Xmas Spirit….or Bah! Humbug?

Are you a yoda or a grinch?

You’re in your 30s. You work hard. You strive to master your craft. You support your extended family. You are liked by both your co-workers and boss.

Problem: You unexpectedly become unhealthy–you find out your kidneys are failing.

Solution: Regular kidney dialysis can keep you alive, by filtering toxins out of your blood.

Problem: Dialysis is time consuming (>3 hours/session, 3 sessions/week) and leaves you feeling tired and weak.

Solution: Your brother, who is a tissue match, offers you the gift of a lifetime–one of his kidneys.

Problem: Because you don’t have health insurance (you are covered under the Medicaid program for your ‘emergency’ dialysis only) you are deemed ineligible for the transplant surgery.

Fact: The estimated cost of dialysis is $75,000 per year. The cost of the transplant surgery and care is $100,000, with an additional $10,000/year in anti-rejection medication costs.

Fact: Research shows that transplant pays for itself vs. the cost of dialysis at four years. Beyond that point, transplant is a tremendous cost saver overall. Patients feel better and live longer with transplant, too.

Solution: Surgeons at a medical center agree to waive their fees to perform the transplant.

Problem: The hospital still won’t allow the transplant to go forward.

Solution: Your kind boss offers to pitch in for health insurance.

Problem: You are denied because your kidney disease is a ‘pre-existing’ condition.

Solution: Raise $200,000 to pay the hospital up front for the cost of the operation and any potential complications.

Any readers out there willing to step up?

You can read the full story of this patient’s plight here. Pay attention to the comments below the article to see the extremes of opinion.

The patient in question is an undocumented immigrant. His children were born here and are citizens. He meaningfully contributes to the community.

But because of his status, he’s out of luck in the sweepstakes world of health care.

I welcome your opinions on how this situation should be handled. Comment on the post or send an email.

Happy Holidays. Thanks for reading and sharing GlassHospital.

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Boomers 2012

I’m reposting an essay I wrote a year ago about aging in America. The baby-boomers have started turning 65. How will they (and the rest of us) find meaning in a youth-obsessed culture as we live healthier, longer lives?

_________________

Happy New Year!

Er, almost.

A closing thought as 2010 2011 becomes history:

In 2011, the first wave of baby boomers will turn turned 65 years old. Sixty-five still has currency because that’s the age at which non-disabled Americans are eligible to be covered under the Medicare program (now itself having reached middle age).

As our economy continues to recover (hopefully) from the Great Recession, the entrance of millions of Americans to the Medicare rolls over the next decade and a half will be a formidable planning challenge.

So is the promise of Health Care Reform (the “PPACA“), which will enlarge Medicaid by an additional 16 million Americans–about half of the projected growth in coverage for those currently uninsured.

A couple of recent patient encounters got me thinking about these phenomena, and how we are very much in historically uncharted territory:

Never have we had so many living so well for so long.

We have an entire generation of people reaching “seniority” who will continue to want the most out of life, without many guideposts on how to achieve it.

As an example, take a patient of mine I’ll call Ted. He’ll turn He turned 65 in 2011. He’s retired, healthy, and financially secure. Every year I see him once or at most twice for a physical and preventive care. He is motivated to exercise and undergo cancer screening, since he wants to enjoy his “dotage,” and not succumb to some of the ravages of aging. I say some, since each year in anticipation of his physical, he sends me an update on his health status.

His numbered list this year was about a page and half, with copious detail on various ailment and insults. But it was number six, the last item, that really grabbed my attention. His prose has a poetry all its own:

Finally, I’d like to comment on the aging process again, if I may. I have alluded to “death by small cuts” in the past as a way of describing what I was experiencing as I think about myself.

This past year I’ve noted several specific things: my drop in motivation to exercise; my arthritis has become more pronounced; a notable decrease in my speed in walking…; I am slower on steps than before, but still able to do as many as I need to; I find a distinct difference in how my sons and son-in-law always take the heavier boxes, packages, air conditioners, etc…; [I see] distinctly more courtesy from those so inclined, in public, as doors are opened, or I’m allowed to leave elevators first, for example; it takes longer to do chores in the yard, and I must pace myself very differently than in the past; I nap for 20-30 minutes in the afternoons, when I’ve done something physical earlier that day.

There’s nothing to prescribe, I’m afraid, short of a daught form the Fountain of Youth, but I thought you’d like to know some specifics on what I’m seeing as another year goes by. It does seem to change a bit every year. I’ll tell Dr. P. [a geriatrician relative of his], of course, but I really don’t think I’m bringing any breakthrough ideas to the field of Geriatrics, as I begin my eligibility for that class.

A man with too much time on his hands? Perhaps. But someone in touch with his body and its rhythms, trying to capture the emotions of aging. I tell him that he’s “in the 99th percentile” of my patients, in terms of his health awareness and motivation for healthful longevity, because it’s true.

I was ruminating about Ted, and what to advise him, when I had a similar sort of encounter with Sally [not her real name]. Sally is also 64, and stuck in the Middle. She cares for an aging mother, and no longer has her children to care for since they’ve been married off.

Sally’s main issue at her visit, other than preventive health (she’s also retired and financially independent), was her anxiety about where to focus her energies.

Then, like a lightning bolt, she asked a simple question:

Had I ever heard of a doula?

Yes! what a GREAT idea! She could volunteer her time and serve as a doula.

Voila: an idea. Let’s have Boomers fortunate enough to afford retirement give back to their communities. Volunteering. Teaching. Attending.

This recent Times column raises the whole question of adult education as a ‘new frontier.’

What would you suggest for our Boomer friends?

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2 Comments Posted in aging, health & wellness, patient experience
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Grand Rounds

Welcome to Grand Rounds, where writers, readers, and bloggers send in their best stuff on a weekly basis to share, cross-pollinate, and build new audiences.

Tip of the hat to Grand Rounds co-creator Nick Genes, MD, PhD, an ER doc in NYC who knows a thing or two about blogging, tweeting and now Tumblr.

a timeless and inspiring read...

The theme of this week’s Grand Rounds is “Finding Meaning in Medicine,” with full attribution to Dr. Rachel Naomi Remen, author of the masterful book Kitchen Table Wisdom: Stories that Heal. My wife and I had the privilege of meeting Dr. Remen in 2008, learning from her during a glorious week in Bolinas, California at the Institute for the Study of Health and Illness.

Dr. Remen is an expert at re-connecting health professionals with what brought us into medicine in the first place. I can think of no better Grand Rounds topic than asking bloggers to share their meaningful stories.

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Stories of Meaning

Starting off, I’m linking to a story from Zocalo Public Square by Ken Murray, a family doctor at USC. His piece titled “How Doctors Die” has gone viral, as evidenced by the fact that I’ve seen it linked, sent, and tweeted more than a dozen times in different media.

Murray’s piece raises big issues of Meaning: namely, the big one: the meaning of life, and a less big one: the meaning of medicine. I, too, wrote a piece like his a while back, expressing my view that most doctors would never wish to die in a hospital, and share it with you here so that you can compare. Feel free to tweet mine, too, if you find it worthy. It’s called “A Good Death.”

-Ed Pullen, a family doctor from Puyallup, WA, sent in a concise post from his self-titled blog explaining the value of ‘Keeping Perspective.’ He demonstrates that doctors offer meaning to our patients when we help them think through and make challenging medical choices. He gives several real world examples.

-Jessie Gruman, founder of the Center for Advancing Health, sent in a poignant piece from the “Prepared Patient Forum” describing her frustration with how slowly the world of medicine makes progress. Using the metaphor of “It Takes Two to Tango,” she writes that a true patient-doctor relationship takes time and practice to establish. Forces outside of the relationship are often having a deleterious effect.

-Medaholic, a medical student from Canada with an eponymous blog, posted about the time his grandfather was hospitalized and the formative emotional impact that it had on his medical education.

-Elaine Schattner posted her reaction to Abraham Verghese’s novel Cutting for Stone on her blog “Medical Lessons.” The book raises the untold issue of doctors going into medicine to heal ourselves. Hmmm…..

-Pranab Chatterjee, a fascinating medical blogger from India who writes at Scepticemia.com, sent in this post finding meaning in the “…madness of…[a medical school] examination.” I can’t believe the nutty things they ask on exams there. I’m glad the concept of ‘educational reform’ has taken hold here in the U.S.

Paul Auerbach, a professor at Stanford and the foremost authority on wilderness medicine, wrote in: “One of the ways that I find meaning in medicine is by educating people. There are many ways to feel good about being a doctor; one of them is having the opportunity to deliver information that might truly help someone prevent or treat a disease or injury.” He sent in a post clarifying breast cancer screening recommendations, particularly for patients that might be going into the wilderness for any length of time.

Finally, Dr. Grumpy, a prolific and funny medical blogger sent in this holiday-themed photo, positing for those that want to keep Christ in Christmas:

Happy Holidays!

Dr. G always reminds me that humor is the highest form of defense mechanism against medical, winter or holiday doldrums. And not taking ourselves too seriously has great meaning.

Grand Rounds will return to the blogosphere in 2012. I wish you a healthy and happy new year…and may the Force be with you!

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Hospital of Horror

photo credit: Times of India

Every once in a while, a tragic news story pierces though the emotional wall we set up to handle the endless torrent.

The news of a hospital fire in Kolkata [formerly Calcutta], India is one such story for me.

The name of the hospital is the “Advanced Medical Research Institute,” known locally as AMRI.

It seems that any place wanting to call itself advanced would consider basics like a fire safety plan and how to execute it.

I was particularly horrified by the utter abandonment of patients by the medical professionals. From a NY Times article on the blaze:

The doctors on duty fled the hospital almost immediately, leaving patients stuck in their wards and at the mercy of the billowing black smoke, witnesses and patients told reporters.

I was reminded of Hurricane Katrina and the brave docs who stuck around tending to those so critically ill that they couldn’t be moved out of the storm’s path.

The Kolkata fire tragedy was compounded by inept administration, security, and rescue response. From the same article:

Local people who tried to get inside the hospital to help rescue patients said they were turned away by security guards who assured them it was only a small kitchen fire.

Hospital officials were slow to call the Fire Department, and then fire trucks were slow to arrive, hospital officials said.

In fact, it took firefighters more than 12 hours to subdue the blaze, Fire Department officials said. The hospital’s fire detection and suppression system did not function…

Who bears responsibility for such a tragedy?

Six senior hospital officials were charged with culpable homicide in connection with the fire, according to government officials.

Goodness.

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2 Comments Posted in death & dying, deaths in the news, global health, hospital care, patient safety
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Filling the void (… the young docs, vol. 2)

The CDC released a recent report (“data brief“) on the subject of physician assistants (PAs) and advanced practice nurses (APNs).

Physician assistants are a growing cadre of professionals who practice medicine under the supervision of doctors. Advanced practice nurses are registered nurses with advanced training, who work independently (but in collaboration) with doctors.

PAs and APNs are often referred to in health care-speak as “physician extenders,” a term I loathe. To me it implies that these professionals are somehow not fully formed human beings, but rather mere appendages of almighty doctors.

There was a lot of initial resentment toward PAs and APNs by doctors. I can still hear some of the claims:

  • They will take our patients, thus stealing our business.
  • They don’t have enough education.
  • Will patients really want to see them, with their “lesser” education and experience?
  • They can’t be trusted to prescribe mediation independently.
  • They’re not doctors.

Those cries have greatly diminished as their numbers have grown. Doctors in the private world relish working with “extenders,” because they help improve volume (i.e. patients seen) which brings in additional revenue. And because they earn less (presumably because they have less in the way of education [two years vs. four for medical school] and experience [one year internship vs. three years-and-beyond residency training periods], they are in fact quite economical for private physicians who hire them, or the larger groups (especially hospitals) that employ doctors.

In a prior brief, the CDC demonstrated that nearly 50% of office-based physicians work with PAs and APNs. The larger the practice, the more likely this is to be true.

The most recent brief, highlighted courtesy of V.S. Elliott in American Medical News, looked at “allied health workers” (PAs and APNs) working specifically in hospital-affiliated medical practices. The data shows a 50% increase in visits to these office sites in which a patient saw only a PA or APN over the most recent eight years.

I find this important for a couple of reasons:

  1. As we inch closer to health care reform, with several million uninsured people expected to enter the insured pool, allied health workers will be more frequently counted on to pick up the load, as the number of primary care doctors isn’t growing enough to meet demand.
  2. In addition, under health care reform it’s expected that one of the formats for improving delivery of health care will be the Accountable Care Organization (ACO). In this model, doctors will supervise teams consisting of nurses, PAs and APNs, who will see most of the patients. It is argued that this will be the most efficient, cost effective, and highest quality deployment of health care personnel.

Some beg to differ on those assumptions. My own feeling is that doctors don’t go to medical school to learn to manage teams of other professionals. Some of us may actually like it or have talent for it, but current medical education models don’t have any bearing on these skills.

It’s a tumultuous time to be in health care. Stay tuned.

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Grand Rounds Coming Here

GlassHospital will bring you the internet’s Grand Rounds next week.

Submission Instructions

  1. E-mail submissions to our editorial board directly at <glasshospital> at <gmail> dot <com>.
  2. Put Grand Rounds in the subject line and give us a <brief> description of your blog.
  3. Please include your name (nom de blog is acceptable), the name of your blog, and the url.
  4. One entry per blogger.
  5. Posts between 400 and 1000 words are preferred; since the theme (below) is timeless, feel free to submit a new or old post.
  6. Posts are to be written for a general audience.
  7. If there’s a potential conflict-of-interest, either don’t submit your post, or disclose it.
  8. Stick to this week’s theme, at least in some indirect way. If it’s not obvious, don’t be shy about telling us why it fits.

This week’s theme:

‘Tis the season. Thus, we want readers and writers to reflect on what’s truly important to them. Our theme will be Finding Meaning in Medicine.

How do you find meaning in medicine? In your work? As a patient? As someone looking to improve the “system?”

What keeps you engaged, fresh, vibrant, learning, writing?

DEADLINE for submission is 11:59 PM Central Time on Sunday, December 11, 2011.

Looking forward to your submissions.

-GlassHospital

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2 Comments Posted in health care reform, health care work force, patient experience, primary care
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