While at Ben Taub, every patient I had (regardless of what they were admitted for) was started on a proton pump inhibitor (PPI) for “prophylaxis against stress ulcers.” I can imagine this being important in patients who, for example, cannot protect their airway and are consequently at risk for aspiration; however, in a patient with an easily treated lower extremity cellulitis, there’s just no need. At St. Luke’s, we routinely start patients (who can tolerate po intake) with peptic ulcer disease on IV Protonix and then transition over to oral Protonix at discharge. Why is this a big deal? Two reasons: a.) the IV and po (oral) forms essentially have the same efficacy, and b.) IV Protonix costs well over 10x as much as oral Protonix. Just in the context of PPIs, imagine how much we’re wasting… each day… per patient.

Another example that my attending and I were discussing earlier today – if you’re doing an upper GI endoscopy or colonoscopy and happen to stumble on an incidental finding (ie, a polyp), go ahead and biopsy!! It takes two seconds and spares the patient the trouble of having to be a.) readmitted to the hospital, b.) prepped for the procedure, and c.) risk the dangers of not catching a diagnosis early. In this case, the additional expense is well justified, and if anything, the patient’s long-term treatment is more efficient.

These are just two minor examples of how we’re constantly wasting health care resources on a daily basis. As the next generation of health care providers, medical students need to focus on understanding that patients are stabilized in the hospital, but actually recover at home. In the next decade, the health care system won’t be able to afford keeping patients in the hospital for extra days to be monitored or await further work-up. Efficiency goes a long, long way in this “health care reform.” In the end, whatever provisions Capitol Hill generates will pail in comparison to a physician’s ability to conscientiously plan the treatment of his or her patients every single day.

Obama’s administration enacted sweeping health care reforms last year, causing both unprecedented controversy and great waves of international acclaim. There has been a wealth of political jargon and inaccurate generalizations regarding the changes. Some call it socialized medicine, a step towards the left the debt-ridden United States can’t afford to take. Supporters, on the other hand, identify the overhaul as a solid step toward eliminating poverty. Both of these common generalizations go a bit too far. More importantly, does it even matter? The law stands to be overturned by the Supreme Court, as many states overwhelmingly file suits against the federal government. Governors and state officials of NINETEEN states claim the reforms overstep the authority of Congress. They want Supreme Court to step in to tell the current administration: It is unconstitutional to make all Americans buy health insurance by 2014. Do you think it is?

As a medical student, are you unsure what this means for your future? Should you be glad more people will get coverage under the umbrella of new reforms? After all, doesn’t the Hippocratic Oath bestow you with numerous obligations towards your fellow human beings? The bill does promote preventative care one of the most important components of the Hippocratic Oath. WAIT, how does this affect your salary? This is a PROFESSION, and you should be rewarded accordingly for all your work just like any other field.

If you’re a first or second year medical student, how can you be expected to sift through all that information? The bill and its addendums take up thousands of pages! The truth is: both parties are trying to address valid concerns. The reforms do try to provide affordable insurance coverage to all Americans, but at some cost to personal choice.  Your opinion on the reforms may be closely related to your views regarding the appropriate degree of government intervention in the lives of citizens. Should governments intervene to make health care accessible to more citizens? If something is beneficial for citizens, should governments force citizens to partake in that practice (in this case, buying health insurance)?  Here are some major changes that may affect your life as a future physician.

You’ll be treating more people who are terminally ill

The bill makes it illegal for insurance companies to deny coverage to patients with preexisting conditions. This may be costly for insurance companies, but many who can’t afford treatment (because they are denied coverage) may finally get the medical help they need.

Potentially Higher Overhead Costs

Medicare will be expanded to provide preventative check-ups WITHOUT co-pays. There are a number of changes that affect Medicare without appropriate funds. This may increase costs of operating for physicians which may be accounted for through higher physician fees.

Uniform Information Exchange

This could help you tremendously when you get new patients. New insurance plans make it mandatory to have uniform system to exchange health information. You won’t have to worry about different systems used by different companies.

Your Patients will Face Penalties for not Purchasing Health Insurance by 2014

This is probably the most controversial component of the health care bill. In 2014, if you don’t have insurance, you’ll be forced to pay a fine. This amount increases if you refuse to purchase insurance by 2016. You’ll have to pay an additional tax (a % of your income). The idea is to increase the pool of insurance plans to make health insurance affordable. Numerous competing plans are supposed to equal out the forces of supply and demand.

Dear Mr. President:
During my shift in the Emergency Room last night, I had the pleasure of evaluating a patient whose smile revealed an expensive shiny gold tooth, whose body was adorned with a wide assortment of elaborate and costly tattoos, who wore a very expensive brand of tennis shoes and who chatted on a new cellular telephone equipped with a popular R&B ringtone.

While glancing over her patient chart, I happened to notice that her payer status was listed as “Medicaid”! During my examination of her, the patient informed me that she smokes more than one pack of cigarettes every day, eats only at fast-food take-outs, and somehow still has money to buy pretzels and beer. And, you and our Congress expect me to pay for this woman’s health care? I contend that our nation’s “health care crisis” is not the result of a shortage of quality hospitals, doctors or nurses. Rather, it is the result of a “crisis of culture” a culture in which it is perfectly acceptable to spend money on luxuries and vices while refusing to take care of one’s self or, heaven forbid, purchase health insurance. It is a culture based in the irresponsible credo that “I can do whatever I want to because someone else will always take care of me”. Once you fix this “culture crisis” that rewards irresponsibility and dependency, you’ll be amazed at how quickly our nation’s health care difficulties will disappear.

Respectfully,
ROGER STARNER JONES, MD

Very well said, Dr. Jones. Now I wonder what “change we need” to address one of the real reasons for our health care system’s corruption.

One of last week’s behavioral science lecturers put forth a hypothetical scenario – when a patient sits in front of you, musters up his or her case, and tries to sway you to their end of the doctor-patient relationship, listen to your gut feeling. If your conscience tells you that “this isn’t right” or you’re just not comfortable with the situation, don’t continue to treat. Every patient deserves a physician who can adhere to the finest standard of healthcare, and if you can’t provide it, there’s nothing wrong in referring the patient elsewhere.

So what if this patient is a member of your family or a close friend? Are you obligated to treat, should you avoid the case entirely, or is it a toss-up?

I imagine most physicians prefer not to treat people they’re closely acquainted with for various reasons:

• Scared they might mess up and jeopardize the relationship.
• Might cause other family members to also seek help.
• Relationship might interfere with medical judgment and ethics due to inherent bias.

I’ve always been the other way. If I’m a specialist in some field ‘X’, and a loved one needs to see someone with ‘X’ training, I want to be the physician in the room. I really don’t intend to sound arrogant, but I just wouldn’t trust anyone else in this case. Yes, there’s the possibility that I could kill a loved one, but it’s a decision that, at the current time, I can see myself still making. Though this could change once I actually start practicing, I think that having a family member’s well being in the hands of another family member is the best situation… for both parties. Again, this is just my humble, first-year medical student opinion and by no means do I wish to sound arrogant.

Primary care physicians, on average, get paid less than their specialist counterparts while many work just as many hours. Sure, the residency programs are shorter, but when it comes down to paying off debt accumulated throughout college and medical school… a cosy salary really helps. Plus, one approach to resolving the healthcare system’s growing costs is to place primary care physicians as the “first stop” for patients, so it should be an important focus for the government.

The chart above shows how we’re not the only country facing this problem (though we do have a considerable lead). With a growing population and progressively longer life expectancy, healthcare will continue to consume a large portion of our GDP. No one really knows how much wasteful spending is built into our national budget, but Washington really needs to tighten the rope and do something… fast.

Primary care has never crossed my mind as a career possibility as I’ve been set on neurosurgery for quite some time. Surprisingly, this inclination towards specialty residencies is shared by the overwhelming majority of my class, and in comparison to previous years, the number of residents in primary care is gradually dwindling. The New York Times published a fantastic article addressing this very issue which I highly recommend.

Now let’s consider a hypothetical scenario. You wake up one morning with unbearable pain localized to your upper left abdominal quadrant (stomach region). You’ve got two logical choices: visit a gastroenterologist (specialist) or your regular physician (primary care). You end up choosing the gastroenterologist because, after all, he/she has been trained to deal with abdominal symptoms for years. After a plethora of expensive tests, you’re diagnosed with a mild case of stomach poisoning. What if the primary care physician could have told you this same diagnosis for less than half the cost?

A few observations can derived from this:

• The specialist had to take time to examine a relatively simple case.
• The patient (and insurance companies) had to spend more than required.
• The primary care physician could have made this diagnosis… probably with less time spent scheduling an appointment.

An interesting proposition made during the presentation was using primary care physicians (PCPs) as a buffer between patients and specialists. In other words, a patient would always present to a PCP and then, if necessary, be referred to a specialist.

This suggestion implies that without an increase in PCPs, the current generation will be working extended hours to meet the increased patient inflow. At this point, an inevitable question must be brought up – how do we adjust physician salaries? The two students argued in favor of increasing PCP salaries (currently, one of the lowest paid physician salaries) while simultaneously decreasing specialist salaries. I’m under the impression that some specialists wouldn’t have been specialists if it wasn’t for the cozy paycheck, but in any case, we have to consider several factors.

• Specialists receive more training (and accumulate more debt)
• Specialists tend to deal with more risky cases (higher malpractice)
• Both specialists and PCPs tend to work roughly the same number of hours

Reducing the compensatory gap between specialists and PCPs is a touchy subject indeed, but what better incentive to attract aspiring medical students towards primary care than an increased salary? Why not focus on primary care physicians to lower healthcare costs from the get go – the patient coming in for treatment?

I really have no fair argument for or against this, but I thought it was an interesting perspective which I had never thought about before. Hence, a blog post.