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A Lesson (Not Just a Joke) From an Orthopedic Surgeon

Ben_3Ben Bryner -- Most specialists have some kind of stereotype associated with them, perhaps none more so than orthopedic surgeons. One of the predominant stereotypes about them is that they’re into power tools and carpentry and things like that, and are less intelligent than other doctors. It makes sense when you walk into an orthopedic OR, and it looks like someone took an old guy’s garage and dumped it on the table, then sterilized the mess.

On your surgery rotation, you will be expected to learn at least three jokes about orthopedic surgeons (nobody loves the jokes more than the orthopods themselves). Here’s one: Q. How can you tell that a chart note was written by an orthopedic surgeon? A. It’s written in crayon.

Of course, not all people within any given specialty fit the stereotypes, and given how competitive it is to get into an orthopedic surgery residency, the stereotype about intelligence is false. But on one occasion in particular, it was a good thing that the stereotype of orthopods being mechanically inclined held true.

One night during my surgery rotation I was on call at another hospital, finishing up examining a patient in the ER and chatting with a friend who was in his last year of orthopedic residency. (This guy was actually one of my favorite people I’ve worked with in all of med school, very smart and competent as well as nice to students and excellent with patients.) A patient came in who had broken his femur doing some kind of extreme sport under the influence of cocaine. (He’d apparently done this once before.)

The orthopedic surgeon wheeled over his cart and got his supplies ready to put the patient in traction (fixing the patient’s leg to the bed to prevent his leg muscles from pulling the femur-pieces past each other) while the ER staff tried to track down the power drill to place the traction pin. For some reason, nobody could locate the power drill, and all they could find was an old (but sterile) hand drill. We asked the guy a few questions while we waited, and finally the surgeon gave up and said he’d use the hand drill, or more precisely, that I would use it. I injected some anesthetic into each side of his leg, and the surgeon showed me how to put the drill together. Maybe he’d had some kind of training for the hand drill in his residency, but it was a pretty weird setup and I got the impression that he was relying on outside knowledge. Either way, it was good that he knew how to put it together, because if I’d put it together I probably would have drilled into my own hand.

He drew a little x where the pin was supposed to go and told me I’d have to put my weight against the drill to provide enough force. I’ll be honest, I had faith in my friend, but with the first few turns of the drill, I was skeptical that this was going to work. It took a lot of pressure, but eventually it went through the bone and out the other side. It was a spectacle, even by ER standards. The combination of the old-school implement and the fact that the patient was awake made it feel like something out of the Civil War. I half expected to look behind me and see Matthew Brady making a daguerrotype in the corner.

The surgeon said “nice job,” hooked the leg up to the frame over the bed and that was it. While my friend filled out some paperwork (in pen), I thought about the fact that although technology offers us unparalleled advantages in diagnosis and treatment, doctors will always have to improvise and fall back on the knowledge of simpler medicine when things don’t go exactly as planned.

March 31, 2008 in Ben Bryner | Permalink | Comments (17)

A Day in the Life

Benferguson72x724Ben Ferguson --

First-year medical student:

6am: Wake up, get ready, breakfast

8am: Arrive to campus in time for 8:30 lecture, sit in class until 10:30

10:30am: Lunch break

1pm: Lecture

2pm: Lab until 4 or 5pm

Evening: Arrive home, dinner, look over a few notes, read a chapter or two, watch some tube, pass out at midnight

Second-year medical student:

6am: Wake up, get ready, +/-breakfast

8am: Arrive to campus in time for 8:30 lecture, sit in class until 11:30

11:30am: Read over notes, +/-lunch

1pm: Lab until 4 or 5pm

Evening: Arrive home, +/-dinner, look over a few notes, read up for next day, do boards questions, freak out about boards, do more questions, chat online with classmates about how mutually freaked out we are, pass out at 2am

First-year grad student:

7:30am: Wake up, get ready, eat breakfast

9am: Arrive to campus, +/-lab, +/-go to lecture at 10:30

11:30am: Lunch break, check on samples in lab

1pm: Lecture

3:30pm: Lab until evening

Evening: Arrive home, dinner, +/-read paper for discussion tomorrow, +/-look over notes, +/-read up on potential thesis topics, pass out at 10pm or earlier

Early second-year grad student:

7:30am: Wake up, get ready, eat breakfast

9am: Arrive to campus, check email, check blogs, check news, check websites

11:30am: Finish checking email, blogs, news, sites; recheck to make sure nothing new popped up during initial round of checking

12pm: Lunch break

3pm: Think about starting experiment or two; decline

3:30pm: Finish thinking about starting experiment or two; begin round two of internet time

Evening: Arrive home, dinner, +/-care about anything, +/-read up on potential experiments for thesis, +/-consciousness, pass out at 10pm or earlier

Late second-year grad student:

5:30am: Wake up, +/-shower, +/-breakfast

6:30am: Arrive to lab, start experiments immediately, freak out about how, at this pace, you’re never going to graduate

12pm: Continue experiments, +/-check email, freak out more

3pm: Continue experiments, totally flip out

6pm: Continue experiments, call fiancee to get reamed for not calling/being home earlier, freak out and/or flip out, sweat profusely

8pm: Arrive home, dinner, +/-think about experiments, +/-catch up with the outside world, +/-appear to have a normal life, +/-freak out

9:30pm: Go back to lab, freak out more

Midnight: Pass out

March 27, 2008 in Ben Ferguson | Permalink | Comments (5)

Socializing 101

Thomasrobey72x721Thomas Robey -- Consider this column a plea for help.

All across the Pacific Northwest, third year medical students are studying for exams this week. As with the season, winter clerkships have reached their finale. For students at my school (the University of Washington) there is another potential stressor: the weekend switch. As in many programs, students here carry out their required clerkships in different cities. Unlike other programs, those different cities could be separated by 2500 miles (Cheyenne, WY to Fairbanks, AK). Such periodic migration creates interesting challenges and presents unique opportunities. I want to focus on one of the challenges here.

Apart from my wife, the only folks I know where we’re heading next have bushy tails. (When we were in Spokane, WA earlier this year, some squirrels took to apprehending peanuts we put out for the birds.) But we won’t be without human colleagues in Spokane. There are a handful of other students in each city, but thanks to a rupture in my educational space-time continuum, I know R3s better than I know my classmates. Thankfully, medical students tend to be an outgoing lot -– it’s easy to get along, and someone is bound to have a “We made it to Missoula” get-together to build local community. So what’s my problem?

I’m worried that grad school converted me to an introvert! I have to admit, six months into the third year, I’m still getting used to this medical student thing. Life in the land of PCR machines, mouse colonies, and lab slumber parties completely deprived me of interactions with my kindred classmates. There were the occasional social events as my colleagues advanced, but as a committed lab-rat, I found myself increasingly distanced from the social aspects of medicine.

When folks consider re-immersing themselves in the medical curriculum after a year abroad or time doing research, it’s usually the factual content they expect to have lost. My worries were endless. Will I keep straight bactericidal and bacteriostatic effects? Nephrotic? Nephritic? The differential diagnosis for dyspnea? Surprisingly, these facts have emerged from the recesses of my mind without much consequence.

What has been slow on the draw for me is filling the gregarious shoes of the social medical student. Do you know what I am talking about? It’s that little circle that forms at open social events where amazing accounts of patient care are shared, frustrations with curriculum are vented, and future schemes are planned. Working long hours with hardly a chance to reflect makes these confluences of experience vital to students’ mental health. (It’s also a good way to practice a succinct presentation of your patients’ histories!) This part of medicine presents me with the steepest learning curve. I’m too easily flooded in sensory overload.

Has anyone else noticed this phenomenon and had difficulty breaking in to it? Sometimes we offer tips on The Differential. This time around, I’m looking for a few myself.

March 27, 2008 in Thomas Robey | Permalink | Comments (9)

To Test or Not to Test: That Is the Question

Kendracampbell572x722Kendra -- Have you ever seen a doctor for a simple complaint and been subjected to a plethora of blood tests, scans, x-rays, urine screens and other investigations, only to be told that you had something obvious that could have been diagnosed without a single test being performed? Perhaps you were sent home with a prescription, or maybe you were just told to go home and see if the symptoms resolved on their own? Many people would feel relieved to know that their doctor ruled out every possible diagnosis with all the various tests. Some people might feel frustrated that they had to be poked and scanned so many times, only to be told that they just needed to wait and see if they felt better in a few days or weeks.

An article recently published in the New York Times touched on this very topic. The author describes how medical testing has been on the increase for a while. He suggests that because of reductions in Medicare payments and the decline of reimbursement rates, doctors have to subject patients to many unnecessary tests just to break even. In addition, many people demand that doctors perform as many tests as possible. There’s a perception that more tests equals a more thorough investigation, and a higher quality physician.

I think there is some truth to his argument, but I think the problem is multifactorial. The number of medical investigations that can be performed has increased substantially over the past few years, for many different reasons. Part of the problem, however, is that many of these tests don’t necessarily rule in or rule out any diagnoses. While I’m not arguing that these tests aren’t important, I’m just saying that they don’t always aid in diagnosing a patient or even lead to a treatment plan.

All of these tests come at a hefty price. According to the article, the overuse of healthcare services probably cost hundreds of billions of dollars last year. And the data suggest that this increase in services is not causing a concomitant increase in the quality of healthcare in the U.S.

The question of whether or not to pay for expensive medical testing was really drilled home with me during the past two months. I’ve been rotating at a hospital in Dominica with much fewer resources than U.S. hospitals. In addition, the average patient is not wealthy and does not have health insurance. Not long ago, I met an elderly gentleman with obvious signs of a stroke. Unfortunately, he could not afford a CT scan, nor an MRI, for which he’d have to be sent off island. We ended up doing the standard interventions with the assumption that he did in fact have a stroke. He ended up faring about as well as he would have if he had the proper diagnostic tests. Obviously, it might not have turned out this well. It’s possible that he could have needed a surgical intervention, but since we don’t have a neurosurgeon on the island, he wouldn’t have been able to get the surgery anyway.

I’ve been amazed at how well the hospital here runs, even with very little means. Patients still get a good quality of care. Of course there are exceptions, but many patients are successfully treated at very low costs. The clinicians at the hospital are all too aware of the deficits, but they use low-tech methods of good history taking and physical examination to diagnose patients.

Because of the current structure of the healthcare system in the States, I don’t predict that rising healthcare costs and the misuse of diagnostic testing will decrease any time soon. But I think that as doctors and future doctors, we should all do our best to not add to the problem. The next time a patient comes in and we consider performing a huge barrage of investigations, we should ask ourselves how much information we really stand to gain, and whether or not it will actually benefit the patient.

March 26, 2008 in Kendra Campbell | Permalink | Comments (6)

Top 10 Signs You're Spending Too Much Time in the Lab

Benferguson72x722Ben Ferguson -- 10. During dinner, your fiancee reflexively asks whether you’re going back again tonight.

9. You come across seemingly random numbers, but to you they are far from random: They are the number of amino acids in your protein of interest (987), or the first page number of the landmark paper you read (again) that morning ($4.02), or the recipe for your cells’ media (449,501).

8. You feel naked without your gloves on and generous amounts of alcohol sprayed all over them. Surely you’ll contaminate something.

7. You develop a giant blister on your thumb from too much pipette use—”pipette thumb.”

6. You’re so tired/distracted/sick of loading plate after plate that you can barely insert a multichannel pipette into a set of strip tubes without hitting the top, so you decide to get some coffee. An hour later, you’re so jittery that you can barely insert a multichannel pipette into a set of strip tubes without hitting the top, so you decide that “some coffee” probably shouldn’t mean three cups in a row in the future.

5. You don’t know how you could possibly get through loading another plate without listening to the latest "Wait Wait... Don’t Tell Me!" podcast.

4. You become genuinely miffed when your lab switches from one pipette brand to another, signaling that fact that your life revolves around the differences between little pieces of molded plastic (and is more or less over).

3. Finding a good spot to hide your stash of pipettes is probably the most excitement you’ve had all week.

2. You know the catalog number for 96-well plates by heart.

1. When you have some free time, you write a blog post about how much time you’ve been spending in lab.

March 25, 2008 in Ben Ferguson | Permalink | Comments (4)

Surgery and the Blowfish

Ben_5_2Ben Bryner -- I like talking about medical school with people who are in different programs or careers. I like explaining what it is I want to do and what I’m studying, and I like hearing about what other people are into. But when people who are less familiar with medical training ask me how long my upcoming residency is going to be, the answer (seven years of general surgery residency including two years of research, followed by two more years of fellowship) often makes their eyes glaze over. And rightly so; it's a long haul. But it’s not like my law school friends are going to be taking the lead in litigating right out of law school. (At least I hope not.)

True, medical training is more formal and longer than that for any other gig I can think of. But in some ways it's hard to believe that that's all the time there is. Especially when you compare the length of surgery residency to things like the two-or-three-year apprenticeship required to serve fugu. (Fugu, the infamous pufferfish that carries the potent tetrodotoxin in most of its organs, is a delicacy in Japan; you can get it at a few elite, licensed restaurants in the States that, by law, must import it all through New York City.) It has to be prepared just so, with the right organs taken out and meticulous avoidance of contamination. If it's done right, you get a delicious meal. If not, you go into respiratory failure and die unless supportive measures are instituted in time (there is no antidote).

High stakes -- hence a two-or-three year training period capped by rigorous examinations. And that's just to learn one procedure, the proper disassembly of a fish. By the time a general surgery residency program graduates one if its trainees, it's certifying that the newly-minted surgeon can safely perform all kinds of procedures, in addition to management of patients before and after operating. The range of skills expected from a new surgeon, or internist, or pediatrician, is astounding even given the length of training.

I remember one time listening to an ER attending explain that although he learned a fair amount in residency, the time when he learned the most was when he was an attending for the first time. He had a lot more time to stop and think about what he was doing, for one, due to the nature of the ER as an attending. But it was also because the new responsibility was a strong motivator for learning, as well as a new perspective. He said he was also fortunate enough to have a good department chair who taught him a lot. This made an impression, since at that point I was pretty new in med school and hadn't really grasped the constant process of learning that is involved in clinical medicine. But it makes sense.

Medicine is so overwhelmingly complex and changes every day; unlike the anatomy of the blowfish, it can never be comprehensively mastered. This continuous growth leads to the large number of subspecialties required to adequately cover all the diagnostic and therapeutic angles of modern medicine, as well as the need for constant learning and teaching by one’s peers. To me, the prospect of continuous learning in a medical career is still exciting -- even more exciting than eating a potentially deadly piece of sashimi.

March 24, 2008 in Ben Bryner | Permalink | Comments (5)

How to Survive Pimping in the OR

NewannaAnna Burkhead -- WARNING: Attempt at humor ahead … Abort your reading if you must…

I’ve written previously about “pimping”, the well-honed tool of many attendings to test students’ knowledge, and/or torture them. Now that I’m on my Surgery rotation, I’m spending more face time with attendings than on any other service. To what does this translate? Multiple un-interrupted hours of being pimped, each and every day in the OR.

For the most part, I don’t mind being pimped, because I know I’m not expected to know everything. Also, I rarely forget the answers to the questions I miss. Pimping can be a good teaching tool.

But some students detest being put “on the spot”. This is a column for these students.

How to survive being pimped in the OR:

-When asked a question, try your best to answer. When wrong, try a pensive silence. If you’re silent long enough, maybe the attending (engrossed in his gastrojejunostomy) will forget he ever asked the question.*

*May be effective only with older attendings.

-Answer a different question (correctly). Example: Attending – “What are the boundaries of dissection for a mastectomy?” Student – “Well, I don’t know, but if we were doing an axillary dissection, the borders would be…” You can still sound smart!

-Never forget that the student wields the suction. Stick the sucker-thing in a shallow pool of blood in the abdominal cavity, and it may create a gross sucking noise loud enough to drown out the nonsense answer that you know is wrong … but you may risk a blood spatter. Due to the risk of this OR foul, this should be your last resort.

-Answer with another question. This is probably the most “smooth” escape plan.

-Before the surgery, tell the attending that you’re hearing impaired. Explain that with masks on, you can’t lip-read.*

*This is probably a bad idea.

-Ask if you can “phone-a-friend”. Most attendings are ok with you passing the question to your intern or resident. Unfortunately you only get an average of two “phone-a-friend”s per surgery.

-Use humor. Example: Attending – “In what situation would one observe a ‘winged scapula’?” Student – “When the patient is in a bathing suit.”

When all else fails, and you know you’re going to be pimped during surgery the next day, here’s a novel idea: Study in advance! The best way to survive long pimping sessions in the OR is to be prepared and to impress with your knowledge. It’s not the easiest or the most fun way to make it through your Surgery rotation, but it is gratifying and it works!

Good luck to all :)

March 24, 2008 in Anna Burkhead | Permalink | Comments (20)

The Curious Similarities Between People and Cars

Benferguson72x723Ben Ferguson -- Ever since my car started having serious trouble early last year and eventually had to be sold (if you can call it that -- it netted $400), I have been particularly sentient of the comparisons that are commonly made between glorified mechanics doctors and actual mechanics, as well as between the things they deal with: the human body and cars.

Both doctors and mechanics are sometimes seen as sketchy people who don’t always tell the whole truth, don’t appear to tell the whole truth, or tell outright lies at times, whether it’s because of potential financial gains, laziness, coercion, etc. Sometimes both are downright unethical in the way they communicate and interact with their patients and customers. Both are in possession of knowledge that most lay people aren’t privy to, and this places them squarely in a position of power relative to those they serve, allowing them to manipulate many aspects of decision-making about a person’s body or car should they want to engage in such decision-making.

Quick: Think of the last time you went to get an oil change and the mechanic told you that your system needed to be flushed in order for your car to run properly, or that you needed a new air filter because your current one is “reducing your car’s performance,” or that your battery may have needed to be replaced -- would you like to take care of that today? I bit the first time I was told some of these things, and I’ve been told them many times since.

Think of the last time repairs to your car were quoted at, say, $400 and you ended up paying $600. “Whoops,” they say, “we didn’t anticipate that.” But you know they did. You know -- at least you strongly suspect -- they underquoted you so that you’d have the work done. If they hadn’t, perhaps you’d have shopped around a bit more. Things like that happen all of the time in probably every field of work, but both doctors and mechanics are in especially enabled positions to pull that kind of crap. Trust can diminish quickly, and this is especially true in light of this recent evidence.

We are all unfortunately familiar with the universal fact of life that our bodies and our cars are expensive to maintain. They break down and inevitably need service every so often. When money is tight, the question of whether to spend money on needed repairs sometimes comes up with both. If you’re a college or grad student living from loan check to loan check, do you really need to get a referral for that back pain, or can you live with it? Don’t you ponder your account balance before filling that antibiotic script? Do you even fill it period? Do you really need to see a doctor for that wart on your hand, or for the abdominal pain you’ve had for the past 6 hours, or for the headache you’ve had for the past few days? Do you really want to blow all your money going to the ER just to r/o meningitis every time you’ve got a stiff neck? Do you think twice, like I did a few days ago, about making that dermatology appointment for five minutes just to get a skin cream script if it’s going to cost you $234.93 every time?

When money is tight, these things don’t seem so dire. What’s more important is not going broke, eating, preserving your sanity, etc. even if you have to live with an imperfect body for a while. Similarly, do you really need to head over to the body shop every time you see a dent in your car? Can you live without air conditioning for the last few weeks in September? Does the rattling under your hood really annoy you, or can you live with that too? Honestly, who needs side mirrors and hubcaps and AC dials anyway? When money is tight, these problems don’t seem like problems; they seem more like everyday annoyances, and even if they do seem like problems, what are you going to do about it beyond blowing the last few dollars in your bank account?

When money is tight, I think many of us would stop and think twice about fixing ourselves and our cars at the drop of a hat. Some extreme things just don’t seem all that extreme anymore. Even with insurance, there’s not much motivation to seek health care or car servicing. Is it really worth it to you to pay $25 for a medication when $50 of it is already covered and you’ve only got a few hundred in the bank to cover you for the month? Perhaps, but usually no: You’re still out $25 whether it’s discounted or not. Do you whip out your wallet and fork over the extra $100 over your $500 deductible to fix the body damage to your car? Likely, no; you can live with a deformed car for now. Spending money like that seems at times like a luxury, not a necessity.

The value of ourselves and our cars must come to mind too. Would you put $1000 worth of repairs into a car that’s worth $10,000? How would that decision change if fixing it would cost you $5000? $500?

You’re 90 and you’ve lived a great, full life; how much time and energy and money and optimism do you want to invest in yourself when you’re not doing so hot in the first place? How would that change if this were your first hospital admission in the past 20 years? Your twentieth in the past two years? How would it change if you’ve been diagnosed with a terminal, metastatic cancer just after your 90th birthday? Diagnosed with pneumonia? Diagnosed with the flu?

And so, as the cautious and skeptical former owner of a crappy car that was in and out of shops before finally breaking down for good, and the owner of a sometimes crappy body that has weird stuff happen to it from time to time, I am now, more than ever, aware of how cautious and skeptical patients who’ve been in and out of hospitals for the past year must feel and how most of the underinsured and, more often, uninsured population around Hyde Park must feel. I used to think it strange that some people with serious medical problems simply don’t seek care, but now I realize that “serious” becomes a seriously relative term depending on your life situation.

March 20, 2008 in Ben Ferguson | Permalink | Comments (2)

If Life Was A Circus, Medical Students Would Be (Commitment) Jugglers

NewaaronAaron Singh -- It never ceases to amaze me how medical students can have so many commitments on their plates and yet manage to do everything at once. Sure, I’m studying at Cambridge University, ostensibly home to some of the world’s most intelligent students (a demographic I am sadly not part of myself, having gained admission due to my unusually attractive eyelashes -- but that’s a story for another day) but still. The number of times I’ve met medics who manage to balance other pastimes and yet still score high marks contributes more to my hair loss than my barber does.

I’ve blogged before about medics who realised that their true passions lay somewhere else, and became big names in those other fields. But now I’ve discovered a whole new subspecies of medic: those who excel in sports, music, theatre, literature, etc. and yet still manage to score highly in medical exams. These people seem to be able to maintain (and in some infuriating cases, combine) their different passions and juggle the time needed to pursue these seemingly incongruous pursuits, yet still show up for lectures on time with all their homework done and not a hair out of place. I swear these folks must have a personal secretary, private helicopter pilot, and make-up artist hidden away somewhere.

Unfortunately, multitasking is as alien to me as talking is to a dog, thanks in no small part to an incident during my childhood involving me being born, a doctor’s slippery gloves, and a rather unfortunate collision between my infant head and the operating room floor. But as I’ve said before, medical school is somewhere you’d expect to find smart people who have been multitasking all their lives, and as much as I may sit and gripe about them, there exists a certain pressure to be just like them, to do more with my life and my time here at university. So I suppose meeting people like this is good for you from time to time, as it drives you and shows you just how much you could accomplish yourself if you just got off your bum, turned off that episode of ‘House’ and actually did some revision. (Metaphors not from personal experience. Cough.)

Take some time to look at yourself and ask: what type of multitasker are YOU? Are you Everywhere-At-Once-Dude, bending the laws of physics to do everything and be everything at the same time, thereby creating hundreds of jealous would-be assassins with your every success? Are you Slide-Projector-Dude, focusing on only one thing at a time but giving that one thing your all? Or are you Aaron Singh Hopeless-Ritalin-Overdosed-Mess, trying your best to do several things at once but inevitably ending up on the floor with all your juggling balls around you?

If you answered Types 1 or 2, good for you; we know why you’re in medicine, and you’ll probably make it big. If you answered Type 3, hey, wanna form a club?

March 20, 2008 | Permalink | Comments (15)

The Politics of Health Care

Thomasrobey72x721Thomas Robey -- Blogging and politics are inexorably linked in today’s media. Bloggers whose core topics are news, health, sports, science, religion and celebrities invariably offer commentary on political issues. The Differential is at its core a blog for and about medical student life, and if you’re at an American medical school, you’ll be hard-pressed to avoid conversations about presidential politics. As a member of the medical profession, you may be called upon to offer opinions about the remaining candidates’ health care plans. Having already been asked by family, friends and fellow precinct caucus-goers which plan is best for America, I’ve done some homework on the competing proposals. Like any good medical student, I am happy to share my study guide with you here. Each of McCain's, Clinton's and Obama's plans have good ideas built into them. This post is my attempt in 700 words to provide a starting point for you to understand them. You don’t have to pick a candidate based on health plans, but considering health will be your business, health care is probably not a bad place to start. This is a ‘just-the-facts’ post. For my opinions about the candidates’ plans, you’ll have to head elsewhere.

Like just about every other issue in the 2008 campaign, there are two health plans that are more similar to each other than each is to the third. For simplicity’s sake, I’ll start with the third. John McCain’s experience as a legislator has shaped his approach to reforming health care in a way that avoids “the ‘perfect storm’ of problems that will cause our health care system to implode.” The main elements of his plan include (1) changing the way plans are purchased, (2) increasing the accessibility and use of generic drugs, (3) innovating new forms of health care delivery and (4) altering Medicare to cover more preventative care and to punish medical errors. The McCain plan leans heavily on point #1. The argument being that current health care coverage is dominated by employer-negotiated contracts and employees given more options and flexibility will force the industry to lower prices. Via tax code changes and other incentives, McCain would permit individuals to buy insurance on a national market and through groups like churches, professional associations and co-ops. His ideas for health care delivery center on a network of walk-in clinics tied together (eventually) with an electronic medical record. This is an attempt to reduce expenses incurred from costly ER visits.

When it comes to the remaining Democrats’ plans, it’s more difficult to parse the differences than to identify similarities. Let’s first consider the similarities. In TV and radio ads, both have claimed to cover all Americans. Because insurance companies still provide the bulk of reimbursement mechanisms, neither plan is fully universal health care. Both plans require insurers to offer coverage no matter the individual’s medical history. Both also allow consumers the option of purchasing government-offered insurance. Finally, both plans seek (via government subsidy) to make insurance affordable to poor Americans. The differences come down to the mandates: Clinton would require every American to be insured either by a public or a private plan, while Obama’s plan only requires children to be insured. In his plan, anyone may opt-out of insurance. He suggests that a more competitive industry faced with cheap government options will lead everyone to buy in. Some health economists have argued otherwise. Clinton would limit insurance costs to a percentage of family income, while Obama would disperse subsidies to income-qualified individuals to help pay their premiums. The main discussion surrounding these plans is how to pay for it and who is covered. Obama addresses more aspects of the practice of medicine by emphasizing a broader implementation of the electronic medical record and rewarding practitioners who keep quality of care high and costs low. Clinton also features cost-saving technologies, but speaks more of targeting insurance company excess than any incentives or punishments for health care practitioners. Interestingly, both plans have adopted elements from the no-longer-running candidate, John Edwards.

In the end, it seems like all three of the candidates are committed to improving the current American health care system. The Democrats argue for a more comprehensive overhaul than McCain, but each plan has pros and cons. As the 2008 contest for the White House intensifies, I expect health care will be argued more and more between the remaining candidates.

Will you be prepared to debate the future of medicine?

March 19, 2008 in Thomas Robey | Permalink | Comments (1)