Final Process Reflection

Now that we’ve come to the end of this semester and are finishing Sociology of Health Care, I think that it is really valuable and informative to reflect on the course. I think that I have gotten a lot out of the course materials. This is especially true regarding everything we have learned about medical training. When I was in high school, I attended the Academy of Allied Health and Science, a magnet school with a focus on preparing students to pursue a career in medicine. Many of my high school classmates are in pre-med programs or even in medical school already, and others are training to be nurses or to be a part of the healthcare world in some capacity (I myself am pursuing a career in public health). Learning about medical training has, therefore, had a personal meaning for me, as it is allowing me to conceptualize and understand just what my former classmates either are going through or will experience in the future in preparing to be medical professionals. I also think that, as I become a public health professional, having an understanding of the mentality that many doctors have due to their training will allow me to better cooperate with them in my efforts.

Overall, I think that this whole course has been very informative. I believe that I have learned a great deal about the whole health care system, from those who provide it to the actual people who receive it. Further, I feel like I know so much more about how people experience health and their interactions with healthcare providers from birth to death. I hope that I can express all I have learned by doing well on the final exam. To Professor Guseva and Rebecca, thank you for making this class informative, interesting, and enjoyable.

Changing End-of-Life Care

After reading “Fighting to Honor a Father’s Last Wish: To Die at Home,” I have to wonder what could possibly be done to change our current system of elder care and end-of-life care. If the system continues to be largely run for profit, then we are never going to get to a point where we stop spending so much money on unwanted medical care and start investing more in social services. My questions revolve around that idea. What can be done to incentivize home health care and social services? For those who are truly too sick to be cared for at home, what can be done to improve treatment in nursing homes and hospitals? If these institutions are turning such a profit, why is there such a staffing shortage? Surely, they can afford to hire more staff, which is frequently stated to be a way to improve conditions in these settings. Hopefully, changes can be made soon, so that less people have to endure what Joseph Andrey did in his last months of life and more elderly people can die at home, if they so wish.

Discrimination in the E.R.

In Nicholas Bakalar’s NYTimes article, “Minorities Get Less Pain Treatment in E.R.” he discusses recent study findings from the Centers for Disease Control and Prevention (CDC) regarding treatment in the E.R. for patients of various racial and ethnic backgrounds. This nationwide study was conducted over a four-year period using “a sample of 6,710 visits to 350 emergency rooms by patients 18 and older with acute abdominal pain.” Despite the fact that severe pain frequency was equal across all patients at 59 percent, Black patients and those of other minorities “were 22 percent to 30 percent less likely to receive pain medication” than White patients. In addition, they were “less likely to receive pain medicine if they were over 75 or male, lacked private insurance or were treated at a hospital with numerous minority patients.” The article ends with some remarks from the senior author of the study, Dr. Adil H. Haider of Brigham and Women’s Hospital in Boston. His remarks were as follows: “It may be that different people communicate differently with their providers. If we as providers could improve our ability to better communicate with patients so that we could provide more patient-centered care, we’ll be making several steps toward reducing and hopefully eliminating these disparities.”

Why even have advance directives?

In the Timmerman’s article “Social Death as Self-Fulfilling Prophesy,” he discusses, among other aspects of resuscitation efforts, advance directives: “advance directives, living wills, durable powers of attorney, and do-not-resuscitate orders” are all various legal methods to give a patient a say in what medical treatment they receive in the event of sudden death. If a patient does not wish to be resuscitated, they can make this clear through these advance directives, as they will be unable to do so if and when they do end up in this situation.

Antibiotics for Acne

In the article “How Long Is Too Long for Antibiotics in Acne?” the advantages and disadvantages of long-term antibiotic treatment for acne are discussed, and it was ultimately determined that most patients on this treatment are on it for too long before being switched to more effective treatment. Arielle R. Nagler, MD published her findings in The Journal of the American Academy of Dermatology, and her results show “that the average duration of antibiotic use was 11 months,” with “almost two-thirds (64.6%) of young adult patients were treated with antibiotics for their acne for 6 months or more” and “a third (33.6%) on antibiotics for a year or longer.” The remaining “15.3% of patients were taking antibiotics for 3 months or less.” The article goes to say that physicians should be able to determine sooner than that whether or not a certain treatment is working, and that they need to forgo ideas that certain antibiotics are universally “superior” to other, similar antibiotics. In addition, Nagler hopes to see more research on alternative treatments in the future.

Medicalization and Tall Girls

The article, “Tall Girls: the Social Shaping of a Medical Therapy,” details the process of using estrogen therapy in previous decades to limit growth, particularly in girls. It was believed and accepted by the scientific community that this was a reasonable and beneficial treatment for girls who may become “too tall” otherwise, especially due to social norms that were easier for shorter girls to conform to than for tall girls. As it became more acceptable for women to be tall, the therapy faded out of use. The medicalization of height (specifically, height that is considered to be undesirable) is an especially interesting example of medicalization, as, in the case of healthy individuals, one’s height has no impact on health, so it was medicalized purely because of social factors.

After reading this article, my question is as follows: what other “medical issues” out there are purely based on social norms? How many of those issues are now considered to be valid medical concerns, and how many of them will be demedicalized in the future, just like tallness in girls?

The Health Belief Model

In chapter two of The Sociology of Health, Illness & Health Care, Weitz outlines the Health Belief Model. This model explains the factors that make people more likely to adopt healthy behaviors, especially in regards to health problems that can be prevented through those healthy behaviors. These factors are as follows: belief that one is susceptible to a particular health problem, belief that the problem is serious, belief that adopting preventative measures will reduce risk, and belief that no significant barriers make it difficult to adopt those measures. This model emphasizes agency (individual free will to make choices) over structure (social forces that limit choices), and Weitz explains that this means that researchers and policymakers who follow this model are more likely to “promote policies such as educating consumers about the dangers of smoking than policies such as banning smoking in public places.”

My question is as follows: are there any preventable health problems that are better prevented through structural changes than through policies that focus on agency? For example, in preventing vaccinatable diseases, would it be more effective to make vaccines mandatory, or to follow the Health Belief Model and provide better and more accessible education regarding vaccine risks and benefits?

Alternatives to the Chargemaster?

In Steven Brill’s article, “Bitter Pill: Why Medical Bills are Killing Us,” he describes the chargemaster as “every hospital’s internal price list,” which is then used in patient bills to calculate the final cost of care. Because each hospital is free to determine their own chargemaster and there is no regulated process for doing so, these chargemasters often have grossly inflated prices for services, especially when compared to the prices for services paid for through Medicare or Medicaid. This leaves every American not on either of those programs to flounder with astronomically high medical bills. Even with insurance negotiating prices down from that chargemaster starting point, charges for services are still many times higher than they cost the hospital to provide. To combat this, Brill says that we must “outlaw the chargemaster” and also “amend patent laws” to limit the power of pharmaceutical companies charging high prices for ‘their drugs,’ “set price limits or profit-­margin caps” on drugs, and cap profits for CT and MRI scans and for in-house lab tests. He also suggests medical-malpractice reform, capping administrative salaries in the medical field, and posting profit margins publicly.

I think that Brill’s suggestions are wonderful, but he does not say enough about how we can manage to make all of these changes happen. So, that is my question: how do we get from where we are now to a world of no chargemasters, legal reform, and caps on costs and salaries?

Process Reflection 1

Taking Sociology of Health Care has been very valuable to me. I have had some level of understanding of the health care system of the United States for many years now, but it has been really interesting to learn about the complexities that exist in health care systems. It has been especially illuminating to learn about all of the different actors involved in health care systems and the varying levels of influence they have over various aspects of that system. Learning about the history of our health care system and how the influence of doctors has changed over time has helped clarify how some of these complexities arose.

New WHO HIV Treatment and Prevention Guidelines

In an article entitled “Millions More Need H.I.V. Treatment, W.H.O. Says,” NY Times writer Donald G. McNeil Jr. explains the implications of the new WHO HIV Treatment and Prevention Guidelines. Previously, those living with HIV were put on antiretroviral therapy (ART) once their CD4 cell count, which is essentially used as a measure of the strength of one’s immune system, declined to a certain level. Now, the new guidelines recommend ART to everyone who is HIV positive, regardless of their CD4 cell count. In addition, the guidelines recommend that more people use a daily oral pre-exposure prophylaxis (PrEP) as a preventative measure. PrEP reduces the chance of acquiring HIV even in the case of exposure to the virus. Therefore, PrEP is highly recommended to those who are at a higher risk of being exposed to HIV, such as gay men, sex workers, and people who have HIV positive partners. The new guidelines recommend this preventative measure to more people than did the previous guidelines, including African women and children. Under these new guidelines, nine million more people should be treated with ART and “untold millions” more should use PrEP.

These new guidelines are backed up by a substantial amount of evidence that they will prove to be effective. According to the WHO, there have been numerous clinical trials, observational studies, and other research released since 2013 that back up both the earlier initiation of ART and the success of PrEP as prevention. In addition, HIV/AIDS experts, such as Dr. Mark Dybul (executive director of the Global Fund to Fight AIDS, Tuberculosis and Malaria) and Dr. Deborah L. Birx (the United States global AIDS coordinator and head of the President’s Emergency Plan for AIDS Relief), support the new guidelines. The Centers for Disease Control and Prevention (CDC) is also a strong source of support for the treatment and prevention combination, and some North American cities have implemented this combination before, to great success.

McNeil raises salient questions throughout his article: how much will it cost to implement these new guidelines? How will those costs be paid? He points out that, not only are the drugs themselves expensive, but a substantial amount of money must go into the health care systems needed to administer those drugs. According to the article, there have not yet been any widely accepted estimates of the cost of these new guidelines; however, some say that current HIV treatment costs would at least triple, with prevention likely costing exceedingly more.

I agree with McNeil. These new guidelines sound wonderful. This combination of ART for treatment and PrEP for prevention has been proven to work, so I would not classify this as excessive treatment or prevention. This is especially true for the treatment: according to the WHO, initiating ART earlier results in better clinical outcomes for HIV positive patients than waiting for their CD4 cell counts to get low enough to start treatment. Recommending that African women and girls use PrEP as a preventative measure is also extremely important, as they are a major at-risk population for HIV infection. That said, before these new guidelines are fully implemented, the issue of cost must be thoroughly examined, and, according to the article, that issue is being largely ignored presently. In countries without universal healthcare coverage, people living with HIV often cannot afford their medications without sufficient health insurance, and that may apply to those at risk for contracting HIV, especially if their insurance provider deems them “not enough at risk” and denies coverage. Even countries with universal healthcare must grapple with the higher bill, and we all must consider where payment will come from in the case of low- and middle-income countries that cannot afford the medications on their own. With these new guidelines, everyone involved with healthcare and the HIV/AIDS epidemic, including governments, organizations like the Global Fund, insurance providers, patients, etcetera, all must closely examine the major problem of cost in this situation.

http://www.nytimes.com/2015/10/01/health/millions-more-need-hiv-treatment-who-says.html

http://www.who.int/hiv/pub/guidelines/earlyrelease-arv/en/