Alabama is still poised to unleash the Death Angel. The night after we wrote that post I suffered a tragic loss. Danielle Juzan, my wife and silent collaborator of 33 years was stricken and died of a heart attack at the age of 55. As you can see from the attached article, she was a wonderful, passionate woman who pushed me to stand up and do the right thing regardless of the personal or professional consequences. She was also a marvelous writer and those who have read this blog over the years will never know how much she added to these posts.

She was a fixture in the local community and fought hard for improvements to Mobile, Alabama. Her attachment to our community was what made this work so important. Over the years I have looked at several jobs in places that are better positioned to provide healthcare for all citizens. Each time  Danielle would give me the reasons not to leave our house (we just got the garden where it needed to be, we are getting a dog park, etc) and ask me if we couldn’t stay in Mobile a while longer. I would agree that we had a nice life despite the seeming callousness of the public officials and we would go back to tilting at the windmill that is improving the care of the underserved in Alabama.

As I grieve, I continue to check my e-mail and am thankful for the hundreds of expressions of sympathy that I have received. For those of you who read this, thank you so much. While nothing will make it better, it is comforting to know that Danielle has touched so many.

Immediately after her death we were challenged in a message as to accuracy of the position that Medicaid (not the expansion, access to Medicaid at all) saves lives. The commenter suggested that the evidence for improved health was wanting. He pointed out that before the passage of the ACA, Oregon randomly gave several thousand people who were uninsured Medicaid coverage and followed them and several thousand uninsured for a couple of years to see what would happen. The results were as follows:

Medicaid coverage resulted in significantly more outpatient visits, hospitalizations, prescription medications, and emergency department visits. Coverage significantly lowered medical debt, and virtually eliminated the likelihood of having a catastrophic medical expenditure. Medicaid substantially reduced the prevalence of depression, but had no statistically significant effects on blood pressure, cholesterol, or cardiovascular risk. Medicaid coverage also had no statistically significant effect on employment status or earnings.

The science is pretty clear, access to health insurance over a two year period for relatively healthy people improved some aspects of their lives but is no panacea. How these findings are interpreted depends on if you live in a red state or a blue state:

Their conclusion is as follows:

In its totality, the research on Medicaid shows that the Medicaid program, while not perfect, is highly effective. A large body of studies over several decades provides consistent, strong evidence that Medicaid coverage lowers financial barriers to access for low-income uninsured people and increases their likelihood of having a usual source of care, translating into increased use of preventive, primary, and other care, and improvement in some measures of health. Furthermore, despite the poorer health and the socioeconomic disadvantages of the low-income population it serves, Medicaid has been shown to meet demanding benchmarks on important measures of access, utilization, and quality of care.

For you, Danielle. Continue to help me keep fighting the good fight.

When asked about folks possibly dying from lack of access if we fail to maintain a Medicaid system that meets federal requirements:

“We all die sometime,” Trip Pittman (R-Montrose) said.  “We’re all mortal. We all have a finite period of time on earth. I think sometimes we confuse saving lives with extending lives.”

Wow! The state of Alabama has passed and overridden the Governor’s veto of a budget that, per the Medicaid commissioner, does not allow us to meet the federal requirements to stay in the “voluntary” program. There was a hearing on the impact of the budget on Thursday. In the lead-up to the hearings (found here) Senator Pittman was quoted as saying that the reason was that “I think there are legislators who need to more fully understand the workings of Medicaid.” A fair statement; as I have as I previously explained (here) the funding of Medicaid in Alabama is incredibly complicated. The hearing included a very informative presentation by the Medicaid Commissioner that can be found here.

Highlights of the Commissioner’s presentation are:

  • Counties with the highest unemployment have the highest Medicaid enrollment
  • Administrative costs are only 4%
  • Cost per enrollee have remained the same but the number of enrollees has increased by 30% since 2008 because of Alabama’s sluggish economy

And, the part that got Senator Pittman’s attention:

  • 1% of enrollees account for 30% of costs with 35 tragic cases accounting for almost $40,000,000 in cost to the agency

Senator Pittman’s response (heard here starting at 4:39 and accompanying article by Glynn Wilson here) would have made international news had this been one of Obama’s surrogates. Many of the federal requirements he  finds onerous provide healthcare to the “undeserving.” For example, the Feds require Medicaid to cover those who are receiving Social Security disability checks:

“[The eligibility rules]may be too liberal,” Trippman said, and “not discerning enough on whether somebody is really eligible.”

Giving to deserving people, it seems is OK. It’s  just that those who could get out and work, in the Senator’s estimation, need to get off their disabled rear ends and find jobs that provide health insurance.

He was then asked to reflect on the 35 most expensive cases:

“We’re spending more than 40 percent of the money on children in their first year of life,” Pittman, said, and added: “We’re spending a lot of money on the elderly, at the end of life. I think as a society we need to debate and look at all of these things. If not, you’re going to get into rationing.”

He then proceeds to outline possible solutions, beginning by referencing Bernie Sanders (8:30 on the video):

“[Bernie Sanders] said 80% of the costs are for elderly and for people in this state in the last few months of their lives and for people with chronic illnesses and the elderly. The reality is that we have to have some discussions about quality of life, about the expenditure of money, and about the cost. You know in this country the transfer of wealth from working to non-working, for every dollar you transfer from working to non-working you are transferring $7 from young people to old people. That’s a moral debate and that’s something people need to start talking about.”

He goes on to say that the cuts will be made, the impacts will be felt, and people will react to what ultimately happens.

There you have it. Willing to turn away $5,000,000,000 and dismantle a state’s care delivery system , so we can find out in our own little laboratory of democracy just how people will react. Again, wow!

'I hate it when people vote with their feet'

‘I hate it when people vote with their feet’

About 10 years ago, Mobile County landed one of the last large pre-recession “smokestack” projects. Competing against multiple states, the state and the county ultimately gave a lot of money in anticipation of “29,000 jobs during construction, and 2,700 jobs paying an average of $50,000 to $65,000 annually once the plant is operational in 2010.” One of the more controversial aspects of the corporate welfare was the amount paid by Alabama and Mobile County ($1 BILLION) as compared to the benefit accrued. Many of the skilled construction jobs were filled not by locals but by a nomadic group of people who traveled from places like North Carolina and Virginia, lived in campers for several months, and left to go to the next big construction job. Our corporate welfare went not to Alabamians but to people from all over the south who sought employment by “voting with their feet.”

Our legislature is electing not to spend $85 MILLION on adequately funding Medicaid. They are going to begin holding hearings on the budget they just passed next week, focusing on finding out why healthcare is so expensive, where the waste and fraud is, and finding out how to “fix the program.”

State Rep. Paul Lee, R-Dothan, said he believed a part of the Medicaid issue might be that the system does more “handing out” than “handing up.”

“We have children in need and elderly in need. …We need to start encouraging those that are able and willing to go to work rather than sitting and waiting for a check to come in,” he said.

“We can fix Medicaid in 24 hours if we could make our own rules (versus federal regulations) and do it the way it should be done.”

The first person to suggest that states should be given much greater leeway to “fix programs” was Ronald Reagan. Pointing to the migration of blacks to the north during World War II and to the migration to the energy belt in the 1970s, he suggested that America was not composed of static folks tied to a community, but was instead a moveable army of workers and others who would move from their current state to another if services were inadequate. Like the construction workers were drawn to Alabama. Or perhaps like poor, sick folks might leave Alabama

Do poor, sick people move from a low-service local to a high-service one? Do wealthy folks move to areas with low taxes? Are we finally entering a Reaganesque utopia to which the Ayn Rand capitalists will move after we eliminate Medicaid funding, creating a little Somalia  right here?

As it turns out, the great migration of poor sick people to blue states after Obamacare never happened. Folks it seems are content to stay put and use the Emergency Department near their family rather than move to an expansion state. The exception are the chronically homeless, as it turns out that up to 40% are rather nomadic  and identify service availability as a reason to relocate. This is about 40,000 people nationwide.

What about the converse? Are wealthy entrepreneurs leaving for the promise of lower state taxes? Despite what the moving company “data” reveals, the truth is nope. In a very well done study by the Center of Budget and Policy Priorities using IRS data which combined income and address change information, it turns out:

  • 70% of folks never leave the state in  which they were born
  • The income tax status of the state does not correlate with the movement of people in or out in general
  • If anything, poor people are MORE likely to move to a low tax state, which probably correlates with lower housing costs
  • Old people are more likely to move away from snow

People move for two reasons, jobs and family. Well, warm weather as well for old folks.

Reagan’s belief was based on a theory by Charles Tiebout, a rather obscure economist, as well as personal observations about blacks moving north and and Houston’s energy-sector driven growth. Tiebout’s theory was based on faulty assumptions, and Reagan’s observations were not really contextual (the reason for the black diaspora was a little more complex).

Folks that vote with their feet, it seems, are nomadic. They come to either work on large construction projects or to seek out services to substitute for their lack of a permanent residence. It is probably more realistic to fully fund services such as Medicaid rather than fight the federal government and hope for an influx of wealthy Ayn Rand followers. I do not think this will come out in the hearings.

 

 

From al.com, italicized  comments mine:

Lawmakers appropriated $700 million from the General Fund for Medicaid next year, $85 million short of the governor’s request.

From an Urban Institute paper about Alabama published in 2004:

An overarching issue is the defeat of the tax reform proposal, which implies that the vast majority of Alabamians prefer lower taxes to improved government services or possibly even maintenance of the current level of services.

In other words, we have been crying wolf for a long time and have always found a work-around. This crisis has been precipitated by past loans from other accounts, one-time payments such as the BP settlement, and other work-arounds coming due and not by Obamacare. 

 

But for the first time they said one option could be to eliminate prescription drug coverage for adults, which would save an estimated $50 million to $60 million in state dollars.

“If we have to live within our means, then we have to make some very tough decisions,” the governor said.

The estimated savings on the prescription program do not take into account increased medical costs that would result from people not getting their medicines.

Wow! Words fail me…

Azar also said Medicaid would not be able to proceed with the plan to begin providing managed care through regional organizations, a move intended to slow the growth in costs and improve health outcomes.

“Together with the Alabama Legislature, we have made significant progress in the way the Alabama Medicaid Agency operates, making it more effective and efficient,” Governor Robert Bentley said. (February 9, 2016)

What a difference a month makes!

The Centers for Medicare and Medicaid Services earlier this year approved a waiver to allow the change and could provide up to $747 million over five years to help with the transition.

Elimination of prescription coverage was one of 10 areas of potential savings mentioned by Bentley and Azar today.

Various combinations of the cuts could be considered and would have to be approved by the Centers for Medicare and Medicaid Services.

Another savings option Azar listed would be for Medicaid to consider a pharmacy preferred provider. That would save an estimated $19 million to $30 million in state dollars.

But would eliminate money we use for matching, I suspect, thus multiplying the  reduction of services

Other programs mentioned, and the estimated savings in state dollars:

— Eliminate eyeglasses for adults: $300,000 – Probably will limit employment opportunities

— Eliminate outpatient dialysis: $3.7 million – 500 people dead or sitting in the ED waiting to get close enough to death they quality for emergency dialysis

— Eliminate prosthetics and orthotics; $500,000 – Hard to work without a leg

— Eliminate Program of All Inclusive Care for the Elderly (PACE): $2 million – putting 150 people into nursing homes, resulting in a net cost to Alabama

— Eliminate Health Home and Physician case management fee: $16.6 million – Adding even more people to the nursing home

— Eliminate primary care bump (pays doctors at Medicare levels): $14.7 million – Reducing the docs taking Medicaid

— Reduce administrative costs: $3.5 million – Reducing efforts to reduce waste,, fraud, and abuse I suspect

— Reduce reimbursement rates for ambulatory surgical centers, doctors, dentists, optometry, hearing and other programs: Zero to $50 million. – Reducing access for these programs and furthering the reputation of Alabama as home of the halt, lame, blind, and toothless.

Please call your state Senator or Rep if you live in Alabama and demand that they revisit the Medicaid budget. Please retweet this under #CanYouHearUsNowAl and #alpolitics

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Public health has an odd place in medical education and the physician’s practice. Although clearly required as a part of the curriculum, it has historically been underemphasized.  By historically, I mean since 1848. Medical schools were created to train doctors in the science of the person (singular) but not in the science of people. Someone had the bright idea of offering further training to doctors (further detailed here) to allow them to have a broader perspective:

To earn this postgraduate certificate, students took courses on“preventive medicine and sanitary science, personal hygiene, public health administration, sanitary biology, sanitary chemistry, special pathology, communicable diseases, sanitary engineering, and demography” as well as“special courses and lectures in infant mortality, social service work, mental hygiene, oral prophylaxis, the prevention of ear, nose and throat disease, hygiene of the eyes, industrial hygiene and medicine, eugenics, genetics, and sanitary law.

Because it was a post-graduate degree, rather than create a cadre of “super docs” it moved public health out of the medical school entirely.

In 1998, the Association of  American Medical Colleges urged medical schools to incorporate public health by “first, teaching students the practical fundamentals of the core disciplines that underpin the effective application of population health; second, giving students experiences in studying real populations; and, third, integrating the teaching and learning into all parts of  medical curriculum rather than relying solely on a stand-alone population health course.”

In the last 20 years, medical schools didn’t answer the call.  From the requirements for medical school curriculum they are required to provide instruction in the following:

  • The recognition and development of solutions for health care disparities
  • The importance of meeting the health care needs of medically underserved populations
  • The development of core professional attributes (e.g., altruism, accountability) needed to provide effective care in a multidimensional and diverse society

As someone with an interest in the health of the population, I sought more than just “recognition.” My medical school offered a joint degree (MD/MPH) which allowed me to obtain instruction in the health of people (plural) in addition to health of a person.

One class in particular sticks with me. It was a health policy class taught by a professor who was a self-described Maoist. Communism in the mid-1980s was scary and having a person who admired a communist leader was more than a little controversial. I would leave my basic science lectures at the medical school and go to a class where we discussed how China had markedly improved the health of their citizens with “barefoot doctors” who indeed were barefoot, and had minimal training. They transformed the Chinese countryside by providing primary health care services, and focused on prevention rather than treatment. They provided immunizations, delivery for pregnant women, and improvement of sanitation. To my medical school classmates they were in no way doctors. To my public health classmates they were a model for the future.

Fast forward 30 years, and we are coming around to learning that China was onto something. People from the community are much more likely to work to improve their community and care for their friends and neighbors. Known as community health workers in this country, they are frontline public health workers who are trusted members of and/or have an unusually close understanding of the community served. This trusting relationship enables the workers to serve as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery. It looks like we are going to start employing these folks to help improve the health of the citizens of Alabama.

Unfortunately, I’m afraid my physician colleagues won’t recognize a good thing when they see it. After all, it’s only been 150 years.

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“Unless there is a public outcry, I don’t see any changes.”

Alabama Senate President Pro Tem Del Marsh on passing a Medicaid budget that reduced payments to physicians, hospitals, and would end all “optional services” including home health programs, hospice, outpatient dialysis, adult eyeglasses and PACE, a program to help some elderly people avoid having to be admitted to nursing homes

How do you create a public outcry? That is the question for the 500 dialysis patients who rely on dialysis to continue living.

Dialysis is a funny thing. When Medicare and Medicaid were established in 1965, renal replacement therapy (known by lay folks as dialysis) was known to save lives. People who had lost kidney function from diabetes, polycystic disease, or some other malady, unless they were fortunate enough to be a part of an experimental protocol, would die from a build-up of toxins in their body. If they were enrolled in a protocol or had the good fortune of living near a place that was experimenting with renal replacement therapy, they would live.

In the late 1960’s, a report came out that identified renal replacement therapy as established as opposed to experimental. In addition, because of the “experiments” funded through Medicare, the number of people on dialysis increased by a factor of 10 (from 1,000 to 10,000) and the number of physicians performing dialysis increased dramatically. This set the stage for the hearings in the 1970 where this testimony was heard:

I am 43 years old, married for 20 years, with two children ages 14 and 10. I was a salesman until a couple of months ago until it became necessary for me to supplement my income to pay for the dialysis supplies. I tried to sell a non-competitive line, was found out,and was fired. Gentlemen, what should I do? End it all and die? Sell my house for which I worked so hard, and go on welfare? Should I go into the hospital under my hospitalization policy, then I cannot work? Please tell me. If your kidneys failed tomorrow, wouldn’t you want the opportunity to live? Wouldn’t you want to see your children grow up? (U.S. Congress, House, Committee on Ways and Means, 1971b)

Following this, the house and the senate passed and President Nixon signed a bill creating a dialysis benefit for those eligible for Medicare.

Fast forward to today. In America we have 400,000 people on dialysis. They have to have their blood cleansed 3 times a week. If they do, they can live a relatively normal life. If they don’t, they can develop shortness of breath (pulmonary edema), feeling poorly (uremia), or a high potassium level (hyperkalemia) and when it gets bad enough that they’re deemed to be near death, they  are given dialysis via the emergency room.

Most people on routine dialysis have it paid for by Medicare. Who gets it on the federal nickel? To quote CMS, these folks are eligible:

  • You’ve worked the required amount of time under Social Security, the Railroad Retirement Board (RRB), or as a government employee.
  • You’re already getting or are eligible for Social Security or Railroad Retirement benefits.
  • You’re the spouse or dependent child of a person who meets either of the requirements listed above.

If you don’t meet these criteria, and require renal replacement therapy, you pay cash (between $52,000 and $73,000 per year), obtain coverage from Medicaid, wait in a state of anticipation until you need emergent dialysis (costing about $300,000 a year as a strategy), or die.

Alabama would be the first state to take it away from ALL Medicaid recipients. Texas does not pay through Medicaid but instead pays through a separate fund.  They were able to take away dialysis from undocumented folks. Because of the pesky EMTALA laws passed by President Reagan, hospitals are required to provide EMERGENCY treatment. The consequence?  A bunch of folks who hang out at the hospital every day getting their blood drawn to see if they win the emergency dialysis lottery.

So, back to my original question. You see, Alabama is $100 million short on their Medicaid budget. On a budget of about $6 billion, that would seem like a small number.  Alabama legislators, though, are ready to make a stand. The 500 Alabama citizens on dialysis will either die or spend the rest of their days hanging out next to the emergency room so that we can prove the value of “low taxes”  unless there is a “public outcry.” How do you stop folks entrusted with the health and welfare of the citizens of Alabama if they are able to murder 500 people to prove a point? I can’t figure it out.

 

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Patient: I can’t afford the insulin you prescribed for me.

Me: It’s a pretty standard long acting insulin

Patient: My insurance says it’ll cost $350 a month to use it, is there something less expensive?

Insulin is a magic drug. Discovered in 1921, it was first administered to humans in 1922. Although there were a long line of discoveries that made the discovery possible, Drs. Banting and Best at the University of Toronto were the first to identify the source (the pancreas) and to extract insulin for use. Even more amazing, the University made the discovery “open source,” allowing the manufacture and distribution without royalty.

The discovery was not without its problems. Although human insulin was synthesized in the lab, it was difficult to make for many years. Insulin taken from cows and pigs was commonly used clinically. Unfortunately, in one of the Creator’s little jokes, these insulins vary from human insulin by a couple of amino acids. Not enough to make them unusable as extracted but enough so that over time the diabetic patient developed antibodies and was unable to use the insulin, leading to his or her premature death.

In 1982 Richard diMarche and Eli Lilly obtained a patent for human insulin made from recombinant DNA. Originally sold as Humalog, this was the first medication manufactured in this manner and it was a game changer. No longer were we putting a foreign body into people to lower their blood sugar temporarily. We were putting human insulin into people and keeping people alive longer and keeping people healthier.

Which brings us to today. Drug companies developed pens, different types of insulins, and different delivery methods. They have also jealously guarded their patents, preventing cheaper generics from being developed. To quote the New England Journal:

“But whether each incremental innovation is worth the price we pay, in a world where insulin remains unaffordable to many patients with diabetes, is less certain.”

Reasons used for the high cost might include the need to ship the medication in liquid form as well as the different delivery mechanisms. The bulk of the cost of the drug, however, is in R&D. These drugs have been developed for years and there are no more R&D costs. Their investment has been recouped. It is becoming clear that a major reason is good old-fashioned “profit taking”:

Between 2005 and 2015 the cost of a lispro vial went up 264 percent, while a vial of insulin glargine went up 348 percent, and a vial of NPH went up 364 percent. That’s a lot, but other insulins went up even more.

The cost of an aspart pen rose in this 10-year period by 389 percent. And the cost of a vial of U-500 regular insulin jumped a staggering 508 percent.,

 

So, in America in 2016 we have people choosing between insulin and food. People that weren’t having to do that in 2006. The speculation is that this profit taking is in advance of the loss of the patent as well as the lack of “blockbuster” drugs on the horizon. Perhaps generics will be developed soon.

What did I do for my patient? There is one type of intermediate acting insulin that is $27 a vial at Wal-mart. No special pen, has to take it twice a day. For now, it turns out that diabetes in now a two-tiered disease, easy for the rich to handle but increasingly difficult to manage if you are poor.

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When the Office of Economic Opportunity, which was funding Geiger’s clinic (the first community health center in Moundville, Mississippi funded by Lyndon Johnson’s Great Society) , found out, they were furious — and sent an official down to Mississippi to inform Geiger that they expected their dollars to be used for medical care. To which Geiger famously replied: “The last time I checked my textbooks, the specific therapy for malnutrition was food.” [Excerpt from “Wellness is More than Not Being Sick” by Rebecca Onie, Chapter 18 in Creating Good Work: The World’s Leading Social Entrepreneurs Show How to Build A Healthy Economy edited by Ron Schultz]

When Dr Jack Geiger got to Moundville in 1964, he found conditions to be reminiscent of those he had seen in South Africa, and not in a good way. The staff of the community health center, who supposed they were going to be dealing with TB, cancer, and other medical problems instead found themselves overwhelmed by the social problems that undermined health in the region, such as hunger and unemployment. In a way that was prescient,  members of the community were included for the first time in decisions about their health and the future of the area through inclusion on the board and the clinic staff.

These medical folks soon found themselves engaged in food security, developing safe drinking water, and economic development, The clinic developed a farm cooperative to allow community members to grow food for themselves and earn additional money from selling produce to others. They not only saw patients in their offices but went into people’s homes to focus efforts on how to prevent illness. In the days of Jim Crow, they were considered a significant threat to the status quo.

Today, the Delta Health Center has a Facebook presence. The community health movement has spread to almost every part of the country. It is not unusual for the local Center to provide services to all, regardless of ability to pay. However, it isn’t enough. Just as Dr. Geiger saw that food was the treatment for malnutrition, we now know that chronic illness, cancer, and premature death are caused as much by poverty and genetic predisposition as by bad luck. The zip code you are born in predicts whether you will live an additional decade and what that experience will be like. The next Dr. Geiger will need to get into the weeds a bit more.

The Center for Health Innovation at CMS has put together a blueprint to get to the next step. Called Accountable Communities, it envisions health professionals hooking folks up with food, pest control, legal services, and other resources needed to help them overcome the tyranny of the zip code. Health Affairs has outlined what resources we as care providers need to overcome that tyranny:

1) Health Systems Need To Commit To Real Clinical Integration Of Social Needs – If we are going to anticipate the “rising risk” patient, we as care providers need to know something not only about the “really sick” but about all folks in the community and their anticipated needs. Some insurance plans are capturing this on all of their covered folks but doing a terrible job of sharing with other members of the health care team. We need to all know who is suffering so we can match people with resources.

2. Commit To Developing A Workforce That Is Truly Focused On Addressing Social Needs – It will take more and different types of care providers to help folks to not get sick in the first place. What should our outreach strategy be? Do we develop community health workers? Do we recruit volunteers? While it takes a village, more importantly it takes way more than just doctors. Once a need is identified, we need case workers engaged in hooking folks up with services such as food pantries, financial planners, pest control specialists, and legal aid.

3. Commit To Giving That Workforce The Information They Need To Do Their Jobs Well– Community resource availability is an ever-changing picture. Static information sources (books, pamphlets, etc) are rapidly out of date. Medical personnel often are unaware of what the community has to offer. Whose job is it to hook up community agencies with sick people?
4. Commit To Follow Up – For folks at risk of getting sick, repeated contact to help them become motivated to change is the key, even when they don’t want to think about their health. Who makes this contact? Do we aggressively pursue those who feel they don’t need services but clearly do?
5. Commit To Collecting And Analyzing Data – This is a lot of data on people. Target knows when a person is pregnant, often before the baby-daddy does. Do we use this data for the forces of good? If so, who does and how do they use it?
The Great Society didn’t make us great but it sure helped this county. Although still poor, the health markers in Bolivar county are better than 11 other Mississippi counties. For rural Mississippi, that is saying something. Maybe through Accountable Communities we can all take that a step to disassociating illness and poverty.

 

 

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Student overheard on interview tour: Boy, I really put one over on Perkins. I told him I wanted to be a Primary Care doctor…and he bought it. I’m sure to get in now.

What do we look for in medical students? No matter what, we want our physicians to be smart. The selection process is designed to weed out “not-smart” people. Unfortunately, we can only measure smart in a couple of different ways (grades and MCAT scores), ways that tend to benefit the wealthy  (60% of medical students are from the upper quintile of income) and non-minority folks (14% of medical students are from underrepresented minorities compared to almost 25% of the population).

Is there  another criteria we should  use for selecting medical students? Altruism in medicine is best described in the words of this medical student:

So, for me, I see it as always putting yourself behind the person that you’re with. So the patient comes first, no matter what. If it means spending extra time past normal office hours to stay, if it means going out of your way for somebody, if it means sacrificing something for yourself, I think that’s what it is. First and foremost, you’re taking care of the patient.

Can we assess this in a medical school application? Unfortunately, not very well and not in a reproducible manner. We tend to put value on things we can quantify, so an MCAT equivalent of 37 (99th percentile) would attract the attention of the admissions committee much quicker than a prolonged experience at a soup kitchen. As one of my fellow admissions committee members said, “You can’t assay for the Give A Crap gene,” but you sure want your doctors to have it. The MCAT predicts how well the student will perform on tests but has no bearing on how good of a physician they will be. The soup kitchen experience may take away some grade and MCAT points, but give me that doctor-to-be every time.

Another marker is not the number of experiences but the intensity and commitment shown. The best people I have interviewed have been folks who have decided on medicine after several years of Teach For America or similar life experience. These folks tend to be better able to communicate with patients and, not coincidentally, tend to seek careers in primary care.

The best way to assess this, so they say, is through the interview process. As an interviewer, I will look at the student’s activities and query them regarding each of the things listed. Although not focused on primary care, I try to focus on whether or not the person has the GAC  gene. To be honest, if in my opinion they don’t, I am not certain enough on my ability to assess to sabotage the application. If they do, I try to recruit them into our school. If not, I try to sell them on the other allopathic medical school in the state.

 

 

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Resident: This is an 85 year old woman who presented in sepsis from a multilobar pneumonia. Her temperature was 103.2 and she had a blood pressure of 100/60. Her chest x-ray showed pneumonia. Two hours after the antibiotics, she is up and around and wants to go home.

Me: Wow

Resident: I know, based on the CURB-65 criteria her predicted mortality is about 50%

I give away a lot of advice, that people may or may not want.  People come to me not for information regarding their disease but for a cure. They want to feel better. This is in part an residual of the miracles of the antibiotic age that I was a part of this weekend. Pneumonia, the “old man’s friend” is now, if treated efficiently and effectively, almost always curable as attested to by my patient form this weekend. The proliferation of “urgent care”s and “immediate care”s is partly because people want to feel better immediately (it isn’t Dr. Perkins I need, it is a prescription and a steroid shot) and partly they don’t want to miss a pneumonia and die (it isn’t pneumonia, is it?).

The antibiotic model is that it works great for pneumonia in old people in part because the outcome is so dramatic. The older person is still old but the pneumonia is now gone. It is a lousy model for chronic illness. Take insulin for 4 days for your diabetes and you still have to take it the 5th day. And the 365th day for that matter. Unlike the pneumonia, which if untreated will kill you quickly, the high blood sugar of diabetes rarely kills. It is the aftereffects, the sequelae, of diabetes that kills with heart disease, stroke, infection, and blindness.

The New York Times covered a science story regarding the differences in premature mortality between the rich and the poor (found here). In it they point out that the differences can be explained by smoking (the poor are much more likely to smoke, now) and prescription narcotic abuse (just because it came with a prescription doesn’t mean it is safe). The third contributor is obesity. The rich are less likely to be obese than the poor, but not that much less (31% vs 37%), so why is obesity more of a problem for them? The investigators didn’t know why, exactly.

We had another patient this weekend who was admitted for her diabetes that explains why obesity isn’t so bad for the poor but the sequelae of obesity is. Her diabetes is well controlled when she has her insulin. Her job provides her insurance. Unfortunately her job doesn’t pay enough to cover the copay for the insulin, her grocery bill, and her housing expenses. So often, she has to make a choice between food and insulin, especially if her job doesn’t give her enough hours. So it isn’t the obesity per se. It really isn’t the diabetes, per se. It is the need to choose between a warm place to stay, food for her family, or her insulin that forces her to neglect herself. The sequelae of being poor in America.

 

 

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