Price competition in healthcare (dental)

The Atlantic has an interesting article up about how more Americans are heading down to Mexico to get their dental work done. The reason can be seen below:

I am only surprised this hasn't happened sooner. Right now, taking advantage of price differences like this is mostly limited to people of means (free time to go to Mexico, money to get there, presumably paying in cash). But it's not just dental work anymore; cardiac surgery in India can start at just $3200.

Whether this delivery of better care for less money will ever happen within the borders of the US, of course, remains to be seen.

"Patient Profiling" and Maximizing Your Doctor Visits

I encourage anyone who sees a physician in the US to look at these two articles:

Are You a Victim of Patient Profiling? - Dr. Pamela Wible

Dr. Gopal Chopra - 5 ways to maximize your doctor's visit

The first article is written concerning the ways in which doctors can stereotype patients and come to inaccurate conclusions. It's almost impossible, in medical education, to avoid doing this; medical education is pretty well obsessed with the "typical presentation" of diseases, which seems reasonable on the face of things.

Young woman with a sudden decrease in energy, weight gain, fatigue? Hypothyroidism! African-American woman with enlarged lymph nodes? Sarcoidosis! Middle-aged woman with fatigue, stiffness, paresthesias, and terrible sleep? Fibromyalgia!

(Seriously, sarcoidosis is almost a running joke in my class at this point. Per our exams and Step prep, apparently every African-American woman who goes to the doctor has it. Except its actual incidence is 1-40/100,000. It's a rare disease, guys.)

So the current heuristic-based system works great, unless you have an atypical presentation of a disease or just a rare disease. This can be a problem. Physician visits are almost always scheduled to be short, unless you have a concierge doctor. Occasionally you can get lucky, and find a primary care doctor who is older and made his or her money decades ago (or who at least has stopped caring about maximizing revenue). My personal experiences with doctors right out of residency has not been incredibly favorable--while they have a good chance of being at the top of their game in terms of medical knowledge, many of them have just figured out 3 things:

1. They have a lot of debt (on average $170,000 per the AMA)
2. They are finally at the stage of their life where they can make Serious Money...
3.  ... if they see as many patients as humanly possible

These 3 things do not really correspond to your goals as a patient: to maximize your time with the doctor, quantitatively and qualitatively. So, towards that end, I recommend you read the CNN article by Dr. Chopra.

Of that list, I personally feel the most important point is the following: Don't be afraid to challenge the doctor if you think he/she is wrong.

I like to think I'm a reasonably informed person, and for quite a while I ended up seeing a physician who incorrectly thought I had rheumatoid arthritis, based on an early miscommunication. This was, as you might imagine, a tremendous waste of time, and I ended up on medicine I didn't need and delayed when I actually began to receive useful treatment elsewhere. I was somewhat confused by the diagnosis at the time, but I have a well-developed instinct to go along with whatever medical professionals say. So I went along with it until it became painfully obvious that nothing was working... 2 years later. This was a huge mistake.

One final thing, of course. If you don't like your doctor, find another. Life is too short.

This is a joke, right? No?

Apparently a group known as the Satanic Temple (1) exists and (2) wants to erect this statue outside the Oklahoma legislature. I think it will look great next to Moses. 

I'd love to know what they plan to do with this statue if Oklahoma decides Satan isn't on their list of approved legislative deities. It sounds like they raised $30k to build it, so I assume this statue will eventually be going somewhere.

And if it does get put up outside the legislature, it will make a great road trip destination.

Graph of the Day

This isn't my area (in any way whatsoever) but this was the most interesting thing I've read all day. Main article: http://www.vox.com/2014/5/1/5671834/this-map-is-bad-news-for-chinas-economy-good-news-for-americas

China will stay a big center of global manufacturing — it's still reasonably cheap, it has the infrastructure, it has the roads and the ports, and it has the supply chain. But that is slowly changing, which is why you're going to see more companies shift their manufacturing to other places: ultra-cheap southeast Asia, Mexico (which has raised its productivity significantly), and fingers-crossed maybe even to the United States.

This is from vox.com, whose main claim to fame as far as I knew was luring Ezra Klein over from the Washington Post. With more stories like this maybe they can permanently establish themselves as a new, interesting news source.

The other major China story going around seems to be that China's economy has eclipsed that of the US if you look at PPP, which is true but inspires the most awful articles about how the US must surely be doomed this time. The real question, I think, is why China? What about India? 

Amartya Sen has an answer for that question, taken from last year's NYT (and bonus analysis c/o the World Bank). It's worth a read--his rough answer is that India is a democracy, and it's made a tradeoff for greater democracy instead of economic growth-- but I wasn't sure whether he really offered any solutions. Stating that India is a democracy is true, but I don't know whether it answers the Really Big Question: what can India do to jump-start its long-awaited economic growth?

(I found several references to India's economy as "the sleeping elephant." China of course is a dragon, a half-awake one or something. I await economic reporting on the giant beaver to our north, or the punchy 'roos of Australia. Surely it's only a matter of time.)

Always a good sign

I chuckled when I got this e-mail. 

After speaking with several fourth year students and Dr. [X]... several of us felt it imperative to inform you all that there is NO box to check or area to denote any form of mental illness or having ever received counseling of any sort on the residency application. You tell a residency program if you have received counseling for or suffer from depression, anxiety, burnout, etc. AFTER you have matched. It will be the paperwork you fill out for the specific program like any other job you have had.
We bring this up because students fear seeking help from counseling services on and off campus. This is unnecessary as you will not be asked about such information when applying for residency during fourth year through ERAS. Please, PLEASE seek help if you need it. We have amazing resources available to us!

This is an old link from KevinMD, but it's relevant: Medical schools need to better recognize mental illness in students. 

Physicians have traditionally experienced higher rates of suicide than the general population – 40% higher for male doctors and a whopping 130% for female doctors. Students who enter medical school with a relatively “normal” mental health profile, in the end, suffer a higher rate of burnout, depression and other mental illnesses. In fact, over the course of med school, up to a quarter of students may suffer from depression and over half from burnout.

This is a friendly reminder that burnout, depression, anxiety, etc. are all a depressingly normal part of medical school. Please get treatment if you need it. To my knowledge nobody will know outside of your school's student health department, or whichever physician or counselor whom you see. Mental health issues are common and highly treatable.

I'm not surprised that one of the main hindrances to seeking help for mental health issues at my school appears to be "What if people find out?" I would like to think doctors and healthcare workers are more enlightened about mental health issues than other people, but I'm not sure the data really bears that out. My anecdotal experience sure doesn't.

So I wonder to what extent should medical students (or residents, or doctors) suffering from mental illness speak out. If you're in a stigmatized group, how much responsibility do you have to other people in the same boat?

Maybe that's the final step in getting better. Where you've reached the point where you aren't afraid to talk about it. Or maybe that has nothing to do with healing at all but rather with where you are in your career.

Step One fun, plus a tiny news roundup

It's nearly Step One time! Which is to say that in about two months' time, I will be tested on anything or everything that I've learned in the first 2 years of medical school. I will then almost certainly forget half of it within one week or so.

So, the part of my brain that isn't re-learning which special bacteria requires chocolate agar (Hemophilus influenza and Neissiria meningitidis, if you're keeping track) or what a PAS stain is checking for (glycogen, Whipple disease) has been reading through the news looking desperately for an interesting story. So far it looks pretty grim. Some guy in Nevada owes the federal government a lot of money. A dude I've never heard of who owns a basketball team made some dumb comments. A missing plane is still, uh, missing.

Instead of talking about those awesome topics, I instead am linking an article by Andrew Sullivan at the Dish, regarding John Kerry's remarks about Israel. If you missed it (and I forgive you if you have) John Kerry stated that Israel was in danger of becoming an "apartheid state" along the lines of South Africa. As far as I can tell, this is pretty basic stuff: unless Israel persuades a whole lot more Jewish people to immigrate, and fast, demographics are going to turn it into a Jewish-minority state.

Nothing about that is particularly controversial, in my opinion. Jeffrey Goldberg, who has written extensively about Israel's present and future, concurs.

By 2020, the Israeli demographer Sergio Della Pergola has predicted, Jews will make up less than forty-seven per cent of the population. If a self-sustaining Palestinian state -- one that is territorially contiguous within the West Bank -- does not emerge, the Jews of Israel will be faced with two choices: a binational state with an Arab majority, which would be the end of the idea of Zionism, or an apartheid state, in which the Arab majority would be ruled by a Jewish minority.

Which is all to say, I clearly don't understand the politics of the situation very well. Unless Israel's demographers have gone mad, the Arab population is going to become the majority group within Israel fairly soon. So if you are inclined to believe that the Jewish people deserve their own state, the only rational future seems to me for Israel to accept a second state. Waiting for demographics to force the issue seems like poor planning, and jumping on John Kerry for pointing this out seems quite frankly counterproductive.

Of course, I do assume people want a reality-based solution and not fantasy (Maybe Palestinians will be abducted by aliens! Maybe ten million Jewish people will immigrate overnight!) so I may be over-thinking things.

Finally, for a well-informed take that is more critical of Israel than I am, Juan Cole provides some good insights.

Galveston's uninsured, physician satisfaction, and concierge medicine

This is an old article, but it's one that's fairly important to me for obvious reasons - I live in Texas, and more specifically in Galveston.

http://www.texasobserver.org/a-galveston-med-student-describes-life-and-death-in-the-safety-net/

If you recall, the island was hit by Hurricane Ike in 2008, and this devastated large parts of Galveston Island. UTMB, the major healthcare provider and employer in the region, was nearly bankrupted in the aftermath, and the solution at the time was to begin cutting services to patients lacking health insurance, or patients covered by programs like Medicaid which are notorious for poorly reimbursing doctors and hospitals.

From another article in the Texas Observer, UTMB went from turning away 35% of uninsured people seeking care to 91% as of 2011.

As a result, the estimated 21.5% of Galveston County's residents who are uninsured suddenly have a lot fewer options. One choice is the student-and-volunteer-run free clinic of St. Vincent's House, which sees patients on Tuesdays, Thursdays and Saturdays. The physicians who oversee patient care are strictly volunteers. Poorer patients may rely on donations of medication from the stores of dead former patients, and access to some basic drugs like antibiotics for simple infections is difficult (a 7-day course with some of those may cost well over $100, which is outside the financial reach of many of those coming to a student clinic).

Luckily, a major resource that the clinic can afford its patients is time. Because medical student education is a goal (and the physicians are not getting paid for their time), the initial patient interviews are conducted by medical students who can listen for longer than the 5-to-10 minute window of a typical doctor visit in the US. This is fairly rewarding, both for the students involved and (usually) the patient. There is little financial pressure cutting the visit short. More important, it is how many medical students envision patient care: you spent a lot of time listening to the patient's health complaints, and then try to come up with a plan to treat them. The relaxed pace of the interview means that you have time to learn about the patient outside of their hypertension or diabetes.

I bring this up because I read an article in the Guardian by one physician who is deeply dissatisfied with the medical care he is giving:

The same "reward and punishment" that is the hallmark of the American free market system has rewarded physicians for seeing more patients (no different than hourly billing rewards for lawyers) and doing more to patients (such as surgical procedures and other interventions). Consequently, physicians have been pressured to see more and more patients in the same amount of time. It should be no surprise that such encounters have become more like business transactions rather than what they should be: rich and intensely human interactions potentially resulting in tremendous fulfillment for both parties.

 He is getting at what I believe is a fundamental part of medicine: the idea that it is not merely a job like many others, but a chance to connect with people on a very deep level. Some of this may be conceit: it is pretty ambitious to view your profession as a "calling", a term I've commonly seen in reference to medicine. But many physicians do enjoy talking to and connecting with their patients. The main reward for primary care isn't financial but being able to build a long-term relationship with patients and their families, if you're lucky.

I find it darkly amusing that this style of medicine has been pushed out of many hospitals and doctors' practices, but is still thriving at a clinic run by medical students for Galveston's poorest. Even with excellent insurance you may not be able to develop this kind of long-term relationship with a physician.

Maybe patient satisfaction scores were highest back in the days when doctors had no medical option but to listen. Surely there must be some way to reconcile the tremendous advances in medicine and technology with an approach that does not dehumanize patient and physician alike. Is it concierge medicine? Will healthcare reform help or hinder this process?

Physicians are too bright to allow office visits to become merely a commercial transaction. I hope.

Concierge medicine is one solution to this problem, but the problem remains how to make this kind of care cost-effective for more Americans. I don't think too many of the patients at St. Vincent's could afford a physician retainer, no matter how excellent their care would be. How can we bring that kind of quality long-term relationship care to more/poorer patients? Is it economically possible?