Coming into this class, my knowledge regarding the U.S healthcare system was limited. I would see articles online and hear stories on the news about Medicare, Medicaid, and rising health care costs and have superficial understanding of what this truly meant. Being a pre-med student I have been exposed to various settings in the healthcare field but have always been a one-sided observer, seeing only what was clearly presented to me. For example, during my senior year of high school, I shadowed with nearly twenty different healthcare providers, ranging from a cardiologist to an oral surgeon to a pathologist who performed autopsies. After being presented with the various facts, statistics, and personal accounts shown in class I often find myself reflecting back on those shadowing experiences with an entirely new perspective and noticing things I did not notice before. For example, while shadowing a veterinarian I remembered being asked if I would like to stay for a luncheon and presentation provided by a drug company, not knowing the Big Pharma’s manipulation of healthcare providers. Moreover, I also shadowed an ER physician in a public hospital located in a poverty stricken area. I remember seeing one child on the entire floor of the ER and reflecting back I realized that this public hospital, rather than a private hospital with a pediatric ward, was probably one of the few places in which the parents could afford to take their child and their insurance would be accepted.
There are certain statistics as well personal accounts from this class that I will not easily forget. This includes certain facts such as how much the U.S. spends on healthcare and how little we receive in return compared to other countries, the existence of overtreatment and a chargemaster, and the influence of the pharmaceutical industry in medicalization and drug pricing. I also did not realize the tremendous amount of people underinsured or lacking insurance all together. Next year being the first time I can vote, this has greatly influenced my candidate choices. With that said, the portion of this course I found most interesting was the beginning of the course, involving the high costs of healthcare and the role of commercialism and consumerism in the healthcare field. This has given me an entirely new perspective on the healthcare field and at times has made me reconsider if I want to be part of this “business.” I have concluded that when I do enter this field one day, I want to avoid the profit driven mindset existing in modern healthcare.
All in all, this has been one of the most informative and eye-opening courses I have taken at BU thus far. I would highly recommend this course not only to those who are health majors but also to anyone who has limited knowledge of the healthcare field.
In Zussman’s article “The patient in the intensive care unit, Zussman discusses how medical providers in the intensive care unit focus solely on physiology alone rather than looking at the external psychological or acute problems the patient may have. It makes sense to a certain extent that this would be the main focus of treatment since the medical crisis at hand usually centers on the physiological the patient has endured. However, what stood out to me after reading this article was the account of the treatment of a patient who tried to commit suicide. This eighteen-year-old patient had overdosed on drugs and was taken to the ICU, where the physicians focused solely on his liver damage. They were not at all concerned about his psychological damage however, or the underlying problems that had caused the liver damage in the first place. In cases like this, the patient’s underlying problem may not be as immediately dangerous as their physiological problem but is the cause of their physiological problem and may be even more dangerous in the long run. Is this underlying problem addressed after they leave the ICU? Do the physicians in the ICU at least acknowledge the underlying problem to the extent that they will refer the patient to a psychologist or another physician that focuses more on treating said underlying problem? Or are the ICU physicians so focused on getting the patient out of the hospital with minimal physiological damage that they simply feel as if this is not their responsibility? How much treatment is really being provided if the underlying problems are not being addressed at all and may cause the patient to end up in the ICU again with a worse medical crisis due to this underlying problem?
In the New York times article “End of ‘Death Panels’ Myth Brings New End-of-Life Challenges,” author Paula Span discusses the debate over Medicare’s coverage of voluntary discussions with a physician about end-of-life treatment preference. When this idea was first brought to the table in 2009, conservatives claimed it was the precursor to government-sponsored euthanasia. This debate came to an end last month when Medicare authorized payment for end-of-life discussions. Doctors can now bill Medicare for discussion with their patients regarding end-of-life decisions. The first half hour of discussion is worth $86 and an additional $75 for 30 minutes more. Representative Earl Blumenauer, who first proposed the provision, states, “the apprehension and concern has slowly ebbed as public support got stronger.” This provision has gained a lot of public support recently. A public opinion survey directed by the Kaiser Family Foundation found that out of 1,200 adults polled, 80% feel that Medicare should cover doctor-patient discussions of end-of-life treatment. However, these conversations rarely take place. Span states “fewer than one in five respondents reported actually having had such a discussion with a health care provider, including only about a third of those over age 75 and about a third of those with a debilitating disability or chronic medical condition.” This is partly due to many patients not wanting to discuss end of life decisions with their doctor either because they do not know they can or do not feeling comfortable in doing so. Additionally, doctors should learn how to approach these conversations. Dr. Diane Meier, who leads the Center to Advance Palliative Care at Mount Sinai Hospital in New York, discusses how doctors are anxious about this and before doctors can start initiating these conversations, communication skills need to be practiced. Mr. Blumenauer intends to introduce legislation in 2016 to train health-care providers in end-of-life discussions and measure how well this provision is working overall. Although this provision may be difficult to get going, it has given health care providers incentive to start these important conversations with their patients.
Span’s article ties into several important issues that have addressed in class, including the manner in which a person wants to die and who should be making the decisions about care in an end-of life situation. Medicare’s authorization of payment for end of life discussions is beneficial for several reasons. First, this provision will encourage more patient involvement in end-of life decisions as well as encouraging doctors to initiate conversations with their patients about these decisions. As highlighted in class, patients or their families want to be the ultimate decision makers in end-of-life situations, but doctors tend to use their medical knowledge to sway patients or their families into making the decision they prefer. Having a discussion about end-of-life treatment with patients when the patient is fully cognitive and aware of their options could both decrease the decision-making authority of the physician and provide the patient with more control over their end-of-life decision. This provision will teach healthcare providers the importance of effective communication in the healthcare field, especially in end-of-life decisions. Only the patient can know definitely what decisions they want to be made in their end-in the way they decided as opposed to a one-sided decision made by their healthcare provider. Most Americans do not prefer to die in a hospital, but when the circumstances do not allow for an alternative, determining end of life treatment before it is too late will alleviate the patient and their family from additional stress and worry.
In Timmerman’s “ Social Death As Self-Fulfilling Prophecy”, Timmerman describes the impact of social value on the fervor and vigor in which resuscitating techniques are applied to a patient. Certain positive characteristics contribute to the patients presumed social viability such as age, social importance, and identification with the patient. Negative characteristics include seriously ill or older patients and addicts, who have less effort put into their resuscitation. In terms of seriously ill patients, less effort is put into resuscitation because the medical staff sometimes believes that sudden death is not the worst possible end of life and these patients may be in significantly more pain living. However, Timmerman does not mention the impact physical manifestations of defects would have on an individual’s social viability. Are those with genetic disorders or birth defects who exhibit these disorders/defects also viewed as less socially viable even though they are not seriously ill? For example, would someone with Down syndrome have less of an effort put into resuscitating him or her even though they may be perfectly healthy and happy in life otherwise? Additionally, would someone exhibiting a physical birth defect but otherwise healthy have less vigor put into his or her resuscitation? What is the impact of disorders and defects on resuscitative efforts?
In Groopman’s chapter titled “Marketing, Money, and Medical Decisions,” Groopman discusses the medicalizing of normal conditions done by the pharmaceutical companies. Gropper states ‘in the past decade or so, marketing directly to the public prompts people like aging men or postmenopausal women to ask their doctor for a drug even if the drug has not been proven to work for their problem.” One particular account that stood out was the prescribing of testosterone replacement products to men. Research found that “ treatment does not significantly increase strength in most muscle groups; compared to a placebo, it neither boost libido nor increases energy.”Groopman then goes on to say “nonetheless, the number of prescriptions for testosterone replacement products continue to rise sharply.” How is it ethical for doctors to prescribe drugs that are not specifically proven to target treatment of the condition the patient presents to them? Many drugs have serious side effects such as stroke and heart attack so what if the patient taking a drug that is not beneficial to their condition is harmed significantly due to the side effects of this drug? What role does ethics play in the prescription decision-making process for doctors?
In the article “The Social Construction of Illness: Key Insights and Policy Implications” Conrad and Barker discuss the impact stigma can have on an individual with an illness. One of the most interesting portions of this article and something I believe most people do not think about is the metaphorical connotations associated with certain illnesses and how this can affect those afflicted with the disease. Conrad and Barker give the example of the metaphor of “obesity as sinful” and how this would either deter or encourage an individual’s support towards public policies aimed at reducing obesity. It seems counter intuitive that the negative connation associated with an illness would make people less likely to want to help lessen the prevalence of this illness, since it would seem as if people would want to reduce the prevalence of an illness they view with such disdain. I think if people would be discouraged to support public policies aimed at reducing certain illnesses, the people with these illnesses would end up like those who are coping with illness experience that is discussed later in the article. Barker and Conrad describe these people managing chronic illness as becoming “increasingly cut off from the routines of conventional life—unable to work, spend time with family, socialize with friends, or move about freely. Thus, the foundation on which a sense of self is based can be lost, there is nothing to look forward to, and nothing to do; time is experienced as unchanging.” This seems like a depressing but likely fate for those who have no support for their illness due to the negative conations associated with this illness. All in all, this makes me wonder if the negative connation associated with an illness would be more likely to discourage or encourage others from supporting approaches to reduce the illness or help those with the illness cope? Would cultural and religious difference impact the decision to support public policies?
“New Screening Guidelines Won’t Assure Fewer Mammograms”
This New York Times highlights how healthcare providers will not necessarily follow the new screening guidelines suggested for breast cancer detection. Recent research has found that annual mammograms for women over the age of 40 are not as beneficial as previously thought. As a result, the American Cancer Society has updated its recommendation, stating that women should not begin annual mammogram screening until age 45 through age 55; then, they should receive screening every other year until they are at an age expected to have less than 10 years of life left. The ACS also recommends eliminating clinical breast exams entirely. These recommendations are based off of several studies, including one that showed a higher proportion of breast cancer diagnosis occurs when women are premenopausal. However, after menopause this proportion significantly decreases. This explains the ACS recommendation for annual screening to stop after age 55 and occur biannually. Harm also results from false positive findings, which can result in a second exam, another screening, or a biopsy. A cohort study conducted in 2005 concluded that performing a clinical breast exam as well as a mammogram resulted in the detection of 0.4 extra cancers as well as 20.7 false positive tests per 1,000 women. This depicts that the cost of performing these extra tests outweighs the benefit. Another study showed that using biennial screening instead of annual screening in women 50 to 69 might result in 57,000 fewer false positives over all for every 100,000 women over 10 years.
Although these studies prove that the ACS recommendations are valid, changing current screening procedures will be difficult for several reasons. Physicians have been conditioned to approach breast cancer prevention aggressively and to be invasive. Studies show that once this happens it is hard for them to reverse course. Moreover, physicians tend to believe that providing more care protects them from lawsuits and malpractice. Lastly, financial incentives also play a role in unnecessary screening.
This article relates to the concept of overtreatment that we discussed in class. The biopsy and screening not only cause unnecessary risks, but also unnecessary money to be spent on screening that is not benefiting the patient. Consequently, one of the reason the new screening guidelines will not assure fewer mammograms is that physicians are driven by financial incentive to provide more mammograms to their patients in order to generate higher income. In turn, unnecessary mammograms can be justified by stating that more care protects the patient by ensuring that harmful results do not go undetected. This is the fundamental justification for overtreatment; being extra cautious when it comes to preventative treatment outweighs the risks associated with the additional unnecessary treatment. Although a significant amount of studies have been performed proving the ACS recommendation for less frequent mammograms is logical, several factors are at play making physicians hesitant to follow these guidelines. These factors include the fear of being sued for malpractice due to insufficient care and the advancing of the medical field toward a profit-driven consumerist business.
Going into this class, I had very little knowledge of the U.S healthcare system. Most of what has been presented to me in this class has shocked and angered me a lot. I have an entirely new perspective on the medical field, my own physicians, and the U.S as a whole. First off, I never viewed healthcare providers in such a negative light until now. I am aware that not all healthcare providers are greedy and selfish, but the concept of overtreatment has shown me the shift in the medical field from helping others to profiting off others. I never saw medicine as a business until now: a business that provides to those who can afford to pay its obscene prices, and for those who cannot, you are disregarded and turned away. I never viewed medicine as a commodity rather than a service: a commodity that is necessary to live but is only given to those who can afford it.
Many of the materials and facts presented to us in class have surprised me a lot. The graphs depicting how the U.S spends significantly more per person on health care but has a significantly lower life expectancy compared to most European countries was both upsetting and shocking. Furthermore, the entire concept of “the chargemaster” seems so outrageous it is hard to believe. Lastly, the fact that overtreatment exists on such a large scale was surprising to me because I always viewed healthcare providers as healers rather than businessmen.
The personal accounts have been the most memorable portion of this class for me. The video showing the man who lost his house paying for his medical bills, the young girl who died from Lupus because she was unable to afford the treatments and medications, the man who was waiting in the emergency room for ninety minutes because his payment to the hospital did not go through. These stories upset me in more ways than I can count. I selfishly and naively admit that I never considered the amount of people both insured and uninsured that are forced to decide between a roof over their heads or medication or surgery to treat their condition. This class has forced me to face the scary reality of the U.S healthcare system today and consider how I as a future physician want to carry about. At this point in the semester, I think everyone is to blame for the corruption of the United States healthcare system: the physicians, the insurance companies, the pharmaceutical industry, and America as a whole for allowing this to continue for so long. This class has provided me with a knowledge and awareness of the multitude of problems facing the U.S healthcare system. It has forced me ask myself: When, how, or will this problem be solved? Advancing in the class, I hope we can analyze in more detail the healthcare systems of other countries compared to the United States and discuss the pharmaceutical industry in more depth.
In Steven Brill’s article “Bitter Pill: Why Medical Bills are Killing us,” Brill recounts Sean Recchi treatment experience for non-Hodgkins lymphoma in MD Anderson hospital. After Sean had been examined for six days in MD Anderson hospital, a visit that cost close to $50,000, he was put on a treatment plan for his worsening condition. Sean’s wife stated that he had been “sweating and shaking with chills and pains” ever since arriving in Houston. Nonetheless, Sean was kept waiting in the reception area for 90 minutes. Not because the hospital did not have an available bed or the equipment needed. Not because there was a lack of physicians or nurses available to see him. But because the hospital could not confirm that the $7,500 check that was supposed to be advanced to MD Anderson from Sean’s credit card had cleared. The thought of someone sitting in a reception area, shaking in pain, and not receiving the immediate care they need because their payment for the service did not go through is both outrageous and upsetting. This may seem like an unusual or rare situation, but in reality it is not. Brill states that “the hospital says there was nothing unusual about how Sean was kept waiting.” When Brill approached MD Anderson’s communication manager Julie Penne on Sean’s situation, she explains that “asking for advance payment for services is a common, if unfortunate, situation that confronts hospitals all over the United States.” If this is happening in hospitals all over the country, how many people are suffering, or worse dying, because they are forced to wait to receive treatment? The withholding of care for profit based reasons poses an important question. Is the purpose of medicine in society today for treatment, for profit, or a combination of both? And if the field of medicine continues on this path, how will this affect the way in which medicine is viewed?
This New York Times article titled “Antidepressant Paxil Is Unsafe for Teenagers, New Analysis Says” highlights one of the most prevalent deception techniques used by pharmaceutical companies relating to drug advertisements. A recent discovery was made involving the safety of the anti-depressant Paxil for teenagers. This goes against a study published by a leading drug maker fourteen years ago, stating that the antidepressant was safe for teenagers to take. The study of the effect of Paxil on young people began in the late 1990s and was conducted by Dr. Martin Keller. Depression was tracked over eight weeks in three different groups- one taking Paxil, one on a placebo, and one on an older anti-depression drug. Although the Paxil group did not improve any more than the other two groups in the standard depression questionnaire, the group did score higher on secondary measures. The trial was submitted to federal regulators, and the drug was on its way to being approved for young people. When the study was published however, critics began to argue that serious side effects were being downplayed. Federal regulators eventually ordered black-box warnings on Paxil labels and prescriptions of the drug to adolescents lowered. The reanalysis study of the safety of Paxil, published in the BMJ journal, states the drug has “no clear effectiveness” and the side effects were completely mislabeled. However, the maker of Paxil, GlaxoSmithKline, stands by its original conclusions and states that they did in fact provide all the data needed for the reanalysis. One author of the reanalysis, Dr. David Healy, stated that adverse events in the original study involved suicidal thinking or behavior but were mislabeled. However, Dr. Keller and his team released a statement saying that to claim their trial was “misreported” is wrong.
This article highlights the lengths pharmaceutical companies are willing to go to market and sell their product. As discussed in class, pharmaceutical companies have a vested interest in understating the dangers of their product to consumers. This is depicted in marketing of Paxil to teenagers. Five of the six candidates in the original study took Paxil and had suicidal thoughts and behavioral patterns, but GlaxoSmithKline mislabeled this information when the study was released. The drug was made to look as effective and safe as possible to teenagers, but further research revealed that this was not the case. Additionally, in 2012 GlaxoSmithKline was forced to pay the US government $3 billion for its dishonesty in marketing. This case is one of many that demonstrate how the pharmaceutical industry is driven by commercial, not humanitarian motives. All in all, this drive is contributing to the worsening of our healthcare system.