“Better is Possible”: On the Cost of Healthcare {Process Reflection 3}

Prior to this class, I wore rose-colored glasses: my perspective of the healthcare system was naive and microscopic. As a student and young adult, I never had to seriously think about buying my own insurance or getting treatment for a particular life-threatening disease. This class has filled a gap in my knowledge that I believe will fare me well in my future years as a healthcare professional, patient, and advocate. I hope to follow in Dr. Atul Gawande’s footsteps, someone that I tremendously admire for taking a critical stance of his own profession, which is, to say the least, not an easy feat.

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There were so many new concepts presented throughout this course that shocked me, particularly, the soaring costs of healthcare. Recently, one of my  friends visited the doctor’s office and was charged with $160 ($320 total, half was covered by insurance) for two spritzes of freeze spray for treating a wart on his skin. My friend was in disbelief, but I nonchalantly told him, “That’s the American healthcare system for ya.” Like Dr. Guseva did with her boot, I decided to follow the money and investigate. I checked that the retail price of a medical freeze spray on Amazon was $19.99. My friend’s experience completely confirmed just how different healthcare services are from other markets: no true cost, no buying power, and no prices are known in advance.

I wholeheartedly agree with Dr. Atul Gawande: all it takes is a willingness to try to make this system better. We won’t know what works best unless we try. Without my rose-colored glasses, I feel like my life has just begun.

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Rite of passage: Should doctors keep wearing their white coats?

Prior to beginning medical school, all physicians must matriculate through “The White Coat Ceremony,” in which they are donned white coats by their school’s leadership. The white coat isn’t like any other garment; it symbolizes the professionalism and authority that the field has gained throughout history. Before the late 19th century, doctors actually wore black but switched to white laboratory attire to signify that medicine was science. However, recent discussions between doctors have revolved around whether the white coat might actually be harmful to patients by spreading infectious diseases.

Dr. Philip Lederer, an infectious disease fellow at HMS, is against wearing white coats in this debate. He believes that the white coat is a “germ magnet,” one that is teeming with deadly microbes that are being picked up in and transferred between patient rooms. He states, “There is no harm in avoiding white coats, but there could be danger in wearing one.” Dr. Lederer prefers wearing something like the picture below on the right: a short-sleeved shirt with a vest for warmth or a dress shirt with the sleeves rolled up–the “bare below the elbows” style.

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Dr. Michael Edmond, then chief of infectious diseases at VCU School of medicine, stands with Dr. Lederer. He cites that, in 2008, physicians in the UK were required to follow the “bare elbows” attire to prevent the spread of infectious diseases. There must have been good reasons for the Brits to authorize this rule.

The physicians took a closer look at the cleanliness of white coats. In fact, “lab coats are infrequently laundered.” A survey of 183 physicians and medical students conducted at Edmond’s Virginia hospital found that only 1% wash the coat every day, 2% every other day, 39% once a week, and 40% once a month. And, get this: 17% said they had never washed their coats. Gross much?

However, there has not been a study to show that white coats are actually agents of germs. But Dr. Edmond believes that it’s not worth the risk–why not get rid of white coats and eliminate the risk factor altogether? Dr. Edmond and Dr. Lederer have parted ways with the white coat, and Dr. Lederer estimates that approximately 20% of his colleagues at Brigham and at MGH have adopted the “bare below the elbows” style.

Of course, there are physicians who prefer wearing the white coat. It is a large part of their clinical identity, and provides a mutual comfort to both patients and doctors. In fact, studies have shown that microbe contamination on white coats compared with other garments or even the skin did not find a difference. Those who favor white coats say that it “engenders trust” while those who do not say that it creates a barrier between the patient and doctor as it diminishes the egalitarian relationship.

In a survey summarized by Dr. Paul Sax of Brigham and Women’s Hospital, an even split of 49% respondents of the general public said to keep the coat, and 51% said to get rid of it.

So where do you stand in this debate? Should doctors keep wearing their white coats, or should doctors give them up all together? Personally, I agree with Dr. Edmond: “If you’re nice to your patients, if you communicate well, you’re empathetic, you give them access to you, they [patients] don’t care how you’re dressed.” No coat? No problem.

Articles: A Doctor Wrestles With Whether To Keep Wearing His White Coat & Doctors debate safety of their white coats

Are we going overboard with standardized care, especially at the end of life?

When it comes to surgery, standardized procedures are of utmost importance. For instance, A surgeon is trained to cut into a person with accuracy and precision. He or she better follow every step to the T as they were taught to avoid forbidden mistakes. Between different hospitals, there should be standardized treatments and care to ensure that every person is accessible to top-notch services, no matter the geographical location.

However, the world can be a little bit obsessed with standardization. As students, we have to take standardized exams to qualify for college and beyond. Neuropsychologists administer various standardized tests to their patients to measure cognitive abilities. And, according to “The Patient in the Intensive Care Unit,” a resident proclaimed, “The numbers, I feel, they are more reliable” (Zussman 541).

As a student, I can only relate to being defined by objective data just as the patients in the ICU are labeled with laboratory values when I am referred to by my BU ID. How might being a student identified as an ID number be different from being a patient in the ICU? A resident proclaims, “‘They [Patients] have names…but we speak of the patient in that bed with this problem.’ Because a lot of people are intubated, they can’t talk. And so you’ve got to just deal with them not as a person but as a problem, a set of numbers and dynamics. We’re not dealing with a walking, talking person” (Zussman 545). Similarly, a college advisor who is interested in learning more about a student can quickly glance at his or her BU ID and GPA to make a few judgments about the student. In the ICU, Zussman states that even when patients’ histories are known, they become secondary data to the objective measures obtained by laboratory tests.

With that said, I wonder if medical professionals are going overboard with standardized care, especially at the end of life by basing their decisions and assumptions about the patient simply on objective data and laboratory values? Throughout our lives, are we all dehumanized as students, as patients, as human beings? As neuropsychologists are well aware, there are certain behavioral problems that simply CANNOT be measured by standardized testing.

 

How much of the epidemiological data can be attributed to CPR efforts (or a lack thereof)?

As we discussed in class, health and illness are not only shaped by biological factors, but also, more importantly, by social determinants. Many social factors, including SES, race and ethnicity, age, sex and gender, and geographical location affect health outcomes. Specifically, there are profound differences between gender groups and ethnic groups. For instance, it is well-documented that African-Americans have higher mortality at each age as well as higher infant mortality, HIV disease, and homicide compared to their white counterparts. In “Social Death as a Self-Fulfilling Prophecy,” Timmermans writes, “Epidemiological studies, however, suggest that race, gender, and socioeconomic status play a statistically significant role in overall survival of patients in sudden cardiac arrest” (335). Timmermans continues to state that “black victims of cardiac arrest receive CPR less frequently than white victims” (336). Thus, to what extent are the mortality data that we currently have on the different ethnic groups and gender groups attributed to, in the case of African-Americans, a lack of CPR efforts? In order words, how many deaths could have been prevented by CPR, but were not as a result of racism or discrimination by the staff? It is sickening to me that “the staff rations their efforts based on a hierarchy of lives they consider worth living and others for which they believe death is the best solution” (Timmermans 336). As Dr. Paul Farmer said, “The idea that some lives matter more than others is the root of all that is wrong with this world.” It is unfortunate that society can decide which lives matter more, when, in fact, all lives matter.

TED Talk: Why Medicine Has Dangerous Side Effects for Women – Dr. Alyson McGregor

Dr. Alyson McGregor, a graduate of Boston University School of Medicine, confirms in this riveting talk many of the points that were raised by our guest speaker, Dr. Patricia Rieker, with one of them regarding the exclusive use of male laboratory rats and clinical trials that were only tested on men, and how that results in dangerous implications for women’s health. The bottom line: “Women are not just men with boobs and tubes. But they have their own anatomy and physiology that deserves to be studied with the same intensity.” Sex and gender matter. In fact, as Dr. McGregor claims, every person, male or female, should have individualized, personalized health care.

After viewing this TED talk as well as its relevance to Dr. Rieker’s lecture, a few questions come to mind: It is evident that there are sexual differences, but does the difference only stop between males and females or are we all different as individuals? How “personalized” can personalized medicine get? To what extent do pharmaceuticals, in an attempt to make profit, push to market a drug that is based on very little research or evidence of its therapeutic effects or side effects?

Why do insurance companies decide what is covered and what is not?

In a system that lauds medical dominance, many nonmedical and alternative healthcare workers face many difficulties in trying to achieve professional status. In Chapter 12, Weitz demonstrates how occupations such as nursing, nurse-midwifery, pharmacy, and osteopathy have all struggled to establish a profession in the midst of mainstream healthcare. Additionally, alternative and complementary medicine practices such as chiropractic, despite medical dominance, can exist by limiting its services to a narrow field. It is clear that in healthcare, there is a stark hierarchy within a profession as well as between professions. For instance, in the field of nursing, Nurse Practitioners hold the highest degrees and enjoy the most professional autonomy and status, followed by Registered Nurses and Licensed Practical Nurses. Why are there so many variations of healthcare professions? Could this be a way to expand job opportunities to more people?
Weitz claims that many services that are outside of mainstream medicine are often not covered by insurance companies. Why do insurance companies decide what is covered and what is not? As a democratic nation, why can’t people vote to have certain services covered? I suppose that the more common the condition, the more coverage there should be, whether the patient decides to seek care from a mainstream allopathic physician, acupuncturist, or shaman. Everyone’s bodies are built differently, and each person should seek care that is personalized to their own needs.

See Something? Say Something: Health Inequalities in Boston By T-Stops {Process Reflection 2}

The discussions revolving around the impact of social factors on health and illness have expanded my perspective tremendously. There is certainly stark health inequality between countries, like the US and Sierra Leone, but what about between cities in the US? In fact, if we zoomed in all the way down to a single city, like Boston, would we begin to see a clearer picture of health inequality at a relatively microscopic level?

Dr. Sandro Galea, Dean and Professor of the Boston University School of Public Health, did just that. In his Dean’s Note, Dr. Galea paints a picture of Boston’s health and its determinants geographically using the map of the T (see below).

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Dr. Galea asks us, “Suppose we are riding the T and stopping at various stops: What does health look like at these stops, and what do the drivers of health look like?” The results are dramatic. First, Dr. Galea starts by mapping the core health indicator: premature death rates per 1,000. We can see that the death rate around the Arlington stop on the green line is the lowest, with 2.6 per 1,000, and the highest death rate is at the Dudley Square station on the silver line, with 5.7 per 1,000.

Premature death rates

He then goes on to map the homicide rates that are linked to violence; again, we can see that the Arlington and Maverick stations have the lowest homicide rates, while Dudley Square and Mattapan (with a whopping 32.2) have the highest homicide rates.

Homicide rates.PNGHealth differences are then mapped onto the T by low birth weights, percent of adults with diabetes, SES, and levels of physical activity. The health inequality between various geographic areas of Boston are large and strong. Yet, what surprised me the most was that, despite how geographically close the T stations were with one another (geographic differences of approximately four miles), and despite how each station had nearby access to healthcare facilities (Boston Medical Center, Tufts Medical, Mattapan Community Health Center), I was shocked that areas so close to one another and with top-notch healthcare facilities still have large health inequalities that exist due to varied health indicators. This case-study opened my eyes to realize that we don’t have to look globally to witness health inequality. It exists right around the corner, in every city, and Boston is certainly no exception.

De-stigmatizing depression: Could depression be caused by an infection or an inflammatory disease?

Prior to the availability of antidepressant medications, doctors were freely performing drastic lobotomies (excisions of white matter connections between gray matter regions in the brain) on patients in an attempt to cure them from mental disorders such as depression and schizophrenia. Psychiatrists were also extracting decayed teeth and removing organs such as tonsils, testicles, ovaries, and colons to treat the insane. Throughout medical history, both physicians and researchers have continuously attempted to track down a unique etiology of depression based on scientific evidence in order to welcome and legitimize patients’ symptoms.

In the article titled “Could depression be caused by an infection?”, researchers now posit that the unique etiology of depression may be related to infection and inflammation of the brain and body. Specifically, Dr. Turhan Canli claimed that depression should be thought of as an infectious disease. Studies in notable journals have shown that certain infections in the brain, such as those caused by the parasite Toxoplasma gondii, may cause mood disturbances that are considered to be a symptom of depression. Dr. Canli notes that a plethora of other pathogens, including Borna disease virus, Epstein-Barr, and varicella zoster (the virus that causes chickenpox), have been associated with mental illnesses. Similarly, an observational study that looked at the medical records of over 3 million people who had suffered from infections acquired a 62 percent increased risk of developing depression or bipolar disorder. In addition to infections, Dr. Canli also believes that autoimmune activity that is triggered by the pathogens may also contribute to mental disorders. At first glance, Dr. Canli’s statement may seem a bit far-fetched, but there is clearly some solid evidence to bolster his claim.

Furthermore, there is also research being conducted to study the relationship between the immune system and the brain in order to elucidate the etiology of depression and other mental disorders. Numerous studies have demonstrated that there is continuous cross-talk between the nervous system and immune system. Recently, researchers at the University of Virginia discovered a network of vessels that directly connected the immune system to the brain that may contribute to certain neurological and psychiatric conditions. Psychiatrists believe that both infection and autoimmune activity result in inflammation, which may be associated with depression. Currently, there is no cause and effect between inflammation and mental disorders, but researchers are hard at work trying to find a plausible mechanism. For instance, Dr. Roger McIntyre believes that psychiatric illnesses disturb the “immune-inflammatory system”. He states, “Throughout evolution our enemy up until vaccines and antibiotics were developed was infection. Our immune system evolved to fight infections so we could survive and pass our genes to the next generation. However, our immune-inflammatory system doesn’t distinguish between what’s provoking it.” It is true that our body systems do not discriminate between different stressors, be it sleep deprivation, grief, or poor academic performance; the immune-inflammatory system stays activated in order to protect us, which may lead to chronic depression and other disorders. Although a conclusion is not yet set in stone, many leading psychiatrists believe that finding a pathological explanation rooted in infections and inflammation may be useful for treating patients with depression.

As we discussed in class, medicalization has the power to either increase or decrease the stigma associated with a particular medical condition in a defined cultural society. With depression, it has largely been de-stigmatized as a result of mental health awareness programs for patients and, as the article demonstrates, support from the medical profession to discover a unique etiology that may be associated with the condition. While the medical model of illness seeks a biological explanation to treat individuals with depression, the sociological model of illness claims that depression is caused by a combination of social and biological causes. Nevertheless, it is beneficial to the patients suffering from depression that the medical profession is open to studying depression as a result of a unique etiology, because it encourages patients to seek help and to be transparent about their mental issues. In reality, there is always a constant shift in how certain conditions are viewed by society depending on how much scientific evidence there is to legitimize it.

Article: Could Depression Be Caused by an Infection?

Huh? Isn’t being a “tall girl” a good characteristic? How does the social context guide and shape the changing definition of tall stature?

As a relatively petite female, I often thought that being naturally tall and lean was a good gene to have as depicted by the models in mainstream media and the arsenal of high-heeled booties currently on sale. Just by glancing at the title of the article, “Tall Girls: The Social Shaping of a Medical Therapy,” I predicted that it would be about providing medical therapies to make short girls taller, not the other way around. After reading it, to think that tallness was once a flaw back in the 1950s was shocking. Now, taller women are seen as “more intelligent, affluent, assertive, and ambitious” compared to their shorter counterparts. In this piece, Lee and Howell poignantly illustrated the power of the social context in which we live that guides and shapes social norms, opinions, and behaviors along with the changing definition of tall stature.

There is no doubt that social norms always change depending on the era. It is often perpetuated by the media: advertisements, magazines, movies, etc. These norms are often arbitrary, as portrayed by the height required for receiving estrogen treatment for girls. First, it was 5 ft 9 inches, then it was changed to 5 ft 11 inches, and then to 6 ft 2 inches, to qualify for estrogen therapy. How are these arbitrary heights set? By doctors? By the patients? These numbers are certainly not embedded in any biological reason. As medicine has transformed into consumerism, do the patients themselves demand for these treatments based on their own opinion of what height is “too tall”? Where do patients get these ideas? If physicians disagree with patients, is the customer always right, or should they have the responsibility to firmly refuse the continuation of the treatment?

It is so interesting that there has now been a shift in society from girls to boys. Growth hormone (GH) therapy targets boys of short stature to prevent them from becoming shorter adults. Although the focus of attention is different, the theme is the same: both of these therapies revolve around the topic of sexual partners. Though not as strongly believed as before, the marriage of a tall girl with a short man is often stigmatized in society. In media, men are often portrayed as dominant figures while women have a more submissive role, and somehow those characteristics are equated with physical height. How can we work on changing these opinions that have been so embedded and solidified in society? Could this be one of the steps towards removing gender inequality?

How will gender convergence affect how our healthcare systems operate?

While women around the world generally have higher morbidity rates than men, the former have lower mortality rates compared to the latter. Weitz posits that the gender gap in the United States and other industrialized countries have been closing, a great improvement for modern times. As a result, gender convergence continues to evolve, which is defined as men and women having similar social expectations for every day behaviors. This will lead to greater convergence in men and women’s patterns of health, morbidity, and mortality. In what ways would this shift affect how our healthcare systems are run? What would the morbidity and mortality patterns look like for men and women?

However, it is interesting to me that traditional gender roles still continue to affect health outcomes for both men and women. The notion that gender roles indirectly impact health outcomes is often dismissed by many disciplines. Yet, it is apparent that the different choices that men and women make according to their gender roles ultimately affect their cumulative health. For instance, Patricia Rieker proposes in “Understanding Gender and Health: Old Patterns, New Trends, and Future Directions” an integrative framework called the “constrained-choice model,” which addresses how structural inequalities limit choices for specific groups, such as by gender, racial/ethnic, and socioeconomic status. Differences between racial/ethnic groups are often exacerbated by discrimination, which creates differential opportunities for various clusters of people. Reiker continues, “This multilevel model explains how decisions made and actions taken at the family, work, community, and government levels contribute to differences in individuals’ opportunities to incorporate health into a broad array of everyday choices.” (62). The “constrained-choice model” addresses three levels of organizational context–social policy, community actions, and work and family–that may affect the differential health outcomes between men and women. Specifically, certain social government policies such as universal healthcare that are not tied to the market or employment (as in Japan and Austria), often result in better longevity and health statuses for both men and women. If gender disparities due to traditional roles continue to exist, how can gender convergence even begin to occur? How could we attempt to intervene on a small-scale?

The “constrained-choice model” reminds me of the “social-ecological model” that is often used in for public health interventions. This model is also rooted in the notion that no individual is an island; our health outcomes are affected by the greater, external forces that surround us, from the interpersonal level and communities, to the larger context of institutions, structures, policies, and systems.