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“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

How Treating Cancer is All About Playing the Odds

The following is a guest post by Dr. Andrew Howard:

Like many Americans, I was sad to hear about Senator John McCain’s recent cancer diagnosis. Though I don’t always agree with his political stances, I greatly admire many things about him, including his service during the Vietnam war.

Senator McCain has a type of malignant brain tumor called a glioblastoma multiforme (also called a GBM). This is the same sort of tumor that Ted Kennedy, Beau Biden, and Ethel Merman had. Since the news about the senator’s diagnosis came out, a lot has been written about the fact that GBMs are associated with a poor prognosis. This has made me think about the term “prognosis.” In my experience, patients and their families often misunderstand how doctors think about that term.

Prognosis is all about trying to answer the question, “What’s going to happen to this person?” It’s not always easy to tell. However, early in my training, my mentors taught me that all cancer patients can be divided into two groups, which they called “curative” and “palliative.”

If a patient was palliative, that meant that there was no real chance for curing their cancer. Treatments may still be helpful for slowing the cancer’s growth and reducing symptoms. But we knew from the beginning that the cancer would eventually cause the patient’s death.

Curative patients, on the other hand, had cancers that were potentially…well, curable. The goal of their treatment was to entirely eliminate their cancer. I often imagined those patients finishing their cancer therapy and going on to live long and healthy life. Eventually, I hoped, the cancer would just be a faded, bad memory in their past.

Even in cases where the goal is curative, there is still no guarantee that treatments will cure the cancer. Instead, treatments are intended to make it as likely as possible that the patient will be cured. Curative treatments are all about playing the odds. It’s like we’re at a casino in Las Vegas, and we’re trying to maximize our chances of winning at the blackjack table. With curative treatments, we’re doing everything we can to stack the deck in our favor.

Here’s another analogy: Imagine you’re out for a walk, and your goal is to cross a busy street. You could just step blindly out into traffic, but your risk of not making it to the other side would be high. There are some simple things you can take to make it more likely that you will make it across. You could:

  • Look to your left before you start to cross
  • Look to your right before you start to cross
  • Cross at a crosswalk
  • Wait for a walk signal from a traffic light

Doing any one of those alone would increase your odds of making it across the street alive. Doing two of them would improve your odds even more. Doing all four would give you the best shot. However, even if you do all four of them, your likelihood of making it still isn’t 100 percent. A speeding truck could come out of nowhere, or you could be hit by lightning, or you could have a heart attack when you’re halfway across. Also, even if you don’t do any of them, there’s still a chance you could, by pure luck, make it across the street alive. However, no one would ever recommend you try that!

Your cancer treatments are like these things you do to improve your likelihood of making it across the street. They are each intended to improve your chances of achieving a cure. They can’t make it absolutely certain you’ll be cured. What they do is shift the odds in your favor.

I’m sure Senator McCain’s doctors will do all that they can to stack the deck in his favor. Glioblastoma is usually treated with a combination of surgery, radiation, and chemotherapy. Though the odds aren’t great, a small minority of patients do achieve full cure, and go on to live years and years after their diagnosis. I certainly hope that for Senator McCain.

Andrew Howard, MD, is an Assistant Professor of Radiation & Cellular Oncology at the University of Chicago. He has written a new book for cancer patients and their families titled So You’ve Got Cancer: A Super Patient’s Guide to Diagnosis, Treatment, and Beyond. You can find it here.

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

Inside Baseball: Health Care Edition

Reader Lisa Livingston submitted this guest post helping demystify one of the very important but poorly understood roles in medical care: radiology technician.

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Most of us have had an x-ray at some point in our lives, and it was probably performed by a radiology technician. But what else does the job entail, and why would someone be interested in it?

What Do They Do?

Radiology technicians perform imaging of the human body for medical treatment. The most common type of imaging is x-ray films, but they may also work with more sophisticated forms of imaging such as fluoroscopy or sonography, which are used to visualize various organs. They may also assist with MRIs or mammograms. They also ensure patient safety before performing imaging, check positioning and operations of equipment, and keep track of patient records.

X-ray of a normal hand.

Where Do They Work?

Radiology technicians may work in hospitals, clinics, medical laboratories, or private practices. They usually work in a room with the diagnostic machines, but they may also perform imaging at a patient’s bedside or even travel to a patient’s home in a van equipped with the necessary diagnostic machines.

What Type of Education is Needed?

Formal training to become a radiology technician can vary. Programs may lead toward a certificate, an associate’s degree, or a bachelor’s degree, though an associate’s degree is the most common. Most programs involve both classroom and clinical instruction in areas such as anatomy, physiology, medical ethics, radiation physics, and pathology. Anyone interested in science, math, technology, and the medical field may be interested in this work.

What Rewards Does the Job Offer?

There are many opportunities for advancement in this job. A radiology technician may specialize in a certain type of imaging. With further education, they could become a radiologist, a supervisor, administrator, or even teach at the university level.

Radiology technicians also have a good amount of job security, because demand for qualified professionals is high. There are jobs available in any area of the country, and the demand isn’t expected to go away for some time.

They also have a significant amount of contact with a variety of people. Radiology technicians contribute to a patient’s treatment in a meaningful way and they will see many different patients on a daily basis. They also make up an important part of a team of other medical professionals such as physicians and radiologists.

What is the Job Outlook?

According to the U.S. Bureau of Labor Statistics, employment is expected to increase by 17 percent by 2018. There will be more demand for diagnostic imaging with the aging Baby Boomer population. As medical technology continues to find new and better ways to treat diseases, diagnostic imaging will constantly be in high demand. There will also be more jobs available as imaging technology becomes less expensive and more clinics invest in them. A radiology technician’s average salary is around $50,000.

Lisa Livingston is a radiologist. She writes about health care and has a website devoted to radiology technician educational information.

Bedside Manner

When you think of bedside manner, what type of person comes to mind?

I often hear people comment on the bedside  manner of various doctors. But what about all of the other folks who care for patients in and around hospital settings?

Reader Elizabeth O’Malley sent in this guest post, which among other things reminds us to be less physician-centric in our worldview.

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Humane care can help decrease patient stress levels, especially in hospitals. Ironically, hospital employees are often the most over-burdened, and are sometimes pressed to be efficient rather than affable. While many workers do their best to consider bedside manner in their interactions with patients, the system and its employees still suffer from strain, resulting in a rushed environment in which some patients feel ignored. This can lead to more stress and longer recovery time for patients—does the system really need more disgruntled patients?

Bedside manner is one of those things that seems like a given in concept, but in practice, it can be easy to forget. However, is it important for everyone? If you are considering who spends the most time with patients, then certainly registered nurses, certified nursing assistants, and nurse practitioners would need to have the best bedside manner. Nurses play a vital role in patient care and spend the most time interacting with patients. In many cases, patients rely on speaking with nurses, as their doctor may be busy working with other patients. Since nurses help administer care for patients, they are often the hospital’s first point of contact with patients and have the ability to create a good first impression. Since nurses spend the most time with patients on a day-to-day basis, not only can they provide patients with important information about their illness, but they can also provide the moral support patients look for in health care professionals.

If the primary factor is who is supposed to be the most trusted advisor to the patient, then physicians would need to have the best bedside manner. If a patient is waiting in the hospital, and keeps being told by her nurse that the doctor will be in to see her, she will put a lot of emphasis on her physician’s visit, even if it is short.

X-ray technicians also play an important role in the hospital setting and can use their interaction with patients to create positive rapport. With more patient needing sophisticated scans from space-age looking body imaging machines, these technicians can ease the fears of patients who may be intimidated by the technology surrounding them.

In today’s troubled economic climate and considering the number of Americans without access to health insurance, hospital billing specialists may also need to tap into their own form of bedside manner in order to deal with the growing number of Americans who cannot afford to pay their hospital bills. According to the Center for Disease Control (CDC), about 50 million Americans reported not having health insurance in 2010. These specialists often deal with patients at their most stressed, and will need to be respectful and calm while speaking with them on the phone.

For some people, a naturally compassionate bedside manner may not come easily. Studies have shown that both self-reflection and modeling someone with excellent bedside manner can be the most effect way to learn this important skill. Despite who may have the most interaction with a patient or the most influence, each hospital employee has a responsibility to themselves and their patients to reflect on their care, because no matter which way you look at it, every employee has an effect on the people they interact with, and the possibility of making the hospitals they work in better places to be.

Elizabeth O’Malley graduated with a degree in Public Health Administration before relocating with her family to Seattle. She is currently a free-lance writer; her favorite topics include health care, work-life balance, and travel.

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