Emergency Advocacy

In my first weekly conference as an emergency medicine intern at Yale, we had several lectures. Topics included D-dimer in pulmonary embolism, atrial fibrillation, chest x-ray reading and emergency medicine advocacy. What? Advocacy in the classroom? One of our EM professors is an expert in the subjects of accident prevention policy, so she gave us a primer on what we can do as new doctors to contribute to the current health care debate. Here's the letter I wrote this morning on my day off.

Dear (Insert CT lawmaker name here),

I am a resident physician in the Yale-New Haven Hospital emergency department. I'm writing to tell you a little bit about ER conditions so that you will have a sense of how emergency care is an important issue that should be included in the currently debated health plan. A health care plan in our country cannot be comprehensive if it does not address emergency care.

When I show up for my 12 hour shift at Yale's level one trauma center, I am immediately inundated with an atmosphere that to an outsider could be perceived as chaos. The scene is far from the clean depictions on your television set, and believe me, there is not time for the intrigue that home viewers expect from “Grey's Anatomy.” Every night at many of the top hospitals in this country, patients sit in emergency room hallways for lack of private rooms. It is not unusual for these folks to receive all of their care in the hallway. I will personally wheel patients in and out of rooms so that they may have the dignity of a private exam. It breaks my heart to tell these folks, “We'll only be in here for 10 minutes before I take you back out into the hallway.” Can you imagine your doctor saying, “You have appendicitis and will need surgery, but until then try to make yourself comfortable on this hallway stretcher,” like I have? When you are having the worst pain of your life, you can't understand there is someone sicker than you.

This brings me to the health plan. There are always really sick patients. President Obama has been championing primary care as the centerpiece of his plan; and rightly so: prevention and a steady relationship with one doctor will go far to reduce health care costs. But increasing resources to primary care will not alleviate the overcrowding problems we face in delivering emergency care. For example, with 97% of the population in nearby Massachusetts insured, ER use has increased by nearly 10%. A refrain we physicians wish to emphasize is: coverage does not equal access. Where do people go when they get sick after hours?

I am familiar with and applaud sections 214 and 215 of the current Senate bill (“Systems for Emergency Care...” and “Trauma Centers...” in “Quality, Affordable Health Care for all Americans” submitted by Sen. Reid), and hope you will support these provisions. The grants and mandates are based on recommendations a 2006 Institute of Medicine report and will go far to improve care through one of the most frequent access points for people in need. In the interim, I'll do my part to see as many patients as I can safely handle so that our ER's hallways are used for walking, not patient care.

Sincerely,

Thomas Robey, M.D., Ph.D.

If you are wondering why I don't post more here in the next year, it's because I'll be using my time to write other things. Such as letters like this...

Hospital Diversion

Is it wrong for a university hospital to turn away a patient because he doesn't have insurance? What if it was a kid attacked by a pit bull? There's been a big splash in Chicago about a child with dog bites to the face being sent home to follow up at a different hospital. The situation has drawn criticism from the American College of Emergency Physicians, but the University of Chicago is defending its position to divert uninsured patients. This story's juiciness is enhanced by the direct connection between Michelle Obama and hospital’s Urban Health Initiative (UHI), which has as its goal to divert non-emergency patients away from EDs. It’s supposed to make the system more efficient by freeing up ED staff to treat the most urgent cases. But ACEP likens it to dumping unprofitable patients.

This creates a tough challenge for me. As the newspapers and ACEP present it, this policy clashes with my reasons for choosing a career in emergency medicine. But I've also held that innovative solutions for improving access to medical care should be able to be implemented from within the ED. I didn't hear much about the UHI when I interviewed at the University of Chicago. But in a recent email to applicants, the U of C emergency medicine residency program director did say that training will actually not be very much different because of the University's policy. This makes a lot of sense, given that training occurs at four hospitals around the city and there are always patients in urban ED waiting rooms. And as Ben points out below, it is important to see both sides of this story. But the impression of the program will suffer. Is that a risk I want to take in assembling my rank list?

If you're in my ethics class, we'll be focusing on this issue in two weeks.

Autistic Politics

Autism is a real disease. Its prevalence in the United States and other Western nations is increasing. It causes suffering for many parents and children each year. I do not intend in this post to downgrade the significance of autism in society today. I wish to use autism as an example of the wrong way health policy is made in our country.

In reviewing the candidates' health care plans, I noticed that two of them make specific prominent mention of one disease: Autism. McCain says on his website,

As President, John McCain will work to advance federal research into autism, promote early screening, and identify better treatment options, while providing support for children with autism so that they may reach their full potential.

He also has an entire policy platform built on autism which you can read here. I noticed that autism is the only disease he specifically mentions in his health platform. Basically he argues that federal money needs to be spent on learning about and combating autism. Pretty harmless, right? I'll get back to McCain in a minute. Obama has also pledged support of autism research. He says he will:

Support Americans with Autism. More than one million Americans have autism, a complex neurobiological condition that has a range of impacts on thinking, feeling, language, and the ability to relate to others. As diagnostic criteria broaden and awareness increases, more cases of autism have been recognized across the country. Barack Obama believes that we can do more to help autistic Americans and their families understand and live with autism. He has been a strong supporter of more than $1 billion in federal funding for autism research on the root causes and treatments, and he believes that we should increase funding for the Individuals with Disabilities Education Act to truly ensure that no child is left behind.

More than anything, autism remains a profound mystery with a broad spectrum of effects on autistic individuals, their families, loved ones, the community, and education and health care systems. Obama believes that the government and our communities should work together to provide a helping hand to autistic individuals and their families.

I like this statement better. Instead of just spending money on research, he recognizes that the autism epidemic can be attributed to "broadened diagnostic criteria." Rather than to promise cures and treatments, he suggests "we can do more to help autistic Americans and their families understand and live with autism." Oh yeah, he also supports spending a billion dollars on autism research.

I couldn't find Clinton's position in her health policy material, but I bet she supports autism research...

Why is this physician scientist concerned about political leaders' pledges to fund research for a specific disease like autism? The physician in me sees hundreds of other disease that aren't adequately studies that cause pain and suffering to millions of people. The scientist in me imagines thousands of questions about the natural world (answers to which invariably contribute to tomorrow's medicines) that remain unanswered. There is only a limited pool of cash that researchers draw from every year. Why does autism get such a big chunk???

The answer is (drum roll pleas...) patient advocacy groups. Using the most sophisticated research tools available to me (Dr. Google), I found the Autism Society of America, Autism Speaks, Unlocking Autism, the National Autism Association, and many more. Almost all of these sites pledge to support research, make a difference in Washington and provide information about vaccines. And this is where McCain comes back into the picture. At the end of February, McCain's response to a question from a mother of a boy with autism was,

"It’s indisputable that (autism) is on the rise amongst children, the question is what’s causing it. And we go back and forth and there’s strong evidence that indicates that it’s got to do with a preservative in vaccines." He added that there’s "divided scientific opinion" on the matter, with "many on the other side that are credible scientists that are saying that’s not the cause of it."

What's wrong with this? Plenty of other people will tell you what's wrong with this. The upshot is that he is using language of the controversy to lend scientific credibility to an idea that is not scientific. It is therefore ironic that McCain wants to

dedicate federal research on the basis of sound science resulting in greater focus on care and cure of chronic disease.

Sound science. That's a good name for a nerd rock band.

So why is the autism lobby bad for health care policy in America? The first reason is that it puts contingencies on basic science funding. The second is that American health policy is so inept at keeping Americans healthy that we cannot even treat diseases we know how to cure. Your best chance at staying healthy is to be rich. While autism is a disease that affects many social and economic classes, its the rich parents that are driving the emphasis on a national autism program. I believe that disease advocacy groups should focus their resources on identifying worthwhile recipients for research funding. The Feds have much bigger fish to fry if the United States is to develop a health care system that affords access to all Americans.

In the end, autism is an important disease that should have access to national resources. But what I hear is "Vaccines cause autism" (which is not a scientific claim) and "We need more money for scientific research on autism." Autism advocates can't have it both ways.

Do you want to vote for health in 2008? Read my other posts about presidential health policy.

Debating Health Care

My piece about the remaining presidential candidates' positions on health care is up over at The Differential. Since I refrained from offering any of my opinions over there, I'm using this space to point out more opinionated perspectives that wouldn't be appropriate for a non-partisan site. The one liner for me about the three remaining candidates plans is:

Each of the plans has good ideas built in, but the Democrats' proposals far better at addressing the critical challenged faced by our health care system today.

By the way, I think one plan is the best, I voted for a different person than who I think has the best plan and see many good ideas in the third person's plan. Stick with me, and you'll learn which names go where. Unfortunately, I cannot devote enough time right now (exhibit A: the 80 hour work week) to post all of the information about the plans, so I'll periodically post follow-ups and link them here. The first post (maybe you've read it) is my primer on the health care platforms over at The Differential. When I write a new article, I'll link it from the list below, or you can click on the Vote for Health link on my Readers' Favorites sidebar.

1. Vote for Health in 2008
2. Autism
3. Walk-In Clinics
4. Electronic Medical Records
5. "Socialized Medicine"
6. Paying For It
7. "Increasing Quality"
8. Generic Drugs
   

That's a fair start. Now you know what to expect. I hope you come back to visit early and often. When you do, be sure to chime in when I'm off my rocker or when I'm right on.

Oh yeah: my biases are: Clinton's plan is the best, I voted for Obama, and McCain has good ideas that the other two should pick up on.