All posts by wingofzock

Empowering Communities, One Family at a Time

By Aaron J. Byzak, MBA, FACHE

Joselin Reyes had dreams of a career in the medical field, helping others and making a difference in the world. She was determined to accomplish her goal, but the odds were stacked against her. She is the youngest of four children and none of her siblings graduated from high school. Both of her parents are native Spanish speakers with limited English ability. Her family could give her emotional support, but she did not have the financial and educational support needed to make her dreams come true.

Joselin Reyes (2012)When we set out to create the HERE Initiative (Health + Education + Research = Empowerment), a community outreach program designed to address some of the unmet needs of San Diego’s south bay and southeastern regions, we had students like Joselin in mind. We wanted to address several of the key social determinants of health, namely health care access, education, and workforce development. Continue reading Empowering Communities, One Family at a Time

Your Medical School Narrative

Originally posted August 23, 2015

By Eve Purdy

socialized_medicineFour short years ago I nervously met a soon-to-be classmate for the first time. It felt like a blind date. We had met on Facebook, through our class group and we were both anxiously awaiting the next day, our first day of medical school orientation. I recall the evening started with half sputtered, nervous conversation as we exchanged standard pleasantries awkwardly over sushi. But now, I can’t help but look back on that evening with a smile. I smile as I remember an immediate bond developed with a complete stranger. I smile as I remember sharing our histories and our dreams. I smile as I remember the pride I had about entering the profession. I smile as I realize I had no idea what I was getting myself into. Continue reading Your Medical School Narrative

Learning Medicine

By Peter Wei, MD, and Alex Chamessian

Medical school is known to test many things to the breaking point – relationships, sleep schedules, ability to handle stress. For us, though, what med school tested to the limit was how we learned – and like so many other students, we came out stronger for the experience.

Like most students, when studying in college and prepping for the MCAT, we tried a number of different approaches – outlines, notecards, cramming, the works. But when we reached medical school, with its famous “drink from a firehose” style of teaching, we realized that these approaches weren’t enough. Continue reading Learning Medicine

Hospitals Are Learning All the Wrong Lessons from Hotels – And Totally Missing the Right Ones

By Jayson Marwaha

Ever since Medicare started using patient satisfaction surveys in 2012 to calculate hospital reimbursements, the health care system has been looking to the hospitality industry to learn how to improve that metric. Hotels do have the answer; but hospitals are looking in all the wrong places.

What hospitals are doing wrong

The concept behind Medicare’s HCAHPS survey, a short questionnaire asking patients what they thought of their stay, is simple: Hospitals can earn more money by keeping their patients happy. Continue reading Hospitals Are Learning All the Wrong Lessons from Hotels – And Totally Missing the Right Ones

The Price of Certainty in the ICU

Originally posted August 10, 2015

By Tom Peteet, MD

Mr. J was as close to a typical sixty-year-old patient as possible, wary of doctors and selective in when he took his blood pressure medications. On a sunny Thursday, he woke up nauseated and called an ambulance. During evaluation in the emergency room, his blood pressures reached atmospheric levels (nearly 300 systolic). He began seizing, which soon stopped; he was transferred to the ICU. As the admitting resident, I dutifully went through the potential causes of his elevated blood pressure: medication noncompliance, surreptitious cocaine use, and even the zebra diagnosis of a pheochromocytoma. As for the seizure, I held firm on the diagnosis of PRES, an acronym for posterior reversible encephalopathy syndrome, an under-diagnosed condition of abnormal blood flow to the brain in the setting of high blood pressure.

Mr. J was on course for a typical hospital admission. We would run a battery of tests, determine a singular diagnosis for his problem, and send him home on treatment. The hospital would be reimbursed for his coded diagnoses of hypertension, PRES, seizure, and he would have close follow-up with specialists.

If Mr. J was a typical case, our discussion of costs and appropriateness of testing was not. Despite a resurgence of “cost consciousness” within medicine, the word cost rarely comes up in the ICU. Much of the discourse around cost and of the Choosing Wisely campaign is an effort to avoid unnecessary tests in clearly defined circumstances. However, Mr. J’s case shows us that the vast majority of clinical decisions live in a gray zone of appropriateness. On rounds, the question came down to this: Does he need a brain MRI and angiography (MRA) to “prove” he has PRES? The clinical history seemed to support the diagnosis, and the study could potentially offer limited prognostic information. Also, in the highly improbable scenario the patient did have a small stroke, we would see it on the MRI. What is the value we place on this minimal increase in certainty? According to the Healthcare Bluebook, the cost of both studies is $1,206.

Taking a step back, I wondered about our zeal to “prove” a diagnosis. Physicians so frequently frame clinical questions around diagnostic proof that we forget this is not the only way. Why not frame clinical questions around appropriateness, cost, or even risk-benefit to the patient? Context matters. In settings like the emergency room or ICU, ruling out the worst is highly valued. If Mr. J continued to be stable after a few days, the diagnosis would be PRES by exclusion, and we would all save time and money.  Similarly, in one month, if he remained fine, his primary care doctor would not rush to get an MRI. But Mr. J was in the ICU, we needed an answer, and a test offered us the psychological boost we needed.

Mr. J walked out of the hospital five days later on a different regimen of blood pressure medications. He thanked the staff profusely, who in turn, felt they provided excellent care. Each actor behaved rationally: the patient and clinician to get a diagnosis, and the hospital to generate revenue. The system, however, behaved irrationally, to the cost of the public and also the patient. Despite a confirmed diagnosis of PRES, Mr. J will follow up with two specialists to verify the results of other rare causes for high blood pressure, again generating revenue, visits, and a minimal gain in certainty.

As a physician in this structure, I struggle to maintain hope, as thoughtfulness contradicts rationality. For Mr. J, I pushed against getting the MRI because I valued diagnostic utility and system costs over diagnostic accuracy. The system pushed back. The neurologist highly recommended the test, the ICU attending changed over, and the fellow “needed to rule out a mass.” Considering the cost and appropriateness of each test is hard work, and too great a task for one person. While I am skeptical of top-down change, I take solace in the ability of clinicians to think complexly: to weigh accuracy alongside cost, risk, and benefit. In the gray areas of medicine, we as clinicians would do well to ask and wrestle with the question, “What is the price of the certainty we seek?

Peteet photoTom Peteet, MD, of Massachusetts is one of the winners in the 2015 Costs of Care Essay Contest. He practices in Boston, where he contemplates the price of certainty in his surroundings.

The Costs of Cancer Care

Originally posted August 3, 2015

By Holly Woodcock

I’m a nurse and a patient. My story starts out during Thanksgiving of 2009 when I was diagnosed with colorectal cancer at the tender age of 47. Stage IIIB. Metastatic but curable, they told me. After three surgeries, hospital stays, blood work, traveling, chemotherapy for six months, all the follow-ups with physicians, CT scans, the medications needed at home, I’m still paying.

As a consumer, it’s really enough to make a head spin. As a nurse, I’m aware of hospital costs. I know it’s expensive. Expenses add up fast as $100 co-pay after $100 co-pay are requested with every doctor’s visit, every clinic visit, and every X-ray visit. Cancer didn’t take into account all the income I’d lost post-surgery or the days I couldn’t go to work because I was too weak or too sick to go in. It ate through my sick leave and savings quickly. I am so fortunate to have great health insurance.

Undeniably, my insurance company paid well. I’d look at the explanation of benefits every month, astonished and overwhelmed that chemotherapy could actually cost $75,000 a month or that one shot to keep my white blood cell count could cost $7,000 and I needed two every month. It’s still bizarre to think I paid them to inject poison in my veins.

When the end of chemo came in 2010, I was well over $35,000 in the red – all from stupid cancer. Costs are crippling cancer patients to the point of losing jobs, losing businesses, losing homes, having liens, going bankrupt. Sadly, due to complications from treatment, I can no longer do bedside nursing. I am currently going back to school for my master’s degree to teach nursing students. A lot of people don’t have that option. What happens to them?

The economic impact of cancer care alone in the U. S. during 2011 was astronomical; annual costs were estimated to be at $88.7 billion.  Yes, that’s billion with a “B.”  In 2012, it was estimated that over 15 percent of Americans didn’t have insurance. Those that are “lucky” enough to have insurance are burdened with the higher costs of deductibles; they’re also paying for the newer FDA-approved medications that are helping win the fight.  A drug that cost a few hundred dollars last year is being replaced with the newer drugs this year, costing consumers tens of thousands a month now. When I sat with my oncologist for the first time, we talked about side effects of chemo. The tingling in my hands and feet, the mouth sores, how my balance would be affected, how I could only eat and drink room-temperature foods, to cover up when it’s cold because it will feel like shards of glass are ripping your skin off. He never mentioned the side effect of my finances. He didn’t tell me just how expensive it would be to fight the beast.

Countless colorectal cancer friends I’ve met along this journey have similar stories. One friend lost his business and his home. He’ll never work again due to the after-effects of this treatments. Even though his insurance paid, his treatments ate up his retirement, his savings and his way of life. Another friend, after his wife died, filed for bankruptcy from the resulting medical bills. His credit is ruined, he drives a $200 car and lives with his mom.

Cancer expenses are about more than just money. Cancer has cost us peace of mind. It’s knowing you wake up in the morning and can never go back to a job you love, one that you planned on retiring from. It’s about keeping the wolf away from your back door.

We’ve worked hard and we’ve mostly dug out from the bills that cancer gave us. I’ve sat my husband down and told him however, under no terms, if this cancer returns, I’m not treating it. I refuse to leave him bankrupt. I believe I live in the richest country in the world, with the best medical care available; fighting cancer shouldn’t have to make you pick between treatment and food or medicine and rent.

holly woodcockHolly Woodcock is a nurse from Idaho.She was one of the winners in the 2015 Costs of Care Essay Contest. Her cancer has returned incurable, not terminal, and she has decided to treat it.

 

 

Inhabiting Graphic Medicine’s “Spaces of Care”

By Lorenzo Servitje

As I sat and typed my notes on a presentation at the 6th International Comics and Medicine Conference, I looked around to observe other attendees’ note-taking. What is perhaps most striking about attending this conference as contrasted with most other academic and professional conferences, is how people are taking notes. Continue reading Inhabiting Graphic Medicine’s “Spaces of Care”

Investing in Medical Research: Resource-Intensive, Long-Term, and Worth It

By Ann Bonham, PhD

As Congress heads into summer recess, we will continue to see some heady days for medical research. The 21st Century Cures Act has provided a light at the end of a long tunnel of stagnant growth in NIH funding. While not a miracle “cure,” the bill is a good start to reversing the trend of stagnant federal support for medical research — setting aside $1.75 billion a year, for five years, for an NIH innovation fund. (See bill’s text here.) Continue reading Investing in Medical Research: Resource-Intensive, Long-Term, and Worth It