature of government's responsibility to its citizens - equality or liberty? Can these two ideals be rectified or are they mutually exclusive?

All heady stuff, discussed forever by political philosophers far more competent than myself, but I'll try to put it into light concerning the current question of the uninsured and universal healthcare.

Economic Caps Deter Lawsuits

The debate over whether fewer lawsuits means cheaper malpractice premiums can continue. The debate over whether economic caps means fewer lawsuits now has more circumstantial evidence supporting the caps.

In Illinois:

Since legislative leaders announced a deal on caps last Wednesday, 58 medical malpractice lawsuits have been filed in Cook County -- three to four times the number normally filed
I suppose there's an argument that these are all legitimate med mal cases and that lawyers are being forced to file early, before their cases are fully prepared, if they hope to get the best compensation for their traumatized patients. It is of note however, that like Texas, upwards of 70% of Illinois med mal cases end without a trial and without a payment to the plaintiff. Here's a discussion of med mal cases in an Illinois county at Illinois Civil Justice League.

This fact is often used by trial lawyers to show that malpractice suits must not be responsible for the rise in malpractice premiums, if so many end without payment. What I believe it shows is a 'hit until it sticks' strategy. Civil attorneys can afford to take on four cases (no matter the legitimacy of any of them), knowing that only one of them will stick and get paid, because such a settlement, or less likely trial award, will be significant. Caps however will force attorneys to choose their cases more carefully as a 25 to 15% success rate will not longer be financially viable.

True, their criteria for choosing may not be ideal. It will likely remain that cases will be chosen often on their dramatic possibilities than on merit but it seems, in my opinion, that a drop in the total volume of med mal cases in Illinois will be seen soon.

With a h/t to Kevin, M.D.

Sunday, May 29, 2005

On Cue

Medrants has an extensive quote from a New York Times article (subscription service) on conservatives and liberals working together to try and fix the uninsured "problem".

As I've already started discussing, just how big of a problem this actually is, is up for debate. As I will opine later, the view that it is right or necessary for the government to try to fix this "problem," should never be as implicit and accepted as it is in pieces like Medrants' comments on the New York Times article. That's a utopian libertarian view I suppose :)

Los Angeles

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For all my complaints about my four years living in Los Angeles; I already miss it.

The Uninsured & Universal Healthcare: The figures (Part 1)

The issue of the millions of uninsured Americans and the most vocalized solution to the situation (further government subsidization of health care, which in some people's opinions should carry to government guaranteed universal healthcare) really consist of two distinct issues, like so many political problems.

There is the pragmatic side of the problem, which I have broken down into two posts. This is the first. Then, there is the political philosophy of the issue, which I'll lay out in the third post.

The side talked about in this post consists of the debatable figures and costs and questions about the uninsured in this country. For all the nitpicking over it, this isn't really at the heart of the issue (at least for me), but there are some facts and figures that should be mentioned. Proponents of universal healthcare often quotes a census bureau figure from 2003 which put the number of uninsured at over 43 million.

This number has been overstated and corrected figures as reported by nonpartisan research groups here and here drop the number of uninsured in this country to 36 or perhaps 37 million.

Even this number however needs to be understood. This is a slice of the 280 million Americans, who at any point in the last year did not have health insurance. The debate over the number of people who go an entire year without health insurance is more muddy. To report the facts, the highest estimate I've seen is about 30 million. The lowest estimate is 19 million.

The other question, beyond the size of the uninsured problem, is just who these people are. There is a conservative, yet plausible and intelligent, argument that many of these uninsured fall into two distinct classes that are not the concern of the federal government. The first group consists of people of resources who make the choice to simply not pay for insurance. Such people may include a large number of university students who appear on the uninsured rolls and the middle class self employed, or those whose companies don't provide insurance, who have the resources for health insurance but choose to spend the money on other things. Figures for how many such people appear on the rolls is debatable but surely they account for millions of at least the 36 million Americans who didn't have insurance at some point in the past year.

The other group that conservatives bring out to argue that roll of the uninsured is inflated is illegal immigrants. Surprisingly, uninsured estimates include such people. Now, a sound estimate of the number of illegal immigrants in this country is probably between 9 and 11 million. I imagine its safe to assume well over a majority of these individuals lack health insurance. There is some evidence for such.

Not even most proponents of universal healthcare deny that non-citizens (both legal and illegal immigrants) account for between 40 and 45% of the nation's uninsured, obviously far beyond their representation as a percentage of the population as a whole. As well, the problem appears to be persistent amongst both legal and illegal immigrants. A study of legal immigrants who entered in the 1980s found that by 1998, nearly 30 years after some of them had entered, almost 40% of them had never acquired health insurance. This may raise all sorts of issues about the economic equality and opportunities afforded to legal immigrants, and may indeed be an argument in and of itself for socialized medicine. However, it is of note that natural born citizens faired better over the same time period in procuring health insurance. It seems reasonable to assume that illegal immigrants would fare even worse in acquiring health insurance.

It appears reasonable that illegal immigrants would also be more likely to appear amongst the most risk situated individuals in the debate; the 19 million who have failed to acquire health insurance in the past 12 months. To be conservative, let us imagine the number of illegal immigrants in this country is on the low end of estimates at 9 million and that only 50% of them have gone the past 12 months without insurance (although it seems likely that the number would be much higher). Under such circumstances it may be that only 14 or 15 million legal immigrants and American citizens went without health insurance over the past twelve months. That's approximately five percent of the population.

We're working under the implicit understanding that this, and all nations, exist to provide protection and services for their citizens and legal aliens. I will not even take the time to offer a response to those who would argue that full non-emergent healthcare is a government responsibility for those who enter this country illegally.

From a pragmatic standpoint consider that as it stands the government already reimburses hospitals for the 1.5 billion a year they spend treating emergency cases involving uninsured illegal immigrants. This is money taken from the Medicare budget. As Rep. Dana Rohrabacher points out, so eloquently, "[taking money from] the American people and legal residents in order to provide a health-care system for people who come here illegally is the most stupid thing I can think of."

More on the impact of immigrants on the uninsured debate can be found at Marginal Revolution.

I've tried here to show that a large portion of the 36 million uninsured, who are quoted, are really without significant risk. That's a vague undefined term. I'm sure that term, "significant risk", and even the figures cited here, can be effectively debated by intelligent proponents of socialized medicine (there actually are some). The real fact however, is that 14 million people is still a lot. Indeed, one person who gets seriously ill without health insurance is a problem. And so, the debate continues.

Tomorrow, I talk about the view amongst the general public that the uninsured are provided care by 'safety-net' features (such as the 1.5 billion spent treating illegal immigrant health emergencies). Researchers at Harvard Medical School said that view was faulty in 2000 and so did the Institute of Medicine in 2002.

Friday, May 27, 2005

Government?

AMSA On Malpractice Reform

I've been told, and have no doubt, that come orientation and the first week of medical school I will be barraged with opportunities to join a stream of clubs, organizations, and groups. One of the chief amongst them is the American Medical Student Association, a link for which can be found on the sidebar.

This is a highly politicized group with a loud voice concerning its nearly socialist agenda for the future of healthcare.

You must give the AMSA credit, it has grown to be the largest representative organization of medical students, while making no secret of its liberal activism. However, here's their take on malpractice reform in this country.

There is plenty of opinion and chatter on the subject of medical malpractice reform. But, amongst the real research and figures, there is a wide debate about the viability of medical malpractice caps to stop the rise in malpractice insurance premiums in this country. What is almost universal, amongst legitimate publications, is the high percentage of lawsuits which are frivolous.

For instance, in Texas in between 1994 and 2000, 85% of all med mal lawsuits were closed without a payment to the plaintiff.

This may certainly look like a good thing, yet even when such cases result in no award or settlement they require physician time. This is time away from patient care, from earning.

The AMSA's proposal to reduce medical errors by no fault reporting and better communication are very noble but they're not solutions to the medical malpractice problems. Not after seeing how many cases that are brought involve no medical error in the first place.

Introduction

I am a film student who decided he was called to go to medical school.

This is my second attempt at a blog.

I consider my three month experiment with blogging earlier this year as a learning experience. Yet, the subject matter is the same as the blog that proceeded this one. Their was an evolution process for the content of my previous blog and I feel that because of that the intent of this blog is pretty set.

I've basically tried to cover three major areas --

First, I've lent an extremely libertarian view to political issues facing all of medicine. I spent significant time talking about the strain of illegal immigration on border region healthcare, the case against universal healthcare, and the need to keep government regulation from limiting doctor and patient decisions.

Second, I've tried to provide links and commentary on academic medicine, the med school admission process, and changes in such.

Finally, and this will emerge as the start of my first year draws nearer and nearer, I'd like to give some insight into the, probably fairly boring, day to day experiences of a first year medical student.

Sunday, May 01, 2005

Signature






Quotes

Doctor,
if only you could see
how heaven pulls earth
into its arms
and how infinitely
the heart expands
to claim this world
-- Lisel Mueller

"Stereotyped movements, such as standing and walking, are preprogrammed within the spinal cord's gray matter. This frees up our cerebrums to do those things which it does best, such as writing sonatas and inventing lite beer ad commercials."
-- Frank Vertosick

"It's only hubris if I fail."
-- Rome

"You can't stop Brian Scalabrine, you can only hope to contain him."
-- Charles Barkley

"I'm just disappointed for my fans...I feel like I let my guys down, let my family down, let the whole cities of Austin and Houston down...I'm still upset [about losing the Heisman]."
-- Vince Young

"The least of learning is done in the classrooms."
-- Thomas Merton

"There is no worse tyranny than to force a man to pay for what he does not want merely because you think it may be good for him."
-- Robert A. Heinlein

"Turn the world over on its side and everything loose will land in Los Angeles."
-- Frank Lloyd Wright

"Aging is the process or processes that increase the incidence of dysfunction and disease and mortality with advancing chronologogical age."

"If all else fails, immortality can be assured by spectacular error."
-- John Kenneth Galbraith

"The advantage of a classical education is that it enables you to despise the wealth that it prevents you from achieving."
-- Russell Green

"I once thought I had mono for an entire year. Turns out I was just really bored."

"Eventually all bleeding stops."

"Be careful about reading health books. You may die of a misprint."
-- Mark Twain

"I was under the care of a couple of medical students who couldn't diagnose a decapitation."
-- Jeffrey Bernard

"The greatest mistake in the treatment of diseases is that there are physicians for the body and physicians for the soul, although the two cannot be separated."
-- Plato

"Success is the ability to go from one failure to another with no loss of enthusiams."
-- Winston Churchill

"The American rights impose no obligations on other people, merely the negative obligation to leave you alone."
-- Leonard Peikoff

"
God heals and the Doctor takes the fee."
-- Benjamin Franklin

"Somewhere, something is waiting to be known."
-- Carl Sagan

"The nicest thing about quotes is that they give us a nodding acquaintance with the originator which is often socially impressive."
-- Kenneth Williams

"[Referee Dick] Bavetta should donate his paycheck for that game to a charity for the blind. That is how poorly called that game was."
-- On Spurs v. Kings

"You will find that the State is the kind of organization which, though it does big things badly, does small things badly, too."
-- John Kenneth Galbraith

"After a year in therapy my psychiatrist said, 'Well, maybe life isn't for everyone'."
-- Larry Brown

"The less people know about how sausages and laws are made, the better they'll sleep at night."
-- Otto Von Bismark

"For the first time in three games [Dirk Nowitzki] doesn't get the call."
-- Steve Kerr, on terrible officiating in the 2006 Spurs - Mavericks Playoff Series

"Cuban has become the equivalent of a poorly dressed youth-league dad who spends an entire hour screaming 'Three seconds!' "
-- Randy Hill


"Win as if you were used to it, lose as if you enjoyed it for a change."
-- Ralph Waldo Emerson


"In teaching the medical student the primary requisite is to keep him awake."
-- Chavalier Jackson

"I don't believe in a government that protects us from ourselves."
-- Ronald Reagan

"It's about as easy is sticking a cooked noodle up a skunk's ass."
-- Pharmacology Prof.

"Statistics are people with the tears wiped from their eyes."
-- Anonymous


"If you are distressed by anything external, the pain is not due to the thing itself, but to your estimate of it; and this you have the power to revoke at any moment."
-- Marcus Aurelius