Preventive Medicine

In the past, I have mentioned that one of the keys to fixing our healthcare system, and more importantly improve people's quality of life, is preventive medicine. I thought it might be good to share what preventive medicine means to me.

As an exercise science major I have studied extensively physical activity's profound impact on our overall health. In fact, increasing physical activity has a greater impact on overall health than any other lifestyle change. All-cause mortality is decreased by increasing physical fitness alone. This is a part of preventive medicine, but it doesn't stop there. Allow me to illustrate using a hypothetical example.

Let's say somebody has numerous gallstones which block the gallbladder and cause immense pain. This pain would lead that person to the doctor's office. The doctor assesses the situation and decides it would be best to surgically remove the gallbladder. This treatment alleviates the pain and the patient goes home happy right? Wrong. This type of medicine neglects the underlying lifestyle which caused the problem in the first place. Let's say that a major reason the gallstones formed was due to obesity. Obesity reduces the amount of bile salts in bile, thereby increasing the cholesterol content. Obesity also decreases gallbladder emptying. Now, the cause of the obesity is the person's high levels of stress, caused by their huge workload, lack of time to exercise, etc. Taking out the gallbladder still leaves the root cause untreated.

Another example is the man who comes into the emergency room with a broken arm. The doctor sets the arm in a cast and the arm heals perfectly. The patient is healed right? Well it turns out that the man has a drinking problem, he broke his arm because he was drunk and fell from his buddy's balcony. He comes into the ER a few months later with another drinking related injury.

Dr. Dan Schmidt shared another great story in one of my previous posts.

Essentially, a specialty doctor quick fixes many people's injuries, but too often the root causes go untreated. I don't really think a universal health care plan will fix this problem. How will free quick fixes give any more incentive for people to make lifestyle choices that will keep them out of the doctor's office to begin with? Preventive medicine helps people make these choices, choices such as controlling their diabetes, their weight, or their nutritional habits.

General practitioners are essential to providing this type of care. GPs see people over long periods of time. They are familiar with a patient's lifestyle and are able to better provide holistic care.

One of the things we need is more incentive for GPs to enter the medical field. Unfortunately, in the U. S., GPs make up only 13% of physicians available to help people. The U. S. is in dire need of this trend to change.

GPs make far less money than specialists and their work environment is far from ideal. Why would I choose primary care when I'll spend twenty years paying off student loans which are pretty much irrelevant to a specialist?

Obama has mentioned that he will help with primary care physicians' student loans. That would be great. Only with more primary care physicians can we really start treating the whole person, practice preventive medicine, and come up with a realistic health care system that is sustainable.

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Obama's Health Care (my optimistic skepticism)

I haven't blogged in quite a while. The time I usually spend blogging has been displaced recently by some really great books (see my updated book list to the right).

An issue on my mind these past few weeks, which I feel affects everyone (especially people in the health care professions), is health care.

Now, I don't claim to be an expert on public health, so keep in mind my thoughts are still being developed (in other words correct me on things you don't agree with). That is the main reason I blog, to develop my thoughts and build stronger opinions.

Obama says his new plan will cost one trillion dollars over the next ten years. He presents a plan as to how he will pay for it. I think this is all well thought out, and I was impressed by many of the ideas he presented. My first point of skepticism is that Obama seems to avoid explicitly stating that doctors will personally pay for a great deal of the new plan. How will this affect our health care system? Many know that to become a doctor takes way more work than it is worth (money wise), should we reduce this already meager motivating factor for quality people to pursue a career in medicine? I don't know.

Second, I think the unspoken truth behind Obama's plan is that having a public plan will create a monopoly, effectively getting rid of private insurers. How can a private insurance company, which complies to the rules and regulations the government puts on it, compete with a government option which makes its own rules? Again, I don't know.

That all said, I love that Obama recognizes the need for more primary care physicians. These are the physicians that get deep into debt in medical school and have trouble getting out. These are also the most important doctors when it comes to preventive medicine, in my opinion one of the most important keys to solving many of our health care problems.

I am glad Obama is aware of Gawande's article on health care. If you haven't read that yet, take some time to read it. I think the observations he made are crucial to understanding health care reform. Indeed his piece has changed the way I approach a solution.

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Universal Health Care

This weekend I will be studying various health care issues and posting short blurbs about them. The first one should be very familiar: Universal Health Care. Here's some thoughts:

Is health care a necessity or a luxury? Right now many consider it a luxury, one that requires sacrifice to obtain. People fear that if a universal health care system is put in place it may ruin the quality health care service provided to those fortunate enough to have health care insurance. Sure Medicare provides care for those over 65, and Medicaid for those in poverty, but has this ensured health care is available to anyone who needs it? With increasing health care costs many employers are cutting those benefits leaving many uninsured. When I am a doctor will I have to turn away sick people because they are uninsured, or will I be forced to perform an operation which will replace injury with debt and bankruptcy? Another drawback of the current system is that PPO’s and HMO’s limit the person’s access to health care. It’s not just a matter of will you receive health care, it’s a matter of where can I receive health care. The US system favors specialty doctors (secondary care physicians). This is represented by the portion of doctors that go into primary care (only 13% in the US, compare that to 66% in England). With more and more people not seeing a primary care physician (PCP) preventative medicine gets neglected, replaced by reactionary medicine. In England, the National Health Service (NHS) requires everyone to be screened by a PCP and then referred to a specialist. With everyone required to have their own general practitioner, people are better educated in preventative medicine for chronic diseases (improving health and saving tons of money). There are plenty of drawbacks to the English health care system as well, the most notorious being the long waits to see a doctor (months if not years). Unfortunately there is no direct study comparing the two systems, and until there is a fair conclusion cannot be made judging which provides better quality care.

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Many doctors plan to quit or cut back: survey

WASHINGTON (Reuters) – Primary care doctors in the United States feel overworked and nearly half plan to either cut back on how many patients they see or quit medicine entirely, according to a survey released on Tuesday.

And 60 percent of 12,000 general practice physicians found they would not recommend medicine as a career.

"The whole thing has spun out of control. I plan to retire early even though I still love seeing patients. The process has just become too burdensome," the Physicians' Foundation, which conducted the survey, quoted one of the doctors as saying.

The survey adds to building evidence that not enough internal medicine or family practice doctors are trained or practicing in the United States, although there are plenty of specialist physicians.

Health care reform is near the top of the list of priorities for both Congress and president-elect Barack Obama, and doctor's groups are lobbying for action to reduce their workload and hold the line on payments for treating Medicare, Medicaid and other patients with federal or state health insurance.

The Physicians' Foundation, founded in 2003 as part of a settlement in an anti-racketeering lawsuit among physicians, medical societies, and insurer Aetna, Inc., mailed surveys to 270,000 primary care doctors and 50,000 practicing specialists.

The 12,000 answers are considered representative of doctors as a whole, the group said, with a margin of error of about 1 percent. It found that 78 percent of those who answered believe there is a shortage of primary care doctors.

More than 90 percent said the time they devote to non-clinical paperwork has increased in the last three years and 63 percent said this has caused them to spend less time with each patient.

Eleven percent said they plan to retire and 13 percent said they plan to seek a job that removes them from active patient care. Twenty percent said they will cut back on patients seen and 10 percent plan to move to part-time work.

Seventy six percent of physicians said they are working at "full capacity" or "overextended and overworked".

Many of the health plans proposed by members of Congress, insurers and employers's groups, as well as Obama's, suggest that electronic medical records would go a long way to saving time and reducing costs.

CLICK HERE FOR SOURCE

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A Different Shade of Gladwell

So I decided since the last article I posted was 8 years old that I would see if Malcolm Gladwell has written more recently in regards to health care. He has and he's flip-flopped! He decided that his previous arguments made with Adam Gopnik were based on the money put into the health care system, i.e. funding problems rather than systemic problems. I really respect Malcolm Gladwell's opinion because his book The Tipping Point really changed the way I think. I want to post a link to his blog stating his current (still 3 years old) opinion on this issue. He says our government blocks any attempt to socialize our health care system (there have been about 6 attempts so far) because of what is called "moral hazard." The idea here is that if people have insurance for something they tend to use it more frivolously thereby adding inefficiency and waste to the current system. He disputes moral hazard using logic, case studies, and statistics. Here is a link to the post: The Moral Hazard Myth

Also, in response to my first post on SiCKO, my cousin Brad proposed the possibility of using an actuarial system analogous to car insurance to help move past our current dilemma. I thought that was a very novel idea. Gladwell addresses this idea. I thought what he said was interesting so I'll cut and paste it here:

"There is another way to organize insurance, however, and that is to make it actuarial. Car insurance, for instance, is actuarial. How much you pay is in large part a function of your individual situation and history: someone who drives a sports car and has received twenty speeding tickets in the past two years pays a much higher annual premium than a soccer mom with a minivan. In recent years, the private insurance industry in the United States has been moving toward the actuarial model, with profound consequences. The triumph of the actuarial model over the social-insurance model is the reason that companies unlucky enough to employ older, high-cost employees—like United Airlines—have run into such financial difficulty. It's the reason that automakers are increasingly moving their operations to Canada. It's the reason that small businesses that have one or two employees with serious illnesses suddenly face unmanageably high health-insurance premiums, and it's the reason that, in many states, people suffering from a potentially high-cost medical condition can't get anyone to insure them at all.

Health Savings Accounts represent the final, irrevocable step in the actuarial direction. If you are preoccupied with moral hazard, then you want people to pay for care with their own money, and, when you do that, the sick inevitably end up paying more than the healthy. And when you make people choose an insurance plan that fits their individual needs, those with significant medical problems will choose expensive health plans that cover lots of things, while those with few health problems will choose cheaper, bare-bones plans. The more expensive the comprehensive plans become, and the less expensive the bare-bones plans become, the more the very sick will cluster together at one end of the insurance spectrum, and the more the well will cluster together at the low-cost end. The days when the healthy twenty-five-year-old subsidizes the sixty-year-old with heart disease or diabetes are coming to an end. "The main effect of putting more of it on the consumer is to reduce the social redistributive element of insurance," the Stanford economist Victor Fuchs says. Health Savings Accounts are not a variant of universal health care. In their governing assumptions, they are the antithesis of universal health care.

The issue about what to do with the health-care system is sometimes presented as a technical argument about the merits of one kind of coverage over another or as an ideological argument about socialized versus private medicine. It is, instead, about a few very simple questions. Do you think that this kind of redistribution of risk is a good idea? Do you think that people whose genes predispose them to depression or cancer, or whose poverty complicates asthma or diabetes, or who get hit by a drunk driver, or who have to keep their mouths closed because their teeth are rotting ought to bear a greater share of the costs of their health care than those of us who are lucky enough to escape such misfortunes? In the rest of the industrialized world, it is assumed that the more equally and widely the burdens of illness are shared, the better off the population as a whole is likely to be. The reason the United States has forty-five million people without coverage is that its health-care policy is in the hands of people who disagree, and who regard health insurance not as the solution but as the problem."

Please respond with any additional insights, any differences in opinion, etc. and help move this discussion forward. I am still far from coming to any sort of conclusion on the matter.

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Positives of Our Health Care System

I just read a debate between Malcolm Gladwell (Tipping Point, Blink) and Adam Gopnik., both are writers for The New Yorker. Each has lived in Canada giving them first-hand experience with the system put in place there. I sided with Gladwell in this debate. He favors our system. This may seem inconsistent with my previous posts, but keep in mind I'm still molding my opinion. How I start thinking isn't always how I end up, I love that about learning :-). Anyway I'll cut and paste my favorite point Malcolm Gladwell made and link you all to the article which shows up in Washinton Monthly published in 2000 (sorry it's a little old, but still very relevant and insightful).


said Gladwell:
"If you look at the level of medical innovation in the world in the last 25 years, virtually everything comes from America. Absent America, medicine in the world is in the dark; it is retarded; it is at a level that all of us would find unacceptable. What is happening right now is that all these cheap single-payer systems are essentially poaching. They are cherry-picking off the American system. The American system is pumping money into research, has got this free market system which is incredibly dynamic and incredibly innovative. Everyone else just sits back and cherry picks all of the things we come up with. What happens if there's no America tomorrow? What happens if we junk our system? Where does medical progress come from? "

"I would like to say as my closing comment that what impresses me most about health care is the extent to which more is going to change around in medicine and health care in the next 15 years than changed in the last hundred. I think, for example, the hospital as we know it is dead. I think that drugs become infinitely more important in the next 10 years than they've been previously. All kinds of diseases are going to be transferred from the surgeon to the pharmacist. What I'm most concerned about is what kind of health-care system is the most flexible, the most willing to deal with these changes, the quickest to adapt to them, the most innovative. To me, it's an open and shut case that single-payer systems are extremely inflexible. That is a great cost. The Canadian system has been very slow even to catch up with the change in the last 20 years. And I worry that if we were to move in this country towards piecemeal social engineering we would in some way compromise the system's flexibility at a time when, to me, the most important thing in the next 15 years is going to be flexibility.

We're about to figure out the human genome, for God's sake. Everything hinges on the speed at which we are able to adapt and bring to market that sort of knowledge base. I'm just terrified of tinkering with such an extraordinarily dynamic system at a time when dynamism is, to me, the paramount. I mean, this is the crux of our disagreement. You're impressed with what the medical system is now capable of providing. I am, on the contrary, impressed by what the medical system has not yet provided. And that's why I favor a system that is, for all its faults, incredibly dynamic; and you favor a system that, for all its faults, is incredibly good at delivering the status quo."

Read the complete article (it's lengthy): Canada Vs. U.S.

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Follow Up On Universal Health Care

I decided to post a few clips from SiCKO that I found particularly moving and thought provoking. I still suggest watching the documentary in its entirety to get the full effect that moved me. I want to make it clear however that I am not an advocate of universal health care. I am simply an interested citizen, curious about what the future of health care can potentially become here in the U.S. My opinions are still undeveloped. These posts are simply thoughts to put on the table. Your feedback is very helpful if not critical to helping me see both sides and form an opinion.

Here's a doctor in London who is extremely satisfied with their system.


Here's an interesting confession .


Interesting words of Tony Benn


There's a few other concepts portrayed in Moore's film but I can't find them on youtube. One is an interview with a room of Americans living in France talking about how they almost feel guilty that they enjoy benefits (5 weeks payed vacation a year, 6mos paid maternal leave, health care, etc.) that their parents in the U.S. have worked their entire lives and have yet to attain completely.

These clips and the movie overall was persuasive, BUT it so so obviously bias that it almost makes a thinker like myself sick. It shows the worst sides of american health care and portrays a utopia-type atmosphere elsewhere. I'm positive that universal health care has its flaws just like any other man-made system (man-controlled) and I intend to do more research. I just want more substantial/reputable sources, right now its just Michael Moore v. Fox News.

Here's two clips opposing Moore's video:




Also here's a speech by President Ezra Taft Benson on Socialism which my cousin Brad sent to me which I found to be extremely insightful. I STRONGLY suggest reading it: http://speeches.byu.edu/reader/reader.php?id=6162

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Universal Health Care

My wife and I watched Sicko yesterday. As many of you know I am a year and a half away from starting medical school, so the state of our health care here in America is of utmost importance in my mind. Michael Moore presents a very bias documentary of health care horror stories here in America and the lack problems with foreign health care systems, everywhere from Canada to Cuba (he didn't seem to show lower class citizens in other countries). Despite the obvious flaws and holes in Moore's reasoning and research, I was left wishing we had universal health care here in the states. The doctor's in France seemed well off (one of my worries is working for the gov't), happy, and successfull overall. They couldn't dream of working in a system where they would have to turn away sick people because they didn't have insurance to cover the cost. I shudder at the thought of myself in the future being forced to stay my hand in healing those I would be capable of healing, in Christian terms burying my talents. The driving force behind my career path is service, to be a self-less physician. Will insurance companies and hospital administrations deny me of this goal? Is the only reason we don't have universal health care here in America because, as Moore said, propaganda against other countries (the French) and fear of change, fear of socialism? Is the idea of a self-less physician the core principle of social healthcare and an impossibility in the U.S.? Maybe I should move to France.

I guess the purpose of this post is to get more of the story. After watching Sicko I am ery moved. Anybody with any other insights on the matter wither for or against universal health care (especially the plans of Hillary or Obama), your thoughts are encouraged.

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