Category: Public Health

Categories
General Public Health

The Doctor as the Advocate

Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has.
– Margaret Mead

Doctors are at the forefront of society. They see the dark pits and abysses of humanity that the rest of us try to forget – those depths of despair that many of us will never experience.

As Medicine continues to change, so too does its definition of illness and what it means to be ‘sick.’ Illness means more than just a set of symptoms or a mark upon an X-Ray; it resides within the choices we make every day, the people we welcome into our lives and the jobs we labor for decades at a time. As medicine continues to encompass more and more of our everyday lives, so it takes on greater responsibility.

Advocacy was defined by Earnest et al. in the January 2010 issue of Academic Medicine as an ‘action by the physician to promote those social, economic, educational and political changes that ameliorate the suffering and threats to human health and well-being that he or she identifies through his or her professional work and expertise’ (3).

An article written in the 2014 edition of the AMA Journal of Ethics further divided the definition into two: agency which refers to working on behalf of a specific patient, and activism which is directed towards changing social conditions that impact our health (6). Although many doctors are comfortable with the direct care of their patients, what can often be forgotten is our social responsibility. Not only do we need to treat patients as individuals, but also as a group – as a community.

The doctor’s role goes beyond the hospital walls. The patient is not just the person sitting in the clinic, but the person next door, the young lady who goes to the shops, the schoolboy who drags his bag over his sullen shoulders every morning. Illness takes place in more than the patient’s body; it takes place in society, in the neighborhood, in the schools that cannot provide support and the families that can no longer cope.; what impacts our health? Is it a parasite within our bodies, a virus that has entered so far into our habitat? Or is it unemployment, poor housing, discrimination, social isolation, loneliness, and abuse? These types of vulnerabilities lead to much higher rates of both morbidity and mortality in those affected (4).

The doctor is the voice of those who do not have one. The status of the medical doctor has been respected throughout the centuries; the curer of ills, the bringer of life. While this is gradually changing in the new era of patient-centered care, it is still a prevalent idea.

The doctor should use this privilege and rank within society to fight for those who cannot. As a group, doctors can hold a lot of power within society. Here in the UK, several Royal Colleges have voiced their opinions in the mainstream media over a number of issues already; in 2015 the Royal College of Psychiatrists spoke out about the long distances many of their patients had to travel for support (8), while in 2013 the Royal College of Physicians highlighted the need to tackle obesity more rigorously (9).

These days it is much easier to be an advocate. All it takes is a few clicks on the laptop and you can enter into the sphere of social media. A quick search on Twitter will highlight numerous debates that are occurring amongst patients and doctors, nurses and pharmacists, families and politicians. The battle is no longer held in the debating arena, but within the public sphere.

There is another side to advocacy. Once one decides to expose themselves to the public sphere, they open the door to a hailstorm of criticism and disapproval. By stepping outside of their niche practice and showing their faces to the world, they invite a whole host of attacks. To counter such negative experiences, many medical organizations have offered advice for healthcare professionals who wish to take a bigger role within society.

For example, the Canadian Medical Protective Association (2) recommends doctors:

  • Approach the issue with transparency, professionalism, and integrity.
  • Work within approved channels of communication.
  • Discuss concerns, suggestions, and recommendations calmly.
  • Provide an informed perspective, and attempt to include the perspectives of patients and other healthcare professionals.
  • Persuade rather than threaten or menace others.
  • Remain open to alternative suggestions or solutions, and try to build on areas of consensus.

Another critique against advocacy is the question of the doctor overstepping her boundary. Is advocacy within the remits of the doctors’ role? There is after all a social contract between medicine and society; it is society that holds up the profession to the highest esteem, expecting them to abolish disease and alleviate suffering. A person does not take off their professional cloak the minute they leave the hospital grounds – rather, its presence can be felt in every setting, whether it be the local shop where they grab their newspaper or the primary school where they pick up their children; it is a type of respect that is rarely be found in other professions (4). Medicine and society are intricately linked, and to claim that the doctor’s job ends once the patient leaves the room is to be blind to the role of healthcare in people’s day-to-day lives.

Yet the role of advocacy is not a role that every doctor may wish to take on. Some doctors may fall into advocacy with burning desire to change the world, while others would prefer the calming atmosphere of the hospital room, with just themselves, their patient and a piece of paper in between. I believe advocacy was described best in 2011 when Dr Huddle, Professor of Medicine at the University of Alabama Birmingham, said that it “must remain an occasional and optional avocation in academic medicine, not a universal and mandatory commitment” (3).

On another level, we must be careful not to politicize medicine too far (5) – medicine is for the public and not just a puppet dancing on the strings of politicians. Medicine must speak for those who cannot, yet still maintain its autonomy. Certainly many of the issues that impact our health are heavily politicalized areas – from housing to employment to funding cuts. Doctors must be careful when speaking for their patients. They must not allow their words to become blinded by their biases. We must remember that the doctor’s duty is first and foremost towards her patients – to the public.

There are plenty of examples of advocacy out there –doctors who blog about the daily struggles of their patients, Twitter discussions about mental health and social care, and the clinicians who write books and articles pursuing public policies with an aim of building a more just, equal and ultimately healthier society.

So, how can you get involved? Grab a book, read a newspaper; join the debates on Twitter, pen an article, start a discussion – go out there and let your voice be heard.

Below are some examples:

The Seven Social Sins:
Wealth without work.
Pleasure without conscience.
Knowledge without character.
Commerce without morality.
Science without humanity.
Worship without sacrifice.
Politics without principle.
– Gandhi, 1925 (7)

References

  1. Oxford Dictionaries. Advocacy [Online]. Available at: http://www.oxforddictionaries.com/definition/english/advocacy[Accessed: 4th January 2016]
  2. The Canadian Medical Protective Association. 2014. The physician voice: When advocacy leads to change [Online]. Available at: https://www.cmpa-acpm.ca/-/the-physician-voice-when-advocacy-leads-to-change[Accessed: 4th January 2016]
  3. Kanter, S.L. 2011. On Physician Advocacy. Academic Medicine. 86:1059-1060
  4. Dharamsi, S., Ho, A., Spadafora, S., Woollard, R. 2011. The Physician as Health Advocate: Translating the Quest for Social Responsibility Into Medical Education and Practice. Academic Medicine. 86:1108-1113
  5. Huddle, T.S. 2011. Perspective: Medical Professionalism and Medical Education Should Not Involve Commitments to Political Advocacy. Academic Medicine. 86:378-383
  6. Freeman, J. 2014. Advocacy by Physicians for Patients and for Social Change. AMA Journal of Ethics. 16:722-725
  7. Easwaran, Eknath(1989). The Compassionate Universe: The Power of the Individual to Heal the Environment. Tomales, CA: Nilgiri Press.
  8. Buchanan, M. 2015. Mental health patients sent ‘hundreds of miles’ for care [Online]. Available at: http://www.bbc.co.uk/news/uk-33535864 [Accessed: 17th January 2016]
  9. BBC News. 2013. NHS obesity action plea by Royal College of Physicians [Online]. Available at: http://www.bbc.co.uk/news/uk-wales-20878210 [Accessed: 17th January 2016]

Featured Image:
Speak up, make your voice heard by Howard Lake

Categories
Clinical Opinion Public Health

The Opiate Epidemic: A tragedy for patients is a warning to physicians

As student doctors, we are entering the medical field in the middle of a raging wildfire: an “opiate abuse epidemic.”[1] The media would have us believe that addicted patients are perpetuating the problem of opiate misuse and overuse, but opiate misuse and overuse might only be a symptom of a larger problem: a medical culture in which physicians fail to practice good prescribing habits.

Overprescription and subsequent overuse of opiates is undoubtedly further complicated by the ambiguous disease process of chronic pain, a topic which deserves its own time and attention. Questioning provider prescribing practices, however, may be the only path forward in making sure that the tragedy of this crisis does not escalate further. In my mind, there are several features that characterize ideal, quality prescribing habits. First, quality prescribing should place an emphasis on patient education about the drug being proposed. A patient should also be screened for the risk of developing any side effects. Included in this should be a review of any other medication that the patient is currently taking, and potential drug-drug interactions. If necessary, a pharmacist should be involved in this evaluation. Finally, a plan between the physician and the patient to manage care should be established. For medications known to be highly addictive, this might involve a phone call a week later, and a follow up in-office appointment to see how the patient is reacting to the prescribed drug. If at any point these benchmarks for safely prescribing a medication cannot be met, then the treatment choice should be reevaluated.

It was curious timing that in the middle of this epidemic, on May 5, Hawaii House Bill 1072 quietly died in the Hawaii state senate.[2] Bill 1072 “Relating to Prescriptive Authority for Certain Psychologists,” was meant to allow psychologists to have medication prescribing privileges in order to compensate for the Hawaiian physician shortage.[3] At first, I was relieved to read that the bill had not passed the Senate. As a future physician, it’s unsettling to imagine another profession encroaching on the special modalities that we have at our disposal to treat patients, such as our prescribing privileges. But then I had a second thought. If the average physician fails to exercise high-quality prescribing practices, then perhaps clinical psychologists, who by definition study human behavior, might actually make better opiate prescribers than the average physician. In general, psychologists spend time listening and learning about their patients’ history and behavior patterns, offer counseling education, and meet with their patients on a regular basis. This model of health care encompasses many of the aspects needed for ideal prescribing habits, as previously described.

You don’t need a medical degree to understand that opiates are powerful drugs that have many side effects and can lead to addiction.  What we don’t yet seem to understand, as a profession, is how to effectively communicate these risks, or evaluate the best patient candidates for the use of opiates. A 1992 study by Wilson et al. found that when physicians increased the time of their patient interactions by just 1.1 minutes, there was a statistically significant increase in the amount of health education that a doctor could incorporate into a standard visit.[4] While it’s difficult to get specific data about the average length of a typical doctor’s visit[5], a 2013 article from the New York Times suggests that the average new physician spends only eight minutes with each patient.[6] If you have ever participated in a standardized patient encounter as part of your medical school curriculum, you have undoubtedly experienced the struggle to perform a history, physical exam, and basic patient counseling in 14 minutes. When you take into account the level of patient screening and education that the prescription of opiates, or any narcotic, demands, it seems implausible that a doctor can satisfy the requirements necessary to safely discharge a patient with an opiate prescription in such a short span of time.

In response to the opiate crisis, the ultimate long-term goal for the medical community should be to better understand chronic pain, and devise alternative treatment modalities for this diagnosis. In the meantime, however, the medical community should view this unfortunate situation as a call to reevaluate the quality of our prescribing practices. Current and future doctors need to commit ourselves to being worthy of the privilege of the prescription pad, so that it remains a treatment tool and not a source of patient harm.

References:

  1. http://www.cnn.com/2016/05/11/health/sanjay-gupta-prescription-addiction-doctors-must-lead/index.html
  2. www.civilbeat.com/2016/05/2016-session-ac-for-schools-help-for-housing-and-homeless/#.VyzIubQqa3o.mailto
  3. http://capitol.hawaii.gov/measure_indiv.aspx?billtype=HB&billnumber=1072&year=2016
  4. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1881485/
  5. http://www.ajmc.com/journals/issue/2014/2014-vol20-n10/the-duration-of-office-visits-in-the-united-states-1993-to-2010
  6. http://well.blogs.nytimes.com/2013/05/30/for-new-doctors-8-minutes-per-patient/

Featured image:
Medication by Gatis Gribusts

Categories
Clinical Public Health

Health Care Responsibilities: Zika

While attending a residency application question and answer meeting, I learned that 2016 marks the first year in over a decade that my mentor will not be taking medical students on an international health elective. She emphatically explained that it would be unethical to expose students to known Zika virus-infected areas, and irresponsible to potentially create a reservoir of Zika virus to bring back to the United States. Her second point resonated with me, because I had just examined a patient in clinic who commutes every two weeks between Puerto Rico and Orlando, Florida. He is a 30-year old male who engages in sexual activity with women only and reports inconsistent condom use. This worries me.

Puerto Rico has been hardest hit by the Zika virus pandemic, and is ground zero for Zika virus infection in the United States and territories. Between index case documentation on November 23, 2015 and January 28, 2016, there were 155 suspected Zika virus disease cases in Puerto Rico (Thomas, 2016). As of May 18, 2016, there are 544 reported travel-associated Zika virus disease cases (10 sexually transmitted; 1 Guillain-barré syndrome) in the United States and 0 locally-acquired vector borne cases (http://www.cdc.gov/zika/geo/united-states.html). The U.S. Zika virus infection in the United States and territories (USZPR) and the Zika Active Pregnancy Surveilance System (ZAPSS) registries are tracking cases of pregnant women with any laboratory evidence of possible Zika virus infection in the U.S. and territories, and reporting data every Thursday at the following website: http://www.cdc.gov/zika/geo/pregwomen-uscases.html  As of May 12, 2016, there were 157 pregnant women in the U.S. and District of Columbia with laboratory-suspected Zika virus infection.

Zika virus can spread from a pregnant woman to her fetus and is known to cause microcephaly and other brain abnormalities (ACOG Practice Advisory, March 31, 2016). The virus can also be transmitted through unprotected sex with a male partner, spurring the Centers for Disease Control and Prevention (CDC) HAN (Health Alert Network) advisory for the prevention of sexual transmission of Zika virus (Oster, 2016). Clinical criteria for Zika virus disease include the presence of (Simeone, 2016):

  • Guillain-Barre syndrome;

OR

  • in utero findings of microcephaly or intracranial calcifications in a mother with clinically compatible symptoms or epidemiologic risk factors (eg. sexual activity with a known Zika infected man) for Zika virus infection;

OR

  • one or more of the following symptoms
  1. fever;
  2. rash;
  3. arthralgia;
  4. conjunctivitis

Zika virus disease is not the first maternal virus infection to cause or be associated with congenital abnormalities, but it is the first known mosquito-borne infection to cause congenital anomalies in humans. The virus’ current behavior and long-term health consequences are still poorly understood, imparting urgency to disease control efforts. The CDC travel advisory for the country of interest by our international health elective recommends the following:

  • Women who are pregnant should not travel to areas in which there is known vector-borne disease;
  • Women who are pregnant should use condoms or not have sex (vaginal, anal, or oral) during the pregnancy with a male who has been exposed to a Zika-infected area;
  • Women and men who are trying to become pregnant should consider the risks of a Zika virus infection and strictly follow steps to prevent mosquito bites;
  • Men who traveled to or live in an area with Zika, and who have a pregnant partner, are recommended to use condoms or not have sex (vaginal, anal, or oral) during the pregnancy.

Reflecting on my clinical encounter with the Puerto Rican male who commutes regularly between known-Zika infected areas and the imminently vector-infected United States, I wonder if he is aware that he poses a risk. Does he believe, as so many often do, that he could not possibly be the one to acquire or sexually transmit an infection? Has he considered the possibility that he could serve as a viral reservoir?

In light of current evidence regarding Zika virus disease and the significant risks, I agree with my mentor’s decision to limit medical student international travel to Zika-infected areas. And I ask myself and readers, what is the responsibility of medical professionals in regards to communicable disease containment?

For more information, please see the American College of Obstetrics and Gynecology (ACOG) and CDC websites for clinical updates. An updated practice advisory by ACOG and the Society for Maternal-Fetal Medicine can be found at this link: http://www.acog.org/About-ACOG/News-Room/Practice-Advisories/Practice-Advisory-Interim-Guidance-for-Care-of-Obstetric-Patients-During-a-Zika-Virus-Outbreak

 

References

Thomas DL, Sharp TM, Torres J, et al. Local Transmission of Zika Virus — Puerto Rico, November 23, 2015–January 28, 2016. MMWR Morb Mortal Wkly Rep 2016;65place_Holder_For_Early_Release:154–158. DOI: http://dx.doi.org/10.15585/mmwr.mm6506e2

Oster AM, Brooks JT, Stryker JE, et al. Interim Guidelines for Prevention of Sexual Transmission of Zika Virus — United States, 2016. MMWR Morb Mortal Wkly Rep 2016;65place_Holder_For_Early_Release:120–121. DOI: http://dx.doi.org/10.15585/mmwr.mm6505e1

American College of Obstetrics & Gynecology. ACOG Practice Advisory: Updated Interim Guidance for Care of Women of Reproductive Age During a Zika Virus Outbreak. March 31, 2016. Available at: http://www.acog.org/About-ACOG/News-Room/Practice-Advisories/Practice-Advisory-Interim-Guidance-for-Care-of-Obstetric-Patients-During-a-Zika-Virus-Outbreak  Retrieved May 23, 2016.

Simeone RM, Shapiro-Mendoza CK, Meaney-Delman D, et al. Possible Zika Virus Infection Among Pregnant Women — United States and Territories, May 2016. MMWR Morb Mortal Wkly Rep. ePub: 20 May 2016. DOI: http://dx.doi.org/10.15585/mmwr.mm6520e1

Featured image:
Zika Mosquitoes (05810440) by IAEA Imagebank

Categories
Emotion General Public Health

What a Horse Named Lightening Taught Me – Equine Therapy and its Unconventional Uses

Lightening is a beautiful white mustang who enjoys back massages. He loves being around his older brother Lincoln, but shies away from people. Lightening came to Hopewell Ranch in Michigan a few years ago, after barely escaping death. He was abused by his previous family, who disciplined him with a metal two-by-four and cracked his skull. Then they tried to starve him to death. Fortunately for Lightening, he was rescued and became a therapy horse at Hopewell Ranch.

What is equine therapy? Horses like Lightening, with troubled pasts, are used in unique psychotherapy for women and children recovering from domestic violence, cancer patients, veterans, and the list goes on. Equine therapy can also be used for professional development, by teaching the importance of using body language rather than verbalization to elicit responses.

Recently I had the opportunity to visit Hopewell Ranch and participate in one such professional development session. Having never been around horses in my life, I was quite nervous prior to the session. As soon as I stepped in the arena, the horses took notice and the silence between us was powerful, but made me even more nervous. The horses studied my body language, determined that I was not going to harm them, and slowly came over to me. While I was still very cautious, the gentle nature of the horses helped calm my nerves.

After the horses got to know me, I was tasked with identifying some of their personality characteristics based on their reactions to my touch or command. Lincoln, another beautiful Mustang, was clearly the leader of the herd and quite protective of Lightening, who was very nervous and cautious around strangers. Responding to my touch, Lincoln remained steadfast and was no longer nervous around me; however, Lightening continued to shy away from me and recede into the shadow of his brother.

Next, I was placed on a team in order to perform a physical exam on Lincoln, our assigned horse, and finally, we were tasked with getting him to maneuver through a self-made obstacle course. Each task focused on cultivating different skills, such as learning to read body language, working in a team, and leading. Physicians are often required to read a patient within the first 30 seconds of entering the exam room. They must be able to work well in a team and step back when necessary so others can get the job done. A physician must also exude confidence as a leader so a patient has confidence in him or her; equine therapy helps integrate all of these important physician skills.

The most powerful part of this session for me was, again, the silence. Many times, we take speech for granted and believe that because patients can verbalize their thoughts and feelings, they will tell us everything we want to know. However, working with these horses, particularly Lightening, revealed to me the necessity of gaining the trust of my patients. If there isn’t a trusting patient-doctor relationship, they will not feel comfortable sharing their life circumstances or the challenges that need to be overcome to successfully implement therapy. For example, a patient may be homeless, abused, or depressed, but there may not be outward signs at first glance. Learning to read a patient and being able to get him or her comfortable enough to share information are great assets to have in the physician tool belt, because they will help make accurate diagnoses and enable successful treatment.

Beyond professional development, equine therapy is an incredible resource for an array of psychotherapy candidates including, but not limited to, addicts and the handicapped. The founder of Hopewell Ranch, Jodi Stuber, has an incredible story of her own that led her to open this ranch. She lost her daughter at five months in utero, but named her Hope, and then decided to name the ranch after her. In Hope’s memory, Jodi has helped people fight drug addiction, has helped cancer victims learn to ride and experience joy while they endure intensive chemotherapy, and has helped children faced with abuse and disabilities feel empowered, all through the teachings of horsemanship.

Equine therapy is a lesser known, but phenomenal, therapeutic method, and my first experience with Lincoln and Lightening will definitely not be my last. I encourage everyone to seek out equine therapy – for fun, for mental health, and for professional growth and development.

Learn more about Hopewell Ranch in Weidman, MI.

Featured image:
Picture taken by author at Hopewell Ranch. Lightening (left) and Lincoln (right)

Categories
General Innovation Lifestyle Public Health

A New Type of Pharmacy – On Food Pharmacies and Their Importance for Type II Diabetics

In a world where drug companies and pharmacies remain pervasive, an innovative take on the word “pharmacy” is being developed in Redwood City, CA. A new food pharmacy has just opened up, stocked with fresh fruits and vegetables. Just what the doctor ordered – literally! Instead of paying supermarket prices for these foods, all you need is a prescription from the doctor.

The first of its kind, this food pharmacy is an annex to the existing Redwood City free clinic known as Samaritan House. Patients with type II diabetes can get a prescription for fruits, vegetables, and even fish from a physician, and then pick up the free food at the pantry to help better manage their diabetes. The food is procured and delivered by the Second Harvest Food Bank, which is one of the largest food banks in the nation, feeding almost a quarter of a million people each month. Second Harvest also provides nutritious cooking demos given by local nutritionists1.

This one-year pilot program serves as a reminder that food is often overlooked as a primary method of treatment and prevention; a reminder we might need during our incessant drive to memorize pharmaceuticals and their mechanisms of action. Even when it is known that a patient’s congestive heart failure and diabetes may not be adequately controlled long term by medication alone, oftentimes physicians are strapped when it comes to options. Providing education on proper nutrition to a patient who simply cannot afford fruits and vegetables remains the passive and limited option, whereas food pharmacies such as Samaritan House are active steps in the right direction.

 

Source(s):

1http://www.sfexaminer.com/food-pharmacy-for-diabetics-launched-in-redwood-city/

Featured image credited to the US Department of Agriculture

Categories
Public Health Reflection

The Flint Water Crisis – The Physician’s Role

Flint, Michigan is a community of 100K residents, the majority of whom are African-American or of lower socioeconomic status. In the recent Democratic debate held in Flint, one mother spoke to the huge challenges that plague the community, including mold in classrooms, unqualified teachers, and the water crisis. In 2014, city officials decided to switch from the Detroit water supply, which gets fresh water from Lake Huron, to the Flint River, which has a long history of contamination, particularly with lead.

Flint residents knew of this contamination and saw brown water flowing in from their taps. They complained for years, long before the media hype, but city officials ignored their voices. Some residents noticed clumps of their hair falling out and an odd taste and smell to the water they were drinking.1

To investigate these claims, Dr. Mona Hanna-Attisha, a pediatrician at Hurley Medical Center and assistant professor at Michigan State University, conducted a city-wide study on the water in Flint. When she recognized that there were alarming levels of lead in the water, she alerted the Environmental Protection Agency (EPA).2 Only then did elected officials start taking residents’ complaints to heart.

Dr. Hanna-Attisha earned the Freedom of Expression Courage Award as well as the respect and gratitude of her patients and peers by speaking up. However, the brave doctor tells CNN in an interview that she was attacked viciously by the state of Michigan when she first presented her research and tried to warn officials of the ongoing crisis. She says she felt “physically ill”3 because of the backlash and professionally vulnerable because her reputation as a physician and researcher was at stake.

Despite the potential professional consequences, Dr. Hanna-Attisha fought for her patients and for the children of Flint, Michigan. In doing so she sent out an important message to physicians: sometimes we must be the voice of the people. It is our responsibility to fight for our patients, whether that means exposing a public health crisis, or more mundane daily tasks like calling health insurance agents to get a patient’s medication covered.

Flint is not the only city in the United States that is dealing with public health crises. However, this particular crisis and Dr. Hanna-Attisha’s role in bringing it to light serves as a reminder for all physicians and medical students: we are public servants and have an obligation to report public health issues in order to ensure the safety of our patients and the general population.

As the notable English physician Sir Henry Howarth Bashford once said, “After all we are merely servants of the public, in spite of our M.D.s and hospital appointments”. Let us not forget this role as we continue through medical school and enter into our practices.

Sources:
1http://www.motherjones.com/politics/2016/01/mother-exposed-flint-lead-contamination-water-crisis
2http://www.freep.com/story/news/local/michigan/flint-water-crisis/2016/01/30/flint-water-lead-health-qa/79475642/
3http://www.cnn.com/2016/01/21/health/flint-water-mona-hanna-attish/

Featured image:
The Flint River, August 2014 by George Thomas

Categories
General Opinion Public Health

The Policy on Policy: Why Medical Students Need to Learn About Healthcare

A 27-year-old woman is woken up by a sharp, stabbing pain in her lower right abdominal quadrant. She feels feverish, nauseous and weak. If you’re a medical student, you want to get a thorough history and test for a positive Murphy’s sign or rebound tenderness. You’re thinking it sounds like appendicitis. If you’re a doctor, you want to examine the patient and consider an appendectomy as a treatment option. You’re thinking of all the cases of appendicitis you’ve seen, and how well your education prepared you to diagnose and treat this condition. Except, none of that happens if this patient is never seen by a doctor. None of that happens if this patient instead, uninsured and unemployed and alone, decides to wait it out because it seems like her only option. None of that training in diagnosis and treatment makes any difference if that patient doesn’t have access to the care that could have saved her life.

The issue of healthcare policy is complicated, and oftentimes controversial, especially when presented in the framework of a political debate. As healthcare providers, however, the issue becomes less of a political one and more of an ethical one. The reported number of uninsured Americans ranges from 29 million1 to 45 million2, with tens of thousands of preventable deaths caused every year by lack of access to care3. That could mean a young woman dying of sepsis when her appendix ruptures, or an inmate asking a parole board to keep her in prison so she can continue to receive cancer treatment, or any number of similarly startling stories being told every day, across the country, about people who we know how to treat if we’re just given the chance.

A good resource for information on healthcare policy is the Commonwealth Fund’s 2014 analysis of our healthcare system compared to 11 other industrialized countries.3 The U.S. spends the most on healthcare per capita each year ($8,745), yet has the highest rate of potentially preventable deaths (96 per 100,000 people) and the highest infant mortality rate (6.1 deaths per 1,000 live births). Given the state of our broken system, it seems strange that medical students are essentially unaware of these issues until they enter the working world. Why are we not exposed to the struggles of healthcare policy in medical school? While it is certainly true that students are already saturated with information, it seems there are few subjects more universally applicable to graduates than learning about the system they will be working in.

To get an expert’s thoughts on the matter, I spoke with T.R. Reid, a leading author and journalist in the field of health policy. His bestselling book, The Healing of America, explores foreign models of healthcare and how we can learn from those systems to reform our policies at home. He currently serves as the chairman of the Colorado Foundation for Universal Health Care, which has recently placed an amendment on the 2016 ballot that would create the first state-initiated universal healthcare system by opting out of the Affordable Care Act.

 

Why do you think it is important to teach health policy in medical school?

The United States has the most complicated, the most inefficient, and the least equitable healthcare system of any rich country. Doctors are graduating into it and they don’t know what a mess it is… I think we need to prepare doctors for what they’re going to face. The second reason is, as a country, we need to fix our healthcare system. It’s ridiculously expensive, it leaves 33 million people uninsured, and the impetus to change has to come from doctors.

Health policy can be very broadly defined. What is the most important element of policy to incorporate into medical education?

The most important point is that a decent, ethical society should provide healthcare for everyone who needs it… In almost all other rich countries, healthcare is considered a basic human right and if you think about what a human right means, a human right is something the government is obliged to provide for you. You have a right to an education. You have a right to vote. If you get charged with a crime, you have a right to a fair jury, a fair judge, and a defense lawyer. We provide that because we’ve decided those are basic rights that every American ought to have. All the other countries say that’s also true for healthcare. If you’re sick and need medical care, you should get it and we have to provide it. The United States has never made that commitment… If you don’t make the basic moral commitment to provide healthcare for everybody then you end up with the American healthcare system, where some people get the world’s finest care in the world’s finest hospitals with no waiting, and 33 million people barely get in the door until they’re sick enough to go to the Emergency Room.

What changes do you foresee in the next ten years, or how do you think the current healthcare landscape will change by the time current medical students are actually in practice?

In the first place, I’m absolutely certain that we will get to universal coverage in our country and I believe we’re going to do it at a much lower cost than what we’re spending now. I’m quite optimistic that we’re going to improve our system. I think that’s going to happen… I don’t think we’re going to get there nationally. I’m convinced the way we’re going to get there is state-by-state…That’s how we got to interracial marriage, that’s how we got to same sex marriage, that’s how we got to female suffrage, that’s how we got free public education. It all starts in two or three states, the rest of the country sees that it works, and says ‘let’s do that’… The reason I’m confident in this is that we’re about to do it in Colorado. We got the initiative on the 2016 ballot. When people see a good idea working in some states, they copy it. Colorado is going to prove to the country that this can work, I hope.

As you’ve been campaigning in Colorado for universal healthcare, have you noticed that misconceptions about socialized medicine are still pervasive in public opinion? Does this influence people’s level of support or questions they raise?

The notion of limited choice and long waiting times in Canada is an issue for us…Our critics say ‘they’re going to bring Canadian medicine to the United States.’ Well, Canada covers everybody, they spend half as much as we do on healthcare, they have significantly better population health, they live longer, they have lower rates of neonatal mortality. But they still keep people waiting. I think it’s wrong to say we’re going to put the Canadian system here but that is a powerful argument…My answer is in fact Australia and South Korea have exactly the same model and they have shorter waiting times and broader choice than the United States.

In your book you examine foreign models of healthcare in detail and you described in a 2009 article in the Washington Post several ‘myths’ the American public believed about health care abroad4. Do you think American misconceptions have changed at all since the passage of the Affordable Care Act?

I think Americans still don’t like socialized medicine. Even if they don’t know what it is, they know it’s bad. That’s still true. Many Americans think other countries have limited choice and long waiting times, which is true in some countries, but many countries have broader choice and no other country has the kind of in-network, out-network business that our insurance companies have created. No other country does that…American companies and device makers say government intervention stifles innovation. I think there’s no question that in other countries regulations drive innovation. Cost controls drive innovation because they have to innovate to make their products cheaper.

If medical students are interested in health policy, how can they get involved and learn more, especially as things change?

The best way is what several medical schools have done, which is to put into the curriculum a course on health policy… I say this to every medical school dean I ever meet, ‘you ought to have a course on health policy’ and many of them say ‘I wish I could do that’ or ‘I’m thinking about it’ but some say ‘I’ve got four years to teach the entire human body and everything that can go wrong with it, don’t get me into that mess. It’s beyond our jurisdiction.’

Final thoughts?

Everybody who is sick should have access to healthcare in the world’s richest country. We have to fix this system and your generation of young doctors is going to be a powerful force for change.

 

Sources

  1. CDC National Health Interview Survey Early Release (2015)
  2. Institute of Medicine, National Academy of Sciences (2009)
  3. Commonwealth Fund (2014)
  4. Reid, T.R. “Five Myths About Health Care in the Rest of the World” (2009)

Featured image:
Healthcare Reform Initiative Announcement by Maryland GovPics

Categories
Lifestyle Public Health Reflection

Can social justice replace medicine?

‘Social injustice is killing people on a grand scale.’
– Marmot (2)

Despite the leaps and bounds that science has made over the past century, with all its shiny new techno-gadgets and ever-advancing drugs, the primary reason for our good health today lies in something much less sexy: vaccinations, clean water and sanitation- changes that we take for granted.

We live in a world that is changing every second. Bigger cars, faster phones, all the information at our beck and call: from the education that is offered to our kids, to the healthcare that is offered to our decaying bodies.

The hospital of today is a far cry from the one half a century ago. The minute you walk into a hospital your senses go haywire. You have stepped into the world of the future. The full scale of our technological advancement greets you within these four walls. The bizarre beeping overwhelms your ear canals, screaming into your brain as the alarms screech constantly in the background. The reams of wires trail along the floor of the wards, wrapping themselves around their patients like Christmas presents, offering nourishment to bodies overwhelmed with disease. We are living in the world of machines, and it is upon them that we place our hopes of immortality.

Everyone knows of the success story of Science. We are bombarded by the media, informing us of the next new cancer drug, the gene unlocked that will solve all our problems. What we forget is that we are not merely organisms residing within a vacuum. Nor are we machines ourselves, whose very pores can be zapped with electrodes, transforming our very identity. We are human beings living and breathing on this planet Earth. We digest the world around us. We are not merely scientists of the world within ourselves, of the DNA that twirls inside our cells. We are also manufacturers of the world around us; of the houses we live in, the food we eat and the lives we live. Perhaps the answer to a better, healthier life lies here instead.

But, is this the role of the doctor? Shouldn’t we leave this task to the politicians, to those who have the power to make these important decisions? Isn’t the duty of the doctor ultimately towards her patient, towards that individual who is sitting opposite, rather than to humanity as a whole? I believe Virchow, the German Doctor, described it best when he said:

‘Medicine is a social science and politics is nothing else but medicine on a large scale.’ (1)

Of course there are diseases that can only be fixed by looking inside our own bodies – diseases that come from within, that cannot be changed by any amount of control over one’s environment; Huntington’s Disease is one example.

But if you take a quick glance at the causes of mortality in both the USA and the UK, you will find that the majority of these diseases are significantly related to one’s lifestyle. The top leading cause of death in both the UK (3) and USA (4) is Heart Disease, which has very strong links with lifestyle, including smoking (5), a high-fat diet (6) and poor exercise (7).

In the past, when tuberculosis and polio wreaked havoc upon the population, the role of the doctor was to prescribe medication; to act as the priest who offered the gift of life through his knowledge and wisdom. Yet now, this power lies upon the patient. Our lives are no longer cut short by the plague, but by the pathways we choose to make while we are still alive.

The role of the doctor continues to change along with society. The doctor is the servant of the public. As our ailments in life continue to revolve around these pathways that we choose to take, so must the doctor focus her gaze away from the leaves of her prescription pad and begin to question the foundations of such paths; the reasons behind these choices, the thoughts and actions that lead a person towards their own destruction.

It is not enough to simply inform someone by saying ‘you need to do more exercise.’ Anyone who has made a New Year’s Resolution to do so will understand this. Even in the UK, a country where healthcare is free, one’s health is still dependent upon how much one earns. The richer you are, the longer you will live (8). How is it that in this day and age, this is still the case? Healthcare is a right. And as doctors, it is our duty to ensure this edict is followed. The politician may sit upon his throne and hand down his judgments, but it is the healthcare professional who is in contact day in and day out with the most vulnerable and marginalized.

Indeed, there are some excellent examples of attempts to try and balance this injustice within our society; free school meals in the UK which lead to improved nutrition in children (9) and the ban on public smoking to try and reduce passive smoking (10) are just two examples. These changes in legislation lead to the question: how much control should our government have over our own decisions towards our health? If someone wishes to smoke and drink all their life, then that is their right. Autonomy is one of the principles the doctor must follow; today’s healthcare system revolves around the patient and her choices. No longer does the doctor hold authority over the patient’s body. Yet this does not mean we cannot improve the world around us; we are still capable of building a healthier society, a society in which we will not only live longer, but be happier in as well. Free education and housing are two examples of societal changes that do not necessarily impose upon our personal rights, yet can lead to healthier childhoods and happier families.

Let’s say you are a single working mother – you are only just reaching your rent each month. You can only work part-time because you need to pick up your son from nursery every afternoon. You have no family who can look after him. This leaves little money for food, so you mainly feed your son. His diet is very poor, not only because of the little you can afford, but you yourself have never learned how to cook. Your own childhood consisted of fast food and the occasional apple or banana handed to you by a father who you rarely saw. You live in a very deprived neighbourhood. You cannot afford heating, and your son is constantly sniffling and coughing, hiding under his hole-infested jumper that you managed to grab from a local charity shop. You are isolated – your husband has left you, you have no one to talk to and your neighbours scare you. When you’re not working, you stay at home for your own safety, and ultimately for your son’s. You try to remain happy for your son. You want the best for him. But you are scared. You are scared for the future, you are scared about your next paycheck, you are scared about being burgled, being mugged, having your son taken away from you. You are scared about becoming a failure, of disappointing your son. You start drinking a glass of whiskey each evening to help you calm these anxieties. You gradually spend more and more money on alcohol, an attempt to grasp control of these spiraling criticisms that constantly call into question your ability to be a mother. But this does not always help. As the days turn to weeks, your thoughts begin to gain a voice of their own, almost screaming through your ears; you are a bad mother. A failure. Maybe you’d be better off somewhere else. Your son would have a better life without you. He wouldn’t have such an awful mother.
You eye the packet of paracetamol lying on the table. What would happen if you weren’t here? Wouldn’t your son lead a happier life? He would no longer have this dark mark tainting his existence. He might even be happy… What do you do?

In various points throughout this story, one could take out their pen and draw a mark where someone could have intervened. Not necessarily to offer medication or money, but things such as social support; someone to help look after the son in the afternoons, advice on how to apply for jobs, or housing in a more residential area. A helpful hand to hold on to during the darkest periods, a pat on the back, a shoulder to cry on, an ear to listen. How different would this story be if these simple interventions had been available?

It is very easy for us, the next generation, to caress our mobile phones and laptops that fit in both hands. It is easy to see the world as decaying pieces of rubble to improve, gadgets to insert, wires to wrap around and transform. No doubt this way of thinking has changed our healthcare; it has saved many lives. But we must never forget that humanity is not a machine itself. It cannot be controlled by our remote controls and our drugs; we must look further afield in order to truly appreciate the complexity of the human being. When we look at the human body, at a life that has been lived hard and is ending early, we see not genes that have played havoc, but decades of depression, underlying abuse, a cigarette to cope, a bottle of beer to forget. Addressing these problems is a task that requires us to go beyond our scientific skills. It requires us to understand the emotional lives of our patients.

“How wonderful it is that nobody need wait a single moment before starting to improve the world.” 
– Anne Frank

References

  1. (with acknowledgements to Siân Anis), J. R. A. (2006). Virchow misquoted, part‐quoted, and the real McCoy. Journal of Epidemiology and Community Health, 60(8), 671.
  2. World Health Organisation. 2008. Inequities are killing people on grand scale, reports WHO’s Commission [Online[. Available at: http://www.who.int/mediacentre/news/releases/2008/pr29/en/
  3. Office for National Statistics. 2013. What are the top causes of death by age and gender? [Online]. Available at: http://www.ons.gov.uk/ons/rel/vsob1/mortality-statistics–deaths-registered-in-england-and-wales–series-dr-/2012/sty-causes-of-death.html [Accessed: 13th October 2015]
  4. Centers for Disease Control and Prevention. 2015. Leading Causes of Death [Online]. Available at: http://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm [Accessed: 13th October 2015]
  5. British Heart Foundation. Smoking [Online]. Available at: https://www.bhf.org.uk/heart-health/risk-factors/smoking [Accessed: 13th October 2015]
  6. World Heart Federation. Diet [Online]. Available at: http://www.world-heart-federation.org/cardiovascular-health/cardiovascular-disease-risk-factors/diet/ [Accessed: 13th October 2015]
  7. Myers, J. 2003. Exercise and Cardiovascular Health. 107:e2-e5
  8. Royal College of Nursing. 2012. Health Inequalities and the Social Determinants of Health. London: Royal College of Nursing
  9. BBC News. 2013. All infants in England to get free school lunches [Online]. Available at: http://www.bbc.co.uk/news/uk-politics-24132416 [Accessed: 13th October 2015]
  10. Bauld, L. 2011. The Impact of Smokefree Legislation in England: Evidence Review. England: Department of Health

Featured image:
Human Genome by Richard Ricciardi

 

Categories
General Public Health Reflection

Are you listening? Using the doctor-patient relationship to curb community violence.

If you’ve paid attention to the news recently, you might share my concern that mass shootings are becoming a normalized part of American culture. According to data collected by the United Nations, America leads the developed world in firearm homicides.[1] As a college student in Washington, DC, social justice was an inextricable part of my education. I volunteered, protested, and campaigned for issues I felt strongly about. Assuming you weren’t a student in our nation’s capital, let me tell you that these are all pretty typical parts of the DC college experience. In fact, my zeal for progressivism in the arenas of health and wellness contributed to my desire to become a physician. Unfortunately, it wasn’t until two of my friends were murdered within six weeks of each other this summer that I felt compelled to take a closer look at how, as a medical student, I could better integrate my passion for social justice into my education and clinical practice.

As medical students, our education becomes our lifestyle. It’s demanding, consuming, and vigorous. My support system likes to remind me that I’m not Atlas and that I can’t hold the weight of the world on my shoulders. They tell me to keep my nose in a book and stay focused on my studies. It’s difficult for me to comply with these directives when I feel like I’m neglecting the part of myself that is aware of the world beyond medical school. It took this summer’s tragedies to remind me that even as a student doctor, I need to hold myself accountable for working to reduce social injustice, particularly community violence. What I’ve realized is that while my activism efforts may not reflect those I experienced as a college student, I can still make simple adjustments in my current practice to potentiate positive change.

Since this summer, one of the modifications I made, in an effort to merge my medical and activist identities, is to ask my patients to rate their stress on a scale of one to ten when I take their social history. On the surface, this might not seem like a significant exercise. After all, I’ve been asking my patients about their life stressors since I started school last year. What I realized is that while most people can easily spout off a list of things that make them feel strained (bills, student loans, family responsibilities, looming deadlines, etc.), it’s an entirely different exercise to ask patients to evaluate their stress from a holistic perspective. Though this practice correlates stress level to a numerical value, I have found that I can actually get a better qualitative picture of a patient’s mental and emotional wellbeing and self-awareness by using the one-to-ten stress scale. Perhaps by using this scale, we will be able to gain awareness of and provide support for struggling patients before they feel compelled to turn towards violence.

I encourage you to employ the one-to-ten stress scale into your history taking routine in the hope that it can open the door to bigger, more important conversations about wellness and lifestyle with our patients. Please feel free to let me know how the scale works for you. I look forward to spending the rest of my medical career advocating for those who are underserved by the medical community, but for now, I hope that having these conversations can be a first step in helping patients deal with problems before they resort to violence. In the weeks and months that have followed the deaths of my friends, I find myself thinking a lot about the people who committed the violent acts that claimed their lives. I wonder if they had medical professionals in their lives who they felt comfortable talking to, and I wonder what they would have said if we, the medical community, had been listening.

References:

  1.  Global Study on Homicide. (2011). United Nations Office on Drugs and Crime. https://www.unodc.org/documents/congress/background-information/Crime_Statistics/Global_Study_on_Homicide_2011.pdf

Featured image:
Brother by Fabrizio Rinaldi

Categories
Clinical Lifestyle Public Health

A League of Randomized Clinical Trials

Frontline recently reported on data released from Boston University and the Department of Veterans Affairs demonstrating that out of 91 former National Football League (NFL) players, 87 had Chronic Traumatic Encephalopathy (CTE).  This degenerative brain disease is believed to be the result of repetitive head trauma, and can lead to memory and mood disorders. [1] It is unclear why the disease develops in some players but not others.

The findings of the above study come with several limitations.  In particular, the gold standard for CTE diagnosis is examination of brain tissue postmortem.  The data comes from players who were concerned during their lifetimes that they showed symptoms of the degenerative disease and arranged, upon death, to donate their bodies and brains for analysis.  As a result, the prevalence of CTE suggested by the data may be skewed due to selection bias.  The brains examined post-mortem came from athletes already concerned about CTE because of their clinical symptoms, making it much more likely that the investigators would find evidence of the disease.  The ongoing work at Boston University and the Department of Veterans Affairs is a retrospective analysis that cannot determine the cause of CTE.  It is important, however, for the identification of factors that are correlated with the disease, which may spark more interest and lead to more focused research on the topic.  Even so, the disease was present in 96% of those who were tested.  This finding is both remarkable and eye-opening.  It demonstrates a real concern for athletes in contact sports like football.

Organized football poses a risk of concussions.  Chris Borland was a college linebacker and All-American drafted into the NFL in the third round in 2014. Although he only had two diagnosed concussions, one during eighth-grade soccer, and the other playing high-school football, he estimates that the actual number is closer to thirty. On March 13, 2015, Borland retired from the league via email. [2] He has since described the move as preventive and outlined his determination to prevent the degeneration of his own brain.  The NFL is aware of the risk posed by concussion and has focused on decreasing the rate of this injury.  In their 2015 Health & Safety Report, the NFL published a thirty-five percent decrease in regular-season concussions from 2012. [3] According to the data shared with Frontline, however, forty percent of those determined to have CTE were offensive and defensive linemen, players who have repetitive, sub-concussive hits on nearly every play. [1] This suggests that recurrent, lower-intensity blows may also lead to CTE.

Chronic traumatic encephalopathy is not unique to football players. It can be seen in other athletes, military veterans, epileptics, abuse victims, and circus performers who are shot out of cannons. [4] The scientific and medical communities should not delve into the controversy of any alleged cover-ups as discussed in the Frontline documentary A League of Denial. [5] Rather, our focus should be on furthering research, because our understanding of this condition is still in its infancy.

Rates of CTE in the general population or even in the professional football community have not yet been established.  The gold standard of scientific experimentation, the double-blinded, randomized controlled trial is not an ethical or practical possibility in this case.  Players without symptoms of CTE must be analyzed to allow for characterization of healthy persons as well as sub-clinical disease.  This may help identify why some people are afflicted with the condition and not others.  Those who suspect they may have CTE should be granted medical care and follow-up to help the scientific community better understand the degenerative progression of the disease.  Research should not be limited to professional athletes, as college and even younger athletes may be at risk of developing CTE.  It also should not be limited to football, as head trauma occurs in many sports.  It is important for professional organizations and sports fans to support research and efforts to implement relevant safety measures to preserve the health of their favorite athletes and to enhance the quality of the sports they enjoy.

References:

  1. Breslow, J. (2015, September 18). New: 87 Deceased NFL Players Test Positive for Brain Disease. Retrieved September 20, 2015.
  2. Fainaru, S., & Fainaru-Wada, M. (2015, August 21). Why former 49er Chris Borland is the most dangerous man in football. Retrieved September 20, 2015.
  3. 2015 NFL Health and Safety Report. (2015). Retrieved September 20, 2015, from http://static.nfl.com/static/content/public/photo/2015/08/05/0ap3000000506671.pdf
  4. Hanna, J., Goldschmidt, D., & Flower, K. (2015, October 11). 87 of 91 tested ex-NFL players had brain disease linked to head trauma. Retrieved October 12, 2015.
  5. Frontline. (2013). League of denial: The NFL’s concussion crisis [Motion picture]. United States: PBS

Featured image:
Football 10.18.08 by Mike Hoff