By far this semester, this course has been my favorite. Through poignant articles surrounding the topics like the flaws surrounding the insurance market to lectures questions questioning my place in the socioeconomic sphere and its effects on my health to discussions regarding improvements to end-of-life care, I have learned a great deal regarding the United States healthcare system that has greatly affected my perceptions as a future practitioner of medicine. Prior to the course, my image of a doctor was based upon several misconceptions. For instance, I associated a doctor with a wise individual whom greatly aided people, and in return gained a deserved amount of respect, power, and wealth. It wasn’t until I took this course that I questioned how such wealth was received, the possible abuses of such power, and sacrifices and issues patients faced while receiving such care. My singular and almost conceited viewpoint thus expanded to a more empathetic and inclusive perspective.
A topic key to the development of my more patient-inclusive mindset was that of end-of-life care. Like the doctors in the videos shown, my thinking had always focused upon “saving” lives. However, following our discussion of nursing home and palliative care, I began to question the correctness of such a goal. What would be the point in expanding a life, if it only meant pain and misery until they faced another encounter with death? Would it not be better to allow them to a peaceful release, one not attributed with loneliness in a depressing hospital room but with the presence and care of loved ones? It was from these questions did I carve for myself a goal: to equilibrate the doctor-patient relationship as much as possible and ensure that, if the time called for it, the death of my patient be as peaceful as possible, especially if it were through their own choice to let go.
Within the article “Fight to Honor A Father’s Last Wish: To Die At Home,” it was mentioned that “most developed countries spend much less on medicare, but twice as much on social supports.” Thus, I wonder how end-of-life care is structured and regulated in other countries? Is nursing home abuse as rampant and overlooked? What checks and balance do they have in place to ensure the people’s best interests? Is the cost much higher in comparison to the US?
After reading the article “Tip-Toeing Toward Conversations About Death,” I was glad to see the encouragement towards end-of-life care planning. While steps are being made to expand the guideline of the “appropriate” patient for end-of-life care planning with their primary care providers, issues still remain with the end-of-life training program. Take for instance the MOLST form. Though the pamphlet cements in writing the desires of the patient the medical steps they would like to be taken in their case, it still has certain limitations. Where the patient would like to be taken or housed in solely designated by two options: transfer to a hospital or no hospital transfer. Should not the option of deciding for or against nursing home care and or home-care be designated as well on the form? Some, like Andrew Stefanides from the article concerning a father’s dieing wish, would probably have benefited greatly for such an option. What other possible limitations are there with the MOLST form? Does giving out a form as simple as this display insensitivity to the patient? Are their better methods with which to initiate the discussion of end-of-life care?
Upon reading the article titled “Fighting to Honor a Father’s Last Wish: To Die at Home,” I was appalled at the treatment given to not only the Stefanides family, but the elderly and or disabled community as a whole in their struggle for adequate and genuine care from insurers, doctors, hospitals, as well as nursing homes. From physical abuse to possible starvation to being left to stew in their own defecation for hours due to lack of professional supervision and neglect, the extent to which older Americans like Andrew Stefanides are forgotten and mistreated makes one question the morality of the US healthcare system and its motivation to “Save lives” as opposed to “palliative care.” Andrew Stefanides was a hardworking man from humble beginnings who served our country in War War II. He, as well as his poor wife whom suffered from mental illness, deserved to be treated with respect and allowed a peaceful death. Yet, both were robbed of those very social rights. As soon as we no longer provide exploitable physical or mental strength, it has long been seen that we as a people lose our place in the job and or relationship market. As shown by this article, the “health market” can be added to the list. Whatever value is granted towards the old and or disabled it seems is solely to provide profit. I guess my question is if others agree with this statement. Do you believe that in American culture, individuals lose value as they age or suffer from disabilities? Would the same treatment have been shown by the health system if children were at the center of the issue instead? How much would the public or political parties have advocated and actively participated in reform then?
Within the article “Does Investor Ownership of Nursing Homes Compromise the Quality of Care,” written by Charles Harrington et al, noted that while non-profit and public nursing homes typically displayed higher quality in comparison to investor-owned nursing homes, the quality of care experienced at such facilities could not be considered average or above average. Such issues largely though not entirely stemmed from the acts of industrial lobbyists, whom blocked the passage of nursing home reform legislation since 1987. After reading of the long term hindrance posed by these groups, why has the government not enacted any means by which break the nursing monopolies? It is possible to do so using legislation, or must other means be used? How can the existence of these nursing homes be maintained for those who truly need them, while minimizing their costs and improving their quality of care ?
Within the article titled “Watching Brian die: The Rhetoric and Reality of Informed Consent, the aggressive mindset of the ICU doctors, which placed little importance on palliative care, undermined the legal authority of Lisa, Brian’s wife and thus next of kin, to make decisions regarding his treatment. The clash of opinions between Brian’s family and Lisa’s family about Brian’s desire to live further accentuated that fact. It is even suggested that due to Lisa’s lack of knowledge regarding Brian’s desire for aggressive treatment, she was less assertive in establishing a line of communication with the ICU doctors, allowing for Brian’s father Jack to take the reins. Had Brian and his family previously held discussions before the accident about their individual beliefs regarding their own end-of-life care, could Lisa have retained her power as legal authority, prevented the usurpation of such position by the ICU surgeons, and avoided familial strife as a result? How early should we as individuals begin having those kind of discussions with our families? If no changes would have resulted from such discussions, how can we increase or ensure patient bargaining power in medical care, specifically in ICUs?
“Marriage May Bolster Recovery from Surgery”
As suggested by the article written by Nicholas Bakalar of The New York Times, one’s marriage status may increase one’s likelihood to recover from serious surgery. Such a statement takes support from a study conducted by JAMA Surgery, a monthly medical journal published by the AMA, which included approximately 1,567 individuals who had cardiac operations and ranged between 50 and older. Of the 1,567 research participants 1,026 individuals were married, 184 were divorced or separated, 331 were widowed, and 35 were never married. Information regarding their need for aid in six specific ways prior to the surgeries was first recorded, and then compared to similar data collected two years after the operations. The six activities included rising from bed, walking, bathing, dressing, and consuming food. The results showed that roughly 20% of married individuals pass on or increase in dependency, whereas 28.8% and 33.8% of divorced/separated and widowed individuals showed similar outcomes, respectively, even after factors like personal habits were controlled for. The survey is praised for the implications it poses on social supports on patient health outcomes.
While the studies does shine light on the importance of support systems for patients, researchers limit themselves by the use of labels like “marriage,” “never married, etc. Marriage does not necessarily equate to the reciprocation of care and comfort, as individuals may fall out of love while holding such a status, compelling them to perhaps despise and or cheat on their partner. In addition, marriage is sometimes used as a tool to gain individual benefits between two parties, and in such cases may not entitle one to receive such personal care from their partner. In contrast, individuals who have never married may receive care and comfort more so than those of married couples. Non-marriage does in no way characterize the lack of social support. For example, the LGBT community has spent many years fighting for the status of marriage, and has very recently made profound advancements in its goals nationwide. Many of this community, while not legally married, upheld relationships or familial units similar to society’s ideal conceptions of married units, displaying that support can be received outside the confines of “marriage.” Also, the inclination to pursue the institution of marriage has waned amongst the younger generations over the years, regardless of their sexual preference, thus increasing the likelihood of long-term couples with supporting partners that may not fall into the categories established in the study described above. The result of non-married individuals are not even included within the results reported by the article, providing an inaccurate view on the social implications of the study. Factors such as whether individuals remained in hospital care or were discharge home were not mentioned either, or whom played a primary role in patient recovery care.
APP Suggests Pediatricians to Screen Children for Food Insecurity
According to the USDA, food insecurity describes the condition by which individuals consistently experience “limited access to adequate food due to lack of money and other resources at times during the year.”1 Within an article presented by the Dispatch Times, the American Academy of Pediatrics (APP) recommended that all US children be assessed for food insecurity, as implied by the title above. Such movements were spurred by a 2013 study which discovered that approximately one-fifth of children in America were struggling with food insecurity in their households.
The possible effectiveness of these screenings was presented by field trials, which asked children two questions regarding whether in the last 12 months they were fearful that their family’s food would finish before their parents could afford to obtain more or if it did not last and they could not afford to buy more. The results provided information just as substantial as the USDA’S Household Food Security Survey, which is 18 questions long. Children with food insecurity were found to have lower overall health and poorer iron levels. In addition, some behavioral and emotional problems were more likely to exist and persist into adolescence in children facing food insecurity. Rochester Medical Chester also discovered that such children take longer to recover from sickness and need more hospital visits.
Many, including an investigator from the national organization focused upon measuring the influence of public health organizations on pediatrics known as Children’s HealthWatch, praise the initiative as an important step of healthcare reform towards the health of populations. I agree, as I believe it provides a means by which to more humanize doctors in the field, in this case pediatricians, away from their authoritarian positions to their patients and their patients’ families. By actively asking their patients about food security and assuring them it is a common issue today, pediatricians may relieve parents of the stigma and embarrassment associated with the inability to provide for their families and or asking for help. Thus, encouraging doctors and patients to communicate more in regards to their health options and resolution plans.
While the article does hint at the fact that doctors would go beyond their fields to provide resources for which their patients can turn to, it fails to clearly explain what exactly that approach would be. Would pediatricians simply provide a number or prescription to go see this or that organization, and that’s it? Would they follow up on the family, and check to see how the resource they provide has resolved the issue? We do not know. In addition, only one line in the article, a quote from the investigator from Child HealthWatch, actually mentions possible organizations the family may be connected to. However, the organizations are neither provided a clear name beyond a simple abbreviation nor is their purpose explicitly described beyond a “federal nutrition program.” The author of the article wrongly assumes the reader knows what the organizations WIC and SNAP do and what their initials stands for.
Within the article “Understanding Racial Ethnic Disparities in Health:Sociological Conditions” written by David R. Williams and Michelle Sternthal, the racial gap in life expectancy was determined to increase, as education increased. I found this highly puzzling, as generally, we have seen that the rise in education typically correlates with the rise in position/power. Due to this rise in power/position, individuals are in turn able to gain a greater quality of healthcare and benefits, and often suffer less medical ailments. Thus, why is it that minority groups still fall behind in terms of life expectancy, when it was presumed that education provided a means with which to obtain an improved quality of life and care? The article denotes the “diminishing returns” hypothesis as the reason. However, what exactly falls under the category of “health returns?” What allows for these returns to decline for people of color as they move up through the ranks in terms of education and occupation? How have the differences in the quantity and or quality of “returns” for whites and people of colored not been recognized previously? If not education, the tool often deemed the key to equilibrating the classes, what could remedy the difference in health returns?
Throughout life, I often considered myself well informed in regards to the topic of health care and administration, largely as a result of my interest in media ranging from articles and books to documentaries and movies centered on the United States medical field. My interest was so great that I decided early on to obtain a doctorate in medicine. However, upon entrance into Boston University’s Sociology in Healthcare class, I realized I had much to learn about my future career path, especially in terms of what defines a doctor and a patient, their roles in the socioeconomic and political spheres of America, as well as the effects of commercialism on the costs of treatment.
To begin, my ideal image of a doctor always depicted a wise individual in a white coat, whose ultimate desire was to cure and ease the minds of his/her patients by extolling his/her medical wisdom and skills. While the patient was free to discuss their issues, the doctor was the one who held most authority in the care process. While I understood that economic gain played a part as well in the behavior of the medical specialist, I assumed such influences engaged in a somewhat smaller role in comparison to moral compassion. After reading Rothman’s article “A Century of Failure: Healthcare Reform in America” and portions of the textbook such as the influence of “Big Pharma,” I was shocked by the extent of my misconceptions. Disappointingly, rather than my ideal, most doctors of today were more entrepreneurs than anything else, seeking to increase hospital profit and in turn their own paychecks by over-treating patients, recommending more expensive medication sponsored by large pharmaceutical corporations, and etc. Even more heart wrenching though was that such a situation was not simply the fault of the corrupt, but of the US health care system as a whole as it valued and promoted individual profit over social benefit and widespread access to affordable care. Thus, patients were and will perhaps remain delegated to the role of weak consumers with little ability to negotiate the costs of treatment due to social, economic, and political forces beyond their control.
The business of medicine has greatly altered my perception of the doctor-patient relationship, as well as my goals as a future practitioner. Rather than a sole authoritative position, I realized that, as a current “consumer,” perhaps it is more helpful and cost-reducing for patients to play a more interactive role with their primary care providers. Thus, as I age and ultimately make my way into medicine, I hope to more equilibrate such roles by allowing my patients to have greater say in the routes they take in treatment.