Archives for posts with tag: healthcare

We’re all sick of the health care debate. But those who are sick, trying not to get sick, or taking care of others who are sick don’t have the luxury of absenting themselves from this debate.

They (we) are looking on in horrified fascination as the GOP makes its plan known: dismantling Obamacare and leaving millions without insurance — replacing it with stopgap subpar underfunded skimpycare.

The so-called “skinny plan” is chockfull of real harm. 15 million more uninsured. 20% premium increases. And that’s before the skinny bill is stuffed even more full with add-ons designed to pacify the elements in the GOP who take moral exception to Medicaid. (The poor should refrain from getting sick, you see. Government should not be involved in healthcare. We should go back to the good old days, whenever and wherever those were.)

It’s as if the check-engine light was blinking on your dashboard, and in response your mechanic doused the car with gasoline and set it on fire.

If you have a Republican senator, call them and tell them your healthcare story. Ask them if they came to Washington to harm the sick. If you have a Democratic senator (or if your senator is Collins or Murkowski!) call and thank them for standing up for what’s right. You can also go to the Indivisible website to be patched through to those in red states, whom you can connect directly with their senators. (I’ve done it. It’s addictive.) https://www.indivisibleguide.com/hubdialer-signup/

Yes, life is full of complications. Things are hard. There’s plenty to do besides this sort of advocacy. You have work to go to, kids to raise, doorknobs and toilets to fix. If you are involved in whatever else you have to do, no one should criticize. But if you can just take a moment to speak up, you’ll feel good, and we’ll all thank you.

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Great first class yesterday at the Berman Institute in my new course, Ethics of Healthcare Decision Making. What is needed for a decision? What are the goals? More to come on these topics, and our fascinating discussions.

Uncertainty is a common experience in health care. For an upcoming book and ongoing research project, I want to be in contact with patients, families, and caregivers to learn their strategies for approaching, dealing with, and understanding such uncertainty.L0074969 All in search of health should wear Harness'

For example, Ms. A. has back pain unaccompanied by underlying serious disease. She has no way of knowing whether it will go away in weeks, months, or not at all. She wants an MRI, which accepted evidence indicates will neither aid in treating her pain nor reassure her.

On the one hand, both she and the healthcare provider would like to do “something” as a sign of care; on the other hand, we want to harm neither Ms. A (with tests/procedures that won’t work), nor society (afflicted by a health care system which costs too much, delivers poor care in comparison to other systems, and treats people unequally).

There are many scenarios in which treatment is pursued despite evidence showing it does not work more than placebo. For example, hormone treatment in the patient with local (not metastatic) prostate cancer; repeated CT scans for thyroid nodules without symptoms; treatment of ductal carcinoma in situ (DCIS), mammograms in a patient without significant family history more often than every two years.

How do you as a patient, family member, or caregiver seek the best care in such a situation, where things are uncertain and more tests/procedures might not work? What strategies do you use? What should healthcare providers do? Please be in touch with me to help guide this work. zberger1 at jhmi dot edu

See the presentation below for another depiction of the problem.

How Do You Deal With Uncertainty In Healthcare? from Zackary Berger

 

This week, I covered for one of the chief residents. I was the attending physician for about 25 patients in the hospital during the space of a few days. On one of those days, I still had scheduled my regular outpatient clinic; the entire day became a way to experience the contradictions inherent in the practice of medicine, crossing the street again and again between the hospital and my clinic like a shuttle on a loom.

How many contradictions, or rather, pairings that we see as contradictions, confronted me with each patient I saw, comparing in my mind the medicine I practice every day in clinic with the kind of health care delivered in our hospitals!images

  • Providing each person the care that works for her uniquely, while uniformly assuring best practices for safety to hundreds of patients at a time.
    Getting the tests and treatments that are needed as fast as possible, while deliberating appropriately on the evidence base of every intervention.
    Treating pain — but acknowledging the dangers of opiate addiction.
    Enabling the patient to make decisions, while recognizing they need the support of a treatment team in an alienating and scary environment.
    Discharging as soon as medically possible, while aiding the patient in their convalescence.
    Hewing to principles of safety and organizational efficiency, while being unafraid to venture out of the box when changed situations demand it.

How can we treat patients while on the very knife-edge of these contradictions? Treating both inpatients and outpatients makes me more sensitive to the edge, but I’m not sure I can dance any better….yet.

Cross-posted to the blog at Talking To Your Doctor.

I am always interested in asking, “What questions should you have asked before….” And with the ellipsis I am talking about any health care situation. What questions should you have asked before you picked a doctor? chose a treatment? heard about your diagnosis? filled your prescription? discussed end-of-life care with your family member?

So what should you have known? What could you have done differently in the process of making decisions, advising, treating yourself or others, or just coping?

And, to take it a step farther, now that you have thought about what you should have asked differently, will that change what you do in the future? How are you going to make that change happen?

Cross-posted to the blog.

I’m going on some smaller and longer trips over the next weeks, which put the topic of health disparities in comparative contexts. Disparities is the scientific term for health inequities. In short: everyone should get the same healthcare, but not everyone does. You get worse care if you’re black, or poor (unfortunately, those are obvious). What about if you are older, or LGBT, or speak a language other than English, or live in a rural area, or have a chronic illness, a disability, or a mental health issue? Probably. But the question is not just yes or no, obviously, but how, why, and what the solutions are.

Next Friday, October 24th, is the most local of the events. I’ll be giving a 400-second talk, that’s 20 slides in 20 seconds each, at PechaKucha Baltimore, the first local rendering of the speedy-talk format that has already been done in a number of other cities. My topic will be Talking Heals. And, while I won’t be mentioning specific health statistics about Baltimore inequalities (400 seconds isn’t enough for statistics!) I will certainly have in mind the great, abiding fact of Baltimore life. “The rich are different from you and me,” as F. Scott Fitzgerald said in another context: yes, they have more money (as Hemingway is supposed to have responded), and thus more health. How can we bridge the gap? Part is access (the poor in Baltimore can’t get in to see doctors, there’s a shortage of internists), part is cost (for obvious reasons) – but part is also quality. And part of that quality piece is to make sure that doctors and patients can communicate across lines of race, class, and origin.

On the preceding Sunday (I’m discussing these events out of their chronological order), October 20th, I’m giving a talk at the National Physicians Alliance: how do we make our doctor-centered system into patient-centered care? You might not be surprised to hear that the solution I proffer is neither all one thing (patient centrism, the advice of the doctor be damned!) nor all the other (status quo and to heck with EMRs!) but something in between: investing in and maintaining relationships.

Finally, in December, I am heading to Peking Union Medical College Hospital in Beijing, at their kind invitation. I hope to acquaint myself with their system and China’s system at large, which I am sure demonstrates some inequities unique to the Middle Kingdom and some shared with the US as well. From what little I know about the current Chinese socioeconomic climate, there is rapid and thoroughgoing social change – which I hope has not swallowed up previous governmental plans to provide better primary care access to millions of Chinese.

Through these multiple dimensions of care, quality, and access, applied across various regions, we can aspire to great change. Lots to do!

Reposted from last year.

After a talk I gave about doctor-patient communication, a woman in her 30s raised her hand and said, “I work at a university, and whenever I see the doctor, he assumes I’m a student, and he talks down to me. This makes me very unhappy and I’m  not sure what to do about that.” I assumed from her circumstances, and from the tone of her question, that she was not free to choose another doctor. What should be done by someone who has this problem? There are various strategies, but part of the answer is to understand why the doctor might be talking down to someone.

1. The doctor’s personality is unsuited to an egalitarian interaction. If they were a chimneysweep there would be the same problem.

2. The doctor was not trained to appreciate the importance of doctor-patient communication.

3. The doctor does not know what to recommend, or recognizes, perhaps subconsciously, that there is no good evidence to prefer one route of treatment over another. This leads to a basic conflict: she wants to help the patient but also acknowledges to herself that there is no one convincing path. Since she has been conditioned to present a front of omniscience to patients, both through the system and the influence of colleagues, she is not allowed to present that ignorance, or to partner with the patient to address it. Thus, she appears abrupt or condescending.

Perhaps I am giving such a doctor too much slack? I would do the same for a patient. Systematic changes mean we should, on occasion, refrain from blaming people without considering the entire differential.

Recently I learned about a pregnancy in which the woman was having frequent painful contractions. Only after her eventual delivery was it clear that she had developed a “uterine window,” where the scar from a previous C-section was almost worn through. The woman was told, after her Caesarian, there had been a significant risk of uterine rupture.

But why then was she not delivered earlier? Because, answered the doctor, there are risks to the baby from preterm delivery.

In that case, what was the balance between the risk of uterine rupture on the one hand and the risk of preterm delivery on the other? No one seemed to consider this tradeoff, or at any rate discuss it with this woman. She kept reporting her contractions; she was reassured and pain relief was provided; but preterm delivery was never considered, as if 39 Weeks were carved somewhere in marble.

Such hidebound protocolism is the norm across medicine. The blood pressure must be lower than 140 over 90, because…, well, because guidelines! The hemoglobin A1C must be lower than 7 because the American Diabetes Association said so, because…they are the experts!

Of course, those who recommend these cutoffs are experts. But that does not mean there are never any countervailing concerns or other possible routes. Is there a way to flip the protocol switch to “flexible” in doctors heads?