Should all doctors get hospice experience?

In the documentary we saw today in lecture, Florence Wald mentioned in her closing comments that she would someday like to see all medical students or residents spend six weeks in a hospice care facility before entering medical practice. My initial thought when I heard her say this was that six weeks was overkill-wouldn’t doctors learn how to deal with death and dying once they were put in their residencies? But as I considered her proposition I began to realize the many ways that experiencing care in a hospice setting would be beneficial for new doctors. What, aside from how to address death, could hospice education offer young doctors? How would giving medical students this experience change the way they interact with patients? Do you think that if medical education incorporated more aspects of the hospice model into their curricula the profession would begin to shift their ideas about emotional disconnectedness and the need to care for the whole person?

We have to start talking about the unpleasant stuff

A video in Tuesday’s lecture mentioned Roz Chast’s 2014 book “Can’t We Talk About Something More Pleasant?” , which chronicles her experience over the course of her parents’ last years of life. I read the book when it came out because it was getting rave reviews from ever critic around the country, but I was surprised at how much it impacted me. Chast is right; talking about the process of dying (and everything that comes with it) is not pleasant. It’s painful, heart-wrenching, emotionally draining, and sometimes, a little gross. But the fact remains that we will all at some point come face-to-face with the deaths of people we love. Maureen Stefanides, the subject of Nina Bernstein’s article, had to deal with many of the same struggles that Chast did, and I think that the experiences of these two women are echoed by millions of adult children around the country caring for their aging parents. I think that part of the reason the system for end-of-life care is in such shambles is that we as a society simply don’t want to talk about death. Would having these discussions a little earlier in life, before our loved ones have reached the point of needing constant care, make people more aware of the need for changes in the system? How can the government do more to help families honor the wishes of their loved ones, instead of handing money to for-profit companies that trap patients in a cycle of hospitals and nursing homes?

Hepatitis C: Is curing the most vulnerable worth the price tag?

Hepatitis C is a bloodborne virus most commonly spread through intravenous drug use, that persists in the liver and causes eventual liver failure in 85% of patients. One of the most heavily affected populations in the U.S. are prison inmates, with 15% infected with Hep C. Up until early 2014 there was no treatment, but after decades of research a drug was discovered that has a 90% cure rate. However, ledipasvir-sofosbuvir, the breakthrough Hep C medication, runs at $1,125 per pill. The minimum length of treatment is 12 weeks, which costs upwards of $90,000 per patient.

The health of prisoners is the responsibility of the government, and the liver failure associated with chronic Hep C requires incredibly costly treatments that often include liver transplants. Because of the high cost of letting the disease progress, a new study shows that the high upfront cost of screening U.S. prisoners for Hep C and treating them now will lead to longterm healthcare savings. Just treating those in prison would save $750 million over 30 years. Additionally, treating prisoners also prevents them from transmitting Hep C to the rest of the community upon their release.   Continue reading “Hepatitis C: Is curing the most vulnerable worth the price tag?”

Chicago’s Hospital Problem and Social Viability

In reading Timmermans’ paper on social death, I began reflecting on a conversation I had with one of my friends who goes to school in Chicago. Her campus is located in Hyde Park (which is in the South Side of Chicago), and the area is notorious for rampant gang violence. Holy Cross Hospital, operated by the University of Chicago through the Sinai Hospital Network, is the only hospital in the South Side, and is the only designated level 1 trauma center for children in the region. However, in 1988 the hospital lost its adult level 1 trauma center designation, so victims of gang violence in the South Side have to be airlifted to Northwestern Memorial Hospital ten miles away for care. The extra time needed for transport can be the difference between life and death for many of these patients. Timmermans asserts that one’s standing in society impacts the treatment they get from healthcare professionals in trauma and resuscitation scenarios, and I think looking at Chicago’s hospital problem through this lens is particularly interesting. This fall Holy Cross Hospital was given approval to build a new, state-of-the-art level 1 trauma center that will serve the South Side, but why did it take nearly 30 years for a much needed medical facility to be placed in that area? How does Timmermans’ view on social viability explain this problem? Can we learn from Chicago to better reach underserved populations across the country?

Genetic Testing and the “Potentially Ill”

Since the completion of the Human Genome Project in 2003, the ease and accuracy of genetic testing have gotten exponentially better, while costs of genetic testing have dropped dramatically. These advancements in genetic testing have been revolutionary in research and practical application. The discovery of cancers and other genetic conditions with some hereditary component has greatly advanced the capabilities of doctors and patients to prevent illness. However, genetic testing in particular has created a new category of patients; “the potentially ill.” Continue reading “Genetic Testing and the “Potentially Ill””

Reducing the Cost of Pharmaceuticals Won’t Hinder Innovation

When talking about healthcare costs in the U.S., one of the most important facets of the problem are prescription drugs and their astronomical costs. Other developed nations around the world have dramatically reduced the prices of pharmaceuticals; but how? In his piece To Reduce the Costs of Drugs, Look to Europe, health economist Austin Frakt discusses a system called reference pricing that has been used across Canada, Europe and Asia to push drug companies to both reduce the costs of existing drugs, and to create new kinds of drugs. What reference pricing does is group medications that have the same active ingredient and do the same thing-like reducing fevers or reducing cholesterol-in one category, and giving all of those drugs one price. This means that drug companies can’t repurpose, repackage, or rename existing medications and charge more for them. Much of the concern about reducing drug prices is squelching innovation, but reference pricing actually does the opposite. By having classes of drugs, pharmaceutical companies are encouraged to make new classes of drugs, that they can therefore charge more for because there are no other drugs that do the same thing. The way each class is priced varies by country and healthcare system, but it ultimately means that drugs cost much, much less than they do in the unregulated U.S. system.  Continue reading “Reducing the Cost of Pharmaceuticals Won’t Hinder Innovation”

How Can We Untangle Socioeconomic Status, Ethnicity, and Health Outcomes?

As discussed in both Weitz and Phelan et. al., socioeconomic status and virtually all indicators of health, from life expectancy, to infant mortality, and to general morbidity and mortality, are correlated. Phelan proposes that differences in health seen between socioeconomic groups are the result of differences in “deployment of resources.” Unfortunately, in the U.S. socioeconomic status is tied to ethnicity, and this has had incredibly far-reaching implication for health disparities between white and nonwhite citizens. The number of factors at play in this issue makes untangling every variable incredibly difficult. Up until well into the 20th century, many politicians, civil servants, and even doctors believed that differences in health between ethnic groups was a result of “genetic inferiority” of non-white Americans. While those notions have since been strongly debunked, the repercussions of decades of deliberate, institutional racism are still being felt in this country.  Continue reading “How Can We Untangle Socioeconomic Status, Ethnicity, and Health Outcomes?”

In the Face of an Opiate Crisis, Could Alternative Medicine Become Mainstream?

Today, the United States faces a rising opiate crisis. Every day patients across the nation become addicted to opioid painkillers prescribed to them by their doctors. When the prescriptions run out, some even turn to heroine out of desperation. An increasing number of patients are overdosing on their pain medications because the nature of opiates forces them to keep on taking more. The notion in medicine has always been that powerful pain needs powerful pain killers, but it turns out that our strongest drugs for pain may not be that effective.

In Oregon, one in four residents received an opiate prescription in 2012. Many Oregon doctors have seen drugs like Vicodin, Percocet, and OxyContin as the frontline against fighting pain, and up until now Medicaid only covered powerful pain medications to treat chronic (and other) pain. However, more research is showing that opiates are not the best way to treat pain, and so Medicaid of Oregon will now start covering treatments like acupuncture, yoga, spinal manipulation, and other kinds of traditionally “Eastern” or “Alternative” medicine that have become popular in fighting powerful pain. These methods may be more expensive than the traditional course of pills, but as the country experiences a growing crisis of over-prescription, addiction, and overdose of opioids, doctors and patients are looking to other options to manage pain.

Many are skeptical of non-pharmaceutical methods of pain management because it has not been conclusively demonstrated that they work better than drugs. Additionally, the mechanisms behind how they work in the body remain unknown. However, for many patients they work wonders, and in the face of a crisis of opiate use I think more states should follow Oregon’s example in covering other methods of pain management for patients on Medicaid.

Opiates are highly addictive, so their prolonged use leads very easily to dependence. Furthermore, sometimes the root of chronic pain may not be physiological. Many of the arguments against treating pain with acupuncture have been centered on the fact that in some studies control acupuncture works just as well as traditional acupuncture, meaning that the effect is probably a placebo. I don’t believe that the way in which acupuncture treats pain matters, as long as it’s working. The brain is a powerful tool in healing even physiological ailments, so I think that utilizing the powers of placebo could be a really important tool in helping patients with pain crisis. Also, if opiates aren’t working, we’re paying for a lot of ineffective medications that are fairly expensive and aren’t providing outcomes. I think that there needs to be more research on the subject before things like acupuncture are introduced into mainstream medical practice. Many current studies on the subject come from other countries, and use methods not up to the standards of most American medical journals. I know it will take a lot to change the minds of the medical establishment on the use of opiates to fight pain, but I believe that if we are to get ourselves out of the current crisis we must explore all options. When it comes to pain management, if it works, it works.

Continue reading “In the Face of an Opiate Crisis, Could Alternative Medicine Become Mainstream?”

Do Overt-Treated Pregnancies Affect Infant Mortality?

As Professor Guseva said in class, infant (children under five) mortality rates are often a more telling indicator than life expectancy of the efficacy of a healthcare system. The United States’ infant mortality rate is seven deaths per 1,000 live births. While that number may seem very small, we have the highest infant mortality rate compared to our peer countries.   The United Kingdom, Germany, France, and Switzerland, all have infant mortality rates of four deaths per 1,000 live births. Iceland’s infant mortality rate is two per 1,000 live births. The United States has the most state-of-the-art healthcare system in the world, yet somehow this has not translated to a decrease in our child mortality rates.

Globally, the leading cause of death in “under fives” is preterm birth. In places with historically high infant mortality rates, preterm birth is most often associated with poor nutrition of the mother, infections (especially syphilis), and smoking. Infectious diseases like pneumonia, diarrhea, and meningitis all contribute significantly to infant mortality, but more has been done to prevent infectious disease in young children than prevent the causes of premature delivery in the past few decades. The PBS “Money and Medicine” special discussed how the large number of induced labors in the U.S. lead to a higher rate of cesarean sections, and therefore took on more risks. While I think that the induction of labor is an important and valuable tool for doctors dealign with complicated pregnancies, the video’s discussion of this as an over-treatment problem made me wonder, is our over-treatment of deliveries a contributor to our nation’s infant mortality rate? How do you think a protocol like Intermountain’s would impact delivery procedures if implemented around the country? What needs to be changed so that mothers get the care they need while pregnant instead of dealing with complicated deliveries? How could the medical establishment help with the public health interventions needed to reduce infant mortality in the U.S.?  Continue reading “Do Overt-Treated Pregnancies Affect Infant Mortality?”