Local perspectives on health care reform

This blog has had a few posts recently on health care reform. What has been missing, however, is the local perspective from local people who are closest to the health care scene right here in Kandiyohi County.

That’s about to be remedied this coming month with a guest-speaker series sponsored by Bethel Lutheran Church. The first presentation is at noon Wednesday, Aug. 5. It will feature Ann Stehn, director of Kandiyohi County Public Health, on "Why We Need Health Care Reform."

Here’s the rest of the lineup:

- Wednesday, Aug. 12: Jay Kieft, director of Kandiyohi County Family Services, on "Do You Know Your Neighbor? The Middle Class and Health Care."

- Wednesday, Aug. 19: Chris Conry of Health Care for America Now, on "What Choices Do We Have? An Overview of the Bills Before Congress."

- Wednesday, Aug. 26: Gary McDowell, administrator of Family Practice Medical Center, Willmar, on "How a Local Clinic Is Now Managing and What the Changes Will Mean for our Care."

All the presentations will take place at noon in Luther Hall at Bethel Church. The organizers promise to furnish water and lemonade; lunch is on your own.

Patrick Foley, the organizer of this speaker series, says Bethel tries to host a project each summer that invites discussion and involvement from the community. "This year I think there’s nothing hotter than health care," he says.

Attend if you can. For those who’d like to be there but can’t, the presentations are being videotaped. Foley hopes to get them aired at a later date on WRAC-8.

HealthBeat photo by Anne Polta

Flunking out of Anatomy 101

Do you know where your stomach is? How about your kidneys or pancreas? If you’re like the subjects in a recent British study, chances are that fewer than half of you can come up with the right answer.

The study was published earlier this month in the BMC Family Practice journal. Researchers wanted to know whether patients and the general public were any more knowledgeable about anatomy than they were in 1970, when a similar study was conducted.

The 722 participants in the study were given drawings of an outline of the human body, showing a specific organ in four different locations, and were asked to pick the organ’s right location. They did well when it came to the intestines and the bladder. Nearly 86 percent correctly identified where the intestines are, and about 80 percent picked the correct site for the bladder.

Here’s where the results become a little surprising, though. Only 31 percent knew the location of the lungs, and 38 percent knew where the stomach is supposed to be. Overall, the study participants got 52.5 percent of the answers right – not much better than the 1970 study, in which 51.4 percent of the answers were right.

The researchers found that patients with a specific disease were somewhat more likely to correctly pick the right anatomical site for the disease for which they were being treated. Of the people with liver disease, 75 percent were able to point to the right place, compared to 45.9 percent of the general public.

This wasn’t the case across the board, however, especially for the lungs. (Who knew the human lungs could be so elusive?) Among patients with respiratory disease, 37.1 percent could correctly indicate where the lungs are located. Among the general public, it was only 27.1 percent.

The study’s authors make the disappointing conclusion that even with more widespread information about health, both in the media and on the Internet, the public’s knowledge of anatomy "is still quite limited." Doctors need to be aware of this knowledge gap, the study’s author’s wrote:

Healthcare professionals still need to take care in providing organ specific information to patients and should not assume that patients have this information, even for those organs in which their medical problem is located. The consultation may offer many opportunities for both checking and improving patients’ knowledge.

It’s a little puzzling that many people would remain clueless about human anatomy, even in the 21st century – but perhaps not all that surprising, considering the rather arcane and occasionally grisly history of the study of anatomy.

The ancient Egyptians and the Greeks conducted some of the first rudimentary studies of anatomy. The study of the body and its inner mysteries also flourished in the medieval Islamic world; the Arabian physician Ibn Zuhr was the first doctor known to have dissected a cadaver and conducted an autopsy.

Modern anatomical science didn’t really get going, however, until the 1500s. There’s no way, of course, to study the inside of the body without cutting it open, which required a supply of corpses - often obtained from the hangman or from morgues and cemeteries. Dissections were often carried out before an audience, like a form of theater; the Rembrandt painting above depicts one of these group lessons by the celebrated Dr. Nicolaes Tulp, a Dutch surgeon and pathologist.

Virtual anatomy now makes it possible to learn about the interior of the body without ever picking up a scalpel. At some point during their training, however, most U.S. medical students will confront the dissection of an actual cadaver.

There’s some debate about whether studying a cadaver should still be a necessary component of the medical school curriculum. Some critics believe it’s too time-consuming. It can also be costly to obtain and store cadavers for use in the anatomy lab.

On the other hand, some studies have found medical students do better on tests of their practical skills when they’ve had some experience with dissecting a cadaver. Dissection isn’t an easy thing to do, as this account illustrates:

At one table, the students were having a hard time peeling back the skin. Teaching assistant Catey Bradford showed them how to cut a small slice in one corner of the flap, so they could put a finger through it for a better grip. "Cutting through the skin the first time, you kind of feel like you’re being a little too rough," observed student Brooke Lane. "I noticed people kind of being bothered at the way you just have to kind of rip off the skin."

For many medical students, though, it’s an important rite of passage that teaches lessons not only about the interior of the body but about death, respect and value for the individual.

When it comes to anatomy, then, there’s still a gulf of knowledge and experience that divides doctors and their patients. Is it unrealistic to think the majority of the population should know where their gall bladder is located? Maybe so. But if the British study is any indication, the public frankly ought to do better at gaining at least a minimal grasp of human anatomy.

Art: "The Anatomy Lesson of Dr. Tulp," Rembrandt van Rijn, 1632

Then there were 3: Cost, choice and the medical arms race

The landscape of the local medical community shifted several degrees last week with the announcement that three clinics – Family Practice Medical Center, Janning ENT Center and the Willmar Asthma and Allergy Specialty Clinic – have formed a medical imaging joint venture with the Center for Diagnostic Imaging.

It’s not the first time the players have rearranged themselves on this particular chessboard. In fact, medical imaging services have been at the center of a series of moves and countermoves among local health providers for at least the past seven or eight years.

For years, medical imaging was dominated by Rice Memorial Hospital, which provided most of the services and also had Kandiyohi County’s only CT and MRI scanners. Then, in 2001, Affiliated Community Medical Centers acquired its own CT and MRI. For the next six years the two organizations operated their medical imaging services more or less independently of each other. Late in 2007 they decided to cooperate, signing an agreement to fold medical imaging into a new joint venture known as Willmar Medical Services and owned by the hospital and ACMC, which share the profits and losses 50-50.

And that’s how the picture looked until now, with the arrival of the Willmar Center for Diagnostic Imaging this fall. Construction is already under way in the Lakeland Health Center building to accommodate a new CT scanner, ultrasound, X-ray, bone density imaging, digital mammography and interventional radiology. The partners in Willmar CDI say they might add MRI services at some future point, if there’s enough need or demand.

So what does this mean for patients? What does it mean for the community? The answers, as it turns out, are not at all easy to pin down. In fact there seem to be more questions than answers.

On many levels, it’s hard to argue with the decisions that have been made. In each case, providers have seemed sincerely motivated by a wish to provide good care for their patients and to ensure there’s local access to high-quality imaging technology. Given the importance of medical imaging as a diagnostic tool, it’s not inappropriate for them to want to make it available to their patients.

But we’re now going to have three CT scanners in Willmar, and maybe three MRIs as well. If you do the math, this works out to one CT unit for every 6,000 city residents. Is this adequate? Or is it too much for a rural community of 18,000?

People come to Willmar’s medical facilities from a much larger geographic area, of course. If you look at Kandiyohi County as a whole, the ratio increases to one CT scanner for every 14,000 or so county residents – the equivalent of a good-sized town. Is this a better, more accurate yardstick?

How do we know when enough is enough? There doesn’t seem to be any objective way to measure this because, as far as I know, no one has ever determined what the ideal, most cost-effective ratio should be.

And let’s not forget the region’s small rural hospitals. Several of them – Benson, Litchfield and Olivia, to name a few - have CT units of their own, many within a 30-mile radius of Willmar. Is this a reasonable investment on behalf of the communities they serve? Or is it good enough to send their patients somewhere else if they need a CT scan, or for smaller rural hospitals to rely on mobile imaging services that come once or twice a week?

What should the expectations be for rural health care? Is the cost of buying and maintaining high-tech medical imaging equipment a worthwhile tradeoff for having it readily available in rural communities?

For rural Minnesota, the Willmar medical community is somewhat of an anomaly. There are two dominant players: a regional referral hospital and a regional multi-specialty clinic system. There’s one medium-sized player, the family practice clinic. In recent years a handful of smaller, independent specialty clinics also have sprung up.

What should the relationships among them look like? Should they compete in some areas and cooperate in others? Compared to many towns, there’s a good track record of cooperation among Willmar’s medical providers. At times they have disagreements (who doesn’t?), but for the most part they’ve worked well together – until something comes along that reveals the underlying faultlines. 

For better or worse, the local medical community is highly interdependent. When someone makes a strategic decision, it tends to reverberate.

Here’s an example: When ACMC started its own CT and MRI service in 2001, hospital officials worried the market wasn’t big enough to sustain two such services. They feared Rice Hospital would lose patient volume – and revenue – for these two types of imaging and, as it turned out, that’s exactly what happened. Rice also found itself competing in a tight employment market for qualified technologists. The hospital’s high-tech imaging program never really recovered until the joint venture went into effect at the beginning of 2008.

How much do we value the ability of medical providers to make strategic decisions they believe will benefit their patients and their business? Should smaller clinics be forced to refer patients to services that financially benefit their competitors? Is there a benefit to offering services that are locally owned and help keep money in the local economy?

How much do we value choice? There’s an increasing push for consumers/patients to participate more in the decision-making and to “shop” for their care on the basis of cost and quality. How is this supposed to work in a rural market with a limited number of providers? Are we willing to accept that there might be only one game in town?

For that matter, what role have consumers/patients played in the medical technology arms race? Have we contributed to it by having expectations of easy, convenient access and a whole menu of options?

How should we view medical technology? There’s no question that medical imaging helps save lives and effectively treats disease. But it’s also expensive; the price for a new CT scanner, for instance, starts at around $1 million. It’s easy for patients, and sometimes health care professionals as well, to be wowed by the gizmos and high-tech trappings. Is it desirable, though, to have the best and latest? Does it mean we’re getting better care? Or do we need to be more skeptical and less credulous?

Overall, the use of medical imaging has been on the rise. The majority of these tests are probably appropriate but some of the time they are not. There’s some evidence that as high-tech medical imaging and other services become more widely available, they’re also used more often, which pushes up overall costs. As for competition, in the health care industry it generally has not led to lower costs; in fact, the opposite is usually true. 

We might not want government telling us how to do health care, but it’s not clear whether the private sector has been any better or more effective at holding down health care costs and expensive duplication of services and technology. If we value a market-driven health care system, are we prepared to accept what this entails? Are we OK with the competition? Are we OK with the fact that at times there will be winners and losers?

Finally, when do we say no? To whom do we say it? Who gets to decide? How should these decisions be made?

I don’t have any answers. Maybe these questions are impossible to answer, or impossible for achieving any kind of consensus. But the questions need to be asked. Nationally, we’re on the brink of health care reform. All the key issues – cost, access, quality, effectiveness – are playing out right here in our own back yard. We can’t afford to not talk about it.

West Central Tribune photo by Ron Adams

Additional reading:

- Factors and Incentives Driving Investment in Medical Facilities, a 2007 report by the Minnesota Department of Health

- The Medical Arms Race Syndome, by the National Institute of Health Policy

This article is from Medical News Today on the relationship between quality and competition in health care. This article, also from Medical News Today, explores the cost and overuse of medical imaging tests. Finally, here’s a thoughtful look at regulation, the free market and inefficiency.

The machine that is Lance Armstrong

If you’ve been following the Tour de France, you’ll know that uber-cyclist Lance Armstrong is having some struggles. Although he has posted the third best time overall, he’s unlikely to move into first place before the race ends in Paris on Sunday. Tomorrow these world-class athletes will tackle Mont Ventoux, a punishing 6,000-foot peak that presents one of the toughest challenges in the entire race.

Le Tour is one of the most grueling races in all of bikedom. It covers 3,500 kilometers and lasts 22 days. You have to be among the elite to even qualify as a contestant. Armstrong, 37, has won not once, not twice, but seven times in a row – a feat all the more amazing when you consider he’s a survivor of an aggressive form of testicular cancer.

He was 25 at the time of his diagnosis, and the cancer had spread to his abdomen, lungs and brain. He was told he had less than a 50 percent chance of survival. His initial chemotherapy regimen included Bleomycin, an anti-tumor drug known to cause lung damage. Rather than risk compromising his lung function – and possibly end his career as a professional cyclist – Armstrong switched to a slightly different combination of chemotherapy drugs.

In an interview shortly after completing treatment, he describes his diagnosis and treatment and also talks about the launch of the then-fledgling Lance Armstrong Foundation, which at last count has raised more than $250 million for cancer research and services.

For all his accomplishments, Armstrong is somewhat of a polarizing figure. Within the cancer survivor community, he’s almost universally admired, and many people see him as an inspiration and a symbol of all they hope to regain in their lives. But others wonder whether he’s setting an unrealistic standard – one that many survivors simply cannot measure up to.

Far more damaging are the whispers and allegations of drug use. Armstrong has always denied it, and it should be noted that he’s never tested positive for drugs. But the suspicions remain: Is he really That Good?

Maybe he is, or at least supremely physically gifted. Researcher Edward Coyle studied Armstrong from 1992 to 1999 and shared his findings in the Journal of Applied Physiology in 2005. Armstrong, he wrote, has exceptional cardiovascular and lung capacity and exceptional muscular efficiency – a combination of lucky genetics and intensive training and motivation:

It is remarkable that at age 25 yr this individual developed advanced cancer, requiring surgeries and chemotherapy, yet these events did not appear to impede his physiological maturation and athletic achievements. Clearly, this champion embodies a phenomenon of both genetic natural selection and the extreme to which the human can adapt to endurance training performed for a decade or more in a person who is truly inspired.

More has been written about Armstrong’s physiological prowess here, and in this article that appeared this past week at MinnPost.com.

If it’s true that Armstrong is guilty of doping, his career and probably the reputation of the Lance Armstrong Foundation will most likely crash harder than a pile-up of cyclists on the downslope of the Hautes-Pyrenees. And it would be an unfortunate loss. But if he really is That Good, he’s a winner – even if he doesn’t bring home the yellow jersey from this year’s Tour de France.

Photo by the Associated Press.

Who are you? Misadventures in misidentification

Being misidentified – or having your identity stolen – can bite hard. But when it comes to your medical ID, the consequences might be especially serious. Not only can it create havoc with figuring out who’s supposed to pay the bill, but it also could lead to unintentional errors in the patient’s care.

I learned this the hard way several years ago when I was hospitalized in the Twin Cities. It happened to be the same hospital where my sister-in-law gave birth to her two children. She and I have the same first name and same last name, with different middle initials. Our dates of birth are the same month and same year, just four days apart.

You guessed it – I was mistaken for her. By sheer chance, the person at the admitting desk mentioned casually, “Oh, I see you’ve been a patient here before.” I had not, and I quickly realized she was talking about my sister-in-law. We managed to straighten it out, but not before the wrong medical chart was sent up to the patient floor.

I thought that would be the end of it. I was wrong. Not long after the bills went out, my sister-in-law called me. The information that we were two separate persons apparently never reached the physician clinic, and as a result they billed her instead of me for the doctor’s services. Meanwhile the hospital bill was languishing in some kind of limbo. I waited for the insurance statement… and waited… and waited. After two months went by, I called my insurer to ask what was taking so long. The reply: They couldn’t process the bill because they didn’t have the medical record. I called the hospital and was told they couldn’t send the medical record to my insurer because I hadn’t signed the release form. It was news to me; I clearly remembered signing a whole stack of forms. Somehow, in the scramble after the identity mix-up, they must have been misfiled or disappeared.

All told, it took several long-distance phone calls and a letter to get this relatively minor confusion straightened out. The admissions paperwork I’d signed never resurfaced. And to this day, I can’t be totally sure that my medical record and that of my sister-in-law haven’t been at least partially co-mingled.

That’s why I sat up and took notice when Rice Memorial Hospital adopted a policy earlier this month on addressing and preventing patient misidentification. Other hospitals are taking similar action; in fact, new rules by the Federal Trade Commission require them to do so. They have until Aug. 1 to comply.

Patient misidentification tends to fall into three broad categories: inadvertently confusing one patient for another; using a false ID; and outright medical identity theft.

Of the three, medical identity theft is, hands down, the most challenging to address. Here’s what the World Privacy Forum has to say:

Medical identity theft occurs when someone uses a person’s name and sometimes other parts of their identity – such as insurance information – without the person’s knowledge or consent to obtain medical services or goods, or uses the person’s identity information to make false claims for medical services or goods. Medical identity theft frequently results in erroneous entries being put into existing medical records, and can involve the creation of fictitious medical records in the victim’s name.

Medical identity theft is a crime that can cause great harm to its victims. Yet despite the profound risk it carries, it is the least studied and most poorly documented of the cluster of identity theft crimes. It is also the most difficult to fix after the fact, because victims have limited rights and recourses. Medical identity theft typically leaves a trail of falsified information in medical records that can plague victims’ medical and financial lives for years.

How common is medical identity theft? One estimate puts it at about 3 percent of the 8 million or so cases of identity theft that occur in the United States each year. Many experts worry that with the increasing use of online medical records, the incidence of medical identity theft will rise.

Many victims might not even know their medical identity has been stolen until they receive an unexpected bill or discover it on their credit report, as this recent New York Times article recounts.

Locally, these situations don’t appear to be too common – at least yet. More often, what local providers encounter is someone using a false ID that has been obtained for employment. It can sow doubt and confusion over the patient’s real identity and increase the risk of an inaccurate or incomplete medical record. It also makes it harder to determine whom to bill.

And any patient, of course, can fall victim to simple error. It may be tiresome for patients to have to repeat their name over and over during a hospital stay, but it helps ensure the wrong procedure or the wrong medication doesn’t accidentally reach the patient. Most hospitals now use at least two identifiers – name and date of birth – to make sure the patient is correctly identified. They also typically have procedures they follow when two patients with the same name happen to be hospitalized at the same time. Some hospitals also have adopted bar coding to further reduce the risk of patient misidentification.

As this case study from the Agency for Healthcare Research and Quality shows, however, mistakes can still happen. In the worst-case scenario, someone might undergo surgery intended for someone else, or parents might unwittingly take home the wrong infant.

The best defense, say experts, is to be vigilant. Get copies of your medical records, scrutinize the bill, and speak up if something doesn’t seem right. The fact is, if it hadn’t been for an off-the-cuff remark by a hospital admissions clerk, I would never have known about my medical identity mix-up until much later. And the longer you wait, the harder it can be to correct the problem.

HealthBeat photo by Anne Polta

What are you drinking?

Coffee, tea, water… or calories? Guest blogger Amy Salo explains the connection between the beverages we drink each day and the number of calories we consume. Amy is a registered and licensed dietitian at Affiliated Community Medical Centers, working in the Health Learning Center, the Willmar Diabetes Center and the Weight Control Center. She received her undergraduate degree at the University of Minnesota in the Twin Cities and is currently working on her master’s degree through Central Michigan University.

By Amy Salo

What would you like to drink? This seems like a simple question that we all hear regularly, but with the number of options that are available, there may be more to this question than you think.

There are any number of beverages available that are: diet, regular, caffeine-free, "zero," or vitamin-enriched. Which of these products to choose can leave any consumer’s head spinning.

In the United States the average person is consuming 21 percent of their calories from beverages. With two-thirds of the U.S. population either overweight or obese, most people cannot afford to get a significant amount of their calories in a liquid form. Beverage intake has become enough of an issue that the University of North Carolina at Chapel Hill has created a Beverage Panel. This panel was formed to provide guidance to consumers regarding beverage intake.

The Beverage Panel has placed beverages into six categories to include:

Level 1: water.

Level 2: unsweetened coffee and tea – iced and hot.

Level 3: nonfat or low-fat milk and fortified soy beverages.

Level 4: diet beverages with sugar substitutes.

Level 5: 100 percent fruit and vegetable juices, whole milk, sports drinks.

Level 6: calorie-rich beverages without nutrients.

The Beverage Panel has determined that the average adult consumes about 114 ounces of fluid daily. A significant amount of this (up to 33 percent) contains calories. This is important because many people do not think about how many calories they’re getting from beverages. Excess calories from beverages, just like excess calories from food, can lead to weight gain.

The Beverage Panel has the following recommendations for adults at each level of beverages.

Level 1: At least 20-50 fluid ounces from water but all beverage needs for adults can be met with water.

Level 2: The recommendation is 0-40 fluid ounces per day of unsweetened tea and up to 32 fluid ounces of coffee daily. The limiting factor is the caffeine amount. Total caffeine intake is recommended to be 400 mg or less daily. A typical cup of coffee contains 143 mg of caffeine.

Level 3: The panel recommends getting 0-16 fluid ounces of beverages from milk. This amount can count towards the recommended 2-3 servings of dairy that the USDA recommends in MyPyramid.

Level 4: The panel recommends 0-32 fluid ounces of noncalorically sweetened beverages daily with limitations regarding caffeine. Though these beverages do not necessarily cause weight gain, there are some studies that indicate that they may contribute to a preference for highly sweetened foods. Therefore these are recommended less than tea, coffee or water.

Level 5: This level includes fruit juices, vegetable juices, whole milk, sports drinks or alcoholic beverages. The recommendation for fruit and vegetable juices is 0-8 fluid ounces. The panel recommends no whole milk intake. Sports drinks should be used very little unless you are an athlete and then these should be limited to 0-16 fluid ounces per day. Alcoholic beverages should be limited to 0-1 drinks per day for women and 0-2 drinks per day for men. (One drink = 12-ounce beer, 5-ounce wine, or 1.5-ounce distilled spirits.)

Level 6: These caloric beverages have been linked to dental caries, increased energy intake, and weight gain. The panel, therefore, recommends between 0-8 fluid ounces of these per day.

I agree with most of the recommendations that the panel provides. For the majority of the population these would be appropriate recommendations. I personally would recommend fruit juice be kept to 4-6 fluid ounces or less per day, diet beverages be kept to 16 fluid ounces or less per day, and sweetened beverages be kept as close to zero as possible.

The more calories we can save through our beverages, the better. This may help reduce weight gain or promote weight loss in people that need it. Simply cutting out 500 calories per day can lead to a weight loss of one pound per week. The average can of regular soda contains 150 calories. Eliminating 3.5 cans of soda per day could lead to a significant weight loss.

The following list shows the calorie content in an 8-ounce serving of these common beverages (the numbers may surprise you):

Orange juice – 110

Kool Aid – 60

Skim milk – 90

Gatorade/vitamin water – 50

Monster energy drink – 100

Coke or Pepsi – 100

Sweetened iced tea – 100

Most of these beverages can be bought in larger containers than 8 ounces so it’s important to remember that if you drink a 20-ounce bottle of Coke, you will be getting in 250 calories.

It is easy to forget that beverages contain a significant amount of calories. By making smarter beverage decisions you can take steps to a healthier lifestyle. So next time the question of "what would you like to drink?" is asked, choose wisely!

HealthBeat photo by Anne Polta

The medbloggers go to Washington

Medical bloggers got their chance Friday to speak their piece on putting patients first in health care reform. HealthBeat promised last week to report on what happened and who said what at the conference, held at the National Press Club in Washington, D.C.

So here we go. First, here’s the text of Dr. Kevin Pho’s comments. The gist of his remarks: Ensuring health care coverage for all Americans won’t solve the access problem if there aren’t enough primary care doctors to see all these patients. He provides the example of Massachusetts, which now requires every state resident to have health insurance:

"Since reform began in 2006, the Massachusetts health care system has been inundated with almost half a million new, previously uninsured, patients, and the demand for medical services has rapidly outpaced physician supply. The wait to see a new primary care doctor is almost 2 months, leading patients to use the emergency room more often for routine visits."

Efforts to reform health care should "value primary care, and make it central to our health system," he said. There’s more discussion in the comments, so take some time to read those as well.

Dr. Richard Fogoros of the Covert Rationing blog makes a similar point: Unless fundamental change takes place, the concept of putting patients first is little more than nice-sounding talk.

Dr. Val Jones of Better Health, the organization that sponsored Friday’s conference, obtained a transcript of Congressman Paul Ryan’s remarks. You can peruse his speech here.

Kim McAllister of Emergiblog posts pictures of some of the participants and reveals a couple of interesting, and disturbing, facts: There’s apparently a sense of urgency to get some kind of health care reform bill enacted soon, and most Congressmen don’t appear to have read the 1,000-page text of the bill.

"Folks, our representatives are being asked to pass legislation they have not had a chance to read," she writes.

That sort of blew my mind and made me wonder if I’d understood correctly, but Dr. Westby Fisher confirms it in his own account of the Washington conference.

I’m still waiting for Dr. Rob Lamberts to check in. He’s blogged already about some of the behind-the-scenes action, and I’m pretty sure he’ll be posting more. I’ll link to it as soon as it’s available.

A good patient perspective comes from Kerri Morrone-Sparling of Six Until Me. She attended the conference and has this to say:

Then there were comments about the current healthcare system, how it’s running the economy into the ground and people are underinsured. I can attest to being a member of the working class, with insurance, yet spending plenty out of pocket for my medical needs. What good is coverage when it doesn’t cover?

There was also plenty of Tweeting taking place during the conference. A Twitter transcript can be found here.

I scanned through the Washington Post’s Web site to see if there was any coverage of the event (it was held at the National Press Club, after all) but didn’t find anything. I’ll keep looking, in case I’ve somehow just missed it.

The real question, of course, is whether this event had any impact. Was anyone in Washington enlightened by the bloggers’ perspectives? Or has the time already come and gone for meaningful input into the health care reform bill? What do readers think? Share your thoughts in the comment section below.

Photo courtesy of Architect of the Capitol.

Update: Dr. Kevin Pho posts another blog entry about the conference. There’s also a clip here from ABC News, featuring physician/blogger Dr. Val Jones, who organized the "Putting Patients First" conference. Duncan Cross, a blogger with chronic illness, dissects Congressman Paul Ryan’s speech.

Doctors, obesity and the new surgeon general

America’s newly nominated surgeon general, Dr. Regina Benjamin, is African-American, a native of Alabama, and has long experience working with patients in poor and rural communities.

She has dealt with setbacks. Raised in poverty, she and her family used to travel to the Gulf of Mexico to catch crabs and shrimps to eat. In 2005, Hurricane Katrina damaged the clinic she founded in Bayou la Batre in rural Alabama. Shortly before the clinic was scheduled to reopen, it was destroyed by fire. Undaunted, Dr. Benjamin continued to see patients in the local hospital and in their homes.

She’s highly accomplished. In 1994 she was listed as one of Time magazine’s most promising leaders under 40, and last year she was one of 25 people who were awarded a "Genius" grant from the MacArthur Foundation. She is the first African-American woman to be elected to the American Medical Association board of trustees and the first African-American woman to become president of a state medical society (Alabama) in the U.S.

I think I like her already.

She’s also, um, kinda fat – a detail that has been dissected by critics and bloggers in a way that speaks volumes about America’s obsession over the body mass index. Check out the snarkitude among the commenters on this otherwise neutral article in the Washington Post:

Obesity is by far the most important public health epidemic facing our nation today and this issue should not be made light of in favor of other skills. We should all have doctors who model the lessons they teach. I would never accept an obese practitioner as my personal physician, so why are we accepting an obese surgeon general?

And that was one of the more civilized comments. (I’ll overlook, for the time being, some of the other comments disparaging Dr. Benjamin’s experience in what one elitist referred to as "podunk" rural clinics.)

Even one of the letter-writers at the Star Tribune of Minneapolis weighed in today on the issue.

Is it OK for doctors to be overweight? This has been a matter for debate. At least one study has found that patients have more confidence in a doctor who isn’t overweight. The writers conclude:

Doctors who actively try to lead healthy lifestyles are more likely to counsel their patients about healthy behavior. Medical students ought to take lifestyle advice themselves and shape up if they want patients to take them seriously.

The flip side to this argument is that physicians may be more likely to understand a patient’s struggles with losing weight if they’ve struggled themselves.

There also seems to be a double standard at work. The girth of one’s physician happens to be visible, so it’s an easy target. But what about physicians who have a hard time handling stress, or who struggle with depression, or drink too much, or don’t eat enough vegetables? Are these physicians any better at being good role models? Or does physician behavior only matter if patients can see it?

The Shapely Prose blog delivers a feisty analysis of Dr. Benjamin’s nomination to the surgeon general’s post:

… this does mean that there’s a chance, however small, that Dr.  Benjamin understands that fat is not automatically inimical to health. And her position as a doctor in a poor rural area probably means that she is more sensitive to the effects of poverty on health and food access, and might understand that lack of access to good nutrition or unbiased health care or leisure for activity – not fat bodies themselves – are problems to be solved. That’s a chance I didn’t expect us to get.

There are also some good perspectives in the comments.

My favorite commentary, however, comes from noted bioethicist Arthur Caplan, who puts the focus where it belongs:

Critics seem to believe it’s ironic that the nation’s top doctor would be overweight, and it’s led the most nattering of nags to conclude that she should not be picked for prom queen, er, I mean, surgeon general.

You would think the entire population of the blogosphere had suddenly reverted to the seventh grade.

You don’t have to be thin and perfect to be a good physician, Caplan argues. In fact, many people are likely to identify with Dr. Benjamin, which could help more Americans connect with her and her agenda as surgeon general. He concludes, "I don’t know about you, but a doctor who chooses to care selflessly for the poor and who has the respect of her peers as a good clinician is a doctor whom I am willing to listen to – even if she wears a plus-size lab coat."

Dr. Benjamin’s nomination is awaiting confirmation hearings in the U.S. Senate. Most observers think her appointment will take place without a hitch, but we’ll see what happens.

In the meantime: You go, Dr. Benjamin!

Photo credit: Bill Starling, Associated Press.

Missing voices in the health care debate

You don’t have to look far to find a lot of rhetoric and discussion about health care reform. But who’s doing all the talking – or at least talking the loudest? That’s right: For the most part, the national debate seems to be dominated by the policy wonks, not by doctors and nurses who actually take care of patients, or by the patients themselves.

Look for the tables to be turned on Friday, when Better Health hosts a discussion between elected officials and several notable medical bloggers at the National Press Club in Washington, D.C. The theme: "Putting Patients First."

Dr. Val Jones, a rehab physician, a blogger and founder of Better Health, organized the event to give a voice to those in the trenches of health care. As she explains it,

… the intent of the press conference was to give medical bloggers an opportunity to speak directly to politicians inside the Beltway about their health care reform concerns. I have invited medbloggers who have been the most outspoken about reform and who have the largest reach.

This A-list includes several of the medblogosphere’s stars, such as Dr. Kevin Pho, emergency room nurse Kim McAllister, Dr. Rob Lamberts, and cardiologists Dr. Westby Fisher and Dr. Richard Fogoros.

The speakers’ panel unfortunately does not include any patients, the one group that arguably has the most stake but the least voice in the national discussion on the future direction of health care. Not surprisingly, and probably rightfully so, this omission has led to a bit of an online fracas.

To be sure, doctors and nurses have a lot to contribute. Over the years I’ve covered numerous meetings between politicians and the local health care community, and at times I’ve had the impression their views don’t seem to carry as much political weight, perhaps because it’s perceived – unfairly so – that they’re motivated by self-interest or have an axe to grind. In fact, doctors, nurses, hospitals and clinics are uniquely positioned to see the system from the inside. They know better than anyone else what works in American health care and what doesn’t work. Their daily encounters with patients give them unique insight into what individual patients face, as well as the overall health of their community. Moreover, every doctor and nurse will at some point be a patient themselves, or have a family member who’s a patient.

There’s value, however, in also hearing from ordinary people – average schlubs who haven’t been to medical school, don’t know where their spleen is located and are often bewildered and frustrated with trying to navigate the health care system. Who’s listening to them or seeking out their opinion? Unfortunately, patients are such a diverse group that it’s unlikely they could ever coalesce into something with enough critical mass to wield clout in Washington – and so their voices often are too muted to be heard.

Several of the bloggers who’ll be participating in the panel discussion tomorrow are trying to remedy this on their own blogs.

At Emergiblog, Kim McAllister is asking her readers for their thoughts:

So, what about you?

What do you think health care reform should accomplish?

What are the three most important aspects that should be a part of any health care reform system?

She’s already had more than a dozen good comments. Over at his blog, Dr. Westby Fisher is looking for feedback too and promises to report on the event afterwards.

Dr. Rob Lamberts is hosting a lively to-and-fro in the comment section of his recent post, "Speak to Me." He also has posted an online poll, allowing readers to pick their four top health care concerns. When I checked the results a short time ago, the leading concern was "the conflict of interest as insurance companies are in charge of the money," followed by "the continued rising cost without better care."

So go and vote in the poll, leave a comment or two on the blogs, or just read the discussion. And check back later for a report here on the conference.

Words and medicine: the doctor as storyteller

It’s July, and that means it’s time once more for Minnesota Medicine’s annual issue devoted to creative writing by Minnesota physicians and medical students. The July edition of the magazine, which is published by the Minnesota Medical Association, was recently posted online. It contains the winning entries in the annual "Medical Musings" contest, which this year drew some two dozen entries.

Why write? Because words can be powerful medicine, explains Dr. Charles Meyer, the magazine’s editor-in-chief.

You get to tell a tale from this amazing work we physicians do. You get to pause from that work, think about it, and see what it means. And you get to let that work enter your being and change you and the way you view it.

And, it should be added, it can change the reader as well.

The winning student entry comes from Rebecca Stepan, a medical student at the University of Minnesota-Duluth. Her poem, "Gone but Not Forgotten," was inspired by a cancer patient who wanted to donate her body to research.

Dr. Therese Zink, a family physician in Zumbrota, penned the winning physician entry, "On the Navajo Reservation", an account drawn from her own experience of working on a reservation in Arizona.

An excerpt:

I pick up a chart from the plastic holder on the door; the complaint reads "weakness." Marge, one of the Navajo nurses, comes up behind me and says, "Mr. Anderson is one of the few authentic medicine men. The weakness is in his chest."

I knock and enter with Marge. Mr. Anderson is accompanied by his grandson and his grandson’s girlfriend. Their shiny black hair in identical ponytails, tied at the nape of their necks, reaches to their waists. They are casually dressed in jeans and sweatshirts. In contrast, Mr. Anderson has dressed up to come to the clinic, as most elders do. He wears a crisp blue denim shirt buttoned at the neck with a bolo-tie clasped with a turquoise stone framed in silver filigree. He sits in the chair next to the desk, the skin of his face and neck the texture of weathered wood.

I introduce myself and extend my hand. Palm touches palm, the Navajo handshake. I mention the rain in the east and, perching on the stool in front of him, inquire about the weakness.

Entries that earned an honorable mention will be published in upcoming editions of Minnesota Medicine.

If this taste of medicine and the humanities whets your appetite for more, here’s a roundup, also from the current issue of Minnesota Medicine, of the creative ways in which the visual arts, story-telling and music are being applied in the world of medicine. "Journey into the Unknown" profiles a physician who is using documentary film-making – and turning the camera’s lens onto his own story – to promote the importance of health screenings. "Tales from the Clinic" describes how medical students at rural training sites use writing to tell stories and gain insight about what they’re learning. And "The Year of Living Creatively" introduces us to six medical students who combine their medical studies with a pursuit of the arts.

This is the sixth year Minnesota Medicine has hosted its "Medical Musings" contest. Entries from 2008 can be found here. Here’s the 2007 issue, which takes a closer look at medicine and films, and the 2006 "Med Poets Society" issue, which focuses on poetry.