Why Jolie’s announcement matters… and also why it doesn’t

Tags

health policy and management, opinion

Angelina Jolie took the media by storm today when she announced in an Op-Ed piece in the New York Times that she had undergone a prophylactic bilateral mastectomy.  She made the bold decision after she discovered she tested positive for a gene mutation that increases the risk of breast cancer.

So why does this matter?  Well for one, women who carry these mutations have a highly increased risk of developing breast cancer.  The average woman has a 12% lifetime risk of developing breast cancer, while women who carry the same mutation as Jolie have about a 65 percent risk of developing breast cancer.  Women with the gene mutation are also at increased risk for ovarian cancer, and the breast and ovarian cancers they develop tend to be more aggressive than in women with an average risk for breast cancer.  Advocates for testing point out that knowing one’s mutation status can help make future treatment decisions.  Women of child-bearing age may decide not to delay pregnancy when they test positive for the mutations.  Surgical options for reducing cancer risk include the prophylactic bilateral mastectomy that Jolie chose as well as potentially removing the ovaries.  Regardless of any surgical options, women who test positive for the mutations are likely to undergo more frequent screenings for breast cancer including mammogram, ultrasound, or MRI.

Awareness is arguably the most critical piece of detecting and treating any disease; never underestimate the importance of getting the world out.  An announcement by a high profile celebrity does far more to instantly increase awareness than any foundation or charitable organization.  If you don’t believe me, just look to the media – Jolie’s story was instantly splattered across newspaper websites as well as Facebook, and Angelina Jolie is currently the top trend on Twitter.

But Jolie’s announcement requires a word of caution, as not everyone who is at increased risk will develop breast cancer.  Nor is testing appropriate for everyone.  As she points out, Jolie was at increased risk for the mutations since her mother was diagnosed with breast cancer prior to age 50.  However, most women with breast cancer do not have the BRCA mutations, nor do the vast majority of women in the general population.  While the BRCA genes (conveniently named BRCA1 and BRCA2) account for between 5 and 10% of all breast cancers, estimates are that only 0.11% to 0.12% of women carry one of the mutations.  Look at those numbers closely because that means that 99.88 to 99.89% of women do not carry the gene.  Clearly testing every woman in the United States doesn’t make sense, as the US Preventative Services Task Force has already correctly deduced.  The real question then, who should get tested?

According to the American Society of Breast Surgeons, only high risk individuals should be tested for BRCA1 and 2.  High risk is defined as a greater than 10% chance of cancer.  Patients with multiple risk factors or with borderline risk are often referred to genetic counseling for more information and guidance about testing and what the results mean.  More than one of the following risk factors is needed to achieve that 10% threshold:

1. early onset breast cancer (diagnosed before age 50)
2. two primary breast cancers, either bilateral or ipsilateral
3. a family history of early onset breast cancer
4. male breast cancer
5. a personal or family history of ovarian cancer (particularly non-mucinous types)
6. Ashkenazi (Eastern European) Jewish heritage in the setting of a newly diagnosed breast cancer or family history of breast cancer
7. a previously identified BRCA1 or BRCA2 mutation in the family
8. Early onset breast cancer (diagnosed before age 50)
9. “Triple negative” breast cancer diagnosed prior to age 60 (triple negative refers to three specific markers of certain breast cancer cells including ER, PR and Her2).

Part of why Jolie’s announcement doesn’t matter is that she is certainly not the first woman to undergo a prophylactic bilateral mastectomy.  Nor is she the first celebrity to undergo a double mastectomy; countless others have done so after a unilateral diagnosis of breast cancer, including Christina Applegate and Giuliana Rancic.  Nor is Jolie the first to do so for purely prophylactic reasons, although perhaps not as publicly.  Sharon Osbourne underwent prophylactic bilateral mastectomies last year due to a gene known to cause an increased risk of breast cancer, although it’s not clear if Osbourne carries a different genetic mutation from Jolie.

I could launch into the discussion of money and resources at Jolie’s disposal and how expensive the testing, and subsequent treatment, currently is.  But that could go on for days and will ultimately devolve into a discussion of whether one likes or hates Angelina Jolie.  But more importantly, that discussion degrades the understanding that this decision is faced by thousands of women, and it is a deeply personal decision.  The most important part of Jolie’s announcement may be that once testing is recommended, the decision to test or not is a decision that cannot be made for you.  Nor is it one to be made lightly; the results can be life changing and prompt consideration of the limited available options.  One needs to ask whether knowledge really is power and how that knowledge may permanently alter life’s course.

Humanity in medicine, part 2

As a follow up to yesterday’s post on humanity in medicine, I’ll refer you to this article in the New York Times WellBlog section written by medical student Dhruv Khullar.  The quote below is fairly powerful – and I believe it would strike a chord with anyone who works in healthcare.

Like many of my classmates, I entered medical school with an idealized notion of medicine. But I will leave with the knowledge that the reality is far more complex. There are patients who don’t listen, who can’t listen; who try, who don’t try; who smile, thank and love; who steal, curse and hate. Each of these patients deserves the full extent of our respect and abilities. But too often those most in need of our compassion are least likely to receive it.

The balancing of complex emotions, time constraints and limited resources will only become more difficult with the influx of millions of previously uninsured people into our medical system. As we continue to carry out the Affordable Care Act and enter an era of tremendous change, we must confront our natural tendencies to favor patients we find pleasant — especially when it comes at the expense of those we find less so. We must recognize that sometimes the patients who behave the worst are those who are hurting the most.

Transparency

Tags

health policy and management

The Boston Globe recently reported that medical mecca Brigham and Women’s Hospital (BWH) started publicly reporting its medical errors beginning in January 2011.  BWH joins its across the street rival Beth Israel in opening the door to transparency in medicine.  BWH publishes the errors in a monthly online newsletter accessible to its employees.

As the article points out, hospitals are not usually so open and honest when it comes to errors.  While they may publicly report information on infection rates to their employees, serious medical errors are often kept under wraps.  While acute care hospitals in Massachusetts are required to report events to the Department of Public Health, ultimately only the frequency of events is reported to the public.  The details often remain unknown.  Hospital leaders often fear that the public will find out exactly how bad things really are, either scaring patients away or opening the door for litigation.

According to the Globe, leaders at BWH started the publication to encourage staff members to talk about mistakes and to also propose solutions in order to prevent errors.  The focus on transparency at BWH supports the notion that keeping errors secret may actually hamper efforts to reduce the errors from occurring in the first place.  Learning from errors in an open forum may be the only means to find out what happened and prevent them from happening again.

“Transparency until it hurts” is a phrase we often throw around at the Bureau of Healthcare Safety and Quality within the Department of Public Health.  The idea that patients and consumer deserve to know what they are getting into is paramount in our organization.  Apparently, Brigham and Women’s took a page out of the transparency book as well.  Hopefully other hospitals will follow suit.

Meet the Gaybros?

Tags

gay, opinion

I’m not going to win any popularity points with this one, but I don’t care.

Brian Lowder wrote an article for Slate that posted yesterday titled “Meet the Gaybros.” The subtitle was “They like sports, hunting, and beer. They make the gay community mad.”

I’ll tell you what makes me mad… articles like this one.

The article starts off with Lowder walking around Boston with a group of men who have dubbed themselves “Gaybros”, gay guys with traditionally manly interests like sports, hunting, and beer.  They travel to the city’s “premiere gay sports bar” Fritz, where Lowder comments on the diversity of the crowd.  To call Fritz a “premiere” anything is a joke; the fact of the matter is that Fritz serves a clientele who, unlike so many other places in Boston, don’t give a f*ck who you THINK you are.  People go to Fritz not because it’s a great place to watch sports but because it’s low key and unpretentious.  The “Gaybros” later head off to Club Cafe, a locale I would ironically dub the exact opposite of Fritz… but also not “premiere”.  Lowder, on the other hand, makes an exit and heads to a house party at a “handsome” townhouse where he is surrounded by the “Crate and Barrel brand of gayness.”

Here’s why I hate this article.  The “us versus them” mentality and the compartmentalization of gay culture in this article (and in real life) is ridiculous and does us a disservice.  At a time when the community should be rallying behind each other in support of legal rights for ourselves and the rest of the LGBTQIA community, instead we continue to separate and ridicule one another.  We do to each other exactly what the straight (male) community continually does to us.  Gay men are, in fact, our own worst enemies.

The whole notion of “masc” versus “fem” is utter ridiculousness.  The idea that gay men can only fall into one category or another is ludicrous.  These labels, if you will, are not mutually exclusive. What this article highlights is a nasty division within the gay community, one that employs labels taken directly from the very people who oppress the gay community in the first place.  The fact of the matter is, there is plenty of room within the gay community for everyone – Gaybros included.

In the words of the person who sent the article my way, “I can love watching the Emmy’s and watching the Pats on the same day.  I totally go to Red Sox games because I’m a fan, but I also love to watch my design shows on HGTV.  Cut the crap – ALL OF US.”

Gays – it’s time to grow up.

in defense of marriage

Tags

gay, opinion, overread

Among social conservatives, the argument against marriage equality that reigns supreme is the notion that same-sex marriage undermines the very institution of marriage.  Since Massachusetts began to recognize same-sex marriages in 2004, voters in many states have approved amendments to their state constitutions barring same-sex marriage.  A number of states have also granted marriages to same-sex couples, and certainly the 2012 election ushered in a historic moment for marriage equality in the United States.  The compromise position for the remainder of the states has been the recognition of civil unions and domestic partnerships, as most recently demonstrated in Colorado.

In 1995, David Boaz wrote an essay for the New York Times on the subject of civil unions and domestic partnerships called “Domestic Justice”.  In that article, he noted that politicians “overlook that there are two kinds of domestic partnerships – heterosexual and same-sex.  Although the most vocal opposition to domestic partnerships is aimed at gay couples, giving them [legal] benefits does not undermine marriage.  Rather, it remedies the injustice that homosexuals can’t marry the people with whom they share their lives, and it creates financial incentives for stable relationships.”  Boaz wonders that for social conservatives who are so opposed to affirming marriage equality, are these not the same goals that we seek in encouraging heterosexual couples to marry?

Giving domestic partnership benefits to unmarried heterosexual couples, on the other hand, does undermine marriage.  They give people who can marry all the financial benefits of a legal union without demanding commitment.

If social conservatives really want to stand on a platform of family values, shouldn’t they be encouraging the creation of long lasting committed partnerships and families?  By offering domestic partnership benefits to heterosexual couples who do not marry, social conservatives undermine the very institution they hold so dear and continually wave in the face of same-sex relationships.  Instead, domestic partnerships and civil unions are seen as a peace offering to the gay community, relegating them to second class citizens and simultaneously undermining the institution of marriage by offering a similar set of rights to unmarried heterosexual couples.

Perhaps because domestic partnerships and civil unions are a step toward correcting a wrong, perhaps they have more bipartisan support than marriage equality, perhaps they are viewed as a compromise, or perhaps people believe the gay community will tolerate domestic partnerships and civil unions and therefore cease the push for marriage equality.  But we know from history that separate but equal is all too clearly separate but never in fact equal.

On the recently passed civil union bill in Colorado, state senator Pat Steadman (D) had this to say. “Civil unions are not marriage. They are something that are separate, and distinct, and lesser, and unequal.  And that really is not good enough. We passed this bill because this is the best we can do.”

Healthcare – the job creator

Tags

health policy and management

If you read the recent TIME article “Bitter Pill: Why Medical Bills Are Killing Us“, you’re probably thinking that our nation’s economic viability is doomed if health care spending continues to grow at it’s current pace.  As so ominously mentioned in the article, “we may be shocked at the $60 billion price tag for cleaning up after Hurricane Sandy” and yet we spent almost that much last week on health care.  It is true that in 2010, the United States spent 17.6% of GDP on healthcare, amounting to over $8,233 per person (as a comparison, Norway was the next highest spender at $5,388 per capita and the Netherlands which spent 12% of GDP on health care).

I have far more to say about the TIME article (so stay tuned for future blog posts) and about how much we spend on health care in this country.  Clearly the $8,233 spent per person is not giving us the health outcomes we deserve (life expectancy, infant mortality, maternal mortality, etc.)  But many people forget that our country’s economic viability hasn’t been destroyed by healthcare, but has been rather dependent on it for years.

Economist Uwe Reinhardt has written on this subject in the past (see “In Defense of a Giant and Growing Healthcare Industry“), but Reinhardt’s most recent article in the NYTimes Economix blog points out that in the past two decades, the healthcare industry has created more net jobs than any other industry.  Healthcare was one of the few industries to add jobs during the “Great Recession”.  Healthcare spending hasn’t beaten our economy down; in fact, the healthcare industry has been leading our economy forward.  And that spending, according to Reinhardt’s analysis (I’m not an economist, so I’m not going to even pretend to know if he’s right or wrong) has been rather consistent over time.

With all the talk about how much we spend on health and healthcare, we forget to mention the thousands of jobs that the industry employs.  In most towns and cities across the country, it is the hospital that is the dominant employer.  Additionally, the health care industry employs people in jobs across the spectrum, from doctors and nurses to technicians and housekeeping staff.  Reinhardt pointedly asks,

When you last visited a physician’s practice or stayed in a hospital, did you see people other than patients there? Do you realize that these people call their work “jobs,” which yield a livelihood that supports a family and raises the next generation of Earthlings? Did it occur to you that their care for you has economic value, especially as you can walk again as you could not before they cared for you? Did you consider that they postponed your death by many years, perhaps even decades? Would you really surmise that their work creates less value added than, say, the fast-food industry? Note, of course, that the latter is a major driver of obesity in America — and thus of diabetes and the many illnesses that diabetes triggers, such as blindness, kidney failure, loss of limb or even early death, the very things the American health care sector fights.

Is there waste in the system?  Absolutely, just as there is waste in every other major US industry.  You could even argue that the fast-food industry is perhaps the most wasteful, by taxing the nation’s future health.  But the mere existence of waste in the US healthcare system does not negate the value the industry has had for our economy.

Having It All?

Tags

opinion

Several months ago, a close friend sent me an article from The Atlantic, thinking it might be a good blog topic.  The article was titled “Why Women Still Can’t Have It All“.  I started reading the article and quickly lost interest in what I felt, at the time, was condescending and utterly too long.  But yesterday’s article in the Boston Globe, “Having it all … wrong” made me revisit The Atlantic.

In the article, author Ann-Marie Slaughter describes her time as the first female director of policy planning at the State Department under Secretary of State Hillary Clinton, and the constant struggle she felt in balancing work life with family life.  With two teenage sons at home in New Jersey and a grueling commute early Monday morning and late Friday night, Slaughter eventually returned to academia at Princeton after her two years of public service.  Her return yielded some strange reactions from her female colleagues, ranging from pity and sadness to disappointment.

Slaughter remarks that the biggest thing that is holding women back from achieving more is not necessarily men holding them down, but rather the pursuit of feminist ideal of “having it all” – an ideal that Slaughter believes is attainable, just not in with the way today’s workplace is set up.  “You can be a careerist, or you can be a present parent, but the world isn’t designed to accommodate both.”  Slaughter is careful not to disparage the generations of women who came before her, noting she was blessed to be born in the 1950′s and not the 1930′s.  She notes that she owes much of her own career opportunity to “the pioneering generation of women ahead of me—the women now in their 60s, 70s, and 80s who faced overt sexism of a kind I see only when watching Mad Men, and who knew that the only way to make it as a woman was to act exactly like a man.”

But Slaughter also admonishes them, as well as her own generation, for continuing to perpetuate the myth that women can have it all if they only work hard enough.  The fortitude and leadership of prior generations allows for “a different kind of conversation”, one that requires “women in leadership positions to recognize that although we are still blazing trails and breaking ceilings, many of us are also reinforcing a falsehood….”  For many younger women, the constant struggle for a work-life balance clearly indicated that “having it all” is not attainable.

Kara Baskin takes it one step further in her article in the Boston Globe, for even if we can have it all – who said we deserve to?  According to Baskin, “we were told we could do anything – but nobody told us we couldn’t be everything.”  Baskin and Slaughter seem to agree that there are some things you have to give up.  Working women today have more choices than ever, yet the pursuit of “having it all” leaves them stuck.

While Baskin and Slaughter clearly come from a female viewpoint, the lessons here are applicable to men as well.  In a world that is increasingly lifting women to new career heights and slowly accepting that men should be able to stay at home, one has to wonder what work-life sacrifices men will have to make in the future, to say nothing about the sacrifices many have already made by diligently focusing on a career at the expense of being at home with their families.  Men would be smart to look at their female counterparts and wonder what the future has in store for them as well.

The tricky part here is that life is full of multiple choices – and unlike the tests we take in school, there may not be one clear right answer.  Instead of trying to have it all, perhaps we should focus less on what we could have and more on what we want.  We need to be realistic and keep proper perspective – until corporate America catches up with what both men and women desire from a work-life balance, we should focus on what is meaningful and redefine what personal “success” is.  We need to tell our sons and daughters that they can do anything they want, they just can’t do everything they want all the time.  As Baskin points out:

No, most of us still cannot run corporations while also running the school field trip while running marathons, too. But we also cannot become so entrapped by the quest for everything that we lose appreciation for the little things, even if it’s just a warm home at the end of a long day, whether we share it with kids or dogs or an untended filing cabinet.

discount at Boston Children’s Museum for low income families

Tags

family, opinion

The Children’s Museum in Boston started a new program in August to offer discounts to low income families.  Instead of the usual set of discounts and coupons, which the museum found was not achieving the goal of attracting low income families, the museum allows families to get in for $2 after showing their EBT cards.  More importantly, the museum actually worked with representatives from Mattapan, Roxbury, and Dorchester to come up with the idea.

According to an article in today’s Boston Globe, “Since the EBT program started five months ago, more than 1,160 visitors — some of whom say they would not have otherwise visited — have used the EBT discount. More than 30 percent of them are from low-income communities in Boston and others live in more affluent Boston neighborhoods and suburbs, according to museum figures.”  No money is deducted from the EBT cards themselves; residents still must pay the $2 out of their own pockets.

I, for one, think this a great idea.  Feel free to agree or disagree.

George Bush 41?

Tags

ridiculous

Um… maybe I missed something about the former President, but CNN – why is the title of this article “Bush 41″?  I mean, I know he’s the 41st President of the United States… but that seems like an odd way to refer to him…

the debt burden

Tags

opinion

No, I’m not talking about the national debt.  I’m talking about the mountain of debt facing most of those who decide to attend medical school.  I personally have my own small fortune to contend with, but the amount of debt that graduating medical students from both public and private medical schools continues to increase.

The median debt of graduating medical students is $160,000 with a third of students winding up with more than $200,000.  These costs not only include tuition but the cost of living as well as travel expenses.  Additionally, there are the numerous exams students must take, the expense of books, and the money associated with applying to and interviewing/traveling for residency interviews.

Naturally, one might think that future doctors should have no problem paying off these debts.  Which is true, the vast majority of physicians earn enough money to pay off their debts.  But consider the financial consequences of carrying around $200,000 in debt.  Paying back this amount of money delays the inevitable for the future young doctors of America – buying a car, buying a house.  The debt that a student carries goes much farther than that; the societal implications are far more concerning.

Studies have shown that students from minority backgrounds are far more likely to return to practice in the areas from which they come.  Yet these same students are highly likely to be deterred from attending medical school due to the high cost of attendance.  Those who do attend report financial considerations as a reason for choosing high paying specialties like dermatology and radiology instead of primary care.

That’s why the recent announcement by entertainment executive David Geffen to give a $100 million fund for medical school scholarships is not only timely, but incredibly important.  33 students in next year’s entering class will have their entire medical school experience paid for – tuition, living expenses, and even travel.  The real importance of David Geffen’s donation is not the fact that is represents the largest single donation in the history of the University of California but in it’s vision for the future of medical education and the impact of one individual on making medical education a priority.  The largesse and the vision of David Geffen’s gift leads to one inevitable question, why has our society been so slow to do the same?

the road, and roadblocks, to hospice

Tags

health policy and management

Hospice is a topic with which I’m somewhat familiar.  From a personal standpoint, hospice was there in the days, weeks, and months leading up to my father’s death from lung cancer.  The team of nurses that worked with my parents was, from what I’ve been told by my mother, a “godsend”.  The hospice nurse that visited my dad everyday was the one who called to tell me that I needed to come home because my dad wasn’t doing well.  She had done all she could to make those terminal months as painless as possible, and someone from the hospice was always available by phone for my mother.  I wasn’t around much during those last few months, but from what I can tell, my mother was comforted knowing that she was not my dad’s sole caretaker.

Hospice is something we talk about quite a bit in medicine.  Common opinion is that when facing the end of life, Americans do not actually want the aggressive therapy they so often receive.  Nearly 70% of Americans report wanting to die at home surrounded by family than in a hospital.  Over 80% of patients report wanting to avoid hospitalization and intensive care when they are dying.  From a medical perspective, hospice should therefore be the preferred method of treatment by patients.  Yet the reality is far different.  Almost half of Americans die in a hospital, a figure that increases by 20% if you include nursing homes and long term care facilities.  Americans face increasingly complex and intensive care toward the end of life, with increasing hospitalizations and longer ICU lengths of stay.

In health policy circles, hospice is often viewed as one way to contain spiraling health care expenditures.  Medicare spends nearly 30% of it’s massive budget on the last year of life of its beneficiaries – and that’s not on hospice care.  By keeping people out of the hospital, hospice decreases the costs of health care by avoiding emergency room visits and expensive intensive care unit stays.  Oddly enough, hospice may also improve the quality of patient’s lives in those final months.  There is even evidence to suggest that patients enrolled in hospice live longer than their counterparts who continue to pursue aggressive therapy for terminal diseases.

Though hospice enrollments have increased over the years, hospice participation still remains absurdly low at just over 40% of deaths from terminal illnesses.  Low hospice enrollment has traditionally explained by the unwillingness of patients and family members to “give in”, by physicians not wanting to broach the subject of death, or more sinisterly, not wanting to lose revenue by no longer treating patients.  But Paula Span of The New York Times points out a reason that largely goes unknown about the difficulty of enrolling in hospice – many hospice programs restrict access to the crucial end of life service.  But why?

Span points out that when Medicare began paying for hospice, the insurance program required eligible patients to forgo life-sustaining treatment in order to qualify for hospice.  Since patients had a terminal illness, defined as less than 6 months (180 days) to live – any treatment would be considered futile.  No chemotherapy, no intravenous nutrition or tube feeds, no blood transfusions.  This is where medicine and health policy once again clash.  Many of these treatments are now considered palliative in nature – radiation and chemotherapy to shrink tumors causing pain or tube feedings to improve quality of life.  But Medicare’s payments are so low (on the order of $140 a day) that most hospice programs cannot afford to take on patients for whom Medicare will not reimburse.  Most of the private insurance companies follow Medicare’s lead.

Ironically, hospice programs that allow patients to continue life-sustaining treatments find that most patients forgo these treatments altogether, and the savings are substantial.  In fact, in 2004 insurance giant Aetna decided to perform an “experiment”.  Rather than requiring people to give up life-sustaining treatment, they allowed terminally ill patients to continue treatment when they enrolled in hospice.  A two year study of their concurrent care approach found that enrollment in hospice jumped from 26 to 70%, and yet patients enrolled in the program visited emergency rooms half as much and dropped their use of hospitals and ICUs by more than two thirds.  The bottom line for Aetna?  Costs for these patients fell by almost 25%.  The majority of these savings were realized in terminal cancer patients.

So maybe our nation’s collective reluctance to enroll in hospice is not because we are afraid of death or because our physicians do not want to destroy hope.  Maybe all it boils down to is health policy standing in the way of good medicine all in the name of saving money.  And maybe, just maybe, health policy may be standing in it’s own way of showing that improving quality and reducing costs are not mutually exclusive events.  But in the end, even if we end up not saving a dime… should we not be providing better care?

For more information on hospice and Aetna, read Atul Gawande’s piece “Letting Go“

Is the GOP fighting its own civil war?

Tags

opinion

Disclaimer: I dont normally venture too much into politics on this blog, mainly because I don’t know nearly enough to eloquently comment.  Please be gentle.

Beginning with the primaries leading up to the 2012 election, many of us on the left side of the aisle and even some within the Republican party are wondering if the GOP is… well, falling apart in front of our eyes.  Several high profile Senate races during the last election showed GOP incumbents being cannibalized by their own members within the Tea Party.  Certainly the blame game following Mitt Romney’s loss to Barack Obama in the Presidential race was another public indication of political infighting.  However, the Congressional display the past few weeks with the fiscal cliff and Hurricane Sandy relief bill has fostered the question in the minds of many if the Grand Old Party is, in fact, about to fracture and break.  Last week, Errol Louis posited just that in an opinion article he penned for CNN.

Louis points to the debate over Hurricane Sandy relief funds as a picture of the large and growing wedge that is dividing the Republican Party, a wedge forged from the fundamental policies of taxation and spending.  He points out that there are some within the party who are committed to reducing the deficit but are willing to negotiate with their liberal colleagues in the House.  On the other side are budget chopping radicals and no tax hike zealots who believe that government spending must be stopped at all cost.  And apparently that includes disaster relief as well.

That wedge was on full display the last few weeks as House Majority Leader Boehner attempted to pass his “Plan B” for the fiscal cliff in the House but ultimately had to pull the deal after failing to muster enough support among the Tea Party members.  The eventual fiscal cliff deal that passed the Senate and ultimately came to a vote in the House has already been criticized by Tea Party Republicans who claim there will be hell to pay.  Clearly trying to force a vote on Hurricane Sandy relief after failing to bring Plan B to the floor just wasn’t going to happen.  Boehner killed the bill at the time, and the flood gates opened.

A rising star within the GOP, the high profile Governor of New Jersey Chris Christie was not afraid to air his feelings.  He lambasted the GOP for not voting on Hurricane Sandy relief.  And who could really blame him?  Many of the Representatives and Senators within the GOP hail from states that receive billions of dollars from the federal government – billions of dollars that just happen to flow out of states like New York and New Jersey.  Christie was quoted as saying that “There is only one group to blame for the continued suffering of these innocent victims: the House majority (Republicans) and their speaker, John Boehner.  This is not a Republican or Democratic issue. Natural disasters happen in red states and blue states and states with Democratic governors and Republican governors. We respond to innocent victims of natural disasters, not as Republicans or Democrats, but as Americans. Or at least we did until last night. Last night, politics was placed before oaths to serve our citizens. For me, it was disappointing and disgusting to watch.”

Ultimately the measure passed on Friday, January 4th for $9.7 billion – smooth sailing in the Senate with an unanimous vote.  The House… not so much.  In fact, 67 member of the House of Representatives voted against the bill – all Republicans.  Interestingly, that list includes the Representatives from Alabama, Florida, Louisiana and Mississippi – all states that received federal aid after Hurricane Katrina.  It only took Congress ten days to approve  aid to Katrina victims back in 2005 – it took more than two months to approve any aid for Sandy victims.

Of course, it wouldn’t be the first time a major political party in the United States has fallen apart.  In fact, there was once a Democractic-Republican party which fractured into two: the Jacksonian Democrats, who in turn became the modern day Democratic Party, and the Whig Party.  The Whig Party also eventually collapsed, although many of their ideals were adopted by the Republican Party that emerged in the 1850′s.  You wouldn’t recognize the Republican or the Democractic parties of the 1850′s though – they look and speak very differently from back then.

So is the GOP really falling apart or is this just political pandering until the new Congress is ushered in?  Can the GOP sweep its Tea Party members under its wing or might we actually see the emergency of a new political party in the US – one that appears to be both rich and powerful.  I’m not sure that we’re going to usher in a new era in American history, but if there is one thing the GOP can hold onto in order for it’s continued survival, it is this – it’s absolute inability to tolerate anything that President Obama says, does, or throws its way.  The GOP should be careful though; popular opinion is that the President is winning this battle much like the election, with several opinion polls showing that if the country had jumped off the fiscal cliff, Americans were likely to blame the Grand Old Party.

Mitt Romney for Costco?

Tags

overread, ridiculous

An article yesterday on boston.com and several other media outlets captured former Republican Presidential candidate Mitt Romney shopping at a Costco near his home in La Jolla, California.

I’m curious as to what Romney was stocking up on… binders perhaps?

mouthing off

Tags

opinion, ridiculous

I will fully admit – I have not watched Two and a Half Men in a VERY long time, long before Charlie Sheen “left” the show.  But my general impression of the show from the few episodes I had seen in the past was that Angus T. Jones’s comments about the show weren’t really that far off…

 

 

 

What do you all think?  Is Two and a Half Men trash and should viewers stop watching or is there some redeeming value to the show?  Was Angus T. Jones wrong to slam the show he is on and essentially bite the hand that feeds him?  Do you think he really needed to apologize?

 

A generation without cars?

Tags

opinion

According to a report by CNNMoney published yesterday, it seems that America’s young people just aren’t buying cars.  In fact, people ages 18-34 are forgoing cars – the share of new cars for this age group has dropped by 30% over the last 5 years.

The article proposes several reasons as to why – primarily citing social shifts as the main reasons.  Certainly the re-urbanization of American cities provides increasing access to public transportation, less reliance on cars, as well as increased difficulty in having a car.  The article also notes that the emergence of Zipcar and car sharing companies has made it easier for city dwellers to get by without having a car around every day.

But the article focuses mostly on the emergence of social media, claiming that the rise of social media has obviated the need for cars among members of this age group.  Social media, and by extension owning a smart phone, has become the new mechanism of freedom.  Likewise, social media has made it easier to meet and interact with people, reducing the need for cars.

I find the idea that social media has made it easier to “meet” people slightly ridiculous.  Interact perhaps; meet – not so much, as you are not in fact meeting anyone through social media.  You only meet people when you actually see them in person.  I digress…

The article seems to downplay the idea that the economy has had a major effect on car buying patterns of young adults.  But even more so the article seems to dismiss the notion that young adults, saddled with debt from college, can’t afford to purchase cars.

I may be biased since I a) own a car and b) have lived in cities for the past 12 years with decent access to public transportation.  But I’m curious what people out there think.  Why do you think young adults aren’t buying cars?

Is it the expense of buying a car, the expense of owning a car, access to public transportation or lack there of, deferring car ownership until later in life, or the rise of social media?  Or is it something else entirely – are car companies not making cars that young adults want?

Ignornace is bliss?

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opinion

I’m actually not going to comment on this one and merely let the rest of you add your two cents.

Fixing the health care system

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health policy and management, opinion

For all the talk about health care reform, improving care coordination, increasing patient satisfaction, and reducing costs, maybe it all doesn’t matter if our nation’s physicians don’t “feel the love” … so to speak.  After all, physicians (although not their salaries) account for a large proportion of both direct and indirect medical costs in the United States.  Physicians largely remain the gatekeepers to further care in this country; 85% of health care costs can be directly or indirectly linked to the doctor’s pen, keyboard, or mouse.

Dr. Pauline Chen comments on the physician burnout phenomenon in her New York Times blog about a recent study of over 7000 physicians and how fulfilled they felt in their careers.

Analyzing questionnaires sent to more than 7,000 doctors, researchers found that almost half complained of being emotionally exhausted, feeling detached from their patients and work or suffering from a low sense of accomplishment. The researchers then compared the doctors’ responses with those of nearly 3,500 people working in other fields and found that even after adjusting for variables like gender, age, number of hours worked and amount of education, the doctors were still more likely to suffer from burnout.

Chen notes that burnout seemed highly correlated with front-line access to care – more than half of physicians who worked in general internal medicine, family medicine, or emergency medicine experienced burnout.

More importantly Chen comments on why the rest of us should care; doctor burnout directly related to quality of care and patient safety.

“What patients must face in the examining room is no less alarming. Doctors who are suffering from burnout are more prone to errors, less empathetic and more likely to treat patients like diagnoses or objects. They are also more likely to quit practicing altogether, a trend that has serious repercussions in a system already facing a severe doctor shortage as it attempts to expand coverage to 30 million or more currently uninsured Americans.”

I’ve certainly experienced burnout during my residency training, and while that statement should bother you, it shouldn’t be surprising.  Most people cant imagine working 30 hours in a row.  I’ll provide real world examples of how it might feel to you.  Imagine you receive 400 emails a day – how much effort and time do you put into emails #399 and 400?  Or maybe you work in the restaurant industry – not only have you been on your feet all day, but the hostess just put sat a new table in your section even though you’re due to end your shift in 5 minutes.

But we’re physicians after all – held to a higher standard even though we are undoubtedly not supermen nor superwomen but merely mortals like everyone else.  The higher standard means we should care more, and every patient should be treated equally… right?  In an ideal world this is true, and even in the not so ideal world that we actually operate in this should be the standard to which we hold ourselves.  But that standard falls apart when you are working hour 29 of 30 with no sleep.

I will fully admit that I’ve found myself at 5:30am in the Emergency Department not caring about what ails the 20th patient I’ve seen that night who happens in front of me complaining of non-specific abdominal pain with no obvious source.  I have definitely answered a page to drain an abscess in the ER only to turn over and set the alarm on my phone for 20 minutes later just to catch some sleep.  I’ve definitely given responsibility over following up a lab value or radiologic exam to an intern so that I could relax for 10 minutes or so.  I’m not proud of those moments – but fact of the matter is they occur.

I always assumed that those moments would end after residency, when the patients were actually MY patients and the hours were not as grueling.  But the research article that Chen cites seems to suggest that it may not get better.  And that delays in care, poor coordination, and management errors may in fact continue long after the rigorous training of residency comes to a close.  And if so, all the health care reform in the world may not fix the problem if, in fact, the problem that needs to be fixed is motivating physicians.

So what do you think?  Do doctors just need to suck it up or do we have a real problem in the physician work force?  Because the repercussions could be critical…

 

The Doctor-Patient Relationship: Is there any truth in medicine?

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opinion

It is truly a relationship like none other.  One person enters into this partnership freely and bares their personal history and “dirty laundry” to the other, hoping for and anticipating sage advice and perhaps a remedy.  The other enters wielding the perceived batons of knowledge and power, listening to the tale of the other, processing the information in a sympathetic manner, forming a plan, and offering a reasonable resolution.  Somewhere throughout all of this is an exchange of information, knowledge, and money.  There is a mutual understanding of respect, honesty, privacy, and confidentiality inherent in this relationship.  This is the ideal tale of the patient and the doctor.

Or so we like to think.  The doctor-patient relationship is one that has stood the test of time relatively well.  It certainly has lasted longer than Kim Kardashian’s marriage.  In some respects, it is the ultimate relationship between two human beings.  For the patient, a chance to seek advice or a cure for the illness that ails in an environment free of judgment.  For the doctor, a chance to practice his/her skill, to comfort the sick, and to alleviate suffering.  All of this in a place where both patients and doctors are supposed to – rather expected – to be honest, forthcoming, and truthful.

For years however, physicians have been taught to question and critique our patient’s responses.  A question asked does not always elicit an honest answer.  Over time, medical education has taught students and doctors alike to begin with broad, open-ended questions – allow the patient to tell their story without interrupting – and then slowly move into pointed and more directed questioning.  Obtaining a patient’s history became more detective than doctor.  This view isn’t entirely cynical; patients are often unable to recall every detail – information that can be vital to physicians but may seem relatively minor to patients.  Patients may be so overwhelmed by their illness that they cannot remember everything… and who can blame them?  Those with complicated medical histories are unlikely to remember who removed their tonsils some 40 years ago or all 25 of their daily medications.  Patients are often anxious and more often embarrassed – it can be extremely difficult to reveal the intimate details of one’s private life to someone who increasingly may be a complete stranger.

So doctors learn to question.  The old social history question “do you drink alcohol?” turns into “how much alcohol do you drink in a week?”; “do you smoke?” has become “how much tobacco do you use in a day?”.  At the heart of our questions is truthfully a fact-finding mission; but there is a degree of skepticism that often assume varying amounts of omission and dishonesty, whether intentional or not.

Several recent articles, however, should give patients reason to pause and question as well.

A survey of 1,900 physicians performed by researchers at the Massachusetts General Hospital and published in Health Affairs reported that nearly 20% of respondents did not report mistakes to patients, close to 40% did not report ties to pharmaceutical companies when prescribing medications, and almost 45% reported painting a better prognostic picture than reality to their patients.  The study authors also pointed out that these results may be lower than the reality, as physicians may have responded to the survey questions according to their perception of the professional standard rather than their actual practice.  The results of the survey suggest that perhaps both sides of the doctor-patient equation are less than forthcoming with the truth, the whole truth, and nothing but the truth.

And as Dr Pauline Chen points out in her article in the New York Times, even when physicians may be telling the truth, the information coming out of their mouth may be less important than the words their body language is saying.  Patient’s perceptions of how we speak may be far more important that what we actually say.  Communication is incredibly important, regardless of how honest it is, and can often be overshadowed by the delivery.  Chen’s article is even more astounding given the emphasis in medical education on communication skills.  Countless hours of curricula are spent teaching medical students not just the information necessary to become a doctor, but equally important how to act like one and how to convey that information in a way that is palatable to patients.  Students are placed in a variety of settings throughout the four years in medical school to test, alter, and hone these communication skills through video tapes, standardized patients, oral exams, and patient feedback.

I’ve often told medical students that learning how to be a doctor was reserved for intern year; learning how to act like a physician is a skill that should be acquired in medical school.  Part of this “act” includes learning what to say and how to say it.  But as last week’s articles point out, what are we really saying?

Physicians often justify their lack of honesty in many ways; the most popular reasons include lacking sufficient time, patient’s inadequate knowledge, or the belief that the information would be harmful to patients.  These reasons not only carry the sting of paternalism but are, quite frankly, insulting to patients.  The physician who chooses dishonesty over careful explanation is clearly shirking his/her duty to the patient.  The physician who bends the truth because he/she believes the patient lacks the appropriate knowledge to fully understand has clearly not done a sufficient job in explanation.  The physician who assumes that an honest assessment of prognosis would be detrimental to a patient’s emotional well-being has clearly neglected to ask that patient when would be appropriate to broach the subject.  Likewise, our honesty has left them uninformed, not fully aware of the possibilities and probabilities they so desperately need to know to make truly informed decisions about their care.  Furthermore, these assumptions, reasons, and accusations are no longer acceptable, particularly since patients are increasingly knowledgeable and self-advocating, and unfortunately increasingly skeptical of and disappointed in the medical community.  This week’s articles, unfortunately, only add fuel to the fire of suspicion in their minds.

Ultimately, our responsibility as physicians is to treat our patients both equitably and honestly.  We are the ones charged with the duty to alleviate pain and suffering, to enhance well-being, and to promote health by working with our patients.  For the sake of our patients, we owe them a doctor-patient relationship that is rooted in trust.  Because if we ultimately fail to step up to the plate in a relationship predicated on honesty and trust, can either party ever truly believe?

NY Times: What Doctors Are Telling Us Even When They’re Not Talking

Boston Globe: Doctors Often Lie To Patients and Hide Mistakes

Original Health Affairs article abstract (referenced in the Boston Globe article; contact me if you would like to read the full journal article and I’ll try to get you access)

Born this way? Does it really matter?

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opinion

Great Op-Ed piece in the NY Times yesterday regarding Cynthia Nixon’s recent comments about her sexual orientation and about the roots of sexual orientation in general.  A must read for anyone who is gay/lesbian/bisexual/transgender or knows someone who is (which is most people by now…)

Genetic or Not, Gay Wont Go Away

Media

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gay, opinion

So once again I’m posting something from the RedEye.  Ok, I admit it.  I’m addicted.  I cant imagine a lunch going by w/o reading the RedEye.  In fact, now I stop and grab a RedEye before I go to Subway so that I wont be disappointed if for some reason, there are none at Subway for me to read.

Today’s article is from the “Boy on Boystown”…and I have to agree with my friend Scott, kinda dumb.  Yet still thought provoking and I have plenty of commentary after the article.  Read on:

Gay media sends dangerous body image message

Apparently, I am fat. I am 6 feet tall and 180 pounds and I am out of shape, overweight and unattractive.  At least that is what the gay media tells me every day when it throws images of shapely men with 0 percent body fat in my face. I’m having a difficult time living up to these unrealistic body images.The latest issue of Genre magazine features a cover model named Travis who has 8-pack abs. Yes, he’s so fit that he actually managed to somehow produce two extra abdominal muscles to beat the 6-pack. I like to think I have one giant ab.

It wasn’t just the cover-model Travis taunting me. Flipping through the magazine I noticed that in every photo of a man, the guy is ripped beyond belief. And this isn’t Men’s Health or any other muscle fitness magazine; it’s Genre, a national news/travel/entertainment magazine for gay men.

I expect to see a ridiculously in-shape man in an article about exercising or an ad for underwear, but is it necessary in one about traveling to Ft. Lauderdale?

Even the stock photography in this magazine is in better shape than I am.

If I, a normal, stable, self-affirming gay man of 33, is having minor body-image issues, it has to be worse for young gays and lesbians who already are struggling with who they are.

It’s hard enough to come out as gay. Once you do you shouldn’t be put down by your own community as not being good-looking enough, fit enough, or living up to what some ad executives’ idea of “perfect” ought to be.

We can claim some responsibility for this problem, as well. I’m guilty of buying what a hot male model is selling because deep inside I think, “if this underwear makes him look sexy, maybe it will make me look sexy too.”

I get home, try on the undies and realize two things: Less ice cream and more sit-ups might make me look like the model, and I need to be happy with who I am.

According to an article at sciencedaily.com, a study done by Columbia University’s Mailman School of Public Health found that gay men are at a higher risk for eating disorders than straight men. The findings were reported in the April 2007 issue of International Journal of Eating Disorders.

In the study, 516 New York City residents were asked body-image questions. Of them, 126 were straight men and the rest were bisexual men and women. Fifteen percent of the gay or bisexual men in the study and 10 percent of the lesbians confirmed that they struggled with body image issues and suffered from at least one symptom of an eating disorder.

This was well above the 5 percent of straight men and 8 percent of straight women who identified as having an eating disorder. The images of hot bodies we see everywhere–from fashion layouts to ads for underwear, HIV medication and even toothpaste–showcase a virtually unattainable body as the model of perfection.

Even the photos of local gays out at the bars in some Chicago gay publications tend to focus on the sculpted boys with their shirts off, not regular men with love handles or a paunch.

The gay media needs to present more real images of the gay community to reflect the community’s diversity, otherwise it’ll help create a generation of gays with self-esteem issues.

Commentary

Ok if you dont like to hear me rant then you should stop reading.  Actually I guess you wont be hearing it so much as imagining what it would sound like coming out of my mouth.

Dont get me wrong, I enjoy looking at the picture of a man with a great body.

My first comment, however, is this is nothing new.  The covers of underwear boxes for years and years have featured pictures of men with amazingly fit bodies.  this is called ADVERTISING.  It’s to make you (the consumer) think that if you buy said product (underwear) featuring the model with the amazing arms, chest, and abs (advertisement), you too will look like him.  The logic behind this marketing ploy has always failed me because I have long known that I would never look like the guy on the cover of the box simply by wearing the same underwear.  In fact, the underwear would be the only thing we had in common.

And if for some reason you think this is something new, go ask a woman how she feels about her body after you show her a picture of Heidi Klum, Tyra Banks, or Giselle Bundchen.  For years (and I would almost say centuries), the popular media, the modeling industry, and the advertising industry have been crafting the image of what is the perfect woman, what is hot.  We’ve been tortuing women and young girls with the idea that the perfect body is attainable when in fact the standard is set so high that most women can never attain it.  Not to mention the standard is constantly changing, the bar set higher and higher.  One would argue that since women have been dealing with these unattainable standards for years, that it’s now the mens’ turn to feel belittled.  And even while more and more advertisements directed at men feature men like the Genre cover model, there are far more advertisements geared toward women with pictures of perfection as well as advertisements toward men that demean women.  Show me an advertisement that demeans a man and I’ll show you 100 more that demean women.

Oh and yes….in recent years, there has been a backlash against the “perfect woman” ideal with the addition of “plus-size models”, although if you ask me they should really call them “normal size models” because they actually are the picture of the REAL woman.  Again, the idea of having a more real representation of certain population groups gracing the covers of magazines is nothing new.

Some other side comments: the guy actually doesnt have an 8 pack.  And yes, an 8-pack is in fact attainable when you go below a certain percentage of body fat.  You dont just sprout a new muscle…it was already there.

Which leads me to my next set of comments:

It is true the Genre is an nationally recognized magazine for gay men.  It is not, however, the gay version of TIME or Newsweek.  By that, I mean that Genre is not known for having journalistic integrity or hardhitting news in it.  It’s a gay travel/entertainment magazine.  It is not, however, the gay version of Conde Nast or National Geographic Travel edition.  It’s the gay equivalent of People, US Weekly, and Cosmopolitan (having never actually read Genre myself, I cant say this with 100% certainty, but one glance at the cover gives you an idea of what’s inside.  And I know you shouldnt judge a book by it’s cover, but this is one time where it fits).

The idea that gay men suffer from body image distortions and eating disorders at higher rates than straight men is nothing new either (although apparently those research articles just came out this year?).  It has been long known that gay men suffer from eating disorders and problems relating to their bodies.  And the gay community hasnt only turned to old standbys like anorexia (manorexia) and bulemia, but also achieving the perfect body through dietary supplements and gym workouts.  Cover models like the one on Genre push those striving to achieve the perfect body back into the gym instead of into reality.

And finally…is anyone actually truly happy with their body?  I would argue that everyone from models, to bodybuilders, to top athletes would love to change one thing about their body…anything to make them more competitive.  There truly are very few people around who are completely satisfied with the body they have been given.  I too fall into this category.

Which makes me think, if you are unhappy with your body, there is a reason.  And I dont think that reason is because you picked up Genre magazine and saw the guy with the “8-pack”.  And if you are unhappy with the way you look, do something about it.  Within reason of course.  If you think you are overweight (and your doctor could tell you if you are) then go to the gym and lose a few pounds.  Not only will you feel better about yourself but you may physically feel better too.  As in the article, put down the ice cream and do a few situps.  And dont think that losing some weight or building some muscle is easy.  It’s not.  It’s hard work and takes time and dedication.

All I’m saying is, be comfortable with who you are and do something about it if you arent.  Get to the point where you are comfortable.  And dont let a magazine tell you where that point is.