Health Reform Update: Baucus releases the new bill!

2 Quick Updates,

First, on Health Care Reform:

Senator Baucus just released the new bill with more than 500 amendments (including all of the ones offered by Senator Snow, potentially the only Republican who will vote for it). The bill purportedly includes an amendment to cut the fine for not having health insurance, and increases the threshold for taxation of high cost insurance plans (tax to insurer, not person). These changes were made to try to increase affordability for low- and middle income people. The mandate still stands and is unlikely (and hopefully) not something that the Committee will budge on. Like Speaker Pelosi has (and many others have) said, we need to make sure everyone is included so that the risk is dispersed among all of us.

Read more at the NPR Health Blog and from the Wall Street Journal article.

Thoughts on health reform that have come up in recent conversations (and aren't really being addressed by this bill...yet):

- should people with expensive-to-treat illnesses have to pay more for health insurance (e.g. someone with cystic fibrosis or type 2 diabetes, who is much more likely to use the services of a hospital)

-Does it make a difference if the illness is hereditary, accidental, or behavior-related? (Type 2 diabetes from obesity v. type 1 diabetes, which is hereditary; or cystic fibrosis, which is inherited, versus cancers from smoking?)

-Should we be able to tax behaviors, such as drinking pop (aka soda, if you're not from the midwest), smoking, alcohol, even fast food - to pay for health care to try to compensate for these costs?

-For the economists out there: would they ever actually compensate for the costs of these behaviors to the health care system?



Second update on med students and lack of professionalism:

We physicians-in-training are not doing a great job of assuring our future patients that we are worth trusting. JAMA just released a paper citing a huge lack of online decorum by medical students. This may seem like nothing compared with the very public trial earlier in the year for a second year medical student at BU who was arrested for murders of women who he met on Craigslist (read more on Boston Globe website)

We had a lot of lectures during orientation and our first block about professionalism - and while many of the topics discussed could seem minor compared to the vast amount of scientific knowledge we're trying to learn - I think it may be the most important.

One of our greatest professors here said that his friend's father was a physician and every time he would leave the house, he would put on a tie. He said that there was always a chance he would run into a previous patient, a current patient, or a future patient - and he wanted them to know that there doctor took his profession seriously. I clearly won't be wearing a tie every time I leave my house (in fact, I'm just embracing wearing jeans again), I do think that you are allowed to have higher expectations for someone to whom you are telling your most intimate life details, who you are letting examine your naked body, and who you are trusting to help you make the best decisions you can about your health.

That said, medical school is quite hard - and incredibly time consuming. The commitment that the path to medicine requires is near total and by embarking on it, you are choosing to have less free time for people and fun - which is not to excuse these students but to provide a framework for understanding the need for a comedic release. But no one tells you medical school will be easy - if anything, they tell you it will be the hardest thing you have done yet. As medical students and future physicians, we really have to consider that even though it may be an arduous path, if we want our patients to trust us, if we want society to continue to hold doctors on such high moral ground, we have to honor this profession, tie or no tie.


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“The greater danger for most of us lies not in setting our aim too high and falling short; but in setting our aim too low, and achieving our mark.”
-Michaelangelo

infections and wrinkles

random thing I learned today (and maybe this is more common knowledge than I thought):

botulism, like the bacteria you're worried about getting from your canned goods that aren't acidic enough, is caused by a bacteria called Clostridium botulinum. But that's not the exciting part - how the bacteria works is by infecting your neuro-muscular junctions (the parts of your body where nerves connect to muscle to stimulate them to flex). When it infects these junctions, it inhibits the release of a neurotransmitter, called Acetylcholinase (it's like, THE neurotransmitter). This prevents any signaling from the neurotransmitter to the muscle, so the muscle cannot be enervated - or flex.

Horrible infection that causes breathing problems and often requires hospitalization with insertion of all sorts of breathing machines, feeding tubes, etc. If you suspect you have Botulism - call your doctor or go to the ER - type stuff. Treatment is with an antitoxin that kills the bacteria and reverses the symptoms.

BUT! (this is the crazy part) the bacteria are exactly what are used in Botox - like the thing you inject into your forehead to prevent wrinkles. In fact, Bo-tox stands for "botulism toxin". Apparently all over the US and world people are injecting toxic bacteria that inhibit neuromuscular junctions INTO THEIR FACES to prevent their facial muscles from flexing into positions that could cause them wrinkles. This explains why the risks of Botox include that you may hit a neuromuscular junction that matters - and get a droopy eye or something. Lucky for people interested in Botox, the effects don't last very long at the concentration given. So if you get a droopy eye it will only be for about four to six months. WHAT?!?!

I guess I haven't thought much about reducing the signs of aging. I've had a wrinkle on my forehead since I started reading, and I kinda dig it. But maybe I'll feel differently in a few decades...

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"I wonder if I can grow fangs when my baby teeth fall out"
-Bill Waterson in Calvin and Hobbes

The Evolutionary Advantage of Microbes

Right now we're working on the fastest biochem review in the history of the world. Okay, so maybe not in the history of the world, but definitely in my world. As a class, I think although we have times of being really frustrated, we're all nerdy enough that learning about bacteria, viruses, and protein misfolding is really really cool. One of our professors who has been teaching us about different types of pathogens answered a question posed by a classmate the other day, about WHY something happened with: "Instead of asking "Why" in science, which is very hard to answer - ask "What is the evolutionary advantage of this..." and I just totally dug it.

Antibacterial medication is now super common because we discovered (totally by accident - see: Alexander Fleming and look under "accidental discovery")that because bacteria had been competing amongst themselves for food, space, and other supplies, they (and plants and fungi) had developed nasty ways of getting rid of each other. But then evolution skipped right past super helpful to somewhat harmful - this getting rid of each other resulted in the selection of bacteria who were resistant to some of these defenses, thereby introducing resistance to antibacterials. It's not that bacteria are super smart...at all. It's just that there are so many of them, that they can naturally select for THE MOST ADVANTAGEOUS traits - even if there's only a one in a million chance of a certain gene being incorporated in a certain place, because there are probably one million bacteria on my body right now (and yours).

While I still am anxiously awaiting our anatomy labs - learning about pathogens and how they evade even our best scientific knowledge is pretty fascinating.

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“I have been trying to point out that in our lives chance may have an astonishing influence and, if I may offer advice to the young laboratory worker, it would be this - never to neglect an extraordinary appearance or happening.”
-Alexander Fleming

What happens when a physician is addicted?

today we talked all about physicians who are addicted to different substances. We're learning about ethics, study design, public health and genetics - so we first read a few papers about an outbreak of a hospital infection in a surgical ICU that was most likely caused by one of the employees tampering with the fentanyl (a type of synthetic opiod) of patients who were acutely ill post-surgery in order to take some and use it. So we got to learn about how you study outbreaks (infection all over the surgical ICU), talk about how you deal with infection (public health), about whether we hold physicians to a different standard when it comes to drug abuse - and if so, why? (ethics), and then about addiction as an illness (genetics).

So suffice it to say, my mind is spinning. I also have my first exam on Friday (eek) so I'm trying to transform myself into a studying machine. I still feel pretty human so far, but here's hoping.

So what we should do for physicians who are addicts? Do we treat them differently than anyone else? In class, we read an excerpt from Abraham Verghese (a physician/writer)'s book, The Tennis Partner, which talks about him playing tennis with a fellow physician and the relationship that forms between them. Dr. Verghese ends up confiding in his tennis partner about his failing marriage, and his tennis partner confides in him all about his addiction to cocaine. Ultimately, the tennis partner gets addicted to perscription drugs and Dr. Verghese has to decide wha the best form of intervention is.

He thinks along the lines of: a physician is worth so much to society that we shouldn't put him in jail; plus rates of recovery from addiction are much higher in physicians than in other professions - potentially because they have more to lose by not recovering. He also thinks: this guy can't be treating patients when he needs to be a patient himself.

Thoughts? Here's a link to an interview with a doctor who treats addicted physicians for more background: http://www.physiciansnews.com/spotlight/397wp.html

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"just because you got the monkey off your back doesn't mean the circus has left town"
-George Carlin (about addiction)

Health Care Reform: Simplify

There are two major questions to health care reform:

1) How do we reform how we pay for health care? The goal of this reform is to make health care affordable for patients, to make sure health care workers are getting reimbursed fairly, and to figure out a way for our government to help subsidize this type of system without increasing our national debt too much.

2) How do we reform how we provide health care? The goal of this is to make health care better. This means putting best practices into effect so that patients everywhere can benefit from them. It means

But like any good market system, systems reform is inextricably tied to financial reform - and a good health care reform plan must address both.

I would like to draw attention to two articles, each focusing on one of these questions while simultaneously showing that the two questions are inter-related and any real reform must take into account.


First, a column in the New York Times Economix Blog by Princeton Economist Uwe Reinhart. Professor Reinhart divides the reforms proposed into those aimed at the supply side (health care provision) and those for the demand side - because yes, he's an ecomonist. He argues for the increased use of electronic medical records and other measures to increase efficiency, but his focus is on how to create the pool of people who will be insured. He says that a good system must include everyone, regardless of their health condition and whether they want to opt into health insurance - so a mandate for insurance companies to accept everyone and a mandate that everyone purchase at least basic insurance. He also admits that even the most basic insurance may not be affordable for many families (especially in the current economy) and that subsidies must be made available - assuring that everyone is in the insurance pool.



The second article is by one of my favorite physician/writers, Atul Gawande in the New Yorker. Dr. Gawande examines the differences between some areas of the country where health care costs are absurd versus areas of the country where they are virtually under control - and finds that in the areas where we spend more money, care is actually worse. The themes in the places where patients receive incredible care AND health care spending is under control seem to have in common several key characteristics including: doctors worked more as a team than as separate entities, there was more of a divide between physicians and expensive procedures (as in, they didn't own the machines that did the scans), agreements about charging similar fees regardless of insurance (so there's no incentive to see the patient with private health insurance over the person with medicaid), and many hospital-wide electronic medical records.

These articles are encouraging in that, from an economics perspective and a practical perspective, they break down health reform from confusing seemingly impossible ideas to concrete - dare I say, logical? - policies that we can and should implement.


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"The lesson of the high-quality, low-cost communities is that someone has to be accountable for the totality of care. Otherwise, you get a system that has no brakes." -Atul Gawande, MD MPH in the new yorker article referenced above

Atul Gawande's Five Rules of Medicine

Now I'm over a week into medical school - which sounds so short, I'm sure - but when I think of all the things that have entered my consciousness and been mulled over in my mind as I talk with friends and family, as I go on runs by the lake, and even while I sleep - it seems like a whole lot.

It's such a different experience to be in class learning only about things that are directly applicable (or could be) to what you will be doing for the rest of your life. And more importantly, perhaps, they're things you will be expected to know - by your colleagues, patients, and the world. It's enough to make me feel like studying all the time isn't too much.

They say that after four years of medical school, students change their reasons for becoming a doctor, change their ideas of what is required of a physician, and try to figure out ways to avoid patient contact, when that's why they went to medical school in the first place. I am pledging that I will do everything I can to remind myself of why I want to join the ranks of this honorable profession - through sleepless months and difficult patients. My reasons for becoming a doctor are because I think it is the best role in which I can serve society - and I never want to forget that.

Atul Gawande, MD MPH, one of my favorite doctor/writers (Che Guavera is another, read Motorcycle Diaries if you ever get the chance), has 5 rules he recommends to new medical students, and by which I am trying to live as a I go through the beginnings of this process:
1) ask an unscripted question (he attributes this to the writer Paul Auster)
2) don't whine
3) count something
4) write something
5) change.

Surely we can all try to do that.

A link to the full text of the graduation speech here.

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You are in this profession as a calling, not as a business; as a calling which exacts from you at every turn self-sacrifice, devotion, love and tenderness to your fellow-men. Once you get down to a purely business level, your influence is gone and the true light of your life is dimmed. You must work in the missionary sprit with a breadth of charity that raises you far above the petty jealousies of life.
-William Osler, MD