OP-ED

OP-ED

When the Patient is a Racist

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Something has changed.

In my first 16 years in practice, I received exactly one insensitive comment from a young child who had never seen an Asian in person. But in the last year, I have received a hateful, bigoted comment approximately every other month. (That includes the remarks by a person who tried to reassure me that the comments were not directed to me personally, but to the “other illegals.”)

My colleagues are experiencing an increase in bigoted comments too. A fellow physician, a southeast Asian man, says he has been called “Dr. Bin Laden” on several occasions recently.

Last September, one of my students was on the receiving end. A patient’s father requested another doctor when he saw the medical student assigned to his son’s case was black. My student and I went to see the patient’s family together. I acknowledged the father’s anxiety and reassured him that we could treat his son. I asked the surgeon-on-call to see the patient.

Is Healthcare a Right? A Privilege? Something Entirely Different?

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Election Day 2016 should have been Christmas morning for Republicans. Long awaited control of the White House and both houses of Congress. A chance to deliver on an every two-year election cycle promise to repeal and replace Obamacare. In 2010 Republicans needed the House. They got it. In 2014, it was the Senate. Delivered. But we still need the White House they said. Asked and answered with President Donald Trump.

So, what happened a few weeks ago when the House bill fizzled like a North Korean missile launch? Disparate factions within the House couldn’t unify behind Speaker Paul Ryan’s plan, despite pressure from the White House. For some it wasn’t a repeal, only a rearranging of the deck chairs on the sinking Obamacare ship. Others in the GOP were happy with the status quo, preferring to rail against Obamacare in campaign speeches rather delivering on empty campaign promises. Still others, #NeverTrumpers, knowing that President Trump was behind the House bill, preferred to see the bill, and Trump, fail.

Kudos to the Democrats. When they ran the show in 2008, they herded their cats and passed Obamacare. No Statist Caucus on one side or a Tuesday (or Thursday or Friday) group on the other side, each wanting their own version of healthcare reform.

Hobson’s Wrong Answer

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Thomas Hobson was his name, a licensed carrier of passengers, letters, and parcels between Cambridge and London in the years surrounding 1600. He kept horses for such purpose, and rented them when he wasn’t using them. Naturally, the students all wanted the best horses, and as a result, Mr. Hobson’s better mounts became badly overworked. To remedy this situation, he began a strict rotation system, giving each customer the choice of taking the horse nearest the stable door or none at all. This rule became known as Hobson’s Choice, and soon people were using that term to mean “no choice at all” in all kinds of situations.

Not to be confused with Sophie’s Choice, the title of a 1979 novel by William Styron, about a Polish woman in a Nazi concentration camp who was forced to decide which of her two children would live and which would die. That phrase has become shorthand for a terrible choice between two difficult options.

Both Choices come to mind when reading this week’s Boston Globe article titled Hope for Devastating Child Disease Comes at a Cost: $750,000 a Year. The headline, as is too often the case, is inaccurate. It’s $750,000 for the first year, and $375,000 annually after that. But let us not quibble. That equals a lot of resource.

Do Asians Have Harder Heads? On Sports Concussions and the Need For a Fairer, Medical Research Funding Policy

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At a January event on “The Future of Baseball” organized by the Sports and Society Program at NYU’s School of Professional Studies, Yankees executive Jean Afterman spoke to the superiority of baseball over football by noting that “at least our athletes don’t have to worry about their heads after they’re done.”  It was an innocuous statement but one that points to a growing assumption that sports concussion is both (a) prevalent and (b) a debilitating disease to be feared.

But is it true that sports concussions are the public health scourge of our time?  Media coverage would make it seem so, with countless stories dedicated to professional athletes suffering through pain and dementia, youthful athletes retiring for fear of brain injury, and billion dollar lawsuits against the NFL.

Key Mechanisms That Define Health City Cayman Islands’ Value Innovation

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Health City Cayman Islands (HCCI), less than three years old and located in the Caribbean just an hour’s flight south from Miami, is a 104-bed hospital outpost of Bangalore, India-headquartered Narayana Health (NH). HCCI has caught the attention of US health care professionals not just as a nearshore health care destination, but for having extremely high quality despite pricing that is a fraction of that in the US, as well as careful attention to the patient’s experience. HCCI is not only a competitor to traditional US health systems, it is potentially a radical disruptor. It’s model is so different that it could significantly change the standards by which health systems are judged.

HCCI’s performance is the culmination of a deep commitment to access, efficiency and excellence. NH’s Founder, Dr. Devi Shetty, began with a mission-driven awareness that health care is an essential need and must be affordable to be accessible. He then spearheaded an enterprise-wide focus on process optimization to deliver the best care possible at the lowest possible price. The results have been remarkable. Fifteen years ago, NH’s bundled costs for open heart surgery in India averaged about $2,000. Now they are about $1,400, or about 1% of average US cost. Interestingly, Dr. Shetty believes that better results are within reach and has set a five year target of $800 for those services.

Who Won When the AHCA Failed?

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You may have heard that repealing and replacing Obamacare recently failed.  The analysis of what went wrong comes from many corners.  Andy Slavitt, former insurance executive and most recent director of CMS, writes that the ‘failure of Trumpcare can be seen as a rejection of policies that Americans judged would move the country backward.’  Apparently, the theory goes, moderate republicans, especially in states that expanded heavily and rely on Obamacare Medicaid expansion, were skittish of a repeal and replace plan that endangered the healthcare of millions of constituents.  The conservative David Frum writes in the Atlantic that most Democrats and Republicans have accepted the concept of universal health care coverage – and that the idea of a repeal of the right to healthcare is sheer anathema.  And if the Republicans were wavering, town halls filled with angry constituents were sure to provide an extra dollop of pressure.

The effort to get the messaging right is clearly important to many, but I find most of it functions as a smoke screen seeking to obscure the real battles being fought over your healthcare.

It is certainly true that Obamacare insures millions of Americans.  But it is also true that having health insurance and having health care are two very different things.  To be clear, the folks attempting to preserve the status quo want to preserve the ability to force all Americans to buy health insurance that costs hundreds of dollars per month.  Put another way, the folks attempting to preserve the status quo want to force Americans to give a monthly fee to health insurance companies.  Remember, these plans have deductibles so high that most of the cost of care delivered during the year in the form of labs, copays, and imaging studies falls on the hapless patient.  The insurer, for the average healthy person, doesn’t pay a dime.

The Child Sexual Abuse Conspiracy

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(After this essay was submitted to THCB the Senate Judiciary Committee held a hearing on March 28th titled, “Protecting Young Athletes From Sexual Abuse.” USA Gymnastics refused to appear and provide testimony likely, in part, because USA Gymnastics’ President, Steve Penny, was forced to resign on March 16th. The issue was framed by Committee Chairman Chuck Grassley as a “heinous crime,” no health care or public health expert testified and the hearing and was reported in sports pages of the The New York Times and The Washington Post.)

If you do not read the sports page you may have missed the news that this past November, December and February Dr. Larry Nassar, a former USA Gymnastics and Michigan State physician, was charged with numerous counts of criminal sexual misconduct and for possessing 37,000 child pornography images and videos of him sexually molesting girls. Beyond these charges, there are at present another 80 and counting related police complaints and several related civil lawsuits filed against Nassar. 1 Before he retired in September 2015, Nassar served on the USA Gymnastics National Team’s medical staff for 29 years and before he was fired last October, he also worked as a physician at Michigan State where for two decades he treated, among others, members of the university’s women’s basketball, crew, field hockey, figure skating, gymnastics, soccer, softball, swimming and track and field teams. Dr. Nassar was also associated with a Lansing-area girls’ gymnastic club and a high school.

The Law of Diminishing Returns of Ethicism

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Many allege that the FIRST trial, which randomized surgical residencies to strict versus flexible adherence to duty hour restrictions, was unethical because patients weren’t consented for the trial and, as this was an experiment, in the true sense of the word, consent was mandatory. The objection is best summarized by an epizeuxis in a Tweet from Alice Dreger, a writer, medical historian, and a courageous and tireless defender of intellectual freedom.

It’s important understanding what the FIRST (Flexibility In duty hour Requirements for Surgical Trainees) trial did and didn’t show. It showed neither that working 120 hours a week has better outcomes than working 80 hours a week, nor the opposite. Neither did the trial, despite being a non-inferiority trial, show that working 100 hours was as safe as working 60 hours a week. The trial showed that violating duty hour restrictions didn’t worsen outcomes. The trial was neither designed nor powered to specify the degree to which the violation of duty hours was safe. This key point can be missed. To be fair, neither the trialists, nor the editorials about the trial, claimed so.

The Coming DRexit

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Brexit was a British version of “I’m mad as hell and I’m not going to take it anymore,” a famous line from the film “Network.” Brits were fed up with intrusive and nonsensical regulations from the European Union, including whether eggs could be sold by the dozen — really important stuff affecting the lives and well-being of our neighbors across the pond.

“Frexit” may be the next iteration, as one of the leading French presidential candidates, Marine Le Pen, promises voters a referendum to leave the E.U. Donald Trump’s election to the presidency is the American version, in which voters chose to leave behind the political and media Establishment and favored a new direction.

Now, in medicine, a similar movement is called “DRexit,” as described by Dr. Niran Al-Agba, a pediatrician in Washington State, who wrote about this in a blog post — and it may be pushing physicians away from stifling bureaucracies of government-run health care. Endless rules, regulations, and mandates are turning physicians from healers into robots and transforming the medical clinic into the post office or the Department of Motor Vehicles.

A Doctor’s Dilemma: A Case of Two Right Answers

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Imagine you are a doctor running a clinic in a primarily lower-income neighborhood, where many of your patients are recent immigrants from different parts of the world. You are granted a fixed annual budget of $100,000 through your local public health department, and it is unlikely that you can obtain additional funding later in the year. Traditionally, you have used your entire budget for the past several years, which usually lasts from January until December. This allows you to care for all of the few thousand patients who come to you for treatment throughout the year.

One day in January, a frightened, thin young man appears to the clinic with a folder of medical records. He is accompanied by his aunt, who explains to you that he has recently traveled from El Salvador, where he was diagnosed with a rare type of cancer that, if untreated, will result in his death within 6 months. After further inquiry, you determine that his cancer is treatable, but will require $50,000 of your budget to save his life. What do you do?

Thinking Through the Moral Dilemma

The ethical dilemma in this case is one that physicians and public health practitioners confront often, particularly in very low-resource settings: the care of the individual versus the equitable distribution of resources to the society at large. For this case, treating this single patient means that there will not be enough money to treat all of the other patients who come to the clinic over the course of the year. In economic terms, we might say that his care is not cost-effective because for the same amount invested in supplying the clinic, we could prevent many more deaths or disability adjusted life years (DALYs) for a greater number of patients. However, allowing a patient to die of a treatable condition feels wrong on many levels.

Thinking through this further, we must look closely at our values as a country and a health system: thanks to EMTALA, we ensure that no patient will ever be allowed to die of an emergency condition while in a hospital; thus, we value saving people from imminent, preventable death.