Health care in Eastern Europe, Singapore and the US: How could pre-paid and concierge medicine help us be great?

American healthcare is expensive. We pay lots of money for it and we have outcomes that we aren't proud of. We gnash our teeth at how terrible we are and look to other countries with lower costs for ideas on how to improve. I have been combining personal and second hand experience of countries that spend very little on healthcare with what I know about medicine in the US, and we really aren't entirely bad. In some ways we are outstanding.

Singapore is a city-state comprised of 20 islands, near Malaysia, which began its modern prosperity when it was reinvented as a port by the British empire. It spends a tiny proportion of its GDP for healthcare, on the other hand, and ranks in the top 20 countries in the world in both life expectancy (15th) and infant mortality (1).

So how do they do it? There are many factors that might enter into the overall health of the population of Singapore. One very striking thing about Singapore is how strict their laws are and how rigidly enforced. There are high taxes on both alcohol and cigarettes. Trial is by judge, not by jury and trafficking drugs is punishable by death, as is possession of large quantities of drugs of abuse. Trafficking in arms is a capital offense as is using a gun in the commission of most crimes. Cigarettes and alcohol are heavily taxed, and cigarette use is prohibited in most public areas, transgression punishable by rather high fines. Singapore provides universal healthcare by a combination of health savings accounts funded by salary deductions along with partially government funded health insurance for catastrophic costs and a government fund to pay for the care of patients who are unable to afford medical care or for those whose resources are inadequate. There are also private health insurance companies to pay for medical services not provided for by the government programs, which many people of means purchase. Actual medical services are subject to market forces since the majority of care is out of health savings accounts which are controlled by the individual patient. Medical care is very good, but is quite limited for those entirely dependent on government programs. Expensive care is not necessarily available, and the basic level of healthcare available to all citizens is not what most Americans would consider adequate, at least according to my experienced ex-pat source.

Eastern European countries spend only a small proportion of their GDP on healthcare and they have poor outcomes, with rising rates of various preventable diseases and deaths. When the Soviet Union collapsed, the universal government funded health programs were suddenly unfunded and, although patients could choose their own doctors, those doctors didn't necessarily get paid and the technology they needed to function well gradually became unavailable. There is no good assurance of quality of care or of practitioners, and they make less than the national average salary. They depend on illegal payments and bribes to survive, and routinely receive money or gifts which are not acknowledged but are a vital part of the survival of healthcare providers. The quality of care is spotty and terrible, or so say my informants. Extremely brief doctor visits with next to no information imparted and no assurance of quality or accuracy is the way things roll.

In the US we are very picky about who gets to be licensed to work as a doctor and there are many assurances of adequate education and skill as part of the process of becoming one. Doctors who practice medicine poorly or do things which can be considered unethical frequently lose their permission to practice medicine. Even though we sometimes get shoddy or inattentive care we expect more, which is not true in Eastern Europe. Doctors actually talk about how to delivery higher quality compassionate care and they  feel bad when their patients are dissatisfied. There is some terrible inconsiderate and stupid doctoring going on, especially in situations where doctors are overworked and burned out, but this is certainly not the rule and it is not an expected part of our culture. We sometimes become greedy and mercenary, but we have the decency, usually, to feel bad about it.

So, what I'm saying is that I don't think we should trade our system in for Singapore's, even though they do get more healthcare for their money, or Eastern Europe's, even though there are more than enough doctors there to go around.

We, here, have the luxury of a healthcare system that is lushly supported and heavily replete with technology and infrastructure. We have high standards which we sometimes live up to. We also do crazy things like spend lots of money on high end intensive care medicine for people who put no energy or resources into taking care of their bodies and who subsequently become disabled and despondent and live short miserable lives. We conversely spend no money on the basic healthcare that could keep the average poorly or uninsured middle class people from becoming very ill, and we have treatment routines that are poorly thought out in terms of value for the patient, leading to medical debt related bankruptcy. Still, every day I work I see miracles of effective, well thought out care delivered with respect and consideration. This sort of thing is not the exception, but more often the rule.

I also see too many doctors losing their joy of practicing because they are encouraged to see too many patients and follow too many guidelines and spend scarce energy on the demands of the many third party payers.

Just a few days ago I read an article about doctors who are moving to "cash only" practices, in which they are paid monthly by patients to be their primary doctor, sometimes with better access than patients whose medical care is paid by insurance. Even though a doctor who is paid by an insurance company is really working for his or her patient, a significant portion of the energy put into an encounter goes toward the insurance company, and the insurance company, be it Blue Cross or Medicare or Medicaid, always defines in some way what care we deliver. Not so in a "cash only" practice where there is no third party payer to please. Because there is no third party payer, the physician can afford to treat less patients, providing at least theoretically better care to each one. Critics argue that only the rich can afford this kind of care and that it will lead to primary care doctors being less productive in a time when primary care doctors are scarce. Since cash-only practice cuts out the very complex insurance billing piece, it is actually a less expensive way of delivering medicine, and there are many affordable cash-only practices, which are way cheaper than paying for health insurance. Someone with zero money can't afford this sort of thing, so it is not of help to patients receiving state funded healthcare. Still, it is affordable to middle class folks who often can't afford to pay health insurance premiums.

Cash-only practices preserve the intimacy of the client-provider relationship, since it is that relationship only that determines what kind of medical care happens. To build a practice, physicians in this kind of a payment scheme have to deliver care that is valued by the patient.

Combining a cash-only (also called "concierge" medicine, especially at the high end of cost and service) primary care model with a catastrophic type insurance coverage for hospital, procedure and emergency care could  help hold on to what is good in American medicine at the same time we tighten our belts and try to start delivering more cost efficient care. Primary care coverage, in the pre-paid, cash-only model, could be paid for out of health savings accounts, much like in Singapore, which could be compulsory and tax free. This would help control costs and improve quality as I've heard it does in Singapore. Most people who get good primary care rarely need expensive hospital based care so a catastrophic policy just for the expensive stuff still need not cost much. If there was some cost sharing for tests and procedures and hospitalization, there would be even more motivation to use primary care and healthy lifestyle based preventive strategies to keep from needing high tech and high end care.

Since cash-only physicians get all of the payment associated with their care, rather than paying for an insurance industry which in turn sucks up their energy, they can survive with fewer patients on their panels. The patients they see can conceivable actually use less time since there is no need to spend time and energy on dealing with insurance. Dealing with insurance companies is, actually, a big energy and overhead sink. These doctors usually treat fewer patients because this practice model hasn't entirely caught on, so it's really kind of hard to have a large panel of patients. Since, however, treating more patients means making more money, I believe our quite human greed will make us as busy as we need to be. If cash-only practices really started to make an impact on medical care and clearly were a better way to practice medicine, government programs such as medicaid might give patients the opportunity to use their benefits to pay for care.

After two years of looking at all kinds of permutations of medical communities I am more impressed with how desirable our medical system is, in terms of quality, though not affordability or access. Ideally we would not get rid of what we have that is excellent, but instead make it more available to everybody. We have such creative people in the field of healthcare and they have thought of so many ways to make their doctoring rewarding to all of us, as doctors and as patients. We should embrace some of these ideas when they are obviously good.

Medical Tourism--some ideas, and maybe what not to do.

There are many ways to visit exotic destinations, including cruises, tours, adventure travel, business related meetings and just plain going there. I always thought it would be most interesting to visit a place and practice medicine, since it would give me the opportunity to meet interesting people, do interesting things and maybe actually help. I first went overseas as a doctor about 23 years ago after finishing my medical residency. I traveled north from Bangkok to Chiang Mai where I found my way to the McKean leprosy hospital. There I spent a week rounding with the American physician who was the medical director, surgeon and primary doctor for all of the leprosy patients. There were also visiting dentists from Germany and other people who helped in various ways, including carrying on a religious mission for the Episcopal Church. It was one of the most memorable weeks of my life and flavored my ideas about medicine for the decades I have practiced since then.

I have looked for ways to visit developing countries in a medical capacity and learned about what seemed to me to be a disturbing development: medical tourism. For a significant chunk of change, a physician can visit some out of the way destination, be assured of room and board and expect to work as a doctor. I have nothing against paying for travel or donating money to worthy overseas medical causes, but it seemed to me that, if it cost thousands of dollars to go far away and do good, perhaps I ought to just donate that money and stay home. Also it seemed that if it was so very expensive to go ply my trade, perhaps my expertise wasn't actually very valuable in those places.

Haiti in 2010 offered me the opportunity to be a doctor in a far away place without actually resorting to a medical tourism agency. I traveled with friends to evaluate the needs of a few small communities on the island of La Gonave off the coast of Port Au Prince. My friends' projects included womens' rights, gardening and the economics of arts and crafts. I brought a suitcase full of remedies which seemed like they might be useful, saw patients, visited dysfunctional health centers and observed the work of a group of flying doctors who come in for 2 weeks every year to treat patients who lined up for hours to be seen. It turned out that what I could do medically in 2 weeks was close to nothing, since people needing acute care couldn't get to me or had died or gotten well all on their own. Many people did need help, but it was more of an ongoing need, and not something I could provide in the time I was there. There were some advanced cancers, HIV, non-healing wounds and severe hypertension. Undoubtedly there were tropical diseases which I couldn't recognize and there was chronic pain, mainly headaches and belly aches. When I made the trip a year later I brought close to no remedies and saw only a few patients in a clinic setting. I concentrated on talking to people about their existing health care and its obstacles, encouraging sanitation projects and handing out condoms. I sat in meetings with women and men in which I tried to address their concerns by blowing up condom balloons and telling stories with the help of a skilled creole translator which made them laugh and perhaps dispelled some rather physiologically implausible myths. In other meetings we talked about what they had and didn't have and what they wanted and what seemed possible and sustainable. Although I can't confidently say I did no harm, we did engage in mutually satisfactory dialogue.

The problem with going to places to help is that it can set up a relationship of dependence, especially if the help that is provided is something that is necessary and not otherwise available in that place. And that kind of help is also exactly what we would want to provide. Our natural impulse is to share our tremendous wealth with people we see as being helpless and destitute. The projects that are most successful in this capacity, I think, are projects that can be completed in a limited amount of time such as cleft palate repairs or cataract extractions, or ones that develop staffing and infrastructure in the country they serve that is at least partly self sustaining. Paul Farmer has done this in Haiti dealing with many aspects of chronic diseases in hospital/health care center settings, as has Jill Seaman in her work treating the deadly tropical disease Visceral Leishmaniasis in South Sudan. Provision of medical care in disaster settings is also a good idea, since its scope is usually time limited, supporting an overwhelmed medical system at a vulnerable time. Providing a higher level of care briefly in a setting where it is needed long term is not particularly useful and can upset the progress in healthcare that may have been developing organically.

Recently I visited Tanzania with some medical students who taught ultrasound to Tanzanian students and medical professionals (see the separate post here), kind of an introduction to bedside ultrasound class. I felt like the techniques were really powerful and the students made sure to coordinate with a school there and a radiologist who would probably continue with the teaching. Ultrasound machines are not so very expensive in the developing world, especially as newer, smaller machines are replacing older, still adequate ones. Increasing the baseline competence of people who will be delivering care has the potential to reduce suffering and improve patients' lives in a country with a staggering deficiency of doctors. The motivation for the project was beautiful in itself, medical students bringing the cool thing they had just learned to a place where it could really make a difference.

Another issue with medical projects overseas concerns scarce resources. When I was in Haiti I noticed that there were lots of small, short haired, gentle dogs who barked at intruders and ate garbage. Most of them were thin, and about half of them eventually had puppies. The puppies were incredibly cute and were treated with complete indifference by most people, even as they appeared to cling so very tenuously to life. Undoubtedly most of the puppies died. Nobody but us rich white people fed the puppies food scraps because there wasn't enough food for all of the people, or even the mother dog. If all of those puppies survived, a person would not have been able to put a foot down without stepping on a dog. The human infant mortality rate in Haiti is high and lifespan is short, which results in a pretty stable population in the very resource limited island I visited. If medical care is really successful and the very young and the old live longer there will not be enough food or anything else to support everybody. In some places healthier people produce more food and shelter which offsets this problem, but we need to be very careful about how we focus our philanthropy. If babies are to survive in families that can care for them, there must also be adequate birth control and improved gardening and other industry.

Should we doctors just stay home? No. Emphatically. Unless we want to. But those of us who are motivated to go forth and help people should pay attention to the complexity of the systems we are driven to change. We should open our hearts to the possibility that it is we who are benefited most by our adventures as we meet, care for and in turn are cared for by people whose backgrounds and social contexts are very different from our own.

A wonderful project teaching ultrasound in Tanzania, organized by awe-inspiring 2nd year medical students from University of California at Irvine

I have just pretty much recovered from jet lag and my anti-malarial drug induced dysphoria (I will attest to the fact that Mefloquine does have side effects) and am excited to tell the story of a project that I got to be part of.

In mid-July I got on a plane and flew to Kilimanjaro airport in Tanzania with 7 medical students from UC Irvine. UC Irvine's medical school is small and encourages its students, after their first year of training, to do interesting projects in the summer, before returning to immerse themselves in massive absorption of data and passing of standardized tests. I met some of these students while doing my mini-bedside ultrasound fellowship, when I acted as preceptor to a group who staffs a regular rural health clinic in Mexico. A project to teach ultrasound in Tanzania was in the planning and not-quite-sure-if-it-would-happen stage, and I signed on, in a not-quite-sure-I-was-coming kind of way. 5 months later I got off of a plane with medical students, took a very large and unreliable bus west to the shores of Lake Victoria and dismounted in Mwanza.

Tanzania is a mostly politically stable East African country with the worst doctor to patient ratio in the world. It provides for basic medical care of children, old people, pregnant ladies and patients with HIV and tuberculosis. Medical care outside of cities is very sparse, and in cities down to the bare bones of adequacy. Or not quite. Into this setting we place 7 medical students keen to teach ultrasound and me.

UC Irvine is on the leading edge of medical schools in teaching all students basic bedside ultrasound, first as a sort of living anatomy class and then gradually adding in understanding of pathology and diagnosis. All medical students become adept at using an ultrasound machine to visualize the human body, from the eyes to the internal organs to muscles, joints and bones. An emergency room physician and well loved clinical teacher, Dr. Chris Fox,  has been a champion of this cause and it is now well established as part of the curriculum. There are other medical schools which do this, but perhaps not as well as UC Irvine. It was there that I did my ultrasound mini-fellowship at the beginning of this year which has made me basically competent in bedside ultrasound. Teaching medical students was part of the fellowship and so I met some of them who decided that they wanted to go to Tanzania to teach people what they had learned about ultrasound in their first year.

This was an ambitious project, bound to fail on some level, and yet it didn't. It also seems to me that it is an example of exactly what we should be doing in the developing world. Its goal was to teach a technology which was appropriate for its target audience and provide materials so that the teaching could be ongoing after we left. The tricky parts involved developing a curriculum that could be learned by people of unknown educational capacity who were primarily Swahili speakers. They did get most of their post primary education in English, but not the English that we Americans speak. We also needed to make sure that ultrasound machines would be available to the students after we left and we had to find the students and a setting in which to teach. Much of this ground work was done before I even joined the project. The students sent out e-mails to various contacts who had connection to medical education in Mwanza, the second largest city in Tanzania. Many were dead ends, but through a Nazarene preacher who had been a host to one of the students on a previous trip, we were introduced to a doctor and businessman who worked at several hospitals and also owned one. He had also, as part of an NGO, recently opened a medical school for clinical officers, like a physician's assistant training program.  In addition to providing access for the UCI medical students to observe medical care in the city, he also provided us with students and a place to teach them.

I came in handy on several levels. The first was that I had just recently bought an ultrasound machine from China, in order to see what Chinese technology, which is much cheaper than US technology, was like. I had thought that the machine should probably be donated to some place where it could serve patients, but since it was not FDA approved, that place was not going to be in the US. The students had been unable to convince anybody to donate a used US ultrasound machine for their project, so clearly my machine had found its home. The students had done a huge amount of work developing the curriculum, but the power point presentations needed adjustment to our students' level of understanding, and my clinical input was helpful, both in the content of the lectures and in learning better how to do and teach actual hands-on ultrasound skills. It also turned out to be nice to have an actual MD along to establish legitimacy.

The students gave 4 classes a week for 3 weeks, with two additional days for hands on practice and one day for examinations each week, a 7 day a week commitment. Each student learned and taught a specific subject area, determined what defined competence in that area and taught the other students to be teachers in the hands on part of each class. The classes started at 5:30 every evening and lasted 3 hours, with one hour of lecture followed by 2 hours of ultrasound practice. They expected to be teaching maybe 20 students, but ended up with about 140, which required having 2 sections to reduce crowding. UC Irvine and Dr. Fox allowed the students to bring 5 Sonosite Nano ultrasound machines with them, and with my Chinese machine, that made 6 learning stations. The remaining student and I acted either as models or floated to answer questions. Our students and friends also played model after some wheedling and cajoling.

Each UCI student giving a lecture first delivered the lecture to the rest, with each word examined and critiqued. They then spent the day of their first lecture polishing their slides and practicing speaking much more slowly and clearly. The results were beautiful lectures, at a level the students could understand which covered the most important points. They skillfully incorporated repetition and simple questions for the audience to make sure that at least a good number of the students understood the material. The same material was presented again during the practical sessions. With regard to our audience, there were excellent students and not so excellent students, but the majority of them became competent in the subject areas that they were taught. Some of our audience had MD and RN degrees and worked in the community. Most were students at the school for clinical officers. They all learned to ultrasound the heart, abdomen, lungs, pelvis, the shoulder and hand and learned the very basic physics of ultrasound. They learned to turn the machines on and off, change the transducers, adjust the various knobs to get the best pictures and to store patient information. They learned that the anatomy they saw in books was really, truly present inside real human bodies. They will never be afraid of ultrasound technology.

Our doctor host has bought ultrasound machines both for his classes and for a couple of the district health centers in Mwanza, which will be used by those of our students who practice in those centers and also by part time radiologists, if they are available. Although our brief course did not cover enough pathology to make the students capable of diagnosing diseases in all of their subtleties, the plan is to have a radiologist who works with our doctor host continue to teach. The ultrasound machines in the district health centers will primarily be used for basic obstetrics, identifying fetal hearts, measuring fetal heart rates, evaluating the position of the baby to identify high risk presentations. The MD students will improve at this with practice and will need to use local as well as online resources to develop competency.

In a year, barring mishap, we will go back and see what the project has unleashed, if anything. Our impression was that the Tanzanian students took to ultrasound like fish to water, and I suspect their abilities to use the technology to the advantage of their patients will progress faster than mine did. East Africa already uses ultrasound far more effectively than most of us do in the US, due to lack of other affordable technology, and it seems likely that our introductory class will feed into a knowledge base that is already becoming well established in that area of the world. One of the directions that I think we should go before returning to Tanzania is to find out where the centers of excellence are in East Africa so that our piece can be incorporated into care improvements that will develop organically.

A question that arises in connection with this project and also with the increasing use of ultrasound at the bedside in the US, by non-radiologists, falls in the category of "is a little knowledge a dangerous thing?" Radiology technicians spend thousands of hours learning how to image the human body, and radiologists then interpret the images that the technicians record. Radiologists are MDs, with 4 years of medical school and often a rotating internship year prior to spending years in dark rooms peering at images of human anatomy in health and disease while being mentored by teaching radiologists in their residency programs. Cardiologists read echocardiograms obtained by echo technicians and look at these images with eyes that are informed by years of familiarity with the human heart. The three dimensional knowledge of anatomy that my colleagues the radiologists and radiology technicians have is truly inspiring. They are able to see things in images that I can't and interpret them in the light of years of experience. Still, when I can see inside a person with an ultrasound as part of my examination, that is extremely powerful, and improves my ability to make a diagnosis and to choose which official imaging tests will be most useful. In Tanzania, the medical students, with only one year of training, were able to help the Tanzanian doctors identify a pregnant woman whose baby was in distress and a few women who, at term, had babies in the breach position, which were not identified on physical exam. These women did not have the advantage of a fully trained radiologist to evaluate their pregnancies, and the limited information we were able to give them was profoundly helpful. In the US and Europe there is active research about how bedside ultrasound can be useful. A few studies have shown that it can diagnose small bowel obstruction when used by resident physicians in emergency medicine, with a few hours of training. Despite the difference in backgrounds, radiology residents were no better at it than ER residents. Medical students with handheld ultrasounds were significantly better at making cardiac diagnoses than cardiologists with stethoscopes, in one study at the Cedars-Sinai School of medicine. Ultrasound is much more sensitive for pneumothorax than x-ray, which is the present standard of care, and requires very little training to perform accurately. There are lots of other examples.

My experience has been that it is very possible to miss important diagnoses with ultrasound as a beginner and to over-interpret findings, and that learning to be more accurate is a constant part of the process of using it as a tool. I think the little knowledge that the Tanzanian students got as part of our course will probably be very helpful, and more so if their training with ultrasound is ongoing and supervised by a radiologist at their school. Ultrasound is a natural extension of the physical exam in this setting and can cost nothing after the purchase of a machine. As more medical professionals become comfortable with the technology, they will be likely to use an ultrasound for answers to clinical questions, just as they might pick up an otoscope to look in an ear, or a pair of glasses to more accurately see a skin lesion. This will never replace the skill of an official radiologist, but in most of Tanzania these are few and far between.

The State of our Health 1990-2010, the very brief version

I was interested to read the recent article in the Journal of the American Medical Association entitled The State of US Health 1990-2010, the Burden of Diseases, Injuries and Risk Factors. It is a vast compilation of data from various surveys and data banks using the methods of the Global Burden of Diseases, which has been performed for 50 countries, allowing comparison on a variety of measures. The article is a clear presentation of that data, and I won't repeat that, at least not much.

In the last 10 years the US has had a significant improvement in life expectancy, from 75.2 to 78.2 years. This is a good thing. Other countries, though, had more significant improvements, so we dropped in ranking among these countries from 20th to 27th, behind Chile and just ahead of Poland. We also spend much more money on health care than they do. We are the very top country in terms of percentage of gross domestic product spent on health care, at over 16%, and Chile spends about half that.

The years of life we spend with disability is actually about stable, at about 10.5 years, and we rank only 6th on that metric, which surprised me. I see so many patients treated with life sustaining hi-technology interventions toward the end of life that I thought this would mean that the US would have a higher proportion of walking wounded than the rest of the world, but that isn't true. At least not as it is measured in this study. We have moved down a point from 1990, at which time we were in 5th place.

We die mostly of heart attacks. Our health is significantly worse because of increasing obesity, diabetes and inactivity since 1990, which increase heart attacks. These are things we could change without spending more on health care. It is interesting that we have figured out how to live longer even though we are less active and fatter. Medical science is full of miracles.

Medical Care in Tanzania--How does this East African republic take care of its people?

I just got back from Tanzania, where I supervised 7 medical students who were doing a couple of really awesome ultrasound projects in Mwanza, the second largest city in this East African country. I will write about the projects in a different blog. Mwanza is right on the shores of Lake Victoria, a huge but relatively shallow body of water which Tanzania shares with Kenya and Uganda. Tanzanians are friendly, and the weather in Mwanza was perfect. We were at the tail end of the rainy season, but saw almost no rain, and the temperature was perfect, in the mid 80s during the day and cooling off at night. Because of the lake, there are huge numbers of birds, egrets, cormorants, storks, kingfishers, brightly colored starlings, and lots of frogs who became vocal at night. Tourists do not come to Mwanza, probably because there are more jaw-droppingly amazing places nearby, including Mt. Kilimanjaro, the island of Zanzibar and the Serengeti. People speak English and Swahili, but mostly Swahili, which makes getting along a little complex. We had wonderful hosts who helped with the language issues, and we all picked up a working knowledge of Swahili, mainly stuff like "hello" and "thank you" and "your liver is fine."

Our projects involved visiting several hospitals in Mwanza and talking to many healthcare professionals. I was able to go on ward rounds with some of the doctors we met and wandered around one afternoon in the very large public hospital, Bugando Medical Center, which has a medical school and is loosely affiliated with Cornell. There were many hospitals, of varying sizes and capabilities. There were district health centers which were publicly funded and provided care to outpatients and had wards for patients who were too sick to return home.  There were dispensaries, which despite their title, did not just act as pharmacies, but also offered clinic services such as doctor appointments, birth control, prenatal care and HIV monitoring. There were also private hospitals which were a little less crowded than the public ones, a little more cushy and required that the patient pay for their own care completely, except in rare cases such as having health insurance (usually only government employees) or having any of the conditions which the government pays for in full. Doctor visits were both by appointment and drop-in, and there was 24 hour availability of doctor care, though doctors were pretty scarce on nights and weekends. The big hospital, Bugando, had a cafeteria and would serve food to the patients, but that was a rarity, and generally families were expected to bring the patient food and drinks.

In the private hospital the rooms were semi-private, 2 beds to a room, 1 person per bed, with a mosquito net. In the public hospitals the wards were open, with 10 or more beds per room, and no curtains between patients. Some had mosquito nets, some didn't.  Usual necessities in US hospitals, things like blood pressure cuffs, oxygen and suction, which are attached to the wall, were absent. Most facilities had the ability to do a chest x-ray, some could do an ultrasound, but usually just for female problems and obstetrics. There were very few CT scanners and no MRI in the city. Basic surgery was available, but more complex issues had to go to the largest city in Tanzania, Dar Es Salaam, which was over an hour away by airplane and 10 hours away by car or bus. The nicest hospital room I saw was a cement floored 2 bed room that was about 200 square feet with a window, a door, mosquito net, bedside table, sheets and an ancient plastic covered pillow.  It wasn't dirty, but neither was it scrupulously clean. There was no electrical outlet or fan, though the temperature was comfortable.

The physicians I saw interact with patients were mostly polite, but clearly didn't spend much time either in examining the patients or taking a history, and it was rare to find any evidence that full vital signs were taken after the patient was admitted, though abnormal ones, such as blood pressure and temperature, were repeated at least daily. Almost everyone got a blood smear for malaria, a urine test, a stool examination for worms and sometimes an antibody screen for typhoid, which was often false positive. Chemistry testing was only rarely done, and not always available, and blood counts were available but not often used. HIV testing was available, and most hospitals had the ability to test CD4 counts to evaluate patients with known HIV.

Prenatal care is available to patients free of charge, as is birth control. Patients are tested for HIV when they first present for prenatal care and receive peripartum prophylaxis to prevent vertical transmission. Vaccination for measles, mumps, rubella, polio, BCG for tuberculosis, hepatitis B, diptheria, pertussis and tetanus are all available and encouraged. There were always lines of mothers with babies at the health centers we visited, there for vaccination. There is no cost to the patient for care for children under 5, pregnant women, patients over the age of 60 and patients with HIV/AIDS or tuberculosis. Women are required to receive prenatal care and deliver their babies at hospitals, though this is far from universal in practice. Since there is very little access to blood tests or ultrasound, it appears that the primary purpose of prenatal care is to identify patients who are clearly at high risk of birth complications and to treat and prevent the spread of HIV.

Sick patients who presented to a hospital would not be denied care, even if they had no money to pay for it, though if they arrived less than dangerously ill, they would be expected to pay for care if they did not fall into a group for whom care was free. Often, regardless of symptoms, patients were treated for one of the top ten diagnoses, based on the few lab tests that were done, and sometimes were treated based on the most common diagnosis associated with their primary complaint, without confirming lab tests, imaging or examination findings. The top ten diagnoses were malaria, typhoid, ascariasis, urinary tract infection, sickle cell disease, pneumonia, pelvic inflammatory disease, HIV, infectious diarrhea and diabetes. I also saw patients who had been identified with hypertension and renal failure (one 90 year old patient), cirrhosis and hepatoma (a young woman who probably had congenital hepatitis B), measles (an unvaccinated baby) and severe iron deficiency anemia. It is interesting that in the fast food stalls they sell little sticks of clay for pregnant ladies to eat. Eating clay (and laundry starch and dirt) is called pica, and is strongly associated with iron deficiency in pregnancy. I do wonder if there may be a significant under recognized prevalence of iron deficiency in pregnancy.

Malaria appeared to be the most common diagnosis in the patients who were hospitalized, and also was a pretty common diagnosis in the outpatients. A thick blood smear was examined in most of the patients who presented with any one of a number of vague complaints, including headache, weakness and low grade fevers. If parasites were seen, they were treated with appropriate medications, but many people in Tanzania harbor malaria parasites and are not sick with malaria and probably don't require treatment. I'm not sure if the inpatients getting their intravenous quinine actually were suffering from malaria, though I'm sure at least some of them were.

IV fluids are generally available as are appropriate drugs for HIV, malaria and serious infections. There is very little choice in medications for hypertension and even a patient with lethargy due to extremely high blood sugars did not warrant an insulin drip since there was no accurate way to deliver it. I saw one older woman whose blood pressure was 250/120 who had run out of her medications because they weren't available at the health center due to government shortages. She was sent to a pharmacy with a prescription which she may or may not have been able to afford to fill. HIV medications and some of the expenses for the health care centers which provide both the meds and HIV testing are funded by the United States Agency for International development (USAID.) This organization also helps fund maternal and child health and tuberculosis treatment, which has improved numbers like prevalence of HIV and death rates. USAID also is involved in promoting use of condoms for prevention of HIV, which is unfortunately not terribly effective in Tanzania. Birth control with pills or the intrauterine device (IUD) are enthusiastically accepted, but in the clinics I visited I heard that condoms were not very popular, and outside of clinics were rather expensive.There has been a huge increase in the number of people being tested for HIV, which may decrease spread of the disease, and treatment will also reduce transmission.

Tanzania has the lowest ratio of doctors to patients in the world, which may be due to a large refugee population since it is one of the most stable countries politically in East Africa. In Tanzania a person can be called doctor if he or she has completed any of 3 different medical education programs. After 3 years of medical education, after the equivalent of high school graduation, a person can become a clinical officer and can provide medical care in a clinic with some supervision. After 3 more years that person can become an assistant medical officer, with more autonomy. The MD program is a full 5 years, and includes an internship year. If a person starts with a clinical officer degree, he or she can work as a doctor while finishing an MD degree. The education being offered to clinical officers appeared to me to be pretty rigorous, including anatomy and physiology as well as practical skills that would be part of the work of a hospital nurse in the US. My Pocket World in Figures put out by the Economist magazine says that Tanzania has 145,667 patients for each doctor, but it is unclear if they include clinical officers and assistant medical officers in this count. It has a prevalence of HIV/AIDS of 5.6% in people between the ages of 15 and 49, 12th in the world, but far better than Botswana in which 25% of this population is infected. There is very little smoking and drug abuse is uncommon, though there are alcoholics. There is no concept of drug treatment programs or even mental health care. Pain is treated only with acetaminophen or oral or parenteral nonsteroidal anti-inflammatory drugs. There are no opiate pain medications in the hospitals I visited, even though physicians recognize that these would be merciful in many circumstances.

I am very impressed by the level of basic medical care provided in Tanzania, and people do have a kind of safety net should they become very ill or injured. Many of the big-ticket, costly items of medical care are heavily subsidized by the US which pretty much bypasses the government, assuring ongoing care of high risk individuals even when government budgets get tight. Still, Americans would definitely rank their own health care system far above Tanzania's. Availability of technology such as imaging and blood tests is vital to making correct diagnoses, given the huge variety of treatments we have to offer in the US, and we have come to expect at least some level of a doctor/patient partnership in making decisions about our health care. Americans expect basic comforts, including appropriate and individualized diets as well as clean and comfortable beds and rooms, which are not at all basic in Africa.

Be back soon!

After doing a week of night shifts, I went to Newark, NJ to take a 3 day course to get me sufficiently full of details of physics and anatomy to take the written test for ultrasound certification (RDMS). It was put on by ESP Ultrasound and is intended primarily for certification of technicians, so there were many mostly young women there who had very different backgrounds than I did. An experienced ultrasound tech knows tons of intimate details of anatomy after visualizing its inner mysteries daily. I have much to learn. As for how those intricate parts behave in health and disease, I definitely know more. The physics of ultrasound is complex and fascinating, but that was not what was covered in the course. It unabashedly provided us with the information we would need to pass the test. I am grateful, if unenlightened. I then hung out with friends in rural New Jersey for a week forgetting anything medical, singing and laughing and eating good food.

Today I head to Tanzania with my Chinese ultrasound machine and several University of California medical students to do a study on ultrasound and Malaria diagnosis and teach medical professionals to start doing bedside ultrasound. This is what I expect we are doing, but from my experience in Haiti, we will probably do something else which is, as yet, a mystery. I will probably not write anything while I'm there, but then it may turn out that it is perfectly possible to post from some random computer in an Internet cafe. I'm sure, at the very least, I will post something by early July, most likely something exotic and fascinating. I will leave my cheap but adequate Chinese ultrasound machine behind and will have a good idea about how it works and some photos to post. See you in July!

How to take a doctor sabbatical

In October of 2011 I left my job of 17 years, which I loved, mostly, and started a 2 year sabbatical. Since sabbatical implies that there is one year of rest every 7 years, I have built up at least 2 years since finishing medical school in 1986. Nobody in my office or medical community did sabbaticals, but we discussed that it would be a great idea when we first set up our practice. Various life changing events including 1 death, a retirement and the launching of 2 children required a response from me, and thus the sabbatical.

Physicians ought to do this. We are frequently overworked and burned out and rate ourselves as undercompensated for what we do despite the fact that we belong to one of the best paid occupations in the US. We develop a sense of duty and dread and get so busy trying to hold families and practices and administrative responsibilities together that we have neither the time nor the energy to figure out how to rejuvenate ourselves. We end up not loving the job that initially energized us through gruelingly difficult medical school and residencies. We were mostly the best and the brightest, the motivated high school and college students with a drive to serve others and the sparkle to get ourselves into competitive medical schools. We become hurried and harried, with compassion fatigue and dark circles under our eyes. We burn out and become worse doctors and serve our patients less well and burden our families with our ill humor.

I gave notice at my traditional internal medicine practice and got hooked up with various locum tenens companies. I found out that, as a hospitalist, I could make more than enough money to support myself. By working blocks of 7 day, 12 hour shifts at hospitals in various locations I could support various educational projects and travel since locums hospitalist medicine is so much better compensated than my regular job was. I wrote about how that process worked here.

I also did the things that I had regretted not being able to do for 17 years. I took lots of continuing medical education. Wherever there was a good class in something I wanted to learn, I went there. When my son went to college, I did a road trip with my husband across 4 states to deliver him and stayed with my sister. We camped along the way. I did a meditation retreat for a week. I went to the Republic of Georgia for 3 weeks and learned to sing new weird folk songs and performed with a small group at a symposium there. I learned to do bedside ultrasound and had enough money, through my lucrative locums jobs, to pay for a small ultrasound machine and a full month ultrasound fellowship in California. I took off enough time to really study for my internal medicine boards and took the test to requalify, which for me was voluntary. I applied for fellowship in the American College of Physicians, attended their meeting and walked in the ceremony to get the fellowship. It was in San Francisco, so I got to walk to Chinatown and eat good Chinese food at the breaks and buy cheap Chinese underwear and tea. I spent some quality time with my dog, walking on the mountain near here. I am visiting friends on the east coast this next week, whom I have wanted to visit for years, but never took the time. I am also going to Tanzania in 2 weeks to supervise medical student researchers and teach ultrasound. On my to-do list are trips to India to see how their medical system works (perhaps I could teach bedside ultrasound there) and to South Sudan to work with a friend who treats visceral leischmaniasis.

I also saw over 1000 patients many of whom were very sick and all of whom taught me something. I saw the inner workings of 7 hospitals and met dozens of new colleagues, who have also taught me stuff I could never get from books or conferences. I learned how to sleep so I could function on night shifts, learned how to use about 5 different computerized medical record systems, how to apply for medical licenses and that I am very hard to fingerprint. I learned how to be very efficient with my time, and that I am not fast and don't care to be. I learned how to pack a suitcase or a car so I don't forget the important stuff, and various things about airport security, including the fact that it feels nice to be patted down when you are cold and tired.

So...some tips for the doctor who is interested in taking a sabbatical:

1. Do it. It's a good idea.
2. Do something difficult. If you do locum tenens hospitalist work, that counts. Intense work that taxes you, combined with a healthy amount of sleep deprivation leads to personal growth, so long as you don't do it all the time.
3. Do something that is not difficult. Maybe even just a few weeks where you only hang out and garden and go for walks.
4. Do something exotic. Once you are no longer burned out and overworked, this is really fun.
5. Do something that is not medicine.
6. Learn something. It's not a bad idea to take some sort of organized review that leads to a recertification, but there are so many interesting things to learn, in and out of medicine. Go for it.
7. If you do locums, set money aside for income taxes. You are an independent contractor and none of what you make is deducted ahead of time. April 15th can be surprisingly painful.
8. See to your family. They will miss you when you are out and about, pursuing your dreams.

So what, one may ask, about my patients who I have deserted, and those that other sabbaticalizing doctors will desert? What goes around comes around, and they will be better served eventually if we love what we do and are better at it. 

I am not done with my sabbatical, but can now visualize a time when I will work here in my hometown and have a regular schedule. I will probably do some "moonlighting" since working away is still interesting. I would like to do both outpatient and inpatient medicine and use what I have learned to help move health care in the right direction, and haven't quite figured out what that is going to look like. This, of course, is an issue with a sabbatical, the re-entry. I will have to design my job in such a way that it continues to allow me to do the things that, when I am on my deathbed, I will look back upon with satisfaction. Right now I'm thinking I'll buy an old ambulance, paint "Doc-o Truck" on the side (like the taco trucks that make those excellent tiny tacos), do mobile medicine in underserved areas, support this clearly financially untenable enterprise with hospitalist shifts, and write about what happens. More on the Doc-o truck later.

Apollo Munich Wins Best Employer Brand Award

Institute of Public Enterprise (IPE) has conferred Best Employer Brand Award to Apollo Munich Health Insurance Company for being a Role Model and Exemplary Leader in benchmarking talent and HR practices by:
• Scaling and managing complexity.
• Committing to continuous improvement by encouraging and nurturing the value of learning and a mind-set of excellence through continuous training and development.
• Pledging commitment to professional growth.
• Measuring organizational health and inculcating values that help in achieving the vision of a social employer and future leader.

Apollo Munich Health Insurance is a joint venture between Apollo Group of Hospitals and Munich Health. It is a standalone health insurance provider coming up with several innovative healthcare products. Working under the guidance of two proficient partners, the company proudly says “We know Healthcare. We know Insurance.” Taking both healthcare as well as insurance needs into consideration, Apollo Munich comes with products that can take good care of health of the person along with access to uninterrupted insurance services.

Since the year of its inception, 2007, Apollo Munich has come a long way. Having established itself in Indian health insurance market with a reputed name and trusted services, it has served millions of families. Having formulated plans against all kinds of health risks, it has provision for all. People of all ages can find shelter under the canopy of its comprehensive health plans. Moreover, the company ensures that it lives up to the promises made. Such consistent and focused efforts has lead Apollo Munich to win the award of Best Employer Brand.

Building upon the clear mission of “Let’s Uncomplicate”, Apollo Munich introduces easiest ways for acquiring health insurance coverage. Providing genuine information about all its products in simple policy wordings, it enables people to develop a clear understanding of the policy coverage.

Apollo Munich understands the fact that healthcare needs differ from individual to individual. Thus, to allow hassle free healthcare to all, it has devised plans of different kinds. Keeping an eye over the changing needs of people, it has formulated plans that can serve them rightly. Being a pure health insurance company, it concentrates purely on the medical care needs of masses. Building upon the clear set of values “Inspiring passion, Managing Relationships, Being responsive to customers, Delivering on our promises and Thinking and Acting Transparently”, Apollo Munich aims to offer best health insurance services along with customer satisfaction.

Beginning its journey with one health plan, Easy Health, today Apollo Munich has a long list of healthcare products to offer. It covers health risks generated during accidents and travel. More so, from a child to senior citizens of country can get insured under the preferred plan. Time and again it keeps introducing plans with innovative features. They entitle the insured people to enjoy first of its kind benefits in health insurance sector. Having provision for all, its plans have been the choice to millions of individuals and families.

Having bagged several awards for its products, Apollo Munich has proved its concentrated efforts. Coming up with flexible products, it takes care of citizens of country. Company has been established with a broader vision of improving healthcare condition across the country. With this view, Apollo Munich started its journey with the prime objective to help stay healthy regardless of worry of healthcare expenses. The company logo- Happy Man depicts the vibrant colors that have specific significance. It collectively illustrates its aim of assisting people in making their life healthy and therefore happy. This has resulted in Apollo Munich reaching out places and measuring boundaries. With a view to move ahead, it aims at going higher bringing further improved services.

Dear FDA (Food and Drug Administration), Please stop regulating the wrong things (ultrasound machines and fecal transplantation).

The Food and Drug Administration was created in 1927 in order to carry out the mission of the Food and Drug Act put into effect by Theodore Roosevelt in 1906. In the early 1900's and before, patent medicines killed and maimed people in gruesome ways and adding chemical substances to foods to mask the fact that they were rotten or substandard was felt to need some sort of legal response. The FDA initially was predominantly an organization designed to regulate sales and interstate transport of foul and dangerous foods and medicines.

Over the years the job of the FDA has expanded as technology has advanced, to include evaluation of new drugs and devices, including those designed and produced outside the US. The FDA has undoubtedly protected countless people from poisonous and malfunctioning medical products. There have also been stories of egregious failures of the FDA (see this New York Times article of 2009 regarding their inability to police conflicts of interest in biomedical research) which are often attributed to lack of funding and overwork.

In the last few weeks the FDA has caused me, personally, significant grief and frustration. I am shocked and angered, as a citizen, when cortisone products containing mold result in death and disability in hapless patients and when food additives which contribute to a nationwide obesity epidemic go unchecked, but a couple of things hit closer to home than these.

I have been shopping online for the last 8 months for an affordable ultrasound machine that I can use to train myself in some of the more specialized applications of the technology. I can't see spending $40,000 for an American machine, so I have been looking at who in the world produces ultrasound machines for the rest of the world, which also can't afford the super expensive technology. I found the perfect machine, a laptop sized scanner with 4 different transducers, so I can get good at vascular, thyroid, musculoskeletal and intestinal ultrasound, and was able to buy it from the Chinese manufacturer for a bit over $4000. I thought that after learning how well it worked it would be something that I could afford to donate to a project overseas. It was delivered to the shores of the US last week and is probably not going to ever get to me because it is not FDA approved. Ultrasound machines are felt to be of low to minimal risk to humans, so the FDA approval process is not as long as for, say, invasive medical devices, but it is too laborious and expensive for Chinese companies to go through, especially with their lower end models which they can sell just fine everywhere else in the world. I wrote the FDA investigator a letter explaining my plans but I think the chances of getting my machine are pretty poor.

The other potentially life threatening stupidity regards the increasing use of fecal transplant to treat a very difficult to treat healthcare associated infection, Clostridium Difficile. I have written about this in several blogs, and will not further harp upon the details, but repopulating the intestinal flora of a person who has this particular infection (and probably several other conditions as well, such as inflammatory bowel disease and even obesity) really works, carries minimal risk compared to our standard of care and is really cheap. I now read that the FDA has decided it needs to regulate fecal transplant. They want to treat it as an "investigational new drug" (IND). This classification is primarily to protect the consumer while fast-tracking a drug which clearly is needed into regulated use. According to the FDA site, the purpose of FDA regulation of IND's is to regulate interstate transport and establish safety before development and marketing. These two purposes are completely irrelevant to fecal transplant, which never needs to be transported across state lines and needs no development or marketing. Also, if the substance to be approved is poop, I submit that poop is not one thing. Even if the FDA did approve or reject a particular stool as being safe and effective, that is hardly known to be the case for a different sample. Why, you may ask, is fecal transplant important to me personally? It is just such an fantastically great idea, with world shifting implications in terms of living in healthy harmony with our commensal bacteria, and it has also saved a couple of my patients.

Both of these situations are excellent examples of how the economics of medicine in the US, with endless deep pockets provided by insurance companies of all ilks, fails to support the development of therapies that do not make money and are inexpensive. If a therapy or device does not have a powerful company or set of financially interested advocates to get it into accepted practice, it can potentially go nowhere for a long time. And if such a thing does make it up through the grass roots to acceptance, the FDA is right there to throw up a roadblock.

So why? If they have inadequate resources and lots to do, can't they perhaps go out there and protect us against dangerous things instead of fussing with fecal transplants and my ultrasound machine? There was an outcry early in the AIDS epidemic at which time the IND fast track and several other modifications of FDA procedures helped to allow medications into the market for patients dying for lack of options. It took some really powerful physician advocates and dying poster children to get these changes made. Perhaps a champion will stand up for the many other great ideas failing to thrive due to inappropriate regulation.

Why are health insurance premiums still rising this fast? Blue Cross proposes hike of 24.7% for county employees.

This morning when I got the local paper, I was greeted with a lead article which reported that Blue Cross of Idaho was asking the county to pay 24.7% more for employee's premiums in 2014. Nobody can afford something like this. They will, of course, start looking for alternatives.

I remember similar situations in the clinic where I worked for 12 years, a group that had about 35 employees. We would be happy enough with our insurance plan, which cost too much but did give us reasonable medical coverage, and then the premium prices would rise, significantly faster than did our revenues. We would scramble around, getting quotes and weighing options, engaging in negotiations and eventually would have to switch everyone to a different company with slightly worse healthcare coverage and fill out many forms, with no guarantee of a stable premium or benefits for the following year. As a physician I had access to the health insurance for the group, but very soon opted out because it was so expensive, had benefits I felt I wouldn't use, and because I could actually do better in the individual market.

My individual market experience was not without its disappointments, as I faced 20+ percent premium hikes yearly, but did allow me to decide on a plan based on my family's individual needs (which, thanks to the irrational bounty of the universe in its inscrutable unfolding, were minimal.)

But since that time we have passed the Affordable Care Act (ACA), a healthcare reform bill that seemed to have promised to make insurance companies behave as good citizens. Is it really possible that Blue Cross will hike premiums by 24.7% in one year to our county employees? And this is a rather large group of customers, a significant negotiating force. What will individually insured people and smaller groups see this year?

I went back to the affordable care act to read what it actually says about insurance reform. What changes has it made or will it make to allow us all to be insured in the America of the future in which we can afford basic and not so basic healthcare?

• In 2010 the Patient's Bill of Rights went into effect which gradually increased the cap on lifetime payouts for essential medical costs. Now this cap can be no lower than 2 million dollars, and by 2014 there will be no cap. Children with pre-existing conditions cannot be denied coverage, and that will eventually be broadened to include pretty much everybody. Adult children up to age 26 can stay on their parents' insurance plans, even those funded by employers. Certain preventive care, including cancer screening and diabetes treatment, need to be paid in full by insurance, without co-pay.  Patients with medical conditions or pre-existing conditions can get what should be affordable insurance through the government under the Pre-existing Condition Insurance Program, if they have been uninsured for over 6 months (which sounds pretty bad to me, definitely courting disaster to wait 6 months.) These reforms are not universal--certain "grandfathered" health insurance policies which have remained essentially unchanged for years can continue as they are, not complying with these regulations, and in 2013, 27.4% of employers still offered grandfathered plans to their employees. The number of people on these plans drops significantly every year.

• Several regulations directly influence health insurance companies' costs and profits. In 2011, insurance companies were required to spend at least 80% (called the "medical loss ratio") of the money they took in on patient benefits (85% for large group plans.) Above that, 15 to 20% can go to administration costs and profits. If the entire 80 or 85% is not spent on benefits, it must be sent back to the consumer as a rebate. There are mixed reviews of how this has worked. It was thought that it ought to cut costs, but it kind of shoots itself in the foot. If insurers want to fund all of the profits and administration that makes them big and powerful, they just have to increase premiums and be sure to pay out at least 80% of those premiums on medical costs. If they can keep increasing premiums, then they don't have to do any work at all to decrease healthcare costs, because paying more for healthcare means they can also keep more money in profits and administration. Health insurers also can't save up for a bad year by making more profits on a good year which encourages strategic premium hikes, or so one economist says.

• The ACA also requires states to review excessive premium increases, those more than 10% per year. Most states have that process up and running, with significant financial support from the federal government. There have been stories of health insurance companies backing down from rate hikes due to this process. I wonder, though, if they have responded to this by raising the initial asking price because they expect to have to bargain to reach a compromise. Insurance premium costs have gone up 131% between 1999 and 2012, which sounds like around 10% per year. This is, of course, far faster than the rise in our gross domestic product but would seem like a sweet deal compared to the 20+percent yearly increases that I have seen with my individual plan, and this proposed 24.7% increase that Blue Cross proposes here this year.

• All insurance companies have to contribute to "transitional reinsurance" funds to help insurance companies pay for very expensive patients, as an incentive for them to provide coverage. This money goes to nonprofit reinsurance agencies which pay the insurance companies that insure these patients to cover their high costs. This also goes to fund a program which keeps early retirees on the insurance that they had received from their employers while they worked. The ACA also allows lower income taxpayers to get their health insurance tax rebates before the end of the year so they can actually use them to pay for health insurance. These regulations are called "Premium Stabilization Programs" which is kind of an overstatement, since premiums don't appear to be stabilizing. The transitional reinsurance fund seems like an awfully complex way to solve this problem, having insurance companies pay other insurance companies to pay them back for providing benefits. These programs are, however, temporary, and will be phased out in 2014 as nearly universal health insurance options become available.

• In 2014 the ACA introduces the health insurance marketplace. This will be an online clearinghouse of health insurance options including many less expensive and subsidized programs for low income households. Many more patients will be insured through fully funded Medicaid programs, and side by side comparisons of health insurance plans will improve competition and make becoming insured easier. As I look at it, this will be better than what we have now, and allow many more people access to basic healthcare. I don't see it reducing costs in the long run, though. Still, civilized countries make basic healthcare available to their citizens, and it behooves us to join the ranks of civilized countries in this respect.

What will happen with this 24.7% premium hike that I read about in the paper this morning? I suspect Blue Cross will be talked down to some lower number by the state government. Premiums will probably still increase painfully, by double digits. The county may opt for a less expensive option and if the health insurance marketplace really fulfills its duty, in October of this year they may be able to shop for the best plan online. Whatever plan they decide upon will have excellent coverage for basic preventive services, because that is mandated by the ACA. Employees who want to opt out will have some reasonable options for individual insurance and some of them may qualify for subsidies. Some individuals and families will choose to go without insurance and pay penalties which will still be cheaper, in most cases, than paying for insurance. They will gamble that their health will remain good through the year. As insurance companies pay for more of healthcare, unless we make some deliberate changes, that care will continue to get more expensive, and those who choose not to be insured will find costs of unexpected injury or illness devastating financially (which they already do.) I look forward to getting my yearly love note from Regence Blue Shield of Idaho, letting me know what expensive options exist for me as my super-high deductible plan becomes obsolete in 2014. Stay tuned.

A better POLST (Physician's Orders for Life Sustaining Treatment) and informed consent for resuscitation: can we do this better without "playing God" ?

To resuscitate or not to resuscitate--that is the question. Whether 'tis nobler to beat the heck out of a person on his or her way out in the hope of saving his or her one precious life, or to allow death to proceed at its own pace with expectation of a peaceful passing.

The United States has come a long way in the last 2 decades since 1991 when the Patient Self-Determination Act was instituted. In most hospitals patients are asked what their wishes are regarding resuscitation and many states have instituted POLST (Physician's Orders for Life Sustaining Treatment) forms which spell out which interventions are acceptable to individual patients when they are very sick, things like blood transfusions, antibiotics, feeding by nasogastric or gastric tubes, intubation and ventilation and chest compressions and electrical cardioversion in the event of cardiac arrest. Theoretically we discuss these things with every patient when they come into the hospital, but we don't really do it very well which results in misunderstandings and needless misery.

When the patient is competent to discuss life sustaining treatments the conversation often goes like this:

Doctor: What would you want done if your heart were to stop? Would you want us to do chest compressions and put a tube down your throat so we can support your breathing?

Patient: (thinking, "Why are they asking me this? Am I gonna die? Of course I want them to save me. My heart could stop right now! What about my grandkids?") Sure I'd like that. Just give it a try. But I don't want to be kept alive if I'm a vegetable.

Doctor: (thinking, "I sure don't want to break all of this nice guy's ribs and traumatize his upper airway and, if we did get his heart started again, have him helpless in the ICU while we try to decide whether to put a feeding tube down and send him to a nursing home. With any luck he'll die in his sleep when he's not in the hospital.") OK then. We'll put you down as full code. Just sign here.

I went online to see how other countries do this, and found that there is a great deal of variation. In many middle eastern countries resuscitation is performed on all hospitalized patients in the event of cardiac arrest, regardless of patient or family preference. In Australia there are many different policies which are different in different hospitals, and may or may not involve patient and family participation in decision making. In England the patient is involved in these discussions if he or she is competent, but if not, the doctor makes the decision, and if the family has an opinion this is taken into consideration but   the doctor really has the final say. I read an online discussion about an 86 year old nursing home resident in the UK with heart failure who was admitted to a hospital and suffered a cardiac arrest. He did not have CPR due to a nurse thinking he had a DNR order, which he did not. After the event it was agreed that CPR would not likely have saved him, but it was the discussion after the article that was particularly interesting. About half of the people said that it was terrible that mistakes like this ended in a patient not getting life-saving CPR and that in many cases doctors made these decisions and "played God." The other half were people who said that they had seen CPR on old people and it was brutal and hardly ever worked.

Clearly doctors should not get to or have to "play God." Clearly, also, people who we ask to make these decisions, patients or families, usually don't know what we are really talking about when we ask them to make a decision about resuscitation ("code status.") Physicians are much less likely than our patients to request resuscitation in the event of cardiac arrest. I think our values are pretty much the same as those of our patients, we just know more about what cardiopulmonary resuscitation and its aftermath really look like.

So here is a good solution that preserves the autonomy of the patient while allowing the physician to do his or her job, which is taking care of the patient while following our Hippocratic Oath to "do no harm".

Cardiopulmonary resuscitation (CPR), intubation and ventilation are medical procedures, just like a tonsillectomy or a hip replacement. There are expected risks and benefits. The risks are not insignificant and the magnitude of the expected benefits vary with each patient. If a patient really wants CPR, he or she or a surrogate decision maker should sign a consent form  (well in advance of experiencing a cardiac arrest) which includes risks and benefits. The benefits, of course, would be to live and recover enough to be able to leave the hospital. In the least complex patient, 1 in 5 of those who have a heart event which requires CPR can be expected to survive to hospital discharge. In the most complex, the expectation is 1 in 20 or less.  The risks include, but are not limited to: pain, broken ribs, punctured lungs, trauma to mouth, teeth and upper airway, aspiration pneumonia, loss of brain function, multi-organ failure, prolonged dependence on caregivers including being confined to nursing home, monetary expense, and all the usual complications of prolonged intensive care unit and hospital stays. Also, should we not be successful, loss of the opportunity to die in peace.

Presently our POLST forms say none of that. Different states have different forms, but I have been involved in completing ones in California, Oregon, Idaho and Washington and they share similarities. They start with a check box for CPR (cardiopulmonary resuscitation) or DNR (do not resuscitate, allow natural death.) Then there are other boxes specifying the general level of interventions, including comfort care (giving only treatments that provide comfort without attempt to prolong life), limited interventions (lengthen life, but generally not in an intensive care setting and not using advanced life support techniques) and full treatment (everything, dialysis, ventilator, electrical cardioversion, the works.) Then there may be questions about whether artificial nutrition by IV or tube is acceptable, whether blood products are OK, whether antibiotics should be used. It is really hard for a patient or family to get through all of these questions, and many of them are too complex for a person without healthcare experience to understand. Still, they are a good starting point for discussion.

In general the patients who I talk to just want me, as the doctor, to make the right decisions at the right time that are most likely to get them what they want. Most of them want as much good life as possible, the relief of whatever discomfort or disease brought them in, and to have this done as quickly and economically as possible so they can go home. We have no box for this on the POLST form.

I would propose that we should add this box, up at the top, as an alternative to "CPR" vs "DNR." I would propose that the choice be called "Resuscitation at the discretion of physician, guided by my goals of care." This would allow a nuanced decision about resuscitation--from none at all if the patient had been declining and not responding to treatment and was found unresponsive and pulseless (a situation which almost never results in success) to full resuscitation for a witnessed collapse with ventricular fibrillation in a patient who had a pretty good level of function.

This does, however, require another piece of paper, which I think should be part of any patient's admission to the hospital, and probably part of the chart at the primary care doctor's office. This would be "goals of care." There was an article in the New England Journal of Medicine last year that talked about altering our ideas of success in medical care to reflect how well we helped a patient achieve their goals rather than focusing on specific markers of disease control. Some patients value not being dizzy and not taking a bunch of expensive pills more than they value good blood pressure control, for instance. I think it is important to know, at the time of hospitalization, what a patient really wants. Do they really need to be discharged by a certain date or time? Do they have lousy insurance and need their care to be as thrifty as possible? Do they really value pain control, or sleep at night, or making sure to have a certain meal on time? Do they need quiet, or visitors? Do they want to avoid antibiotics or medications that can cloud their thinking? Do they think that spending time in a nursing home would be OK? Are they hoping to die in the hospital because their burden of disease is becoming intolerable? Do they want to make it home for Christmas or live until a grandbaby is born? We don't ask these questions and we should, or at least somebody should.

If a person chooses "CPR" or "RDP" (resuscitation at the discretion of physician) they, or their surrogate, really need to read and sign the informed consent form for resuscitation, because they do need to know what this means.

I hate filling out forms, but if they help focus treatment so it is more appropriate and if they help me understand my patients and communicate with them more effectively, I'm OK with that.

So... bottom line: In order to have patients make better decisions about resuscitation, we need to share more information with them and allow them to depend on our clinical judgement to help them have the outcomes they really want. To do this we should: 1. Add a box to the POLST form that specifies "resuscitation at the discretion of physician" as an alternative to "CPR" or "DNR".  2. Create an informed consent for resuscitation which makes clear expected risks and benefits and have everyone who wants resuscitation sign it. 3. Make sure that patients are asked about their goals of care at the time of admission to the hospital and that physicians read them and honor them as much as is practical. 4. For those unable to complete a POLST form or give informed consent for resuscitation, physicians should make the decision about whether to resuscitate based on most patients' goals of care and good clinical judgement. This is, after all, what we would do for such a patient with any other procedure that we perform in the hospital.

A rant on the hopelessly ill (of course it's not their fault) and how maybe mass media could help

I have been working in the intensive care unit and have been finding it ethically difficult to facilitate the care of the some of the hopelessly and incurably ill patients who rotate through. Many of these patients live in nursing homes that are qualified to manage patients on chronic life support, not just tube feedings or oxygen, but ventilators and tracheostomy tubes. They can live like this for years, with deepening bedsores and pasty disused limbs, foley catheters, rectal tubes or colostomies, with gradually increasing colonization by multidrug resistant organisms. They are brought to the hospital and then the intensive care unit when the bacteria colonizing their endotracheal tubes finally take hold and cause pneumonia or when a catheter in a blood vessel or bladder becomes infected or when one of their vital signs tells their caregivers that some unspecified thing is terribly wrong.

Once a person is on chronic life support, usually nobody talks to them anymore and it is assumed that they will continue as they are until something happens that no force on earth can stop and they finally take their eternal rest. We, as the medical establishment, must continue to use all of the fancy medications and procedures at our disposal to keep them alive. Usually nobody even asks the family anymore if they think that we should stay the course. None of the recipients of this care--family or patient--hear that care like this costs a million dollars a year or more.

Occasionally we can't stand to do the same heroics again or add more complexity and expense for clearly horrible quality of life, and then there are debates with all of the many involved people (and there are MANY involved people with each one of these folks) about medical futility, and what is the value of a life when it has become so very small. These debates are never settled for good, and are new and interesting for every patient, with heated opinion and bitter disagreement and misunderstanding. I spent hours, this week, convincing an ethics consultant that doing chest compressions on a 90 year old non-verbal demented woman with lung cancer and, most importantly, critical aortic stenosis was unconscionable, even though, 7 years earlier, when she could still talk, she had asked to be "full code." I explained that chest compressions do not cause blood to flow through a heart when the aortic valve will no longer open more than a smidgen, and thus the procedure was as futile as removing a non-diseased appendix because a patient requests it.

But it is not necessary to revisit the debates of medical futility, at least not tonight. People with good hearts and good minds, invoking the words of scholars and philosophers, disagree vehemently on what is futile and when a physician's responsibility to do no harm outweighs a patient or family's desire for us to do "everything."

What we really need is prevention. We need to work on the attitude and the economic pressures that lead people to be in advanced care nursing homes and intensive care units when they have no hope of gaining any sort of independence.

Some doctors think a lot about this sort of thing. They suggest that perhaps patients would not ask for million dollar a year heroics in order to lie in beds getting fed through tubes in nursing homes if they, or the family that requests that we continue to treat them, had some sort of financial responsibility. If they had to pay even one tenth of the costs, or one one hundredth of the costs, there would be considerably less of this kind of care. Perhaps it isn't such a bad solution. Even the very richest of people would have to face the question of the value of life support if continuing it meant $100,000 out of pocket costs per year. One might ask if there might be some actual societal value to maintaining a patient on life support when they are never going to be well enough to be off of it, and one might think of Steven Hawking, whose remarkable brain is able to function because his shell of a body is supported in all ways by medical technology. There are undoubtedly other examples, but I can't think of any.

I'm told that the amount of excessive end of life care that I have been seeing this year is nothing compared to how things are done on the east coast of the US, in New York or Boston, at the larger hospitals. There are wards devoted entirely to patients on chronic ventilator support, most of them severely brain damaged. These patients are not paying privately and are not on private insurance but usually have both medicare and medicaid, and are using the same dollars that are pinched tightly when it comes to providing care that might lead to greater independence and function in other recipients.

So--prevention. We need, somehow, to communicate to patients what we know as physicians about the human cost, as well as the very real economic cost, of keeping people alive by artificial means when they become very old or very sick or horribly injured. Americans are on the very edge of the spectrum of world societies in terms of valuing the individual and individual autonomy over the needs of the family or the community. Nevertheless, most people, when asked, will say that they do not want to live so as to become a burden on their family or friends. In a time of crisis, though, it is of great biological value to think only of oneself, and so decisions are frequently made to "do everything" when a person is close to death, which means that they must, after being saved, get really sick many times and eventually only die because we, as caregivers, are not quick or clever enough to save them. This equates to misery and loss of dignity at the end of life.

The end of life for the various people we care for can go different ways in the hospital, depending on the patient's or family's goals of care. If we have heard, quite clearly, that a patient wishes to die in peace when it seems that death is coming, we respond to a drop in blood pressure or high fever or loss of consciousness with clean sheets, soft music, coffee and cookies in the room for family members, pain medications if they are needed, clergy visits if appropriate. If we have not heard that, people rush to the bedside, shake and prod the patient, put in IV catheters, run fluids, perform CT scans, move the patient to an intensive care unit, attach EKG leads, voices are raised, invasive procedures performed. In the first case, the patient will usually die, though definitely not always, and the second case the patient will sometimes die, but may be resuscitated to do it again, hours, days or weeks, and occasionally even years later. Both scenarios have their place, but the first is vastly underutilized.

The cost of the aggressive approach is not inconsiderable. For the day of the decompensation, depending on what actually happened, costs run upwards of $10,000, and the whole hospitalization probably more than $50,000, even if we are unsuccessful. We don't like to think of money as influencing any decisions about life and death, but they are inseparable. Money used at the very end of life is not available for prevention of illnesses in other patients, which interventions cost much less and buy much more happiness and productivity. If our electronic medical records simply told us what each thing we ordered cost, and patients had easy access to that information, behaviors would be much different, and overuse of technology would be less common. We have tripled the use of imaging procedures such as CT scans and MRIs in the last 15 years without any clear improvement in outcomes, and it is likely that reducing our behavior of frivolously doing imaging will probably have no negative effect on our patients' health. Our overuse of antibiotics, especially expensive ones, is fueling an epidemic of drug resistant organisms in our hospitals, so if some financial information made us do this less, it would be great.

Because taking care of hopeless resuscitation disasters is very emotionally draining, it increases physician and nurse burnout and worsens the quality of care for everyone. I'm torn, much of the time, between the fact that I love working with excellent ICU nurses and discussing physiology with cardiologists and intensivists and the fact that the patients for whom I do this are without hope for recovery and are huge resource sinks. I even like the patients, those who can communicate at all, I just feel terrible about the system that got them there and put them in their impossible situations.

Maybe we, as a society, really do want to support patients with all sorts of life support technology rather than allowing them to die, unless they specifically refuse such treatment. I'm pretty sure there is no clear consensus on the subject. If we do want to do this, we must gracefully accept the fact that there will continue to be more people in this situation lasting even longer and costing even more as our technology improves. This means that we will be spending progressively more health care dollars at the end of life. If we also want to be able to take care of patients who have simple and easily treated conditions, our healthcare spending will rise significantly as a proportion of our national budget, primarily through the Medicare and Medicaid programs.

As silly as it seems, I think the solution may not be in forcing doctors to make more difficult decisions, but in effectively communicating what we know with folks who have very different backgrounds. In Brazil women used to have huge families, lots of children, which was economically very hard on the country as it modernized. When they got television, they started seeing soap operas in which women had only a couple of children, or even none, and had good and interesting lives. They then started having less children. No public health campaign, just a sort of sharing of stories, using the wonders of mass communication. We have these well loved doctor shows, ER, Gray's Anatomy, House, which show how cool it is to be in a hospital having technological medicine happen to you and being resuscitated from death to good normal life. These are the stories that are fun to watch and they are mostly not true. Could it be possible to make a popular TV show that actually shows things as they are and models the choices that those of us in the know would make if it were us our the ones we love who were desperately sick in the hospital? An infomercial even? A music video? Doctors don't particularly excel at this sort of thing but perhaps there's someone out there who will take the challenge.