Saturday, June 30, 2012

Sutured for the first time ever!

Last week was really exhausting. I spent ten-hour days in clinic, looked up stuff my preceptor asked me to learn, attempted to be an informed citizen about the Supreme Court decision, and tried to maintain a prayer life and daily Mass. Phew!

A highlight, however, was Wednesday's surgeries. I stitched closed two surgical incisions! I am very happy because, although it was my first time suturing, I performed a subcuticular stitch and the closure was very neat. It was neater than my preceptor's, in fact; however, she closed three incisions for each one of mine. I also wonder how good a job I did to prevent complications like dehiscence and infection. My preceptor was pleased, though, and I was, too.

Wednesday, June 27, 2012

3 Reasons Obamacare is Bad for Patients

One problem with Obamacare is that it is very hard to find out what it will really do to my future. I feel like almost no one can summarize it without bias and when I find someone who can, I can't take that knowledge with me because others believe that I am biased.
Happily, however, I belong to a profession which is supposed to put aside all interests besides those of the patient. Let's talk about patients. Here are the top three reasons that Obamacare is bad for patients, especially young adults and the poor (parenthetically, it's also bad for young doctors, since we are in both of those groups):
  1. Community ratings
  2. Weak individual mandate
  3. Increase in Medicare coverage to 133% of poverty line
The law requires that insurance agencies cover individuals with pre-existing conditions. (Right now, it can be hard for people who are already sick to get insurance, because insurance companies know that those patients will not profit the insurance company.) To avoid lawsuits from insurance companies, Obamacare also requires all healthy people to purchase insurance to offset the expenses of the sick. This is the individual mandate, and without it I cannot see how the law will stand.

However, offsetting the expenses of the sick drives up costs for the healthy. Community ratings require that companies not charge their elderly or sicker clients more than three times what they charge the young and healthy. In order not to lose money under this requirement, insurance companies may lower the more expensive patients' premiums, but will certainly inflate cheaper patients'. This is unfortunate for young people, who now leave their parents' policies at 26. It's especially bad news for the patients I am very interested in caring for as a future OB/GYN: the young women, especially those made vulnerable by poverty, homelessness, abuse, or pregnancy.

Community ratings, combined with the weak individual mandate, create what Forbes' Avik Roy calls the "adverse selection death spiral." Simply speaking, the fine for not purchasing insurance is cheaper than insurance premiums. This is especially true for the young (whose incomes, from which the fine is calculated, are relatively small, and whose premiums are inflated) and the poor. Suppose I, who am living on loans, choose to pay the fine rather than purchase insurance. If I have an accident or get sick, I can purchase insurance easily (since there is no discrimination against pre-existing conditions) for the duration of my treatment. I then return to paying the cheaper fine, or stay on insurance for my lifetime. If many healthy people follow my example, then who is subsidizing the sick? If many chooses the fine, the sick and those who feel obligated to purchase insurance (e.g. young families) will still pay high prices for their care.

Finally, the increase in Medicare coverage, while in theory benevolent, is probably going to be awful for those it aims to serve. Already, many physicians do not "take" Medicare patients because Medicare reimburses services and drugs below their market cost. If the number of patients eligible for Medicare increases in a community, the population of people trying to make appointments with doctors will reflect this shift. Doctors will be faced with more under-reimbursed hours. Many physicians deal with this problem by refusing to take Medicare, or by limiting the number of Medicare patients they see.

Ultimately, Obamacare doesn't seem to change the status quo much, except by increasing the number of regulations and government-paid employees. The poor will still have trouble getting into doctor's offices (some offices may topple in the shift). The sick will still pay heavy totals for their conditions (now they will pay the insurance company instead of the hospital). The young will still be the largest group of uninsured (though now they will pay an annual fine for being that way).

In short: Obamacare is problematic, and I, as a future physician (and as a young, poor, relatively healthy patient) want a different solution to our national dilemma.

Where does Human Dignity Come From??

Dr. Daniel Daly
This is a continuation of reflections on Dr. Daniel Daly's IBPCA lectures. He spoke about the source of human dignity.

As a high school volunteer in my local children's hospital, I remember standing in front of a plaque emblazoned with the patients' bill of rights. It began with:
______ Medical Center affirms each patient's right to receive care delivered in a considerate, respectful, dignified and comforting manner.
Why? I wondered, as I stood there in my candy-striper polo. Why dignity? Where does dignity come from? Where do documents like the Universal Declaration of Human Rights base their claims on dignity?

That was the beginning of a many-year period of frustration with secularized healthcare that insisted on human dignity. I was glad, of course, that they maintained human dignity. However, I could not discover a source of that dignity, consistent with an agnostic or pluralistic worldview.

And, in fact, it is not to be found. Dignity without God is a relic of a post-Christian society. (A good relic, but an inconsistency.) Dr. Daniel Daly discussed the source of human dignity very lucidly. We are made in the image of God (“imago Dei”): we have intellects, imaging his omniscience; we are social, imaging his Trinity; we have free wills, imaging his will; we have inherent value, imaging his essential goodness. Because we image God, men have transcendent value which cannot be taken away. Moreover, we are all equally valuable, because we all share equally in human nature.

This value is different in kind from the value of the rest of enmattered creation. Non-rational animals, plants, and non-living creatures have intrinsic value--that is, they are good in themselves and should be loved as creatures of God and means to him. Men have this, and more. Men are persons. What is a person?

Monday, June 25, 2012

Dr. John Bruchalski on Becoming a Physician in this Age

Dr. John Bruchalski
"It is always a challenge to be the point of the spear," Dr. John Bruchalski began in a slow, quiet tone. Five medical students and he were seated around a collapsible particle-board table topped with a vase half-full of drooping sunflowers, in the Tepeyac Family Center, the clinic Dr. Bruchalski started.

As much as I want to become a doctor, I am pretty depressed by the state of medicine today. I've known three PAs in my life, and two of them have (independently) told me that "the golden age [of doctoring] is over," and becoming a PA is "the fastest way to get to do what [you] want to do." Doctors are doing more paperwork, dealing with more lawsuits, and being subjected to more government regulations than ever before. They are seeing patients for shorter and shorter times; they are seen in a poorer and poorer light by the public; and their profession is yielding to self-destroying ethical choices.

As I applied to medical school and continued through my first year, I kept asking God: "is this the right profession? Should I be a nurse/practictioner, or a midwife, or a PA, or fertility care specialist, or a counselor, or a psychologist, or...? Am I sure? Are You sure?? Should I pull out and cut my losses?"

I persevered. And for the first time, I felt really excited about that perseverance when Dr. Bruchalski said, "Everything's imploding. [But] be encouraged--it's actually an awesome time to be a doctor. There is hope, not because it's getting better, but because there is love." By this, he meant that there are great and widening opportunities to show love to patients and colleagues. Because of this love, he said, "when healthcare [implodes], we'll still be and filled with social justice."

"It's a perfect time to be a doctor," he restated, "because you can make a huge difference."

Dr. Bruchalski told us briefly about his conversion; as a resident, he performed, but he's now the founder and director of the Tepeyac Family Center, a pro-life, OB/GYN, integrated healthcare practice with top notch medical expertise that cares for the whole person (according to their website). Next, he counseled us in ways to become a good physician.

Sunday, June 24, 2012

Principlism is a House of Cards

Dr. Daniel Daly
This post is less about an IBPCA lecture as the previous ones have been. In fact, it is actually original content (i.e. a real post) which sprung from the content of one of our lectures.

Dr. Daniel Daly, an assistant professor of theology at St. Anselm College in Manchester, NH, lectured on healthcare ethics (especially benefit/burden analysis), globalization, and resource allocation. As he introduced himself and explained that he was a Catholic and would be using Catholic ethics in his presentation, he threw out a few startling, refreshing statements: “The roots of medical ethics are found in Catholic theological ethics,” he said unapologetically. He added that 15% of hospital beds in this country are Catholic; that number rises to 25% world-wide.

He then began his presentation by reminding us of the predominant system of ethics taught in medical schools today. This system, developed by Thomas Beauchamp and James Childress, was articulated in Principles of Biomedical Ethics (1994). Beauchamp and Childress sought to find basic ethical principles that all could agree upon. They found four and listed them in this order, though they maintained that there was no hierarchy:
  1. [Patient] autonomy
  2. Beneficence
  3. Nonmaleficence
  4. Justice
Obviously, this is a principlist system (built out of principles to be respected), unlike the system that people like Aristotle, Christ, and the teachers of the Church propose (i.e. virtue ethics, built from a goal--the happiness of being a good or holy person).

Principlism has become the favorite of medical schools and I was up to my ears in it last year. Frankly (we are now leaving Dr. Daly), it makes me tired and angry, for several reasons.
  • Principlism is a philosophical house of cards
  • Principlism makes good-hearted ethics professors (who lack understanding of what they're teaching) inconsistent: insofar as they really want to make us good people, are teaching virtue ethics anyway!
  • Principlism is a sign of the destruction of the profession of medicine (a loss of the end...)

Saturday, June 16, 2012

Deadly Medicine: Creating the Master Race

On the final day of the IBPCA week of lectures and research, my fellow externs and I visited the U.S. Holocaust Museum. While there, we saw the “State of Deception: The Power of Nazi Propaganda” exhibit and spent a little time in the Wexner Center on the Nuremberg Trials. Unfortunately, there was not enough time on our schedule to see the entire exhibit. I hope to return some day and complete my tour.

We also had a special presentation on medical ethics by Dr. Patricia Heberer (some audio clips of her here). As is well known, The Nazis carried out experiments on eight to ten thousand involuntary human subjects. According to Dr. Heberer, these studies were often not soundly conducted and frequently were testing racist hypotheses (she gave an example of an attempt to prove that Aryan immune systems were better than French ones, which were better than Slavic ones, and so on down the supposed racial hierarchy).

Friday, June 15, 2012

Maternity Homes: Reverse Morbidity with Hope

This is the presentation I gave at the Research Summit of the International Institute for Bioethics and Patient Care Advancement, modified slightly for this venue.

I am currently involved in the preliminary efforts to open a maternity home in my community and I would like to explain that I am taking that particular step because maternity homes are among the best remedies to the profound needs of special pockets of the female patient population—namely, racial minorities, adolescents, and the urban poor. (For the sake of brevity, I will only speak about a smaller group made up of adolescent women who are impoverished and among the country's larger racial minorities: non-Hispanic black and Hispanic.)

First, some numbers from 2009, the most recent year that the CDC provides birth and pregnancy rates. Of every 1000 women between ages 15 and 19 in this country, 39 give birth to a child. This number is not evenly distributed among the various racial groups in the US. Of 1000 Hispanic teens, 70 give birth; of blacks, 59 do; of whites, only 25.

Birth rates are not the same as pregnancy rates, since some pregnancies end in abortion or miscarriage. Pregnancy rates are not available for 2009, but if rates have remained relatively stable since 2005 (the latest year the CDC provides), then we can estimate even more distressing statistics: the differences between racial groups are even more pronounced, and the abortion ratios are probably also skewed, as high as 50% among black adolescents compared to maximums of 43% in whites and 36.5% among Hispanics.

Thursday, June 14, 2012

International Patient Care and Bioethics Externship

This week I have been at a series of lectures in bioethics as the first part of an externship with the International Institue for Bioethics and Patient Care Advancement (IBPCA). This series of lectures will be followed by five weeks of working with Dr. D, a local GYN (she gave up OB some years ago, sad face).

The preceptorship begins with five days of lectures and research, culminating in a presentation of the results of our research and a plan for project over the next five weeks.

International Institute for Bioethics and Patient Care Advancement (whew)

This week I have been at a series of lectures in bioethics as the first part of an externship with the International Institue for Bioethics and Patient Care Advancement (IBPCA). This series of lectures will be followed by five weeks of working with Dr. D, a local GYN (she gave up OB some years ago, sad face). The ethics have been surprisingly (refreshingly) good. Everything labelled with IBPCA is from that week. Enjoy!

Edit 7/19/12: Please note that some of the content I had posted about the IBPCA preceptorship has been removed because of the terms the lecturers had with the Institute (about publication of their research, etc).