Broken system

Last time I mentioned a little bit about the different aspects of medicine: knowing the science and being a people's person are equally important to this process of becoming a doctor. Since last time I wrote, I have had some pretty awesome experiences on the clinical side of things. I got my assigned spot for this thing called PLACE - Patient-based Longitudinal Ambulatory Clinical Experience. This a newer thing most medical schools are trying to do to "get first year students out of the library" as my preceptor explained to one of her patients last week. My assignment is at a private office nearby with a young internist. Based on the location, I thought that this would not be very exciting: it's like when I go to my primary care doctor, it's usually to get records for something, get a vaccine or a prescription for something when I have a sinus infection. Well, it turned out to be pretty interesting after all, although she admitted that I just happened to be there on a day when more of her "trouble" patients were in the office. The idea of the program is to pick a patient and try to follow him/her for an entire year through all of his or her health care appointments. This obviously only works if someone actually goes to see the doctor at least somewhat regularly; and then let's not even talk about the scheduling nightmare that might arise from trying to go to the doctor with a stranger every time they go. We didn't really have enough time to discuss this aspect very much, since she was seeing patients every 15 minutes, with about 2 minutes in between to talk about them, but two of the cases we saw together were really interesting and might be good for follow-up; although I am a little hesitant because neither patient was particularly friendly, had some clear emotional problems and I just really doubt that anyone would enjoy a first year medical student following them around when they are probably already anxious enough trying to deal with their health care issues. What was pretty cool though was that my preceptor allowed me to talk to each patient myself before she interjected. I was supposed to elicit what's called the "chief complaint": basically, why is the patient there, and then try to find out more about it. I know it sounds trivial, but believe me, when a flesh and blood sick person is sitting in front of you, it's not that easy! 

The other thing I got to do last week was to volunteer at the NYC Free Clinic. The idea behind it is this: every Saturday, a bunch of med students form NYU and two attending physicians see uninsured patients who have been seen by social workers previously. We offer all kinds of services for free. Most people want and need a lot of blood tests, pap smears for women, STD testing, vaccines, etc. But the coolest thing is that if they need it, they get referred to Bellevue, and NYU still pays for the follow-up visit. Now, as someone who has always had good insurance through school or work, and never had to deal with a situation that nearly 50 million Americans have to deal with daily, I had a pretty skewed idea about "the uninsured". While I was volunteering at the ER before med school, we saw tons of really really poor people there, who literally had nowhere else to go; lots of them homeless, drug addicts, living in shelters, etc. But what's even more frightening is the number of people who are just like me - similar age, social status, education, etc - who are also uninsured. 

This past Saturday, I was in charge of the labs at the clinic. That meant I had to go through the lab results of people who had any lab tests done from the week before, and discuss with one of the attendings each of the cases, and if something was off with any results, contact the person for follow-up. So I got to look through many many charts and many many test results, and I would say that the majority of the people who go to the free clinic are young, very young, and mostly women. In 2 weeks, when I get to be on a real clinical team, I am sure it will be much more interesting - although I quite enjoyed the lab experience too, I looked up so many different drugs and lab values, and got to discuss them with a physician, who was really cool and very knowledgable and caring (ok, here I also have to admit that I had a not-so-flattering view about primary care/family doctors, but damn, I am just starting to realize how freaking important it is that they are good doctors and they know their shit!!).

I have been so privileged my whole life - in terms of my health, my opportunities, the family and place I was born into, and also my health care. I have never before been forced to think about this very much, because honestly, it's so easy to ignore the problems when you don't have to deal with them personally. These past few weeks, however, I have been thrown head first into thinking about the health care system. I really like it that they are putting a huge emphasis on this at a place like NYU: a huge academic medical center with billions of dollars in endowments. Despite this, there seem to be many socially conscious people here, who are trying to change the system from the bottom (aka by educating the youngest generation of future physicians about the need for change). 

Just some things I have seen in the past 6 weeks: 

A woman in her early 40's just discovered she has a rare genetic enzyme deficiency that is causing her lungs to slowly fail. She should be on enzyme replacement therapy for the rest of her life but her insurance company is currently denying her claims because she "does not meet all the criteria" the insurance company has set for that particular disease to be covered. On top of that, her two teenage children have both inherited one bad copy of her gene, making them at higher risk for future lung disease. When they turn 26 and they have to get their own health insurance, depending on the political climate and the health care law at that time, they might be denied coverage for pre-existing conditions. So in a case like that, is it better to know that you at risk for something? Why is this not medically confidential information? How is this fair? On top of all that, after going through an insane few weeks with the new diagnosis and trying to figure out her insurance benefits, she found out she was pregnant. How will she be able to afford another child?

A man in his 40's who has had a history of serious heart disease, including a heart attack in his 30's, lost his job and therefore, his insurance for a few years, and so his heart disease has been unmonitored for years. He just got a job, a new insurance plan, and is now back at the doctor's office. Blood pressure sky-high, not on any meds. Still reluctant to see a cardiologist because he is worried about the high co-payments and he is afraid to go back on medication because he is not sure he can afford it month-to-month. 

A young woman without any insurance getting her first gynecological exam ever. She is having sex for the first time; she does not want birth control because how the hell would she pay for it? The doctors inform her that the free clinic also offers abortions. She says "that's great". 

A medical student in his early 20's who has just been diagnosed with type I diabetes. He discovers that injecting himself with insulin several times a day is really inconvenient, especially when he is seeing patients all day in the hospital. So he applies for the insulin pump. He has the university-negotiated student health plan that I also have. With one of the biggest private health insurance companies in the US. They deny his claim. He fights them for 10 months before they finally approve his insulin pump. Endless phone calls, emails, letters, lawyers involved by the end. 

That's all I could think of for now, but I am sure that there are endless stories like these ones. I've only been in medical school for 6 weeks! 

The system is broken. Completely broken. So how about this new universal health insurance plan that Obama has been so enthusiastic about? Sadly, the more I learn about it, the clearer it becomes to me that it is not even close to universal, it will still be really expensive and unfair in many ways, and it does not change anything about the way private health insurance companies operate. And honestly, if I didn't have insurance, I would rather pay the ~$700 penalty for not having it than buy a plan that costs over $2000 a year. As a side-note, insurance linked to employment is a dangerous thing, especially in an economy in which more and more people are losing their jobs; and their options. 

A couple of weeks ago, I went to a student conference on single payer health care systems. Single payer is the system used in nearly all other industrialized countries in the world. It does not equal socialized medicine as some Americans like to argue. It is also not just an idea: Vermont is the first state in the US that has voted on and accepted a new single payer health care bill, to go into effect in 2017 (only then because the new Affordable Care Act aka Obamacare has a restriction on the date when it can go into effect). Of course, Vermont is a tiny state, with no major metropolitan areas, and only 14 hospitals total; but it's proof that this is not a crazy idea even in this country. Of course, being from an Eastern European country, I am all too familiar with a socialized single payer system, which is also broken. In different ways. But I don't want to talk about that. Ideally, in the US, the system would be government funded but privately run. Funded through the savings that would amount to billions of dollars if all the administrative overhead associated with private insurance companies (eg. the 10 months long fight over the insulin pump - how much money could be saved if that wasn't necessary??) was eliminated, also reorganizing the way tax payers currently pay for things like Medicare an Medicaid, payroll taxes, and some individual taxes based on income. (On a side-note, currently, in employer-based health care, the CEO of the company pays the exact same premium as does his secretary.) People think that their taxes would sky-rocket if there was a single payer health care system, but it's just not true. We currently pay for some amount of health care expenses in our taxes, and there is so much waste in the system, that lots of money could be saved. The other thing is about choice. Especially on the conservative side, people love to talk about how Obama is taking away our choices, our freedom. (Of course, choice is only good when it comes to insurance, not when it comes to women's reproductive rights.) They talk about our freedom to choose our insurance plan, our doctors. Bullshit! I don't have a choice of health care plan,  never had. My school offers exactly one crappy plan, that costs me over $2000 a year, plus copays, etc, and if I was diagnosed with diabetes, they wouldn't even cover an insulin pump! I don't have a choice of doctors either. If a doctor I want is out of network, I might as well pay out of pocket! Choice is an illusion! 

Yesterday, we had a guest lecturer from Weill Cornell, a physician who is committed to advocating for single payer health insurance. He calls it "medicare for all". He gave us an hour and a half long overview of the history and current state of the US health care system, talked about some of the changes that are happening currently, about the politics and the economics behind it. I am little surprised by how politically outspoken our professors are. Not surprisingly, being in NYC, all very liberal so far; I think more and more people are realizing that something needs to change drastically. He showed us statistics that showed that by 2050, the average cost of health care premiums for a year will exceed the average income in the US. That is INSANE! And looks at this from today's NYT! This is a step in a completely wrong direction. 

The article states that there is already a shortage of physicians in the US, and that is expected to rise, especially in primary care. Already, a primary care doctors sees patients pretty much every 10 minutes throughout the day. And that is in NYC, where, I am assuming, there isn't that much of a shortage. But then why would I want to go into primary care when I will be in over $200,000 in debt when this little adventure is over? No matter what, I will have to do at least a 3-year residency. I'll be 36 then. If I was to go into primary care, I could start working after those 3 years; even get some of my debt forgiven if I decide to work in certain areas of the country where the shortage of primary care physicians is especially acute. But then again, I could do a one or two year fellowship, let's say in Oncology, do some research, which, with my background, would only make sense, and then come out on the other end as a specialist earning so much more money than a primary care doctor. I am not in this for the money. But a $200,000 debt hanging over my head in my late 30's is less than ideal. 

That was a bit of a digression. But my point is that the system is BROKEN! On a lot of different levels. Something needs to change. I have never thought of myself as much of an activist or trailblazer, but maybe it's time to look for ways in which individuals can make a difference. I am not so sure what that it yet, but I am looking.