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Category: medical education (page 1 of 14)

“Public Charge” is a Public Health Disaster in the Making

The following post was written by Sam Aptekar and Dr. Phuoc Le, Associate Professor of Medicine and Pediatrics at the University of California – San Francisco and Co-Founder of Arc Health.

I was born in a rural village outside of Hue, Vietnam in 1976, a year after Saigon fell and the war ended. My family of four struggled to survive in the post-war shambles, and in 1981, my mother had no choice but to flee Vietnam by boat with my older sister and myself. Through the support of the refugee resettlement program, we began our lives in the United States in 1982, wearing all of our belongings on our backs and not knowing a word of English.


Though we struggled for years to make ends meet, we sustained ourselves through public benefit programs: food stamps, Medicaid, Section 8 Housing, and cash aid. These programs were lifelines that enabled me to focus on my education, and they allowed me to be the physician and public health expert that I am today. Looking back, I firmly believe that the more we invest in the lives and livelihoods of immigrants, the more we invest in the United States, its ideals, and its future.

So, when I first learned of the current administration’s plan to make it harder for immigrants with lower socioeconomic statuses to gain permanent U.S. residence, the so-called changes to the “Public Charge” rule, I felt outraged and baffled by its short-sightedness.

Chart courtesy of www.cgdev.org

If this proposal comes into effect, government officials would be forced to consider whether an applicant has used, or is deemed likely to use, public benefit programs like Section 8 Housing, Medicaid, the Supplemental Nutrition Program (SNAP), and Temporary Assistance for Needy Families (TANF).  Additionally, applicants with pre-existing health conditions could be rejected purely on these bases.[1]

The implications of this rule are not hard to predict (and have already been observed throughout the country)[2]: noncitizen parents who are hoping to get green cards will not enroll their citizen children in government healthcare, which they have a legal right to obtain, out of fear that harnessing public benefits will prevent them from gaining legal permanent residence. According to the Kaiser Family Foundation, President Trump’s proposal could lead to a decrease in Medicaid and CHIP enrollment by a minimum of 15% and as much as 35%.[3]  Any proposal that decreases the number of insured American citizens, as this measure surely would, would increasethe financial strain on taxpayers who will be forced to compensate for unpaid coverage. Furthermore, Forbes estimates that Trump’s proposal would decrease legal immigration to the United States by more than 200,000 people a year and therefore “would have a negative impact on the Social Security System”- a deficit that American taxpayers would have to help cover.[4]

If the moral argument that every human being deserves the pursuit of a better life doesn’t work for you, then let the economic one suffice. A 2016 study by the National Academies of Science, Engineering, and Medicine concluded “immigration has an overall positive impact on long-run economic growth in the United States” and “immigration is integral to the nation’s economic growth.”[5]

Whether you are an immigrant or were born in the US, we all have a responsibility to vocalize dissent against the Department of Homeland Security’s morally and fiscally-flawed anti-immigrant proposal. Vote, attend town-hall meetings, write to your representatives, conduct personal research, engage in constructive dialogue, and comment below to get the conversation started. Remember, the Statue of Liberty reads: “give me your poor, your tired, your huddled masses.” If we match xenophobia and ignorance with empathy and facts, we can ensure that America remains a beacon of hope for future immigrants, just as it was for me in 1982.

[1] http://apps.washingtonpost.com/g/documents/world/read-the-trump-administrations-draft-proposal-penalizing-immigrants-who-accept-almost-any-public-benefit/2841/

[2] https://www.washingtonpost.com/outlook/2018/12/18/proposed-new-public-charge-rule-puts-childrens-health-insurance-risk/?utm_term=.82971bc137f9

[3] https://www.washingtonpost.com/outlook/2018/12/18/proposed-new-public-charge-rule-puts-childrens-health-insurance-risk/?utm_term=.0ac0803db1a9

[4] https://www.forbes.com/sites/stuartanderson/2018/12/14/these-flaws-may-kill-the-public-charge-rule/#17d961c72884

[5] http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=23550

# This is Our Lane

Dr. Judy Melinek

The American College of Physicians recently released an updated position paper on “Reducing Firearm Injuries and Deaths from Gun Violence in the United States.”

The College’s recommendations center around the notion that gun violence should be treated as a public health epidemic, and that it’s well within the purview of doctors and other health professionals to ask their patients about firearms—namely, do you own them, and if so, are they safely stored? Are they kept in a place where your children can’t get to them?

This makes sense to me, but I’m a doctor. I don’t hunt, nor have I ever owned a gun.

The College’s position makes some very uncomfortable—it’s not a medical issue, they say. This is about personal behavior. Choice. Individual rights.

The NRA sent a tweet in response to the position paper:

Told to “stay in our lane,” doctors have loudly declared #ThisisOurLane, and now have a Twitter handle and thousands upon thousands of tweets stating that it’s medical professionals who care for gunshot victims. Many sent pictures of themselves spattered with blood from taking care of gunshot victims in emergency rooms and operating suites.

One doctor, a forensic pathologist and medical examiner in Oakland, tweeted back to the NRA:

Understandably, Dr. Melinek’s tweet went viral, and she was interviewed the world over—from Africa to Australia—even on Amanpour.

Dr. Melinek was kind enough to speak with me—our interview occurred recently for #MedicalMonday on KWGS-Public Radio Tulsa, and drew a tremendous response.

Like Dr. Melinek, I find it frustrating that the NRA’s strong advocacy has had such a chilling effect on research into gun safety and gun violence in the U.S.

Shutting down attempts to gather more detailed information is a bully tactic of someone or something afraid of truth. How can people make informed decisions without really knowing the effects of gun ownership and use?

Advocate for gun rights all you want. But let the research be done.

End of Life Rallies

Let’s say your loved one is at the end of life. She’s 84, with advanced cancer that is no longer treatable.

A decision has been made to put her in hospice–which is a level of care more than an actual location. [Most hospice actually occurs at home.]

The patient waxes in and out of consciousness, sometimes lucid, but mostly not.

While no one is ready for her to die, this end-of-life process brings some solace–it’s what your loved one has indicated she wants, and the time at home without aggressive, often fruitless, medical treatment, allows other friends and family members to make visits and share stories.

One afternoon, she perks up and asks for a sandwich. This is surprising, because she’s barely eaten anything in the last ten days. But we get her that sandwich!

She nibbles at it, happy, but doesn’t eat much of it.

That afternoon, she’s talkative and engaged with others in a way that she hasn’t heretofore seemed able to muster.

Is she making a comeback? Healing from her illness?

More likely, this is what is called “rallying,” and while there’s ample anecdote of its occurrence in situations like this, we have very little understanding of it.

How does it happen? As a recent NYTimes article stated:

Physiologically, experts believe that the mind becomes more responsive when a hospice patient is taken off the extensive fluids and medications such as chemotherapy that have toxic effects. Stopping the overload restores the body to more of its natural balance, and the dying briefly become more like their old selves.

It’s deceiving because we think our loved one is getting better. And while she’s more like her old self, unfortunately, it’s not bound to last. Which is why it can be upsetting for some.

Spiritually, some suggest that the dying loved one is simply readying for transition–making sure that earthly concerns will be attended to in her absence and that final goodbyes may be uttered.

I’ve seen it–and especially in elders afflicted with dementia, it can be heartening to see them rally and seem to know what’s going on–accepting their impending death, and engaging with their loved ones before drifting off.

Triage

The following is a guest post from Dr. Sarah Fraser:

During my surgery rotation as a third year medical student, my resident sends me to the Emergency Department to assess a new consult. She tells me to “make it quick” and I hustle down to meet my patient.

Mr. Jones is a 64-year-old male who rarely goes to the doctor. He has been vomiting for two days and has a fever. His heart rate is up and his blood pressure is low; his belly is swollen up like a beach ball. When I examine his abdomen, he winces in pain with even the lightest touch. The x-ray shows a bowel obstruction and free air in the belly, a sign of intestinal perforation. I know he needs surgery.

Stat.

I text my resident who tells me I have five minutes to get the paperwork in order before transporting him to the operating room. As I am about to start writing my note, a frail, elderly woman emerges from a different room with a troubled expression on her face.

“I need help. My husband’s IV is beeping and we need to shut it off.” There is fear in her voice.

I quickly decide that her problem is not an urgent one. The IV is probably beeping because the fluid is done dripping in, or maybe the line is kinked. But the man with the busted bowels–that is urgent. I need to devote every ounce of my attention toward finishing my note and getting that man into surgery.

“I’m dealing with an emergency right now, but your nurse should be back shortly.”

“We need to stop the beeping!” She is on the verge of tears.

“It’s probably nothing serious. I’m really sorry but I can’t help you right now.” I put my head down and continue writing.

“The help here is awful,” she says, returning to her room with her sick husband and his beepy IV.

A knot forms in my stomach as I continue with my note.

Was there time to have helped her? Maybe, but I had a short deadline and was feeling the pressure. Relieving the concerns of this elderly lady would have taken away from the care I was providing for a the very sick Mr. Jones. So I prioritized, and in doing so, I failed to address her request, leaving her disappointed and probably scared.

Though I didn’t realize it at the time, when I ignored one person and prioritized a sicker patient, I was doing something called triaging. Every day in the Emergency Department, doctors and nurses are forced to choose who needs help and attention more critically.

Before entering the field of medicine, I remember sitting in the Emergency Department as a patient with a fever and chills, watching others who came in hours later being treated before me. Nobody likes to feel ignored. What the general public does not always realize is that there is a triaging system, where patients are given a score from one to five based on how sick they are. It is a system that helps us deal with the sickest first, though it can lead to long wait times for those with less serious issues.

Though I postponed dealing with the concern of the elderly woman that day, I also learned an important lesson. In medicine, you need to assess and assign degrees of urgency, and in doing so, you can’t please everyone all the time. And you have to be okay with that. What matters most is that you prioritize to the best of your ability, and do your part to keep everybody healthy, and most importantly, alive.

Dr. Sarah Fraser is an author, family physician and human rights activist in Nova Scotia, Canada. She is author of Humanity Emergency, a poetry collection about the need for more compassion in the field of medicine. Her work appears in the Canadian Family Physician, Ars Medica and the Journal of Academic Psychiatry, The Coast, Capital Xtra and on kevinmd.com

Match Day 2017

Click on the link below to see an essay from NPR on learning from and working with foreign medical graduates.

All in honor of St. Patrick’s Day, which this year is also Match Day — when medical students learn where they will match for residency — the next chapter in their training.

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