in the trenches

Last week I visited with a local book club, and one of the members was a nurse practitioner working in the trenches herself. She’s at a nearby community health center, a joint that will take care of anybody who walks in the door, where the charge is $15 for those with the lowest income. It’s a critical piece of the local safety net.

Anyway, she told us that finances are forcing her patients to lapse on their medication on a regular basis, and mental illness has gotten out of control in so many. And then there is the occasional patient who becomes insured and asks whether they’re still allowed to see her for medical care.

The nurse practitioner smiled but shook her head. Somewhere along the way we came to believe that those with health insurance don’t get health care at the same places as those without. Like all community health centers, this one is desperate for even the tiniest bits of income, so she says “yes please,” and all but begs her insured patients to keep coming back.

Community health centers provide a tremendous amount of primary medical care and doing so keep people out of Emergency Rooms. The reward? These unsung folks work incredibly hard and make less money than pretty much any other outfit in town. It’s yet another striking example of how sorely misaligned incentives are under our current system.

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mostly dead

Tuesday’s special election in Massachusetts immediately and dramatically reshaped the political landscape in Washington D.C, and it’s no longer clear whether the health care bill, which proposes to insure thirty million more Americans, will survive.

Rumors of the demise of health care reform caused insurance company stocks to rise on Wednesday. But weirdly, this year’s push for universal coverage might have been the best long-term growth opportunity for insurance companies. The New York Times reports that insurance companies are steadily losing customers as employers lay off workers and scale back or do away with health insurance coverage altogether. Universal coverage would have brought a significant infusion of new business.

Of course, that’s only true sans public option.

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all eyes on massachusetts

The future of the health care bill may hang on today’s special election in Massachusetts, to fill the late Sen. Ted Kennedy’s seat. Should Republican Scott Brown defeat Democrat Martha Coakley, Democrats would lose their filibuster-proof 60 votes in the U.S. Senate. A Republican win may discourage other Democrats in tight re-election races from voting for health care reform. Eyes are peeled.

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remembering the reverend

“History will record that the greatest tragedy of our period of social transition was not the strident clamor of the bad people, but the appalling silence of the good people.

-Martin Luther King, Jr.

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helping haiti

Hearing about Haiti’s latest catastrophe, with homes and hospitals reduced to rubble, mountains of corpses decomposing in the 90-degree humidity, dwindling food and clean water supplies — who doesn’t feel compelled to hop on an airplane headed for Toussaint Louverture International Airport? The impulse to do something, anything, feels overwhelming.

But then what? Let’s face it — this is not a time when just showing up is enough. The most effective rescue and repair efforts here will come from organizations that run a tight ship, with the structure and experience to roll out operations quickly. We saw that with Wal-Mart in the Hurricane Katrina aftermath. We’re now seeing that in Haiti with the U.S. military, and with smaller non-profit groups like Zanmi Lasante, aka Partners in Health, Paul Farmer’s organization, that already have infrastructure in place.

Zanmi Lasante has helped to bring clean water and basic medical care to rural Haiti for twenty years and, importantly, has trained locals to operate and staff a network of ten small town hospitals and clinics. According to Tracy Kidder, Z.L. may be the largest functioning health system in Haiti at the moment, being located in areas not as badly affected by the quake.

So be smart in how you decide to help. Give money to organizations with a long track record of working towards social justice in Haiti such as Partners in Health, Fonkoze, or Yele Haiti, to quickly bolster their resources. If you’re a trauma surgeon, anesthetist, or surgical nurse, if you have large quantities of surgical supplies to give, or yes, a private plane that can get skilled hands and supplies to Haiti, volunteer or donate now.

And if learning about Haiti is “all” you can do, do that, and support efforts towards basic sanitation, schools, health care, and local economies even after the country fades from the headlines. Favorite Haiti readings are Edwidge Danticat’s Brother, I’m Dying, a story of growing up in Haiti apart from immigrant parents, and of our flawed border operations, and Tracy Kidder’s “The Good Doctor”, with reporting on how American agriculture policy in Haiti wrecked small local producers.

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a simple intervention

I was invited to participate in a public conversation last night with Atul Gawande, a surgeon who writes for the New Yorker on such things as the cost of health care, solitary confinement, and reducing errors in the ICU. What, you were busy organizing your sock drawer?

OK, so I really do think it’s fascinating stuff. Gawande makes it so — I learn interesting things every time I read his writing. And besides, I can’t help admiring his style and voice and the way he tells a story.

His third book, The Checklist Manifesto, is just out. It’s about adopting a simple intervention, a checklist, prior to surgery or in critical care, or other such clinical scenarios. He and colleagues have proven that well-constructed checklists save lives, and yet the hardest part may be convincing doctors to use them.

I’d love to see checklists created for patients to use. Patients are motivated to obtain appropriate health care — even more so than their doctors, I’m afraid — and we should make good on that energy.

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health care reform approaches

Separate health care bills were finally approved in both the House and Senate during Christmas week. The two pieces of legislation will need to be reconciled in a joint House-Senate conference, so nothing’s final, but the end result will almost certainly bring the security of health insurance to tens of millions more Americans.

One thing is already clear: the reforms won’t be perfect. They’ll be incredibly expensive, and though both bills are said to be deficit-neutral, efforts to clamp down on rising costs come mainly in the form of pilot programs, dozens of them. To secure adequate votes for the initial bills, our elected officials engaged in unsavory horse-trading, most notably over public funding for abortion, and you can bet on more of the same before it’s all said and done. But we ought not let perfection be the enemy of the possible. Denying millions of Americans health insurance is not an acceptable way to control costs, and as our present experience suggests, it doesn’t work.

These bills are a good start, but the need for reform doesn’t end here. The health care experience even for those who are insured can be very challenging, and we’ll discuss that further in the months to come.

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two stories


Last week I got to talk writing with a dozen smart medical students, all with writerly inclinations. I’m a believer that writers learn best from what they read, so I’d asked the students to look at two short narratives, “The Unknown Assailant” by Frank Huyler*, and “Sudden Death,” by Emily Transue**, both of which describe the inner life of young physicians.

Huyler, an emergency physician, grapples with the discovery that he’s taking care of an accused murderer. Among the students there was much appreciation for Huyler’s storytelling skill — spare sentences and images, effective use of minor characters — and though he never overtly tells you what he feels, you’re sure of it by the end.

Transue’s story, about an elderly man who codes and dies unexpectedly, explores the moment a physician comes to understand she can’t always exert perfect control over a patient’s outcome, that people may still die regardless of how well she does her job. In contrast to Huyler, she tells you exactly what she’s feeling. And the writing is just as effective because it’s so clean, unaffected and honest — she doesn’t try to sound like a writer.

For those who write medical narrative, there’s lots to learn from these two very fine stories.

*from The Blood of Strangers, Holt, 2000.
**from On Call, St Martin’s Press, 2004.

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Health care bills are slowly making their way through both chambers of Congress. Last night the House passed a $1.1 trillion bill that would insure an additional 35 million Americans. Importantly, the bill makes it illegal for insurance companies to deny health insurance to those with pre-existing conditions, or to cancel your policy if you develop an expensive disease.

The House bill also calls for a ‘public option’, or government-sponsored health plan available for individual purchase. This isn’t thought likely to survive a Senate vote.

While I was being interviewed on XM Satellite’s Book Radio last week, a caller expressed dismay at the proposed level of government intervention in health care. I sympathized with his point of view. While writing House of Hope and Fear I learned that Seattle’s public hospital, Harborview, remained financially healthy in spite of very little government funding. How? Partly because the hospital needs to compete for business with every other hospital in town. Public hospitals operating primarily on the dole don’t do nearly as well.

But the free market isn’t a cure-all. Private sector success has increasingly come from excluding sick people from needed health care. Nearly one in six Americans is now inadequately insured, or not insured at all, and the problem is only growing worse. No doubt health care reform will be expensive. But doing nothing could cost even more. We pay for universal health care now, and in the priciest way possible — through our Emergency Rooms. This year’s health care bills won’t solve all of our problems, but they look to be a reasonable start.


Filed under health care reform, house of hope & fear

a local review

Check out this latest review of House of Hope and Fear: Life in a Big City Hospital, which was published in today’s Bellingham Herald.


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