Healthcare Reform, from a Doctor's perspective.

I have been putting off doing this post given the politically charged environment we live in, but now feel I need to share my perspective as the finish line to the presidential election draws near. For obvious reasons, health care is a VERY IMPORTANT issue to me. I feel I offer a unique perspective as I have seen our health care at work from several different angles. I have been a patient in the system: I remember being a young 16 year old boy who suffered sudden onset hearing loss and being told by a doctor that I may have a type of brain cancer and needed to get an MRI right away to rule it out. Talk about scary(not to mention horrible bedside manner by the Dr, which deserves a blog post all on its own). I have worked in the field as a medical records clerk, a courier transporting blood back and forth between clinics and labs, an x-ray/lab technician, a medical student and now a resident doctor. I have seen our health care system at work across multiple different specialties and in very diverse patient populations across the country. Each area had its unique challenges and circumstances, but also many similarities. I am currently living in the epicenter(Dallas) of the worst West Nile virus breakout our country has ever seen! Kind of crazy and tragic to see first hand the effects of a fairly new and relatively unknown disease that does not yet have a treatment! But even more exciting is to see the passion and dedication of outstanding neurologists, researchers and public health officials who are spending long hours trying to figure out the best way to save lives and restore function during this viral outbreak that acts very similarly to polio. In any honest discussion on healthcare, most will say our system as whole is broken in some form. When examined from a purely economical point of view it is a very unique marketplace. I admit I am no economist but I will attempt anyway to articulate my understanding of our current system. What we have right now is essentially a third party payer system. In other words, the person offering the goods or services(doctors, other providers) are not directly paid from the person receiving those services(patients) but instead from a third party(insurance companies). Ideally, we(patients) all contribute a small monthly amount to these third parties(insurance) to "subsidize" the costs of healthcare as a community to cover the large expenses that would be difficult for the individual to cover alone. It gets a bit more complicated when we consider employers who also contribute partially or fully to pay for employees health insurance as they sort of also become a third party payer. I believe understanding the third party payer system is crucial to understanding why healthcare costs are such a big portion of the GDP. Unlike other markets where consumers are behooved to find and shop for the best and least expensive "deals", consumers(patients)do not worry about costs as long as the third party(insurance)will pay for it. This is a big reason why, for example, a pacemaker sold in the USA can cost 70,000 dollars and the same device in other countries(like Canada)cost 7,000. It should also be pointed out that diagnostic equipment(like MRI machines) are more expensive for hospitals to buy in the USA than other countries because the companies that build the machines know hospitals can charge more to pay for the scanner because of the third party payer system. And not too confuse things any more than I already have, but we also have two little government third party payer programs called Medicare and Medicaid that are a part of this system. Medicare of course being for those over 65 or disabled and Medicaid for low income consumers. And lastly, malpractice law suits and defensive medicine undoubtedly drive up medical costs in an already expensive marketplace. More on this later. Now, one of the more frustrating parts about the current system is that insurance companies and plans are not equal and premiums are all different based on a variety of factors. One of the most obvious factors is the exclusion of consumers(patients) because "pre-existing conditions". I agree wholeheartedly that this needs to be eliminated when considering whether someone be covered with insurance(although I do support requiring those who choose to use tobacco, drugs,or excessive alcohol be charged higher premiums as these are known to increase costs and the patient can do something to change it). For me as a doctor, the most frustrating part with the system at present is the fact that insurance companies very literally decide who will live and who will die. In other words, I can recommend a life saving treatment but the insurance company will have the final say if they will pay for it or not and ultimately if the patient will receive it or not. I hate to say it, but when considering treatment for patients we absolutely have to consider their insurance and may alter our treatment plan based on what type of insurance, if any, the patient has. Ok, is there anyone still with me after my very barbaric attempt to be an economist? I applaud you if you are. :) So, I have finally arrived at the reason for this post. Healthcare reform! If you made it through the post, you probably guessed I support reform. And you are right as I indeed support reform. I support getting rid of pre-existing conditions as exclusionary for insurance. I support creating more portability of insurance plans so if you lose your employment you still can have insurance. I actually support requiring everyone to have health insurance(it pains me to write this sentence as I HATE the government telling us what we HAVE to do, but people without insurance who can't pay drive up costs for everyone else, and for those who have assets but no insurance end up losing their house, retirement etc trying to pay which also hurts everyone else). BUT, I do NOT support Obamacare(Patient accessibility and affordable care act) as a whole. And here is why: 1)NO malpractice reform. Did you know there is not a single mention about malpractice reform in Obamacare? I am not sure if it is because he is an attorney himself or what but do not believe anybody who tells you malpractice and defensive medicine do not drive up costs. They absolutely do! Every day I order tests just to be on the safe side in case I get sued. I was trained when thinking about a diagnostic plan to order enough tests to show you thought about EVERYTHING. This absolutely drives up costs. Not to mention malpractice insurance can cost a doctor over 100,000 dollars/year! Just like any industry, that cost transfers over to the consumer. 2)No medical education reform. My education cost several 100,000's of dollars. It cost more for some. This is a big deal, especially when Obama wants to pay for the bill by CUTTING provider payments...which brings me to my next point. 3)Cutting provider payments. I am not sure why Obama keeps saying this is how he will pay for the bill, because cutting provider payments will NOT actually pay for his bill. He probably says this because so many people have this vision of mean, rich doctors that are overpaid and so he thinks it will win votes. I understand doctors pay only account for 8 - 15% of all healthcare costs! I acknowledge there are some specialties that do make too much money(ie orthopedic surgeons) but on the whole, many doctors struggle to keep their offices running and pay the bills as medicare payments are DECREASING every year and office costs such as paying staff, supplies, electricity and rent continue to rise. Most physicians I worked with haven't had a raise in their salary for YEARS. In fact, many have decreased. Can you imagine working in your chosen field, gaining more experience, being more efficient, and getting paid LESS as the years go by? That is what is happening to most doctors and here is why. When Medicare first began, a doctor could submit a bill for a service to medicare and expect to get 100% of what he billed back. Over time medicare started to realize that this model was unsustainable as they were paying out a lot more than the program was getting in. So it started developing ways to scale back payments to providers and standardized how much it would pay for different services to providers. One politician took it to the extreme and developed the sustainable growth rate(SGR) formula years ago which calls for a percentage of cuts to providers every year to keep the program sustainable. Sounds reasonable right? Its only Medicare, so whats the big deal? There are a lot of other insurance companies to pay doctors a lot of money, right? Well, not so much. Since Medicare was scaling back payments, all the other insurance companies decided it would also scale back payments and follow the payment schedules set by medicare. Despite the fact that most insurance companies were and CONTINUE to have record profits, they decrease there payments to providers based on what medicare does. That is why its a big deal. And this year with all the baby boomers, the SGR formula called for a 21% cut to providers to help pay. So that means across the board all insurance companies would cut payments, despite making record profits! And Obama wants to cut provider payments further to pay for the bill. Ouch! 4)Increasing taxes on successful insurance companies. There is language in the bill that calls for an increased tax by 2018 I believe on those insurance companies that are more successful than others. I don't have a lot of love for insurance companies, but it feels very UN-AMERICAN to tax a company a higher rate just because it is more successful. That is my view anyway. And lastly 5)Quality based measures for payment. By the year 2015, Providers will not be paid on the amount of patients they see but by the outcomes of the patients they see. Sounds great, right? Actually, I think its a bad idea, and here is why. Let's say I'm treating a patient with diabetes and I only get paid if the patient's Hemoglobin A1c(3 month average of blood sugar) gets down to a certain level. Now imagine, despite my best diet teaching and prescribing the correct amount of insulin, the patient decides to eat whatever he wants and doesn't follow the insulin regimen. His A1c is still high at the next visit. Which means I don't get paid. But I will likely give him one more chance to get his A1c down and if his A1c is still to high at the next visit, I will likely fire the patient(yes, doctors can fire patients). Then I will start to be VERY selective with who I will take as a patient, as will other doctors, leaving this patient who really needs care, to be left untreated. Since it doesn't matter how many patients I see a day, I will likely only see a few select patients day, thus making for very LONG waiting lists to get in to see me. And I will have no incentive to see my patients any faster during the day, so it will be long wait times if you did get an appointment. So, if you think you wait long at a Dr's office now, just wait. And lastly... 6)I fear obamacare will cause a downward spiral on the healthcare profession. This is my own conclusion based on conversations I've had with many currently practicing doctors and my own analysis based on what I have read. It is no surprise with the baby boomer population there will be more people than ever to be treated. But I have spoken with many doctors who say they will retire if the new healthcare bill goes in effect, thus further worsening the projected physician shortages. I also believe that with physician payments AND salaries decreasing, and medical school costs continually rising, we will lose many bright minds to other less rigorous and equally or more lucrative fields. In fact, we may lose so many potential doctors that it further adds to the predicted shortage. Which means for doctors like me who are in the field and could not possibly retire or switch fields, we will likely be overburdened with too many patients AND underpaid since it really won't matter how many patients we see. I believe that ultimately leads to poor care and worse outcomes when a doctor has responsibility over too many patients. As a result of decreasing enrollment, med schools will be forced to lower tuition, thereby lowering pay to their professors, and thus causing many of those top minds to seek other fields. This will further cause the downward spiral of a smaller force of poorly trained physicians. I do believe that the field will always attract those who are altruistic to the cause and simply want to take care of their fellow mankind. I feel it a great privilege to be in healthcare and and a great honor in the trust people put in me to take care of patients. And this brings us full circle to my story about the West Nile outbreak. I'm not sure in an Obamacare world we would find the cure, or at the very least, adequately treat the symptoms of the worst outbreak of west nile or any other potential outbreak of X,Y,Z disease. I believe patient care will suffer. And that ultimately is the reason why I don't support Obamacare. I also think it a mistake to completely repeal it. Unfortunately, there really is no easy solution. I think Mitt Romney is right to say he will keep parts of the bill and repeal others. And I don't consider this a flip flop. The question is, what will his bill look like and will it address my concerns? Will it be similar to his Massachusetts bill or will he truly defer to the states to develop their own reform? I sincerely hope we find out.

Hennessey Phone Pictures 0-3 months

We love this girl and cannot get enough of her!  Enjoy these pics!

Almost Here

I am writing this while on a night float shift during a surprisingly calm night. I should be sleeping since we have an OB visit in the am and we may be heading to the hospital for a delivery, but there are weird sounds in the call room preventing me from sleep and I can't turn off my hearing aids for fear I will miss a page (yes I have come to appreciate my ability to turn off my aids for blessed silence. :) ). So you read the title correctly, our baby is almost here! Despite the fact that her due date is not until April 8th, our doctor has been telling us that she could come any day now...for the past month. Talk about anxiety provoking! You see, little Hennessey was diagnosed with possible intrauterine growth restriction and was not growing properly. Her abdomen was about three weeks behind her head measurements, meaning her little body was ensuring her brain got most of the nutrients while her abdomen lagged behind. Why she was not getting enough nutrients for the whole body we are not sure. Her Amniotic fluid index was perfectly normal, her non stress tests showed perfect fetal heart tones, the umbilical artery ultrasound showed good flow, and Mak does not do drugs. So Makenna was put on bed rest, quit her job, and basically put life on hold to help funnel more blood and nutrients to help promote growth for this little one. There are no solid proven studies that bed rest actually works, but since there were no other underlying reasons that were easily correctable, this was our best option. We also had to report to the OB office twice a week for non stress tests and Amniotic fluid index measurements. It was tough for Makenna to stay down because she is always on the go. It was hard for her to stop working. It was hard not to make dinner, do the laundry or be unable to go to the store for a quick errand. But, like she has handled everything else with the pregnancy, she put aside her wants and made the sacrifice with grace and dignity and really did a great job obeying the bed rest. Her visiting teacher Sister Bechtal was so gracious and arranged meals for us to be brought by members for us while I was busy studying for my step 3 board exam and working. These deeds will not soon be forgotten and it made us so grateful to be apart of a church that looks after and takes care of each other, especially since we have no close family in the area. We hope to pay it forward some day.

Speaking of my step 3 board exam, this was another megathon test. I was privelaged to take another 400 question, 9 hour exam on March 20th. When I scheduled it in October 2011, I thought scheduling it three weeks before the due date would work out perfectly and I could get it done before the baby arrived. Well...fast forward to a a few weeks ago...remember how the doc said the baby could come at any time?? So our OB visit the Thursday before the test, Mak was found to be 3cm dilated and 80% effaced. Yikes! She was right on the edge of being in active labor! We were instructed to go directly to labor and delivery if she started to have constant contractions for greater than one hour that lasted 30-60seconds for 4-6mins apart. Talk about a nerve racking weekend! So I studied as hard as I could and constantly checked on Makenna to make sure she was fine. I was convinced that she would either go into labor the night before my board exam or during the exam when I would be unavailable/unreachable all day. The night before the exam Makenna convinced me to take her with me for a quick trip to Walmart to get a few last minute things I needed for lunch the next day. I have NEVER been so nervous at walmart, NEVER. I was convinced that the longer we stayed at walmart, the more likely her water would break and we would be heading to the hospital. As each minute ticked by, my heart beat pounded a little harder, my breath became more heavy. The odds were against us, I was sure. And of course Makenna was quite oblivious to my plight, she enjoying her first night out of the house for quite some time and doing her very best to linger. Who knew Walmart would be so exciting for a cabin feverish prego woman! Well, luckily for us her water did not break and we had an uneventful night. :) Even more lucky and blessed really, was that Makenna did not go into labor during my exam! Sister Mooney from the ward was even "on-call" to take Mak to the hospital in case she did go into labor. I was able to finish the exam without much problem...though I won't know my score for 6-8 weeks, ugh.

So here we are on March 26th, six days after the boards and still no baby. I am really ok with that because it means Hennessey is continuing to grow! On our most recent OB visit, the ultrasound predicted she weighed approx 6lbs...and we were unsure at one point if she would get to 5 lbs. Awesome! Her biweekly monitoring continues to look reassuring. And the doctor thinks that perhaps she no longer is growth restricted but just is a little small because she has small parents. (I was only 6lbs 4ounces at birth). Yahoo! So despite not many studies showing the benefit of bed rest, I am believer that it works. I am also grateful to my Heavenly Father for the babe's continued good health, and also Makenna's. I'm grateful that I was able to get through another dreaded board exam. I am also grateful for my parents and grandparents for what they went through rasing me and have a better understanding of the emotional roller coaster of being a parent...and I'm not even officially a Dad yet! I'm sure I'll be a basket case the first time a boy asks Hennessey out and if he brings her home late...I don't want to think about it! :) The bottom line though is I CAN'T WAIT TO BE A DAD! She is ALMOST HERE!

PS: please ignore any spelling or grammatical errors as this post was written at 4:30 AM and I have not slept all night!

More than halfway through

"The intern learns while staffing the hospital. The financial model of the hospital system depends on medical interns' manpower and low salaries"
-eHow.com definition of a medical intern.

Internship year is more than halfway through! In fact there are only 19 weeks and 2 days left of internship, much more than halfway through. :) Predictably, I have a hard time finding the time to blog during this year of 80+ hour work weeks. This has been one of the most exciting but challenging years of my life. I liken it to the first year on a mission: you are excited to get things started, but when you finally get there you realize there is SO MUCH you don't know. Some days I feel completely satisfied when there is a tough problem I am able to figure out with the knowledge i've acquired and think about how fun my life will be with a job that challenges me intellectually every day. Other times I feel overwhelmed by the sheer complexity of the human body and despite my four years of focused medical school learning I have no idea why someone is sick. In those instances I sometimes feel that I am standing on the edge of a pirate ship plank doing the hula hoop with sharks(attorneys) circling in the ocean below waiting for me to make a mistake and fall into their mouths.

If you don't believe in defensive medicine driving up medical costs you are kidding yourself. In every conversation with my supervising doctor, he always makes sure we have done everything we can to "protect ourselves." Every note is written with the scrutiny that if something goes wrong, we will be able to use it to defend ourselves in court. We over test for things that we have a low suspicion for because of potential 1% chance that there is something wrong and we don't test for it, we can get sued. Some argue that this has improved healthcare in America. They say that doctors are being held accountable for their actions. They say doctors no longer get away with bad outcomes. I'm not convinced this is helping. Let me give you an example: a 55 year old male who is a little overweight comes to the emergency room with minor chest pain. EKG's (which test electrical activity of the heart) are normal. The troponins (which is a blood test that measures enzymes in your blood that is elevated when you have a heart attack) are also normal. The chest pain is now better and the man admits to eating a spicy meal that afternoon. He does admit to having chest pain before and has had a negative stress test in the past. Despite the fact that his pain is probably heartburn because this guy is male, older than age 50 and is overweight, he will likely be admitted for a 50,000+ dollar work up to make sure he isn't having a heart attack, including another stress test. After he is admitted the next day his stress test is negative. But sadly he comes down with an infection from a super resistant bug that is only found at the hospital and has to spend a couple of weeks on IV antibiotics at the cost of several hundred dollars a day. Additionally, each night at the hospital costs at least 4000-5000 dollars, not to mention the physician costs, other medications and laboratory tests that will increase the cost of hospitalization. So several hundred thousand dollars and an infection later, we have ruled out definatively this guy is not having a heart attack and protected ourselves against a law suit. But really all this guy needed was reassurance and treatment for heartburn. Unfortunately the ER doc was afraid that if by some small chance this guy really was having a heart attack and he sent him home, he would be like "that one case" where the doctor got sued for several million dollars for "missing" a heart attack because the doctor "should have known" that the guy would go home and have a massive heart attack even though the chest pain event was not even close to normal heart attack chest pain and all the screening tests were negative. Am I making any sense? There are so many reasons for chest pain besides a heart attack, but because of potential lawsuits, almost everyone with chest pain that has a risk factor(being male is a risk factor) is admitted for further testing. Ideally, a good doctor should be able to listen to the nature of the chest pain and then be able to tell if it is a heart attack...but because of "that one case" that presented a little differently no one takes the chance to send the patient home without definative(and expensive) testing. I'm not sure this is better medicine...but what do I know??

I didn't mean to get on that soap box. Oh well. I really wanted this post to be about what my life is like right now in the middle of intership. My day consists of waking up around 430-500am, getting to the hospital between 530-600am, reading the updates overnight and rounding on my patients from 6-8am, attending morning report from 8-9am, rounding with the supervising doctor between 9-12, attending noon conference from 12-1pm, writing orders, notes and answering pages about patients from 1 to 5 or 6pm. On days that I am "on call" I will additionally admit new patients to the hospital and cover for the other interns patients after they leave until 8pm when I sign out to the night float doctor.(I am grateful that 30 hour on call shifts are now gone and 16hrs is the maximum...just changed this year!) When I come home I like to spend as much time with Makenna as possible. Of course I have to study on some nights when I have complicated patients or need to be preparing for my board licensing exam. I also enjoying reading a good non medical book at night from time to time and Im in the middle of "The seven Miracles that saved America." We try to go to bed between 930 and 10pm. Exciting life...I know. Admit that you are jealous. :)

Makenna is 31 weeks along and has been amazing. She has handled pregnancy with such grace. She rarely complains and never lets her "hormones" get out of whack. I have to ask her to slow down sometimes because she wants to do everthing she normally does when she is not pregnant. Her belly most certainly looks pregnant but not the rest of her body. I love to feel the baby kick, and she is super active. The only food Mak has not been able to eat is scrambled eggs. The weirdest craving she had was a combination of pickles and peanut butter cookies at the same time (which gave her a stomach ache and she has not had since). Mak is so good for me because she is a planner and I am not. She has already planned out the delivery of the baby, the first couple of months of her life, our impending move to Texas and I wouldnt be surprised if she has already planned out what the baby will wear on her first date when she is 16! ;) We talk alot about what life will be like in Texas a lot. We enjoy Reno and have made some good friends here. We have a group that we eat sunday dinner with and enjoy playing games afterwards. The Mooney's have been lifesavers and have helped us out a lot. I have one more week of internal medicine wards and then I switch to night float. I have missed alot of church this month due to my work schedule and I really don't like missing church. I have new respect for saints who are faithful but have to work on sunday and will never again judge a person for missing church. That being said, I know it is possible to work all night and still be able to go to church the next day(and give a talk at church), because I have done it. Well, life is good despite the crazy times in which we live. I have a lot of debt, a small salary, live in a one bedroom apartment, drive an old car and work 80+ hours a week. But I couldn't be happier living with my best friend with a baby on the way, seeing different parts of the country and enjoying the journey!