H1N1 Vaccine

I've begun my series of blogs on vaccinations, H1N1 included, but it's still a work in progress. I know many people are very eager to hear about my perspective on the H1N1 vaccine now, as they are contemplating whether or not to vaccinate presently. For that reason, I'll make this post on my views of the H1N1 vaccine first, and then go into the details of the science of the H1N1 vaccine and vaccines in general on future posts.

First, please let me be clear: I do not believe people are bad if they decide to vaccinate or if they decide not to vaccinate. There is so much publicity on both sides of the issue, it makes it very difficult for intelligent well meaning parents to make decisions whether or not to vaccinate themselves and their children. The most important thing is to not get caught up in the hype, but to instead make well thought out decisions which you could be comfortable with the outcome.

Medicine is not a perfect science. People's bodies behave uniquely, and we don't understand everything about the human body- nor do we understand all the science in relation with the human body. We have, however, made significant progress in our understanding of things despite not knowing everything. We can reasonably be sure of patterns and how the body will behave. When we carry this onto a larger scale, we have the study of epidemiology and public health. In this field, we must decide what are generally good principles to take on how to keep a person healthy within the population. We can start with the easy ones.

Wash your hands! The H1N1 is a virus which gets carried on droplets and secretions. It is most often picked up by our hands, and then we touch our mouth, eyes, or some other part of our face to get infected. Washing our hands properly (soap, warm water, getting under nails and between fingers, and singing yankee doodle while doing it) will prevent so many people from getting sick. Coughing and sneezing into your elbow is also a good idea because you keep from getting your hands contaminated, and you also don't cough into the open for a droplet to hit someone else. Staying healthy, exercising, eating a well balanced diet, and taking vitamins if you need them will also go a long way. Be careful with which vitamins you take, because many aren't tested, there are no regulations to make sure you get the same amount of vitamin in each pill, and vitamins can still be dangerous. Vitamins are another blog post altogether, but they can be beneficial if used properly.

The H1N1 virus is a strain of influenza A. The H stands for hemagglutinin which helps the virus bind to the cell. The N stands for neuraminidase which is an enzyme that helps the virus trudge through the mucous in the respiratory tract. The numbers just help us classify the virus. In short, this is like any other flu virus except it seems to illicit a very strong immune reaction in healthy individuals. That is where most of the concern comes from: this H1N1 flu virus has been shown to cause significant illness and sometimes death in healthy individuals. Previously, we had seen significant illness and death mainly in children, the elderly, and other people without intact immune systems. The H1N1 virus, therefore, is a concern for even healthy individuals. Children are usually vaccinated for mainly two reasons: they are susceptible to infection because they don't have the reserve an adult has, and they are incredible vectors to pass illness onto others. The same illness which would be bothersome to a parent, could land a child in the hospital. Children don't have the same ability in the short term to take a substantial hit. We also know what kind of grubby little germ bags they can be. They seem to get into everything, get their hands on everything, and go everywhere. This can put the entire community at risk because the more exposure a person has to a virus, the more opportunity to get infected. The seasonal flu vaccine was given to children so they could be protected themselves, to keep from spreading flu to other kids, and to keep from getting grandma and grandpa infected. The seasonal flu was far more risky for grandma and grandpa, but now we're seeing H1N1 being just as risky for us as the seasonal flu is for our older individuals.

So what about this vaccine? The H1N1 vaccine is designed to expose your immune system to the protein sequences of the virus without actually getting the full viral infection. There are two forms: the injection and the intranasal. The injection is a killed virus and doesn't have any ability to cause infection whatsoever. The intranasal is a live attenuated virus, and has been so weakened that it cannot cause the full infection and its sequalae. It cannot mutate back to its original virulence, and does not infect other people. Studies have shown antibodies produced from people who have come in contact with a vaccinated individual, but not to the degree where immunity can form. That means someone around you who has gotten the vaccine can't make you immune, and can't get you sick.

Often, a person thinks they got the flu after the vaccine. They may have muscle aches, runny nose, even feel feverish with chills. They did not in fact get sick, but their immune system may be mounting a response to the vaccine because they had already been exposed to similar viral proteins prior to the vaccination. The body thinks it got infected, and charges up the immune system to fight the "infection." Keep in mind, care for the flu is supportive: tylenlol, liquids, rest, etc. The symptoms are far shorter than if a person actually caught the flu, because the person really didn't catch the flu. There is also the possibility a person got sick with something else around the time they got their flu shot. During flu season, many other bugs are going around at the same time. Any viral illness causes similar symptoms, and a person may get sick with the cold and feel as though their flu shot got them sick. That is the reason people aren't given the flu shot when they are sick. Not because it makes them sick or is dangerous, but because we don't want our patients to correlate being sick with getting the flu vaccine. Since the nasal spray is a live attenuated vaccine, it is more likely to get some of these symptoms: runny nose, headache, etc. The body will kill the virus within a couple days, and develop immunity to H1N1 thereafter.

Many of the conerns of the H1N1 vaccine are because it is a "new" "experimental" vaccine. This is in fact not true. A similar H1N1 vaccine was used in the 70's. A lot has changed since the 70's. Technology is better, the vaccines are more pure, and the virus has mutated so that the same vaccine wouldn't be effective for the current strain. It is true the H1N1 outbreak is relatively recent, so a different vaccine than the seasonal flu vaccine needed to be made. Flu vaccines are made at least a year in advance, where researchers study the strains of flu affecting Asia. From there, they choose the 3 most likely strains of flu to cause a problem to the general public the following year. There are tons of different flu strains in existance, and the flu vaccine does not protect a person from all of them. If the H1N1 outbreak were discovered sooner, the H1N1 vaccine would probably have been combined with the seasonal influenza vaccine.

Another concern is regarding additives. By far, the most commonly cited additive is thimerosal. Thimerosal is a mercury containing compound which is used as a preservative in vaccine bottles to prevent other contaminants (bacteria, fungus, etc.) from growing in multi-use vaccination containers. To make it cost effective, many vaccines have multiple doses in a bigger bottle rather than packaging each one separately. Prior to this additive, many people would get sick when vaccines from a contaminated bottle were continually being used to vaccinate people. Now, the concern has been raised from possible effects of the thimerosal.

It is unethical to inject doses of thimerosal into the human body to find a toxic dose. Animal studies have given us a better understanding of the effects of thimerosal. When thimerosal is injected into the body, it breaks down into ethylmercury. This is a mercury which contains a 2-carbon atom chain. Anything that contains carbon is called organic. This therefore, is an organic mercury. Contrast this to elemental mercury (inorganic mercury) which is purified mercury we see in thermometers (which we have all been taught is toxic). The reality is, you could drink all the mercury in a thermometer and probably be ok- though I don't recommend trying it. It has been proposed organic mercury is far more toxic than inorganic mercury. One important thing to realize is organic mercury may be ethyl mercury or methyl mercury.

Both ethyl mercury and methyl mercury freely distribute throughout all parts of the body. It is primarily excreted through feces. Toxic affects can be cumulative, and guidelines have been made to reduce exposure to mercury throughout life. Ethyl mercury takes about 2-3 weeks to clear, methyl mercury takes about 3 months to clear. Studies demonstrate mercury gas to be far more toxic than mercury solid or liquid. Most of our exposure is not mercury gas. Studies have not been performed extensively on ethyl mercury because it is not the primary form of exposure. Most exposure takes place by methyl mercury, although both appear to have similar effects, but different elimination profiles.

As I stated earlier, it is not ethical to intentionally dose someone with something you think may be toxic, so we can't test for toxicity that way. We can, however, study levels in people's bodies when they are exposed to mercury on their own. The most common form of mercury expsoure is ingestion by eating fish. 1 parts per billion (PPB) is equal to 1 microgram per kilogram. Tuna, for example, has 118 ppb. Salmon has 14 ppb. A H1N1 vaccine may contain up to 25 micrograms of mercury. The current standard by the FDA for maximum exposure is 187.5 micrograms of mercury via vaccination in the first 6 months of life. Quaker oatmeal has 0.350 ppb. Hershey's chocolate syrup has 0.257 ppb. Kellog's Nutragrain bars 0.180 ppb, Coca Cola 0.062 ppb.

As you can see, humans are exposed to mercury every day. We often ingest more mercury than what is included in vaccines. 90-95% of ingested methyl mercury is absorbed by the gastrointestinal tract. The mercury absorbed is freely distributed throughout the body, so arguments about the body's "natural" filtering process as opposed to injection by vaccine are ill-informed. Furthermore, the argument about mercury is often not comparing "apples to apples" and when actually studied properly, mercury included in vaccinations is far safer than ingested mercury because; ethyl mercury is eliminated by the body more quickly than methyl mercury, the damaging effects of mercury are primarily gaseous and not liquid, and deleterious effects "blamed" on thimerosal have not changed in incidence following elimination from many vaccinations (which will be discussed in the next paragraph).

Despite overwhelming evidence to the contrary, the non existent link between autism and vaccinations is often brought up. Multiple studies have been performed which do not demonstrate any link between autism and vaccinations. The most notable studies are from Denmark in which nearly half a million children over nearly a decade were divided into vaccinated and unvaccinated groups. There was no evidence of autism being linked to vaccinations in any way. The results were also posted in the New England Journal of Medicine November 7, 2002 edition. Of course, this was not the H1N1 vaccine, but multiple studies have continually failed to show a link between autism and vaccinations. Rather than citing all the studies, I will give my opinion on why people believe there is a link.

Autism is admittedly a very difficult and devastating disorder. It affects multiple areas of life, and may lead to profound social and educational deficits. No parent wants their child to have autism, and if their child does obtain the diagnosis of autism, they want a reason why. We do not have any definitive idea of what causes autism, and non knowing is very difficult for many people. Instead, we have a tendency to grasp at possible correlations. Vaccinations were stated to be a commonality between almost all autistic children. The problem is, having a birth mother and father is also a commonality in autistic children. The point is: correlation does not imply causation. Just because something is common, doesn't mean one thing caused the other. Thimerosal was stated to be the source of autistic risk in vaccinations, but following its removal from most vaccines in the 1970's, the incidence of autism has not decreased... it has increased!

Some vaccination opponents have cited extremely low autistic rates in the Amish. The Amish do not vaccinate, and therefore, vaccination opponents propose this as evidence of a link between autism and vaccinations. The problem is, just because something is not diagnosed, does not mean it does not exist. I currently practice in Amish country. The Amish have a type of insurance where they pool their money as a community. Before going to the hospital, they group of elders meet and decide if the condition warrants going to the hospital and spending the community money. The Amish do not rely upon government programs, so they do not have any incentive to go to the doctor and obtain the diagnosis of autism. It would be really difficult to disguise a severely autistic child amongst a group of regular children, so lack of diagnosis can't be entirely the story. What we have found, is the Amish community has significantly greater rates of mental retardation than the general population. This is the proposed discrepancy. Rather than diagnose the children with autism trait, autism spectrum, or any type of autism, they are grouped into the larger category of mental retardation.

Are there cases of children who are not immunized who still develop autism? The answer is yes, but far more people are vaccinated in the westernized world than unvaccinated. Furthermore, in countries where vaccines are not common, there are not sufficient medical resources to diagnose autism. The motivation for sending in medical teams to diagnose autism in third world countries would be purely academic, and would appear to be very distasteful when so many children are dying. A notable case would be the son of John Travolta. He was reported to have autism and not to have been vaccinated. Of course medical information is confidential, and the information released by the Travolta family may or may not be influenced by the church of Scientology. If you take all reported cases of autism at face value, the answer would be clearly that autism does occur in non vaccinated individuals.

We don't know what causes autism, and we don't know why the incidence is increasing. Possible factors for the increase are: increased understanding and propensity of diagnosing autism, greater population size, and increased funding and resources for those diagnosed with autism. Autism is a relatively new diagnosis and we are currently learning more about it. Developmental pediatrics has made substantial progress in understanding this disorder, and we are now better able to identify it than previously. It is possible the disorder was always there, but we now have labeled it and the incidence therefore is increasing. With greater population numbers, there is also greater chance of having individuals with autism. Just by having more people in general, we also have more people with autism. You can also see how resources in America have significantly increased for children with autism. Although this is beneficial for individuals with the disorder, the increased resources create an incentive to have the diagnosis made. Children with autism have the potential for special tutors, more time for exams, and financial assistance. As you can see, there is greater benefit to having the diagnosis of autism made, greater ability to make the diagnosis, and larger population to make the diagnosis from as potential alternative reasons for the increased incidence of autism.

Some complications which have been associated with the H1N1 vaccine are also a major concern for patients. One of the most distressing complications is Guillian Barre (GB). GB is a neurological syndrome with many variants. It is thought to be immune mediated where the body's own immune system attacks the nervous system. It has an incidence of less than 1 in 100,000 in the general pediatric population. The incidence following vaccination is about 1 in a million. Since it occurs without vaccinations, vaccinations are NOT the cause of GB. GB can occur with any viral illness, with a bacterial gastrointenstinal infection being the most common. A person can get GB from a flu or a cold. The most devastating effects are respiratory arrest (in which a person stops breathing), or paralysis. 13% require intubation and ventilation (being put on a breathing machine), and 60% are unable to walk. 79% experience neuropathic (stinging electric shock) pain. Symptoms are often transient in which they resolve within 6-12 months in 85% of cases. Death occurs in roughly 3% of cases. Understandably, this syndrome is distressing. I do want to point out it is exceedingly rare, but may occur. If you compare this to the H1N1 virus, the latest CDC report in November revealed 3,900 deaths, an incidence of 22 million, and 98,000 hospitalizations in America this year alone.

On a personal note, I have seen somewhere between 10-20 deaths from H1N1, and have a friend's brother who developed GB 24 hours following the H1N1 vaccination. He is currently not doing very well and may need to be intubated. It's one thing to look at the numbers as a scientist and give a recommendation. It's a different thing altogther as a human being and a doctor to put the numbers and real life together to make a recommendation.

Concerns have also been raised regarding vaccine dosing. In reality, there are pediatric and adult dosing concentrations, but concerns have been raised as to why vaccines are not weight based. First, vaccinations are not medications in the strict sense of the word. Medications are substances used to heal and return a person to their prior state of health. Vaccines are substances adminstered to prevent disease. The science is very different. In antibiotics, for example, we have terms of distribution, absorption, half-life, metabolism, elimination, dose-dependent, bacteriocidal, bacteriostatic, etc. These relate to pharmacokinetics/pharmacodynamics or the study of a drug on the body and vice versa. A vaccine is different because it is not a drug that kills anything or gets changed to kill anything. A vaccine presents a protein to the body's immune system just like us coming across things every day of our lives. We eat things, smell things, touch things, see things and our bodies respond to them. The body gets exposed to protein sequences in a vaccine and remembers them so it can protect itself when the real virus comes along. In real life, we don't choose to be exposed to 1 virus or 1000 viruses. It just happens. How much of the ocean do you have to drink to know it's salty? Once again, the argument is comparing "apples and oranges." We don't weight base vaccinations because they are not medications.

Why the fears? If scientific studies, expert opinion, and the test of time demonstrate vaccinations to be safe and effective, why is there still so much contraversy? I believe the problem, of course, is the media, hollywood, and the government. For those of you who know me well or have read my other posts, this is where the politics come in =). The media has always pushed an agenda. Disguised as entertainment and rationalized as art, the media has introduced many dark sides to the general public. Death, torture, gratuitous sex, drugs, violence, etc. have all become images we see daily- even hourly. To make things worse, these entities have even become glorified. After turning what is right, pure, and good into perversion, people become mystified to the point where hollywood and the media are able to then push the irrational as fact. They combine the surrealism already portrayed in movies with plays on our hopes and fears to encourage us to make irrational decisions. The media similarly uses sensationalist stories to make the most rare obscurities a seemingly every day occurence. More driven towards ratings than responsible journalism, they persuade the public through graphic images to make irrational decisions.

We would hope the government would take a responsible stance to encourage the public to make rational decisions for their safety. The problem, however, is the government has allied with the media in different instances (the most recent presidential elections, for example), to lose all credibility with the general public. When combined with apparent attempts for government control, we now see how a healthy skepticism of the government has disuaded the public from vaccinations. Previously, the "hippy" "liberals" were the strongest opponents of vaccinations. With the recent intense distrust of the government, we now see the right wing conservatives as large opponents of vaccinations. When the government starts mandating individuals (as it did in New York) to become vaccinated, the immediate response is "hell no." None of us like being told what to do. Anti-big government conservatives absolutely don't want to be told by the government to be vaccinated. With both conservatives and liberals against vaccinations, it does not take long before the moderates follow suit.

To round out the opposition to vaccinations, the public has a profound (and somewhat warranted) distrust of pharmaceutical companies. As seen in the proposed health care reform bill, and current health care ledgers, pharmaceutical companies make a substantial profit off the American public. I have often met with my representatives and senators to express concern of this conflict of interest and the detrimental effects of allowing pharmaceutical companies to continue this trend. Rather than listening to myself and others who have the same concern, the government decided to position themselves in a way to also make a profit. After not trusting the government and pharmaceutical companies independently, there's almost no reason to trust them together. Despite my firm discontentment with the government and pharmaceutical industry, I tend to agree with the decision to vaccinate. Pharmaceutical companies stand to profit when medications are brand name. When they are generic and off patent, the profit margin significantly decreases. The cost to the public is between $10-20 per dose for the H1N1 vaccine. Many places will administer the vaccine for free. Contrast this with the brand name HPV vaccine which is more than $100 per dose and requires 3 doses. The government has accepted a contract with pharmaceutical agencies where the government incurs 40% of the cost. The reason the government subsidizes the manufacturing is because it would not be profitable for the pharmaceutical agencies to sell the vaccines without this joint venture. We all know the government doesn't do anything out of goodwill, so the government benefits through the millions of productivity hours gained by people not being sick with the flu. Additionally, the government doesn't have to pay for the hospital bills for the sick. If there ever were a win, win, win situation, this would be it. The business benefits with profit, the government benefits by saving money and productivity, the public benefits by staying healthy.

The latest fad is to go "green." Many individuals argue the biomolecular engineering of a vaccination is "messing with nature" and we should just use vitamins and have a healthy lifestyle. Although I agree with trying to maintain a healthy lifestyle, the problem with this argument is: natural does not mean safe, manufactured does not mean deadly/dangerous, and vitamins and a healthy lifestyle alone do not guarantee a disease-free existance. We know so many things which are "natural" and still harmful. Cocaine, marijuana, heroin are natural... and are illicit drugs! Millions of patients are hospitalized each year because of complications from vitamins! You can even drink yourself to death with water! Clearly, a balanced lifestyle is important, but to say green is safe is misleading and dangerous.

As an aside, the "green" agenda has benefited Al Gore millions. Additionally, albuterol inhalers were off patent and are a life-saver for asthmatics and patients with COPD. With the new regulations on CFC's, they have gone from being around $5 to around $50! That's a 1000% profit change for the pharmaceutical companies! Environmentalist cite the CFC's are harmful to the ozone. The problem is, the medication goes into the lungs and not the atmosphere! If you want to see how the government is getting their share of the profit, look at the cap and trade bill. By using "global warming" and "environmental protection" they are now taxing every manufacturer an additional amount. I believe it is important to protect the planet, but the weather cycles. The planet has been warmer and colder than this in the past. There is NO scientific evidence of global warming because it cannot by definition be scientifically tested. We cannot reproduce it, we cannot manipulate it, but as you can see, the government can take advantage of it!

On the flip side, manufacturing does not necessarily mean dangerous or deadly. Advances in engineering, production, and biochemical research have saved millions of lives. From stronger larger crops, to safer running water, to safety features on cars, technology has been shown to save lives. We have eliminated smallpox through vaccinations, and many other diseases are being eliminated also. Clearly, there are benefits to using the minds we have been given.

What if we eat naturally, take vitamins, and exercise? Does that keep us from getting sick? This should be a rhetorical question, but many believe it does. If you look at individuals who do their best to be vegan, do yoga, and stay clear of vaccines... they still get sick and die. Everybody dies at some point in their lives. There is a very large population of Amish near my hospital. Believe it or not, they still come to the hospital because they get sick. Before technological advances, settlers and native americans got sick. If you look at life expectancy from the past until now, it's pretty clear technological advances have increased length of life... and possibly quality of life independtly of vitamins and "green" living.

After careful consideration, I agree with vaccinating according to the CDC guidelines. (http://www.cdc.gov/h1n1flu/vaccination/public/vaccination_qa_pub.htm) I don't believe individuals are "bad" if they don't vaccinate themselves or their families, but I do believe the benefits outweigh the risks. I am extremely skeptical about the H1N1 vaccine, but I do not find medical grounds for recommending against vaccination. I received both the seasonal and H1N1 influenza vaccines. I encounter sick patients every day, and it is extremely likely I will encounter a patient with H1N1 or the seasonal flu. As a duty to my patients, it is responsible for me to get the vaccines so I don't inadvertantly infect my patients who are unvaccinated and not infected. People have very valid concerns about the risks of the vaccine. Often, I believe the risks of vaccination are overstated or incorrect.There are risks in everything in life. We get in our cars every day and weigh the risk. Ultimately, the decision must be made by the individual. As I stated before, we as adults must make an adult decision weighing the risks and benefits. We must also take responsibility for the consequences. I believe the best and most responsible decision is an informed decision, and I hope my blog is helpful in achieving that decision.

My letter to my colleagues

We were once different. At one time in the not so distant past, there were 3 professions known as the “learned professions.” These professions were revered and respected, where its members were looked upon to protect the most important aspects of human life. For the unparalleled hours devoted to intense training, we were trusted to self-regulate, to draw on the best resources the country had to offer to serve our fellow man, and to earn a fair living. The only other “learned professions” were theology and law. Through a series of cataclysmic events, the learned professions came under intense fire, with the exception of one- but it isn’t ours. Are we still professionals?

Self regulation is one of the major components of the learned professions. We’ve all been there: Daily rounds where we are mercilessly “pimped,” standardized tests so often it feels like we’re testing every month, and the dreaded “morbidity and mortality” conferences where every move is scrutinized to the smallest of minutia. Despite how it may sometimes feel, these are good things. Look instead at what is happening now. Five years ago, I walked up the Capitol steps to meet with my senator, Dianne Feinstein, regarding Tort reform. I argued it was a threat to our profession, it was bad for patient care, and would ultimately cause ruin in our health care system. Although I wasn’t the only one, the few of us who descended upon Washington, D.C. weren’t enough to reform the practice of suing without limits. Four hundred million dollars a year later into the pockets of trial lawyers, the health care system is in shambles, physicians are having trouble paying back student loans, the numbers in primary care have dwindled to a splattering, and we are under the assault from the nation and even the president himself. We are looked upon by our patients as sometimes uncaring and inconsiderate as we leave them waiting while we fill out endless forms. We have become relegated to “providers” as we now are checking boxes and performing algorithms. Even our own president accuses us on national television of banding together to cut out tonsils and cut off legs for more money. Clearly, we are no longer trusted to police ourselves.

Roughly 40 years ago in 1965, the program called Medicare started. About 35 years ago, the Health Maintenance Organization act passed in 1973. With the formation of these entities, the best resources the country has to offer became less at our disposal. Terms like “pay for performance,” “preauthorizations,” and “rationing of care” became household terms. Years before, I sat in my high school classroom reading 1984 and about medical ethics believing we would never get here, but here we are. “Death panels” may or may not be completely accurate, but is “allocation of scarce medical resources” really that far from the truth? Whether we believe the actual terms are correct, it is happening. The problem is, it is happening and we are sitting on the sidelines. Once regarded as a “holy sanctuary,” the exam room has been infiltrated by CEO’s and special interests. Our decisions are made by “defensive medicine” and reimbursement. We have lost our self direction and ability to use all America has to offer to help our patients.

In regards to making a fair living, I don’t believe I need to talk about diminishing reimbursements and increasing medical school loans. Rather, I will focus upon fairness. Legislation is in process which would penalize physicians who are in the top 10% of Medicare cost 5% of their reimbursement regardless of the reasons. What greater incentive would a person have refuse care to the sickest of patients in an effort to avoid being in that 10%? It is then upon our conscience to harm people so we can feed our families and pay our bills when we took an oath to the opposite. Furthermore, someone will be in that 10% no matter what. If they are doing what is right for their patients, do they deserve to lose 5% of their income? Also, pay for performance is making its way through the legislative process. If the government has its way, even if our patients refuse to make changes to improve their health, we will be penalized for it. We will see reductions in our reimbursements despite making the correct medical decisions. Additionally, if a patient doesn’t respond to our treatments and requires longer hospitalization than what has been “deemed acceptable,” their extended hospital stay will come directly from our pockets. Furthermore, the protections of the conscience clause are not being included in the health care reform bills. This means we are open to not being hired, being fired, being sued, or being forced to perform procedures we find morally, ethically, or religiously objectionable. To top it all off, a National Provider Database has been set up in which any adverse action taken against us becomes public knowledge whether or not it has any merit, or we actually become convicted of the charge. This means there remains incredible incentive to sue us, and then we have it affect our record whether or not it is true. Some states also have a “3 strikes” law in which three accusations against us results in disciplinary action regardless of the validity. Even child predators are granted due process under the constitution! Evidently, fairness is not a principle which legislators believe applies to physicians.

As you can see, our profession is being systematically dismantled as we stand by and watch. With all the publicity of the recent reform bills, this is our chance as physicians to take a stand for ourselves and our patients. Irrespective of your political viewpoint, I argue there is more we want for healthcare reform than what HR3200 currently gives us. Our greatest leverage is before a bill is passed. Once a bill passes, we may find ourselves in the same position as tort reform: standing around complaining about what should be. Please take the time to tell your friends, family, and patients your views when appropriate. After all, it is their healthcare, our healthcare, and all of our lives at stake. Never before in our lifetime have we had such an opportunity to make a difference in the lives of our patients, family, friends, and neighbors. Health care reform will pass no matter what because it needs to pass. When and what type of health care reform that passes I hope will be up to you. If you don’t make it your goal to be a part of the change, you leave it up to lawyers and legislators to do it for you. We have all seen what happens if we allow that to come to fruition. Please call the Capitol switchboard at 202-224-3121 and speak with your representative about what you, as a physician, want done in health care. We have less than 3 weeks to be heard, as HR 3200 reaches the House floor for vote in 3 weeks. When done, please forward this letter to as many fellow physicians as possible. If you do not know your representative, please go to https://writerep.house.gov/writerep/welcome.shtml.

Respectfully,
Johnny Do

This isn't about health care anymore...

Just when you thought you had heard all the rhetoric possible, you hear about "death panels, evil mongers, unpatriotic, unamerican, villains, socialists, nazis, mobs, and astroturf" to name a few. You hear about bipartisanship, and then republicans unanimously opposing and democrats vowing to pass the bill unilaterally. What really is the issue? The argument has been superfluous at best, but the selling points have been to conceal the underlying themes of "no big government" and "universal care." If that's the point, why are we arguing about everything else and not the real issue?


The selling points in support of the proposed health care reform bill are: not being able to deny coverage based upon preexisting conditions, giving all Amercan citizens healthcare, arming the patients with information about end of life care, and supporting a standardized minimum level of care to protect both adults and children. The argument against this has been increased spending, diluting health care, less individual control, rationing of care, and loss of conscience.

If the arguement is solely about health care, why can't we agree upon a plan if we all want health care? The real issue is actually much deeper than the selling points. The selling points are there to intentionally or unintentionally distract because if the root of the matter were really being argued, we could never even hope to agree on the bill. The conservatives argue the issue is about the intrusion of government onto personal rights. They argue they support universal health care, but not in the proposed bill Obama would like to pass. The liberals argue they want universal health care, and this is how we address it. They deny a "government takeover."

So let's take a look at what's really going on. If the republicans argue this is a government takeover, can there be any merit to their arguement? Health care accounts for one fifth of the nation's total economy. During this present administration's short time in office, they have proposed sweeping legislation to control the financial sector, automobile industry, education, and energy. Keep in mind, they already control the millitary, and continue to seek to disarm the public with gun control legislation. With the government controlling and seeking to control basically every aspect of the American life, it is very reasonable this is a move from liberals for a government takeover.

On the other hand, the liberals argue this legislation will adquately deliver much needed health care to all American citizens. I disagree with this statement for many reasons. First, having insurance does not equate with having good health care. The government will tell you otherwise and cite a Harvard University study done over 10 years ago. The study is a comparison in health outcomes between the insured and uninsured. The problem with the study is it can never account for all the reasons an unisured person can be more sick than an insured person. This doesn't mean that insuring the person will give them good health. Maybe the unisured person has bad habits which a person who went out and bought health insurance doesn't have. Also, the criteria for judging health was a subjective rating by both the patients and doctors. If I wanted to have someone give me health insurance and I were uninsured, would I write on a survey I believe my health is better than an insured person's health? Absolutely not. Futhermore, if I spent my hard earned money and purchased insurance, would I say I think my heath is worse off by having insurance? You can see how subjective ratings can be misleading. What is ultimately the most misleading is that the study compares the uninsured with people who bought private insurance. It threw out medicare and medicaid which are government programs. I have argued private insurance is much better than the "public option" or government insurance. If anything, this study would support my argument better than theirs. Of course private insurance health outcomes are better than uninsured. Why don't they compare the uninsured with the government plans since that is what they are arguing for? This question is left mysteriously unanswered. One thing is clear, private insurance exceeds non insurance.

How does private insurance compare to public insurance? The two most logical comparisons would be between the United States and Canada, and the United States and Western Europe.
I've already written before about how cancer survival rates are much better in the United States than Europe or Canada. Likewise, the time to see your physician is much less. I'll instead take this moment to address the counter argument from the liberals. Michael Moore produced a statistic which shows infant mortality is less in Europe and Canada than the United States. What he fails to report, is that the definition of when we consider a baby alive is different. For example, viability in America is defined at 22 weeks, whereas 28 weeks in France, Denmark, and Sweden, 24 weeks in Italy and the United Kingdom. This means, they don't calculate the death of an infant earlier than these dates. Naturally, the United States would then register a higher infant mortality rate. If you look a the numbers, the infant mortality rate in America per 1000 live births is 6.3, 5 in Italy, 4.8 in Canada and the UK, 4.2 in France, 4.4 in Denmark, and 3.2 in Sweden. So the thousands of additional births in America at weeks earlier gestational ages results in 1.5-3 additional deaths per 1000 births. For any of you who have been around pregnant women, the difference between a 22 weeker and a 28 weeker is night and day. So much development takes place, it's actually extremely remarkable the United States does so well. With the recent adjustments made to make the statistics more comparable, other countries numbers on infant mortality now surpass the United States. It is very reasonable to say, therefore, the care in the United States surpasses that of countries which utilize a government/universal health care system.

So the government plan does not necessarily deliver better health care by insuring Americans in general, and also does not necessarily deliver better health care than what we already have. Is the government plan more sustainable than our existing system? The other prominent government plan in the United States is Medicare. Currently, medicare is on schedule to go bankrupt in 10-15 years. Under the new health care reform bills, no significant changes are being made to medicare. This means it will still go bankrupt in 10-15 years. What will happen to all those people when medicare goes bankrupt? If you look at the reform bills, the financial projection is for 10 years. We've heard the price tag for this plan to be between 1-2 trillion dollars. What we don't hear so much about, is that for the health care reform bill to even have a "chance" at breaking even, it needs to pull money from other bills such as "cap and trade." President Obama says he needs these other bills passed in order to be able to provide health care. Does that mean he's trying to use healthcare to get other bills passed, or does that mean he hasn't came up with enough money to balance the healthcare budget? Either one is inexcusable. If he can't even balance the budget in his 10 year plan without taking into account a faltering medicare plan, what makes us think he can do it after 10 years? I have already argued Obama would likely take the money from elsewhere (rationing of care, higher taxes, etc.). Clearly, his plan is not selfsustaining, and would likely go bankrupt at the same time medicare does, unless the United States goes bankrupt first.

So what's my recommendation? Part 2

It is clear something needs to be done about health care in this country. It is without a doubt a major problem, and calling it a "crisis" is not too far from the truth. That does not mean, however, we must rush to just ANY solution rather than wait and look for a good solution. Health care has been in crisis since the early nineties and arguably since before the Great Depression. Medicare was first proposed following the Great Depression in 1945, by Harry Truman. Twenty years of debate later, Medicare was started in 1965. Medicare is projected to go bankrupt in 2019. I personally do not have a problem with a government program made to act as a safety net for those who need it. My concern grows when the government becomes such a large entity that the private sector cannot compete. We have already seen this government program called Medicare fail, and I believe it is a bigger mistake to establish a much larger government program in its place.

Ironically, Democrats assert that private programs exist outside the government and in fact thrive. In a rather poor argument for his health care plan, Obama himself stated that UPS and Fedex do "just fine" and it's the "postal service that has all the problems." Why then would we need a larger postal service with all the government inefficiency and beauracracy? Why not improve the existing postal service (or allow UPS and Fedex to thrive and pick up the slack)? Likewise, Medicare is failing, and I will soon give some good reasons why it is. Why not eliminate those problems rather than making a larger goliath that is more of a fumbling baffoon than the first?

Capping malpractice lawsuits/Tort Reform has long been the most needed change in health reform. Currently, only certain states have placed restrictions on how much money a person can sue for. This is problematic because there are no laws against suing in general, and when there are no limits, there's really no harm in filing a lawsuit. Additionally, many lawyers will take the case based upon a potential settlement without any cost up front. This creates a major problem because there is substantial financial incentive without deterrent or regulation. In fact, many cases are settled outside of court, despite no wrong doing from the physician, just because a trial costs much more money. Malpractice insurance then increases substantially, and physicians begin practicing "defensive medicine" where they order more tests just to protect themselves from a potential lawsuit. This also drives physicians away from areas needing physicians because it costs too much to practice in that area due to malpractice insurance, or the risk is too high because one lawsuit can devastate an entire career. Tort reform would therefore:

1)reduce paperwork
2)reduce unnecessary tests
3)lower malpractice insurance
4)increases access by encouraging providers to serve all geographic locations


Another way to decrease the cost of healthcare is by restricting pharmaceutical advertisements. We have all seen those drug commercials on the televsion set, but we never know what they're for. All we know is, a middle aged man is throwing a football through a tire and then going away with some woman we presume is his wife. Sounds sort of benign, but what does that commercial do? From the very beginning, people have been skeptical of doctors receiving incentives from the pharmaceutical industry, and for good reason! All the studies demonstrate drug representative dinners hosted by pharmaceutical companies does influence prescribing practices. So the lawyers caught on and introduced legislation to prohibit pharmaceutical companies from "buying off doctors." No problem there; I made it my own decision not to be influenced by drug companies long before that law came into effect. Many of my colleagues did the same. The reasoning is this: having a really nice dinner for free, or whatever else they give you, really isn't. Nothing is free. Universal health care is NOT free. A dinner by the drug companies is NOT free. The truth is, less than a quarter of the total budget of pharmaceutical companies actually goes to research, development, and production. More than two-thirds goes to marketing and advertising. The drug companies spend millions of dollars on these 2 minute commercials because physicians have chosen not to allow them to influence our prescribing habits. They now have the patients ask us if the drug "is right for you." Which amounts to the same thing. I was opposed to drug rep dinners because the dinner wasn't on the drug company, it was on my patients. The cost of advertising and marketing (or soliciting doctors) gets passed directly on to the consumer. The pharmaceutical company is in it for the money. You can ask a few of my friends who have worked at drug company parties how much they're bringing in. The millions of dollars in a commercial is passed directly onto the patient. That's why brand name drugs cost an arm and a leg! Think about it, when was the last time you saw a commercial for penicillin?

We have already heard of the government's plan to impose a tax on "junk food." Rather than having the government regulate everyone, why don't we regulate those who are already depending on the government? Advanced disease conditions are already associated with lower socioeconomic status. Why don't we prevent part of this by regulating use of food stamps for "junk food?" A person could argue we tax cigarettes because they are unhealthy, why should junk food be any different? Cigarette smoke is correlated with disease, but it affects everyone and is therefore a greater public health issue. The risks of second hand smoke are well documented, and if it causes an increase in our health care costs, by all means it should be taxed. Eating a hamburger does not harm the person who is in the room with you while you eat it. If the lower socioeconomic class creates a greater burden on the system by depending on the system for food stamps, and then also by having poor health, why not reduce the strain on the system by promoting healthy food consumption? The government already regulates food stamps so that a person cannot by drugs or alcohol, it would be fairly simple to extend it to junk food.

Another option would be to allowing insurance companies to cross state lines. This would encourage competitive rates throughout the nation rather than in states alone because the insurance companies could negotiate deals with hospitals and physician groups are a broader scale. It would also allow greater access to care and reduce costs in other ways as patients would not have to worry about being "out of network." Obama has stated he believes the bad guys are, in addition to doctors, insurance companies. Similarly to pharmaceutical companies, I don't believe insurance companies themselves are the problem. I believe the problem is allowing various sectors of the health care industry to go relatively unchecked. By placing regulations on the insurance companies, we can avoid the problems, and still reap the benefits. Just like banks are not the problem, unchecked banks who give bad loans to everyone are the problem.

One important issue that hasn't gotten any media attention, but deserves just as much attention as Obama's healthcare reform plans, is illegal immigration. Please note the emphasis is on "illegal immigration." Obama's plans for next year have been stated to include legal immigration, but the discussion on illegal immigration has been surprisingly absent for the last decade.

The most illustrative perspective of this problem is from the perspective of what is happening in California. Please note that I did two years of family medicine residency in Santa Ana, Southern California. Emergency rooms around the entire southland have shut down permanently due to the strain on the hospital - much coming from undocumented immigrants who cannot or will not pay for care. Typically, emergency rooms aren't a very lucrative investment for hospitals unless they are able to admit patients to the inpatient service. Unfortunately, hundreds of thousands of emergency room visits are for uninsured patients, and additionally uninsured undocumented patients. ER's are not permitted by law to turn anyone away, consequently they absorb the brunt of uninsured undocumented patients.

With all of the manpower involved in the ER, this can be a very costly endeavour if the patients cannot pay, will not pay, and there is absolutely no recourse to make anyone else pay. They get all the best resources the ER has to offer, and they are discharged. That's the best case scenario. What happens when the patient is really sick and needs additional care? The hospital cannot turn the patient away from the ER in the first place, and therefore also cannot turn them away if they're really sick and need to be admitted. The hospital then admits them, and they are treated on the inpatient service even though they still can't pay.

The consequence is we all pay. All of us tax paying Americans. A couple cases here and there aren't a big deal, but when hundreds of thousands of people use the ER to see any doctor because it's free health care for them, it becomes an enormous problem. I see people for colds every day, just because they can't or won't pay for a clinic visit. It becomes the most expensive clinic visit ever, but at the American tax payers' expense.

Additionally, why not go to the hospital for an expert opinion for everything if it's free? I have seen a child run into the emergency department and jump on my lap so I can examine his scraped knee. If a child runs through your office and jumps into your lap, chances are there's nothing wrong. It was even worse because mom didn't even clean it or look at it. She didn't have any reason to do anything - we would do it for her for free.

Additionally, illegal immigrants also do not have the same vaccination policies and health care from their native countries. They may expose our current population to communicable diseases which otherwise may be eliminated from our society. This can be seen in the rise of pertussis, tuberculosis, measles, etc.

There is also the phenomenon of "anchor babies." The law is interpreted as anyone who is born in America is now an American citizen. Illegal immigrants count on the sympathy of Americans to keep them in the country because if their baby is born in America, we wouldn't separate them to send their parents back to their country of origin. This places tremendous incentive for them to utilize the health care system. If they wait until they're going to deliver, run into the hospital for free health care, their baby and themselves are taken care of, the baby is documented as a citizen, and they have just punched their ticket to stay in America- all on the tab of the American tax payer. What makes it worse, is these babies have little or no prenatal care. The physicians have no idea what they're walking into, and these babies can potentially be very sick.

Even more difficult than seeing an illegal immigrant receive care for free, is seeing a tax paying American citizen get the same exact care and having their savings wiped out, their credit destroyed, and their wages garnished because they have a social security number. Why should people who haven't contributed any taxes to our system be bailed out for free, when someone who has contributed their entire life gets everything taken away from them? It should not be a punishment to be a tax paying American. What is important to note is that equality does not mean equivalence. I believe people have the same inherent worth, but that doesn't mean they should get the same treatment. We love our children the equally, but we wouldn't allow our 5 year old to drive our 16 year old's car. Likewise illegal immigrants are equally as valuable as citizens, but that doesn't mean illegal immigrants should recieve benefits at the expense of tax paying citizens.

I do believe emergency rooms should always be available for everyone, no matter what their citizenship, in the event of an emergency. However, I believe if they are not an American citizen, after their condition is stabilized, they should be deported to their country of origen. This alone would decrease the burden on our health care system by hundreds of millions of dollars.

Passing legislation to close our borders and elimate "anchor babies" would therefore:
1)ease burden on emergency rooms
2)eliminate wasteful spending
3)focus health care attention on tax paying Americans
4)decrease potential risk of some diseases

My final point I believe everyone would agree with. It is important to legislate against denying care based upon preexisting conditions. Obama stressed this as an important point, and I agree completely. I don't, however, believe we must implement universal health care reform to do so. Simply making a bill to stop health care insurances from discriminating against people with preexisting conditions would do the trick just fine. By doing so, it would allow equal access whether or not a person is already sick, it would increase preventative care because their condition can be treated before it gets worse, and it would encourage patients to obtain health insurance for other medical needs. A simple solution to cover the cost, rather than overhauling the current health care system, may be to increase copays.

These points I've presented are not new to health care reform, but have been argued for years without any response from the politicians. Rather than creating a brand new health care system, why not implement these changes to improve the current system? As I've said earlier, a health care "crisis" does not mean we opt for the first suggestion that comes along, but we instead carefully plan out a health care system which would be maximally beneficial and reasonable for everyone. These changes are a good place to start while we're working those details out.

Why all this now?

Physicians have been surpisingly quiet in the past during health care debates. There are many reasons for this. First, we are extremely busy. We spend over 12 hours a day (sometimes 18 hours a day) working, and any extra time is usually spent with family and friends. Very rarely will you ever find a doctor doing nothing for extended periods of time. It just isn't in our wiring to be sedentary. Most of us are "type A" personalities, and we feel guilty sitting around. While we spend so much time working, that gives us less time for advocacy. Going to Washington, D.C. to speak with congressmen is hard work, and it takes massive coordination. It's rare for us to have multiple days off, and even more rare for them to be in a row.

Second, doctors are taught to be as sure as we can about things, but we've seen nothing is ever "black and white" or clear cut. Unexpected things happen all the time, and we can't tell the future any better than anyone else. It may be a product of our culture, but that makes us not as vocal when asked about our opinion. We try to be sensitive to others, and as I've said before, if this were a completely one-sided issue, everyone would probably be on the same side. These issues, however, are multifaceted and we often have to concede one point in order to obtain another. Just like voting for a president often feels as though you're voting for the "lesser of two evils," health care legislation is usually loaded down with "pork," special interests, and other uneccessary provisions. We also try to be sensitive to others' viewpoints. It just wouldn't be very "kosher" for a physician to get in a debate with a patient during an appointment, and would actually be counterproductive. A patient has probably waited a long time to see their doctor for a medical issue, and it takes time to get the correct diagnosis and treatment. It would be wrong to spend that time on politics, or to take that time away from someone else who needs treatment.

Third, law isn't our area of expertise (just like medicine isn't the area of expertise for lawyers and politicians), and we really don't like how it has intruded on our ability to practice medicine. All doctors are familiar with malpractice, and it's like driving a car: you're likely to get into an accident someday. It is the norm for a physician to be sued at least once in their lifetime. For that reason, we quietly despise getting involved in law. Furthermore, part of the push for physicians to become specialists is that we are "type A." We want to be good. We want to know something really well. If we're not trained in it, we likely don't want to comment on it as much because we don't want to be incorrect or wrong. If you spend any time watching TV, you can see the "beat down" residents get during their training (on a side note, the TV show Scrubs pretty much hits the nail on the head).

On a personal note, I am absolutely opposed to "lining the pockets of politicians." I believe a person does that "right thing" because it is the "right thing to do." It makes me furious to have to pay someone for my rights, or the rights of my patients. Lawyers knew of the conflict of interest created when money gets involved in patient care. For that reason, multiple laws have been passed to prevent money from being the determining factor of someone's health. In every other field, a person can receive monetary or tangible incentives for their business. It is not uncommon to go golfing, to a show, or on a vacation in other businesses. It is unethical in our business. Laws were passed to keep pharmaceutical companies from "buying off" their doctors prescribing practices. I myself was opposed to getting freebies from pharmaceutical companies before rules were passed by residencies prohibiting such a practice. Furthermore, physicians hire office staff for their accounting, because we don't like getting bogged down in the billing aspect. We are much more interested in proper diagnosis and treatment. Call it a weakness, if you will, but wouldn't you rather your doctor spend time treating your illness correctly instead of cashing his checks? For goodness sakes, we go on missions trips ALL THE TIME to give free health care to people- on our vacation time!


Activism organizations have been set up to represent physicians on these important issues. Each of our professional affiliations have an advocacy wing. Unfortunately, those organizations don't always represent the views of their constituents. Sound familiar? Congress seems to have the same problem. There is nothing more infuriating than your representatives not representing you, and instead representing their own interests, agendas, or political goals.


I chose to finally blog about this now because this is a pivotal time in health care for our country. There are definitely important issues to address and, if we are not heard, the United States may go down a path that would take years if ever to repair. I hope my opinion gives all you readers a greater perspective from a physician's viewpoint on the situation we face in the American health care system.

So what's my recommendation? Part 1

If we could have the perfect healthcare system, what would it look like? It would be affordable, everyone could get it, you couldn't be rejected for preexisting conditions, you didn't need pre approvals, you could see your doctors whenever you wanted, doctors couldn't get sued for tons of money, doctors would still be held accountable for delivering good health care, you could see whichever provider you wanted to see, prescription drugs would cost as much as generics, medications and services would still be good quality and consistent no matter where you went to get them, waste would be minimized, and everyone gets a fair share for honest work.

Healthcare can therefore be divided into these categories:

Quality
Accessibility
Cost
Autonomy

As far as quality goes, America ranks amongst the highest quality health care systems in the world. Technology is unmatched, and outcomes are comparable if not exceeding other nations. According to the Lancet Oncology journal 91.9 per cent of American men with prostate cancer were still alive after five years, compared with only 51.1per cent in Britain.
The same publication suggests that 90.1 per cent of women in the U.S. diagnosed with breast cancer between 2000 and 2002 survived for at least five years, as against 77.8 per cent in Britain. Overall life expectancy in general is very similar between the United States, the United Kingdom, and Canada; varying only 2 years according to the World Health Organization (WHO). Wait times are comparable if not shorter in the United States. According to the nonprofit Commonwealth Fund, which studies health-care policy, U.S. patients had the second-shortest wait times if they wished to see a specialist or have nonemergency surgery. Germany was the fastest, which does have nationalized health care, but interestingly has gone through massive reform recently with the conservative party taking control. So the question then is not whether or not the health care in the United States is any good, but is instead if the health care in the United States will be the same or better with Obama's proposed reforms. Technology shouldn't be affected very much, but if you bombard the health care system with 40 million more people without changing the number of practitioners, it is doubtful the wait time will decrease, or that the outcomes will improve.

After comparison has been made to universal health care models in other countries, the argument could be posed that our society is somehow different. We do things differently in America for sure. What would it look like if the government had a larger role in the health care system. To do that, we can look at what the government already does in health care. The best example of currently government run hospitals are the Veterans Hospitals (VA). Without even attempting to find written evidence VA hospitals are poorly run, I can tell you first hand of my experiences there. I also challenge you to discuss with ANYONE who has worked at the VA hospital in ANY CITY about how terrible the health care can be. I have worked at the VA in Lebanon (PA), Phoenix (AZ), Long Beach (CA), Hampton (VA), and Portland (OR), so I would argue I have a fairly representative sample.

Employees in the VA system run on a different time scale than the rest of the world. If you thought government employees at the DMV were slow (no offense, but we all know it's true), just imagine if your grandfather were dying and we needed a CT scan. He may get one tomorrow, or monday if it's the weekend. It better not be a holiday on monday, because he'll definitely have to wait until tuesday. What about blood? If your same grandfather came into the VA complaining about chest pain and needed to be evaluated for a heart attack, we draw blood every 6-8 hours to make sure his heart is ok. There better be someone else who knows how to draw blood because the ONE phlebotomist in the ENTIRE hospital may decide to take a break, not come to work, or quit without telling anyone. Yes, all three have happened to me, and I drew the blood MYSELF because I didn't want my patient to die. Now I don't think I'm above drawing blood, but if every doctor had to perform each test he ordered himself, no patients would be taken care of. That is why we do hire phlebotomists, nurses, and technicians. A person may argue it doesn't take that long to draw blood. Try doing that on all your assigned patients in the hospital, and then there's definitely a problem. For the sake of argument, I'll give you an example of something that takes longer than drawing blood. A man comes into the hospital with liver failure and about 8 liters of fluid in his belly. He's having a lot of abdominal pain, so I perform a pericentesis where I stick a needle in his belly to drain the fluid for comfort and to make sure he doensn't have an infection which can kill him. I drain the fluid and take the sample down to the laboratory and order a stat gram stain and fluid studies to make sure he's not infected. The lab tech responds by asking me if I know how to do a gram stain because he doesn't "feel like doing it." Once again, I'm not above doing gram stains, and I did them in medical school, high school, and college biology. The problem is, you have to put the sample on a slide, dry it, stain it twice, and look under the microscope. This is something a physician would rather not do when he's on call, and all the new sick patients need his attention, but yes I did the gram stain. I have also wheeled my own patients to the CT scanner, MRI, and Xray because nobody else wanted to do it. To make things worse, I've had at least a couple patients who the nurses decided to let stay at an oxygen level of 60% without calling a doctor because they didn't feel the need. Just so you know, a person needs much more oxygen than that, and all of them died that morning. I filed incident reports on all of those, and the people still work at those same hospitals. The problem is, my experience is not unusual, and I doubt anyone would want that kind of care for their loved one.

In regard to accessibility, I would argue EVERYONE in America has the potential to access the health care system. This doesn't mean everyone has good care, but everyone can obtain health care in one way or another if their life depended on it. There are private hospitals if the patient can afford it, there are county hospitals if they can't afford it, and there are countless low cost commuity clinics to render care to people. There are also many charity programs available. Please don't take me as saying I am satisfied with the current state of healthcare, but rather there are minimum standards currently being addressed in America. Why then would the entire health care system require an overhaul to a completely different system if a little improvement could go a long way? I'll discuss my ideas for improvement shortly.

One last comment before I discuss some suggestions we initiate prior to revamping the entire healthcare system. I believe everyone should have health care, but I don't believe everyone should demand it from others or be entitled to it. What ever happened to personal responsibility? I would like everyone to live in a big house and have lots of money, but that's not how the world works. In fact, I work very hard for my salary, and would like to choose to who and what cause it goes to benefit. The private sector donates millions if not billions to charity and health care in various forms, why should everyone then be mandated by the government to give a percentage of their hard earned money to specific causes they don't believe in? I volunteer at free clinics, go on medical missions trips, and contribute my share in addition to taxes to the poor. I don't believe everyone should be FORCED to do what others do voluntarily. Why did some of my patients at an underserved clinic in Santa Ana, CA come to my clinic driving a better car than I do? That's not me saying I want a really nice car, that's me saying they can probably afford to pay for their care. Monthly insurance costs roughly $300 a month. As you add people/dependents, the relative cost per person decreases. It comes down to priorities. If they value a nice car more than they value health care, why should someone else pay for their health insurance? If they truly are unable to pay for it, as I've stated before, there are programs to assist them.

The AMA, AAP, ACP, AAFP

If physicians are too busy taking care of patients to devote a lot of time to advocacy, who does this for them? That's a great question! Each specialty has an organization which represents them, and a professional membership that they can obtain. In each group, there is a specific wing dedicated to advocacy. The problem, however, is the group doesn't necessarily represent the values of their constituents 100% of the time. We all know how frustrating it can be when your elected official decides to pursue their own agenda for the sake of their professional advancement, or personal beliefs. We also know each person is also interested in job security. Unfortunately, the most vocal (and the group which donates the most money) often gets disproportionate representation. This is no different in politics or professional groups.

Since the days of Andrew Jackson (who was notorious for this practice), politicians reward those who support them. Obama is no different in this course of action, as you can see the millions of dollars in earmarks added at the last second to his bills once he became president. The AMA, AAP, ACP, AAFP, and other groups all met with Obama in the infancy of his health care reform bills. Previously, they had supported other measures (Tort reform for example), and following the meeting they publicly endorsed Obama's plans, even though the plan is not necessarily in the best interest of physicians or patients (see prior posts). Of course, going into the meetings, they had some pretty significant concerns. Do we honestly believe when we watch months of debate, that the questions were all answered in those brief meetings? I would hope not. It would be more reasonable to believe there was some incentive for changing their position.


We can see an example of incentive and reward in the pharmaceutical industry. According to Bloomberg, "two firms that received $343.3 million to handle advertising for Barack Obama’s White House run last year have profited from his top priority as president by taking on his push for health-care overhaul. This year, AKPD and GMMB received $12 million in advertising business from Healthy Economy Now, a coalition that includes the Washington-based Pharmaceutical Research & Manufacturers of America, known as PhRMA, that is seeking to build support for a health-care overhaul." Besides having already received massive compensation for their efforts in getting Obama elected, they have the potential for substantial gains if his health care plan goes into effect.

How, you ask? Allow me to explain. In medicine, there is something called a formulary. This is a list of medications the hospital has chosen as the first line agents it keeps available for use. For example, there are many competing "statins" on the market to treat cholesterol. The hospital chooses a particular drug because the hospital has worked out a deal with the distributor to get the drug at a lower cost. This helps the pharmaceutical company because its drug is chosen over other cholesterol lowering agents, and the company is banking on the number of people who will be using the medication. It helps the hospital because the drug company offers the medication at a lower cost. By "scratching Obama's back" (multiple times), the drug companies have a lot to gain. There is a good chance that the government will decide which drugs (manufactured by certain companies) a hospital can use to "control costs". Does this sound like special interest to anyone else? Oddly enough, Obama and other politicians refuse to pass legislation against pharmaceutical agencies. Instead, insurance companies are "villains" and doctors take tonsils out "for money."


What kind of incentives can Obama offer the various specialty groups? The AMA, for example, has been arguing for tort reform for nearly a decade without success. On the other hand, the current administration has been steam rolling bills through the house and senate without pause. If the specialty groups would like a different type of legislation passed, it would be plausible to assume cooperating with Obama on his most aggressive reform to date would be a good starting point. Additionally, one of the techniques to get a bill passed is to make it appear as though it is inevitable for that bill to be passed. Politicians don't like to vote on the "wrong side" because the people who maintain power passed the bill. It would make for difficult working conditions later.


It is far easier, then, to go along with the health care reform bill if:
1) it's presented as though it's going to happen anyway
2) what you're already seeking seems unable to come to fruition (tort reform)
3) current concessions or future promises are made by those in power to look "favorably" on your cause
4) you have a way to "spin" it so you still achieve success.
Keep in mind everyone has different priorities, and how we prioritize is only that. Just because we put something in a bill at the top of the list does not mean we want everything else that is included in the bill, nor does it mean we completely devalue everything else. Obama stood at a press conference recently amongst liberal Christian leaders who support his plan. They cited the need for universal health care. This is the same citation the AMA uses. Both groups believe that the uninsured are a priority, but it might not mean that they agree with the remainder of the bill. I discuss access to care in another post. First, I don't believe access to care is the primary problem. Second, I don't believe this bill adequately addresses this problem (also discussed in another post). Third, in some cases this may be a "smoke screen" or "spin" so both parties can claim "victory."

In any case, regardless if you believe Obama used the "carrot technique," these professional organizations are their own entity and do not necessarily exemplify the beliefs of their members. Personally, for every 25+ physicians I discuss the issue with, only 1 agrees with Obama's health care reform plans. Although this isn't a scientific argument, it just is to make the point that people have varying opinions - even physicians. The choice, ultimately, is in each one of us when we discuss these issues prior to congressmen voting on them in the future.

Tackling the numbers problem

So let's say this nationalized health care comes to fruition, what would that look like? For starters, many more people have to be insured. We have a limited number of practitioners, so more must be recruited. There is no way to churn out that many physicians in a short amount of time, so the health care will then mostly be managed by nurse practitioners, physician assistants, nurse anesthetists, etc. Although this may be very cost effective and address the immediate need, everyone must admit there is some benefit to having someone who has gone through the rigors of medical school, residency, and possible fellowship to examine a medical illness. Coughs and colds are one thing, but what happens when the cough is because of a rare toxic exposure? It's fine to say that's rare and doesn't happen very often. The problem is when it's your mother and she's dying because her asbestos exposure turned into cancer which didn't get detected early enough. That doesn't mean we shouldn't insure people because we don't have enough doctors, what I'm saying is this plan is not addressing all the needs at this time.

While we're discussing resources, health care costs have "skyrocketed." Fifty years ago, current and cutting-edge technology did not exist, but we now have the capability to do amazing things - which can be expensive. The question is, how do we give cutting-edge care to everyone? When we instantly increase the number of people with access to care, we now have to decide how much care to give. If we gave everyone total care with access to everything at our disposal, there is no way we can fund it. It's simple budgetting. We're feeding a family of 4 on a certain income. Now we're feeding a family of 40 on the same income. You can see, that would be impossible.

So Obama is proposing ways to increase the income or decrease the expenditure. Obama is brokering deals with hospitals and services to try to reduce the cost of care. This is no different than what is occuring right now. The other way to increase income is to increase taxes. He has said he would not tax the middle class; he also said he wouldn't tax anyone making less than 250K annual income. However, his own treasure secretary Tim Ghentner has said they would not rule out increasing taxes on the middle class. With the sheer volume of people in this country (40 million uninsured) it would be difficult not to increase taxes across the board.

The other plan is to decrease expenditures. He has stated numerous times that he believes cost is due in large part to wasteful spending. He then blames physicians for taking out tonsils for allergies in order to make personal gain, or for ordering unneccessary tests for the same reason. A quick day in the life of a physician and you can see why tests are ordered.

A Doctor's Dilemma

For instance, a person comes into the emergency room for a fall where he hit his head 3 days ago. He states he had a brief headache which went away within the first day. He's been otherwise normal and without any medical illnesses. His neurologic exam is normal. Evidence based medicine would state that for post-concussive syndrome, a person can have a brief loss of consciousness and headache with vomitting in the first 24 hours of head trauma. After that point, if symptoms improve, the risk of a head bleed is very small and does not require further examinations. That would mean no further testing is required. We can observe the patient safely, and have him return if things get worse. What do we do instead? We order a head CT scan without contrast to rule out a head bleed because we are afraid of being sued. Why you ask? Because too many doctors have been sued for outrageous amounts of money and were either forced to settle or lost the suit because of an adverse outcome which was not affected by the doctor's decisions. Often, the jury will have pity on the patient and/or does not understand medicine enough to see that the physician followed accepted standards of care. Unexpected bad outcomes happen just as often as unexpected good outcomes. The percentage of head bleeds in this case are extremely rare, however, they are still possible. The less than 1% chance of a head bleed can put a hospital out of business and/or destroy the doctor's career and send his family rocketting to the poor house. For that reason, the doctor orders the CT scan to CYA (cover your a$$ets). This results in thousands of dollars in wasted resources for "defensive medicine."

The AMA has sought for years to place restrictions on the amount of money a person can sue for (tort reform). In addition, frivolous lawsuits are settled all the time to reduce the cost of a lengthy trial. Suing for millions, or settling out of court, even when the doctor is not at fault is commonplace, and drives up the cost of malpractice insurance, which is then passed on to the patients. Attempts for reform have been rejected many times by politicians. I myself have gone to Washington D.C. to speak with Diane Feinstein about this matter. Her response was "why, do you want another BMW?" Honest. (By the way, most physicians I know live modest lives. We don't go into this profession for the money.) So, who benefits from these trials? The person who gets the settlement, and the lawyers. What profession are most politicians? Lawyers. I do not discount that there may be legitimate wrongs that require compensation, but having a cap on the amount someone can sue for (as well as what they can sue for), and limits on lawyer fees, would greatly reduce the cost of health care.

I do not consider myself a greedy person. I drive a Corolla and live in an affordable apartment. Residents make 40-45K/ year and work 80-120 hours per week. We graduate with an average of 200k in student loans. However, Obama has proposed that a doctor pay money out of his or her own pocket if a patient ends up staying in the hospital too long or requiring additional treatment above and beyond a set "evidence based" care structure. (Now, who would establish the "evidence based care structure" I don't know, but I have a hunch it would be a government establishment.) I really don't have too much else to give out of my own pockets, and every single day a person is in the hospital is actually more work for the doctors and nurses, and exposes the patient to possible risk of infection. Needless to say, the goal is to get a patient out of the hospital as quickly as possible while still providing excellent care. I would personally prefer to not have to write a note on a person I didn't have to see in the hospital another day.

How else can we reduce costs? We have already seen that not everyone can see a specialist whenever they want. As it is, the wait time for an appointment with a specialist can be as long as 6 months. What happens when we add 40 million new insured patients? The answer is that the people have to wait, or they cannot see a specialist. It is simple supply and demand. A dermatologist can only see so many patients in one day. They are human also. What happens if the specialist is an oncologist for your mom's cancer? She has to wait, or not see the specialist. Cancer doesn't wait. She may not make it to the appointment. Obama has used the same argument for current health care. How is he suddenly going to have enough oncologists to see a potential 40 million new patients? There is no easy answer to this situation, but rushing a bill through congress will definately not help.

Finally, Obama has brought up this idea of "evidence based medicine." That means we don't do anything that is outside the realm of scientifically tested double blinded control trials that have a number needed to treat small enough to warrant the intervention. Sound complicated? What that means, is we need to have 2 groups. One group gets a pill, one group gets a placebo. They both don't know what group they're in, and the tester doesn't either. If it turns out the pill is better than placebo, and not too many people have to recieve the pill to benefit, then we do it. What does that mean for experimental drugs? It's not covered. What does that mean for drugs that can't be tested that way? For example, we can't test to see if a drug is teratogenic (harmful to an unborn baby) by giving the drug to one group and placebo to another. What if it is harmful? Then you just harmed a whole bunch of babies. Ouch, not so good. So you can see, not everything can be evidence based. Have you ever done everything right, and things still didn't turn out? Why did that happen? Because nothing is perfect, and nothing is a machine. Then again, how many times have you wanted to throw your laptop against the wall? Even machines aren't perfect. Why do we think people fit into nice little cookie cutter shapes and boxes? Following evidence based guidelines does not mean the outcome will be positive every time.

The other can of worms is that medicare (government run) is the largest insurer of people in the country and dictates reinbursement costs and standard of care currently. If medicare states that a certain procedure is worth a certain amount of money, the other insurance agencies then base their reimbursements on medicare. When the largest insurer of Americans gets even larger, it will completely dictate care and reimbursement. Obama has already stated his plans for algorythms and standards of care. At that point it will be politicians, the government, or lobbyists who determine the care of your loved ones ... not the doctors. I don't know of any politicians who went to medical school, and I certainly don't want the doctors who are on the politicians payroll to be making medical decisions - you know, the whole "conflict of interest" thing.

Clearly, there's a problem with the numbers. We can't reduce the cost with his plan, we can't increase our revenue to support it with his plan, how can we throw more demand into the picture and expect to afford it? I am not opposed to making affordable health care more easily available, but it has to be done right, cannot eliminate physician and patient choice, and it should not be run by the government.

A brief on my understanding of our current health care system

Types of Care

Health care can crudely be divided into 3 parts: Prevention, restorative/corrective, and palliative

1. Preventative Care: this is your well-child check-ups and your annual physical exams. Nothing is wrong with you yet, but you go see a doctor to optimize things so that you don't get sick, or don't get as sick. We vaccinate, do mammograms and pap smears, discuss anticipatory guidance, blood pressure screenings, etc. This typically isn't reinbursed very well because it's not considered very difficult but necessary to prevent things from getting really bad - and expensive! Another very important aspect of preventative care that is often ignored in the health-care discussion is the aspect of personal responsibility. Your doctor can lecture and encourage you about the benefits of diet and exercise, or even prescribe a necessary medication, but if YOU - the patient - do not choose to follow through with this, all preventative care will have been in vain. Doctors cannot control what their patients choose to do and what not to do.

2. Restorative/Corrective Care: This is where there's actually something wrong and something needs to be done about it. The correction can be with medicine, lifestyle changes, surgery, or some other intervention to try to restore a person to health. This is reinbursed higher depending on the difficulty of management or severity of illness. Procedures are currently reinbursed at higher rates than diagnosis and treatment with medicines.

3. Palliative Care: This is where a person's quality of life takes precidence over quantity of life. Measures are taken to keep the person as comfortable and functional as possible. This doesn't mean a person isn't treated, nor does it mean the person gets euthanized. Reinbursement isn't particularly high because major interventions typically are not performed with this option.

Payment/Insurance Options

The usual ways people pay for healthcare in this country are listed below.

1.HMO (Health maintenance organization): People join a group that manages the way care is provided in order to reduce costs. The member pays a premium and may have a copay to see a physician. Procedures and visits are scrutinized closely to assess appropriateness. All things require approval in some form, and if deemed inappropriate, the HMO may not cover the cost. There is a heirarchy in place to help manage the utilization of care. Patients go to a primary care provider first, and are referred to specialists on an as needed basis. The HMO still reviews the case for appropriateness and must approve the visit or procedure before it takes place otherwise it may not be covered. HMO's may broker deals with different hospitals or services to get a discounted rate. For this reason, you must go to an approved provider, otherwise it may not be covered. This is often a good option for those are in good health and/or seeking affordable care.

2.PPO (preferred provider organization): Similar to the HMO, this is a group that has contracted providers to obtain a more competitive rate. The member pays more in copays and possibly more in dues, but has the freedom of more providers and requires less approvals. Typically, the member can see whoever they want as long as they pay the copay. Required tests and studies are similar. It still has a review board for quality assurance and cost management, but it is generally less intrusive than in an HMO. Contracted providers are listed as "in network" and provide a greater discount. The person insured can still see out of network providers, but at a less discounted rate. PPO's are generally more expensive for an individual to buy outside of an employer benefit package.

3.Medicare/MediCAL: This is a federal/state government single payer system started in the 60's. People "pay into" the system during their working years as a percentage is deducted from their paycheck by the federal government. Once people turn 65, or if they become disabled, they are able to receive benefits from medicare. Again, there is a review committee to assure proper utilization of resources. Being that it is government run, doctors are less afraid of not getting reimbursed since it would be difficult for the government to go out of business. Also being government run, it is very large and sets the standard for reinbursement which HMO's, PPO's, and other plans follow. Each state has a program for those who fall a certain percentage below poverty level. They are then eligable for the state run health care (MediCAL in california).

4.Cash Pay: This has basically no strings attached. You get what you pay for. You can go wherever you want - or wherever you can afford. You are only limited by your resources, which can run out extremely quickly with the current cost of health care. A new type of medicine (concierge medicine) has developed in which for an additional amount of money, a physician will give you particular attention. He/she will only take on a certain number of patients to ensure you get easy access. This of course comes at a premium, but would be the easiest form of health care if you have extensive resources. On the up side, many doctors are willing to give you a discount if you pay with cash, as it lowers the cost of paperwork and processing, and is a guaranteed payment for the physician.

5.Free Clinics/charity: This is where I often worked while in residency at UCI. It was a discounted clinic with lots of grants and donations from the government, school, and community. The aim is usually to give the most effective health care with the resources you have. If it's offered and you meet the criteria (limited resources and need), you can get in line. Definitely not ideal, but better than nothing. All of my medical missions trips were all free-clinics.

MD vs DO:

1.Allopaths: These are your traditional "MD's." They are trained in western medicine where the emphasis is on the scientific method - or scientifically testable hypotheses. They must complete a residency in their specific fields ranging from 3 to 5 years. Afterwards, they can go on to a fellowship for more specialized training for an additional 3+ years. They are required to take USMLE "Step 1" basic sciences exam first year of med school, "Step 2 CK" clinical knowledge exam second year of med school, and "Step 2 CS" clinical skills (patient interaction) exam second year of med school. "Step 3" (clinical knowledge again) is taken during the first year of residency.

2.Osteopaths: They are also medical doctors but "D.O.'s" encorporate adjustments and body manipulation into their practice. It is generally more holistic in its approach to health care. It is also a 4 year medical school, with similar residency requirements. There are specific osteopathic residencies, but to go to an allopathic residency instead, the doctor must take all USMLE "step" exams in addition to the osteopathic "COMLEX." Both osteopaths and allopaths must take licensure exams to become board certified in their specialty. Admission criteria has generally been a little lower in regards to GPA and MCAT scores, but the attempt is to obtain more "well rounded" individuals with a broader range of life experiences.

Types of Practitioners

1.Generalists: Also known as primary care provider (PCP), or general practitioner (GP), these are your general pediatricians, general internists, family doctors, etc. They handle non advanced medical illnesses routinely, preventative care, and manage the overall care of the patient. When medical illnesses become advanced, the patient is referred to a specialist. At that time, the generalist is still involved to help coordinate care between the specialists. They are generally easier to get appointments with, and cost less money. They also are paid less than specialists. This is typically the doctor the patient develops a long standing relationship with. The managed care/insurance companies use generalists as "gatekeepers" who act as filters to keep the higher paid specialists from being bombarded with patients.

2.Specialists: These physicians have gone through fellowship training to become board certified in their area of expertise. They focus on that specific area almost entirely. They know a particular organ system very well, but may not pay as much attention to other organ systems. For example, a heart doctor (cardiologist) manages heart stuff, but may not pay as much attention to the kidneys. If the patient has both a cardiologist and a nephrologist (kidney doctor), the primary care doctor will maintain the big picture to ensure the kidneys, heart, and other organ systems are taken care of.

3.Non Physicians: These are physical therapists, occupational therapists, speech pathologists, podiatrists, nurse anesthetists, physicians assistants, and nurse practitioners (to name a few). They do not go through as much schooling as physicians, but handle the common diseases very well. They are utilized primarily to expedite care, extend care to a greater number of people, and control costs. They all may work under the supervision of a physician to prescribe medicine or render other care.

Medical Philosophies

1.Evidence Based Medicine: this is the idea that the practice of medicine is based upon scientifically reproducible non-biased evidence. There are many different statistical analyses that are done to ensure the patient is getting care based upon things proven to be effective. The example of our most reliable statistical analysis is the double blind control trial. In this experiment, two groups are formed at random. Both groups and the experimenter do not know which group they are in. One group gets the drug or procedure, and one group doesn't. Extraneous factors which may influence the results (confounders) are controlled (held constant) to not influence results. For example, if you're doing an experiment on whether or not a diabetes medicine works, you would want the groups both to have similar lifestyles. If one group is comprised of people who eats sweets, and the other group comprised of vegetarians, this could influence your results. To control for this, you can either completely randomize the group selection so it probably will even out on both sides, or you can only get people in the study who are vegetarians, eat sweets, do neither, or do both. Ideally, you would obtain a very large, diverse group which is representative of the population you want to treat, and then base your patient's treatment on the results of the study.

2.Apprenticeship/Practice Based Medicine: When it is impossible to do tests on humans because of ethics or other reasons, or if studies have not been performed on the treatment in question, it is also possible to base treatment on experience gathered from previous physicians. For example, there haven't been studies showing what to do if you are in the operating room perforing spinal surgery and accidently cut a nerve. At that point, a more senior surgeon would say what his experience has told him to repair the mishap. Practice based medicine is valuable because the human body is not a machine, and a doctor with a lot of experience would have seen patients react differently to different treatments or situations. Additionally, you just can't test every patient for every possible disease.

3.Standard of care: This is the term for accepted/expected practice drawn as a consensus from the majority of physicians.

4.Defensive medicine: This is the term used for practice influenced to protect against possible litigation.

5.Malpractice: This is a legal term for failing to act in accordance with standard of care which directly results in damages to the patient.

Medication Options

1.Prescription medications: These are medications monitored by the FDA and approved for use when determined appropriate by a physician. They may be brand name, where they're still on patent and cost more, or generic, where the patent has expired and they are now available at a cheaper cost. The active ingredients are the same and must meet FDA standards of safety and efficacy. Insurance companies cover varying percentages of brand names and generics.

2.Nutritional Supplements: These are substances which are not regulated by the FDA, do not have to meet standards of dosing, and are not allowed by law to be advertised as treatment for a condition. There are ways the companies get around this with their wording. They often use the term "all natural" but that does not mean "safe." Both prescription medications and supplements are billion dollar industries. There usually has not been testing for efficacy or even safety, but many patients report improvement of symptoms while on these substances. Some studies show nearly 50% of Americans take supplements. However, just as with prescription drugs, over use of nutritional supplements (even vitamins) can be detrimental to a person's health.

3.Over the counter (OTC): These are medications which have been approved for use without a prescription. This does not mean safe. All medications have side effects.

4. Behind the counter: These medications are available for purchase without a prescription, but are held behind the counter because of potential for abuse or for safety reasons (eg pseudoephedrine).