Anyone Can Serve

I don’t think I’m alone in occasionally feeling discouraged in my ability, as an individual, to make some positive change in the face of powerful corporate interests. A few recent events have allowed me to reflect on this feeling and given me some guidance in how to proceed.

The first was a recent lobby day organized by some very inspiring, intelligent, and thoughtful first and second year med students at my school. It was organized by VCU‘s chapters of Physicians for a National Health Program (PNHP) and American Medical Student Association (AMSA), with some help from National Physicians Alliance. The goal was to advocate for closing the coverage gap in Virginia – expanding Medicaid. They set up appointments for us with some extremely difficult targets, so I knew it had the potential to be tougher than some other lobby days I’d participated in. Having grown up in the South, I wasn’t surprised at the undertones of sexism and condescension (ie., referring to adult, professional women as “honey” and “girls,” etc.) I even expected the ideological arguments grounded not in published research or testimony from health policy experts, but in pure opinion. Del. Orrock, an otherwise friendly, likable man who probably is great at his job as a high school ag teacher (bet you don’t have those up North!) remarked that he wouldn’t support Medicaid expansion because the program didn’t adequately ensure “personal responsibility” in enrollees. Never mind the economic arguments (Virginia is losing $5 million dollars a day for a projected total of $2.8 billion), the health outcomes arguments (over 7,100 deaths attributable to consequences of no healthcare access), or the fact that Medicaid expansion is primarily targeted toward people who aren’t (obviously) already covered by Medicaid – mostly the working poor. I tried emphasizing that I have seen many patients with illnesses that aren’t a result of lifestyle, and that we are all vulnerable to disease and death. The idea that people don’t value health care because it’s free and visit the doctor – what, for fun? – on a whim is not really even worth entertaining as a serious reason to inform public policy. I wonder whether people even believe that, or if they just latched onto that idea as a way to resolve their cognitive dissonance about how doing the morally and economic right thing would jeopardize their position as a Republican legislator. Then there was the meeting with Del. O’Bannon, a member of the Medicaid Innovation and Reform Commission (MIRC), the group currently charged with making the decision to expand Medicaid. He also refused to support this expansion without “significant reforms” though didn’t specify what, exactly, those reforms would be. It was a tiresome meeting. 

We did meet a well-dressed, attractive young woman who answered some of our questions about the general assembly process though – she was a lobbyist for Pfizer.

One thoughtful grad student in another profession remarked when I described my lobby day experience to her that it can be useful to talk to representatives just to remind us that there isn’t but so much that can be accomplished inside of the system. It’s true – I was pleasant but serious, balanced listening with speaking, and did all of the “right” things during the lobby day, but I’m not sure how much difference it made. It is very useful for these representatives to know that future physicians are paying attention and educating themselves on these issues; it’s clear we care deeply. But that may be more of a long-term strategy. Using a variety of tactics to accomplish change is something that I continue to grow increasingly respectful of.

The second is my participation in an elective at my school that is designed to introduce students to the workings of a large health insurance corporation (I won’t mention which one it is, but it’s probably not too difficult to figure out.) I signed a non-disclosure agreement to not report their proprietary information, and I won’t do a huge med student expose on my experiences because a) I don’t want to jeopardize the chances of them not offering the elective for other med students and b) my integrity is very important to me – I said I wouldn’t reveal specifics in exchange for the incredible opportunity to spend time learning what goes on there (or more likely, how they present what goes on there), and I won’t do it. So, very generally, I will say that it is difficult to envision disengaging our health care system from these huge, entangled webs of companies that offer very little value outside of what is being accomplished already by CMS. That isn’t to say the employees aren’t talented, thoughtful people who have much to offer to society – and who could easily offer it in the public sector instead. Very often when meeting with them I feel extremely sad that such bright people are being used by the company for the ultimate aim of keeping them ahead of their competitors. If this results in great patient care, that’s wonderful, but if not, money is what matters. Publicly-traded for-profit companies have but one obligation – to increase the wealth of their shareholders.

One common misconception about those who seek to limit the overreaching powers of corporations – It’s not that these companies can NEVER benefit society, it’s just that in instances when benefiting society conflicts with making money, the bottom line always wins.

I’m currently working on a review article about the impact of cost-sharing (deductibles, copays, etc) on low-income Americans, ie., the people targeted via Medicaid expansion. Getting acclimated with the literature in this area has been a combination of frustrating and inspiring. On the one hand, there’s so much clear evidence that imposing extra costs on poor people doesn’t improve their health or save money that it’s unbelievable there is still so much support for these types of policies. On the other hand, it’s incredibly inspiring to read about the brave actions that researchers have taken in conservative states. Some people have really aligned themselves with the poor, putting their reputations and careers on the line. They’re not really famous, they don’t have movies coming out, they’re not on “The Doctors” or anything like that, but they are worthy of recognition and admiration.

A few examples:

Gordon Bonnyman: A lawyer and advocate of Tenncare, an innovative and controversial experiment in Tennessee that aimed for universal coverage. It ultimately failed due to budget cutbacks and a variety of other reasons.

Teresa Coughlin: A senior fellow at the Urban Institute. Among many other things, she conducted research about how well Florida Medicaid recipients understood the extremely complicated reforms that occurred in 2006 under the premise of increasing choice and benefit variation and providing incentives for healthy behaviors (personally, the only thing I’m confident I understand about Florida Medicaid reform is that it involved a lot of paperwork). She and her colleagues demonstrated that, unsurprisingly, people had great difficulty understand the details of the plans, or even knowing that they were enrolled in the plans.

One of the core issues in assessing consumer-choice models is the degree to which individuals have the ability to make informed choices among different plans, which is central to the success of a competitive model. Informed choice presumes that key information on enrolling in and using a plan are communicated in a way that is easily accessible. It also presumes that sound plan information (for example, information on provider networks and prescription drug formularies) is readily available. Equally important, people must be able to use the information to make the complicated decisions required to ensure that they select a plan that meets their needs and preferences. Previous studies, however, indicate that understanding and acting on health care information is a problem for nearly half of the general population. Making sound decisions may be an even greater challenge for Medicaid populations, as research indicates that advanced age, limited formal education, and poor health status—characteristics common among program recipients—are associated with poorer health literacy.

Robert Reich: Ok, this guy is famous, and he DOES have his own movie (check it out – it’s great!) But take a look at this facebook status he posted today:

Behind the political theater over Obamacare – from the botched rollout to yesterday’s false claim it will increase unemployment – is a reality that’s barely mentioned, not well understood, but the most important of all: It’s leading to the biggest consolidation of insurers and health providers in history. Giant insurers like WellPoint are taking on an ever-greater share of enrollees, hospitals are merging into huge systems, and physicians are fast becoming system employees. Last year alone 247 hospitals merged, three times as many as in 2008. A decade ago, hospitals owned a quarter of all physician practices; by 2011 they owned half. Why? Because large insurers and giant hospital systems are each racing to increase economies of scale and market power over the other — in order to capture more of the revenues from the Affordable Care Act as well as an expanded Medicaid and, not the least, the surge in baby-boomer Medicare.

The endgame here is either (1) huge healthcare monopolies that rake in tens of billions of dollars a year while delivering mediocre services, or (2) a single-payer system with regulated prices that turn on healthy outcomes. I predict (2), within the next decade. Which do you predict?

It’s these people that remind me that we are in class war, for lack of a less divisive term, and it’s composed of everyday, local battles. We can’t fight them all, but we can choose an aspect of to gain expertise in. We can support each other through diverse causes, recognizing that many struggles fall under the same umbrella. And eventually, I still think, we will succeed in holding the flood gates against special interests and will be able to forge a more just society.

On serving the Underserved as an incredibly privileged person

Prior to starting medical school, I was a research assistant in a pilot program, a multi-disciplinary assessment of community reintegration in people diagnosed with HIV and recently released from incarceration. My job was to conduct detailed psychological interviews and perform neuropsychological testing in order to establish history of trauma, previous psychiatric and psychological treatment, and any cognitive challenges patients faced. I had expected the project to be challenging, but I had not anticipated the depth of my own emotional reaction. This project would set in motion my understanding and subsequent commitment to social justice. It would highlight the necessity of responding to suffering, which includes not only caring for individuals but also combating systemic barriers to health and human flourishing.

My patients felt they had paid their debt to society, but society would not give them a chance. Most had limited education and job training, and during the recession, it was difficult enough to find a new job without a conviction. Prior to incarceration, many had suffered mental illness, including substance addiction and depression. All of them now faced complicated HIV medication regimens and doctors’ appointments despite frequently unstable housing, transportation, and employment status. After release, many met criteria for devastating post-traumatic stress disorder, some resulting from horrifying events occurring while under the “care” of the State. Almost all were from poor backgrounds and the majority were people of color. During the interviews, many expressed themes of detachment, a sense of alienation from society starting in childhood. Some intimated a sense that outcomes many Americans view as basic rights or inevitabilities were never options for them, like freedom from an abuser, a safe home and school environment, or deciding what to be when they grew up.   

How do we interpret and respond to another person’s experience outside of our own perspective? When we consider the background of ourselves and our peers, perhaps even the process of becoming a health professional could be a hindrance to meeting the needs of the Underserved. Consider: to even become a doctor almost demands that we are from a background where adults took time to read to us, encouraged our intellectual development, loved us, and met our needs. Without emotional and financial support and some degree of stability, it would be impossible to achieve the sustained academic excellence required to even gain acceptance to medical school. We are told that we are here because of merit, when the reality is far more complicated.

We are taught to feel negatively toward those who have committed crimes, yet most of us do not understand the complex criminal justice system, including how we decide what a “crime” is and is not, how we determine its punishment, and how incarceration affects not only the individual’s psychological and physical health, but that of their families, their friends, and our entire society. People don’t commit crimes in isolation of social influences. The medically Underserved do not exist in a vacuum of poor decisions and bad luck.

What if our way of life has necessitated an underclass, and all attempts to attend to their medical needs are stopgap measures?  

For me, the process of dedication to attending to the needs of the Underserved has been continuous and ongoing, requiring learning and re-learning, questioning, research, and learning about the history of my own privilege. My work with individuals has informed understanding of the effects of a profit-oriented medical system that is incentivized to treat disease instead of promote health. This is in the context of a short-sighted economic and political environment that values the accumulation of capital and wealth to such an extent that even its pursuit is an act of violence against the poor.

On an immediate level, meeting needs of the Underserved involves helping individual patients develop self-efficacy while also helping people learn to meet challenges as a community. These are skills that must be promoted in medical and other health professional schools; it is much easier to tell patients what they need to do than it is to figure out why they aren’t already doing it, especially in a time where patients will often come in having googled symptoms, diagnoses, and treatment options. As healthcare professionals, we must unravel the previous paternalistic view of physician-as-expert. We are partners in promotion of the health of our patient, who visit us in recognition of the training we have undergone to provide medical knowledge and perform procedures as safely as possible, free from the influence of those who simply view the provision of healthcare as a commodity to be bought and sold.

Some illnesses and treatments are so well-established there is an actual algorithm for what medications to prescribe. Diagnosing and treating high blood pressure comes to mind. While there is still a need for a careful history and physical exam to rule out other causes, many people could read the JNC-7 report and figure out what blood pressure medication they should be taking. Some have criticized that our move to evidence-based medicine instead of intuition, prior practice,  and “expert”-based medicine has taken the human element out of care. A recent study provided some evidence that artificial intelligence can apply treatment rules better than doctors and with better outcomes! What will be the role of medicine as these technologies are further developed? Will there even be one? I think there will be; human behavior is much more complicated than knowing what one should do and simply doing it. I am interested in how contributions from the fields of positive psychology (the study of human flourishing) and behavioral economics (the study of how people make choices) may inform the practice of medicine.  The human element of the patient-physician relationship provides room for encouragement, some accountability and motivation, and identifying other barriers the patient may not have considered. To be a good physician requires training developing these skills. Yet it is not the primary focus of current medical training, which overemphasizes memorization of scientific facts. Knowing the specific enzymes and substrates in the cholesterol synthesis pathway may help us understand how cholesterol-lowering medications work, but choosing a medication for a particular patient is often based less on how it works, but more on how well it works and its side-effect profile.

On a broader level, helping the Underserved demands recognition that all people’s struggles are related. It requires the development of an empathic mindset starting in childhood.Maybe it means that terms like “Underserved” are themselves divisive and kind of perpetuate themselves without solving the problem.

When it becomes especially challenging and seems overwhelming to address all injustices, it might be helpful to try doing something like a silent prayer: May we be able to recognize the common vulnerability to disease, suffering, death that all people share.