Category Archives: Health Care and Medicine

Resident Perspective

I was encouraged by my wife to keep a journal for thoughts and feelings surrounding the developing coronavirus pandemic because I may be able to offer a unique perspective as a resident in medicine who is also a new parent and attempting to overcome fear of the unknown and what’s to come. I will try to update as frequently as I am able.

Monday March 23rd 2020

I found out that the Attending Physician I had been working with all last week and who was coughing during rounds was getting tested for coronavirus last night in the emergency department. I can convince myself I’m having symptoms of fatigue, sore throat and maybe a headache but I’ve also been working in the hospital for almost four weeks straight and this could just be general exhaustion mixed with a touch of seasonal allergies. I try not to think about it too much.

I haven’t been wearing any masks or other personal protective equipment around the hospital yet. At this point I feel like we are still in the nascent stages of the impending unknown so wearing a mask right now seems premature. The practice isn’t mandatory but I see more and more random staff in the hallways with facemasks on, many of whom aren’t clinicians which is a greater indication that I should probably get on board. Every now and then I’ll check a supply closet or outside a patient’s room to see what the surgical mask inventory is like. There are constant rumors floating around that, like the N95 facemasks, other equipment will be locked up and parsed out by a charge nurse on an “as needed basis”. If a run-on-the-banks situation were to occur, I want to make sure I hit the sweet spot where I don’t contribute too much to the hysteria but ensure I’ve got a mask without having to fight for scraps. I’ll continue to assess the situation.

Meanwhile, I observe more PAPRs (Powered Air-Purifying Respirator—special protective equipment) next to rooms on the wards, awaiting their donning by newly trained hands. They’ll be used for all COVID patients but since there aren’t any confirmed as of yet in our hospital, the purpose is to be used by all COVID “rule-outs” for now–those that are being tested and don’t have results back. We have a three to five day turnaround for test results right now, meaning we simply don’t know if the virus is already in our presence. The increasing numbers of PAPRs seen daily act as a surrogate for the proximity of the disease to Philadelphia and as a gauge for the level of concern amongst residents.

Over the last several days quite literally every discussion between residents in the hospital is about the coronavirus. Either discussing potential treatments; rumors as to what’s going on in China, Italy, or New York; sending memes or chatting about our trepidation and general anxiety that has gripped the entire hospital. Even when seeing my patients, every TV seems to be tuned into the news, all of which are giving up-to-the-minute global figures alternating between death tolls and economic indices. Patients ask questions for which I don’t have answers. No families or visitors are allowed in the premises. No students or “non-essential personnel” permitted to the hospital. Residents are instructed to follow social distancing protocols and there are to be no gatherings of more than five.

I went to a stroke alert today at a patient’s room for a patient that I wasn’t directly taking care of, I just happened to be nearby. The patient was in a designated “rule-out” room meaning all personnel involved need to treat the patient with extreme caution, and to limit those in contact with the patient to only those “essential.” Two nurses and a tech were in the cramped room already while the neurology resident was outside the room, not wanting to unnecessarily expose herself, miming the actions for a neurologic exam to one of the nurses. She gave instructions through the patient’s door window and into a speakerphone in a patient’s room a mere 4 or 5 feet away. The nurse and the tech cautiously proceeded to ask the patient to perform the maneuvers coached by the neurologist. It was an odd scene as clearly the patient could hear the instructions from the hallway through the door as well as the speakerphone but was polite enough to not mention that to the nurse directly in front of him. The nurse dutifully relayed the commands, “can you follow my finger with your eyes and keep your head still?” and the patient dutifully followed them. It would be funny if it weren’t so bizarre. Turns out he wasn’t having a stroke but it was good to have the opportunity to work out kinks regarding the protocol for patient emergencies. Residents are instructed to make note of instances in which normal protocols can’t be followed given the extra necessary precautions we now have to take. No doubt there will be plenty.

The hospital is both quiet but buzzing lately. Most of the services only have a few patients on each team and I walk down the wards and can find four-five-six! rooms in a row without any occupants. I’ve never seen more than two consecutive empty beds during my years here. The hospital policy is to discharge as many patients as possible with the impending influx of COVID cases to come. No elective surgeries and if you don’t absolutely need to be hospitalized you’d be safer at home. The atmosphere was akin to the episode of Game of Thrones just prior to the final battle in the last season. Nervous and anxious, we have no overflowing wine to keep us preoccupied and stumbling about. The morale is low and the silence in the hallways and in the former resident-gathering areas from our lounge to the cafeteria forces it to reverberate. Philadelphia has the temporary advantage of being able to watch from the shore as the tidal wave from China picks up steam as it makes its way across Europe, to New York City and crashing down I-95.

That night at home I continued to mentally scan my body for any possible symptoms. I hardly ever get sick so I don’t know if I’m short of breath at the top of the stairs because I’m out of shape or because I have a deadly infection. Best to push it to the back of my mind as there’s nothing I can do about it at this moment.

Bedtime routine completed. I get a text message at 10:00pm from a co-worker saying that the Attending I had been working with came back positive for coronavirus.

Image from Getty Images.

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Governor Wolf and the Courts Must Act Now to Mitigate Public Health Threat

On Monday morning, the ACLU of Pennsylvania filed an emergency request to the state Supreme Court to order county courts to release vulnerable populations from city jails. Philadelphia activists amplified the call to action through an organized social distancing caravan targeted at key decisionmakers. These actions follow the first confirmed cases of COVID-19 in Philadelphia prisons and jails, which were reported last Friday.

For weeks, the ACLU, local activists, community organizations, the Defender Association of Philadelphia, and the Philadelphia District Attorney’s office have been urging the release of vulnerable populations from conditions where social distancing is impossible. The First Judicial District (FJD) courts and Governor Wolf, however, still refuse to step up to inhibit the rapid and fatal spread of COVID-19. Two weeks into the alarm being raised on coronavirus in Philadelphia, the FJD has released minimal numbers of immunocompromised and elderly individuals, far fewer than the hundreds or thousands that have been released in other jurisdictions across the country and world. The courts have also rejected emergency release petitions based on public health concerns for those detained on probation or parole violations, barring many youth and adults who pose no threat to society from returning safely home.

Despite a foreboding history of communicable disease outbreaks inside detention centers, Governor Wolf has also declined to proactively save lives by closing inhumane facilities and exercising his gubernatorial powers of compassionate release. People awaiting immigration cases in York County Prison are on hunger strike to protest insufficient measures for their safety. The Berks County Immigration Detention Facility in Leesport, PA, one of the nation’s three immigration detention centers for families seeking asylum, lost its state license to operate in 2016 due to dangerous conditions and ongoing human rights abuses of residents, including infants. Yet Governor Wolf’s administration reiterated last week that they would not issue an emergency removal order unless there is a serious threat to public health inside the walls, an irony not lost on advocates and immigrant families currently fearing for their lives at the prospect of COVID-19 entering the unsanitary facility.

Jails and prisons as institutions pose a greater public safety risk than any individual they cage. This was true before the pandemic began and is an even more urgent truth as the virus enters jails, prisons, and detention centers. These overcrowded facilities lack access to soap, sinks, paper towels, and hand sanitizer and put both those who are incarcerated and those who enter these facilities for their work at risk, as recently seen on a large scale in New York City’s infamous Rikers Island Jail. The FJD and Governor Wolf could immediately reduce overcrowding and mitigate this risk without any threat to public safety. Governor Wolf could enact massive compassionate release with just the stroke of a pen, which would free any elderly or immunocompromised person at increased risk for contracting and dying from the disease. He could also order the release of community members detained by Immigration and Customs Enforcement (ICE) who are held for no crime other than lacking documentation while they otherwise contribute robustly to our communities. The FJD could supplement these efforts by releasing all those charged on low-level offenses from county jails and discontinuing arbitrary bail amounts. There’s no good justification for wealth-based detention in general and it is particularly indefensible during a pandemic. The courts and the governor also have the power to extend compassionate release to individuals who are up for parole review, individuals within six months of their release date, pregnant individuals, and youth in county and state detention facilities – many of whom are medically vulnerable and in conditions violating the federal ban on solitary confinement of youth because of facilities’ attempts to follow social distancing.

Community members are anxious to welcome children, parents, siblings, aunts, uncles, grandchildren, grandparents, partners, and friends home, people they have often traveled thousands of miles and spent thousands of dollars in travel expenses and private prison phone company bills to stay connected to during the months, years, or decades of their incarceration. Precautionary measures for COVID-19 now forbid most visits to jails and prisons. Most facilities have not replaced those visits with video conferencing alternatives or lowered costs per phone call minutes to talk with lawyers and families. This strains already obstacle-ridden bonds between those behind barbed wire and those in the outside world. If and when our loved ones are connected to the basic resources and support systems they need to survive, they are less likely to commit crime and more likely to contribute positively to society when they come home, as so many returning citizens do. In the midst of this deadly pandemic, allowing them to sustain those bonds through early release also grants them access to health-sustaining resources and the ability to social distance, preventative measures mandated by the governor himself to ward off and slow the spread of the novel coronavirus.

Governor Wolf and the FJD must take immediate action before they risk condoning hundreds if not thousands of preventable deaths in the state. Government inaction on continued overcrowding of carceral facilities has already resulted in chaos and deaths in places such as Italy and Colombia. Our city and state have an opportunity to instead follow the example of neighboring states, to embrace humanity and public health common sense in mitigating the disastrous effects mass incarceration will lend to COVID-19’s rapid spread.

Hannah

About the Author: Hannah Prativa Spielberg is currently pursuing a Master of Social Work at the University of Pennsylvania. She worked for four years as a social service advocate for the Defender Association of Philadelphia. Hannah is inspired by the leadership and love-based activism of community members and friends who have experienced life from the inside of prisons, jails, and detention facilities, who moved her to write this piece.

Hannah recommends following @YASP2, @aclupa, @powerinterfaith, @DecarceratePA, @Closethecreek, @Phillybailout, @phillybailfund, @mediamobilizing, @BBworkers, @BLMPhilly, @LILACPhilly, @JustLeadersUSA, @AmistadLaw, and/or @reclaimphila for updates and ways to get involved in the fight.

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Pro-Choice? Bernie Sanders is the Clear Choice.

On reproductive rights, the records of Bernie Sanders and Joe Biden are about as different as Democratic candidates’ records can be. “Biden over 36 years in Congress staked out a reputation as one of the Democratic Party’s most conservative voices on abortion,” as Politico summarized last year. According to the Planned Parenthood Action Fund’s 2016 review, on the other hand, “There’s no question: Senator Bernie Sanders has a strong record on reproductive rights.”

Here’s how Politico elaborates on Joe Biden’s record:

For decades, [Joe Biden] opposed late-term and so-called partial birth abortions, lamenting that one ban enacted in the 1990s did not go far enough. He supported Republican presidents’ prohibitions on funding for groups that promote abortions overseas, and backed legislation that would have allowed states to overturn Roe v. Wade. He even fought unsuccessfully to widen religious groups’ exemptions from the Affordable Care Act’s mandate for birth control coverage…

In public statements, interviews and recently resurfaced videos, Biden said he believed that “abortion is wrong from the moment of conception,” and said he doesn’t “view abortion as a choice and a right” but rather “always a tragedy.” He also said he did not believe that “a woman has the sole right to say what should happen to her body.”

Biden voted for the adoption of the Hyde Amendment in the 1970s and later opposed efforts to make exemptions and fund abortions for women who were victims of rape or incest.

He held that position until [the late spring of 2019, after he began his 2020 presidential campaign.]

Here’s how the Planned Parenthood Action Fund elaborates on Bernie Sanders’s record:

Sanders Has a 100% Voting Record on the Action Fund Scorecard
When the Action Fund started scoring congressional votes in 1995 (a few years after Sanders began his tenure in Congress), one of the first votes we scored was an amendment to allow over $190 million for family planning projects under Title X. Then-Representative Sanders was a key vote in moving that amendment forward. Throughout his career, he has continued to vote to protect access to safe and legal abortion, as well as federal funding for family planning and health care provided at Planned Parenthood health centers.

Sanders Supports Expanded Access to Birth Control
To this day, Sanders also has reliably and consistently voted to ensure women’s access to the full range of birth control options. During the fight over the Blunt Amendment, which would have allowed employers to opt out of providing insurance coverage of birth control, Sanders gave a speech on the Senate floor voicing his opposition:

“…there is growing anger that members of Congress, mostly men I should add, are trying to roll back the clock on women’s rights… Let me add my strong belief that if the United States Senate had 83 women and 17 men rather than 83 men and 17 women that a bill like this would never even make it to the floor.”

What’s more, he supports the Affordable Care Act, including its mandated coverage for birth control, and co-sponsored a bill that would protect women from bosses who want to block this coverage from them…

Sanders [also] signed onto a friend-of-the-court brief to the Supreme Court advocating against the Hobby Lobby’s decision to deny insurance coverage for contraception to their employees…

Sanders Supports Access to Abortion
To sum-up Sanders’ stance on abortion, just read what he had to say in a 2012 op-ed:

“We are not returning to the days of back-room abortions, when countless women died or were maimed. The decision about abortion must remain a decision for the woman, her family and physician to make, not the government.”

His strong position that we, as a nation, will never go backwards when it comes to access to abortion care is a major reason why Sanders is in our corner.

Sanders has also been a cosponsor of one of the most proactive pieces of legislation that would prevent states from chipping away at abortion access: The Women’s Health Protection Act, introduced in 2015 and 2013. This act would prevent politicians from passing laws aimed at shutting down health centers by imposing unnecessary building regulations and medical procedures such as mandatory ultrasounds — which have the sole intent of shaming women and making it harder for them to access safe, legal abortion…

On the campaign trail, Sanders boldly defended abortion access at the Christian institution Liberty University despite the fact that the university is so conservative that Ted Cruz announced his run for president there…

Sanders Has Stood With Planned Parenthood
The PPAF thanks Sanders for being an unwavering ally of Planned Parenthood patients and consistently voting in favor of protecting patients who rely on federal funds to access birth control, cancer screenings, and other basic health care at Planned Parenthood health centers.

If Bernie Sanders is elected, pro-choice women can feel confident he’ll have their backs. If Joe Biden is elected, regardless of what he says during campaign season, pro-choice women will have a lot of reasons to worry.

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On Both Politics and Policy, “For All” Beats “For Some”

Medicare for All or Medicare for All Who Want It? Free college for all or free college for just the non-rich? The debate between universal (available to everyone) and means-tested (available only to those who meet certain criteria) programs has defined the Democratic primary. Bernie Sanders, often joined by Elizabeth Warren, argues for universalism, declaring education and health care to be basic human rights. Amy Klobuchar, Pete Buttigieg, and Joe Biden argue against, contending that government resources must be targeted only to those in need, rather than wasted on the rich and/or on those who ostensibly don’t want them.

On the most commonly cited rationale for each position – sustainability for universalists and resource constraints for means testers – proponents of universalism have the upper hand. Medicare and Social Security, two of the United States’s largest, most successful, and most popular programs, are as close to universal as we’ve got. By giving everyone a stake in these programs, proponents argue, their near-universality has insulated them from attack. Bob Greenstein (the President of the Center on Budget and Policy Priorities, where I used to work) points out both that these programs have been cut and that their popularity could conceivably be due to the perception that they’re tied to work rather than to their quasi-universal nature, but the Alaska Permanent Fund, a state-level universal program not tied to work, also enjoys overwhelming public support. So do universal programs that aren’t tied to work in other countries – other countries’ universal health care systems, for instance, are way more popular than our means-tested approach. It’s reasonable to expect a universal program to be more sustainable than a means-tested alternative over time.

The Buttigieges of the world counter that universal programs are too expensive; in December, for instance, Buttigieg said they would require “the kind of taxation that economists tell us could hurt the economy.” But even if you reject the notion that government spending can be substantially increased without raising taxes, concerns about higher taxes are entirely without merit. Research has consistently (and predictably) failed to support such concerns, the United States has significantly lower taxes than the rest of the developed world, and scores of reputable economists support tax proposals, like those Sanders and Warren have released, that can fund the universal programs on offer. When Buttigieg says he’d prefer to “save those dollars [that would otherwise be spent on free college] for something else,” he is presenting a false choice. It is only his and others’ political preferences, not actual resource constraints, that stand between us and full funding of all the priorities he listed: education, infrastructure, child care, housing, and health care.

Still, the most compelling case for universal programs isn’t political. It is, ironically, that they’re better at achieving two of means testing’s major goals: helping people in need and doing so efficiently. They reduce stigma, arbitrariness, usage barriers, and administrative costs.

Universal programs help people in need by reducing stigma

Most low-income people work incredibly hard to put roofs over their heads and food on their tables. Yet they’re constantly accused of being unskilled, lazy, good-for-nothing loafers in search of government handouts. Afraid of being perceived that way and/or ashamed of their economic situation, many people who are struggling to get by decide not to access the means-tested benefits to which they’re entitled. They’d rather go hungry than risk someone catching them using food stamps in the checkout line.

Correcting false stereotypes is a top priority, with universal programs a useful complement for improving the experience of people in need. If everyone received SNAP benefits (SNAP, which stands for Supplemental Nutrition Assistance Program, is the contemporary name for the food stamp program), for example, using them would no longer identify someone as low-income. We would thus expect higher rates of SNAP usage among low-income people.

That’s exactly what we’ve seen with the school meals program following the introduction of a program called “community eligibility,” which enables schools and school districts with a certain percentage of low-income students to offer free school meals to all students – regardless of their income levels – free of charge. Research suggests that reduced stigma is at least part of the reason students at schools that have adopted this program are more likely to take advantage of school breakfast and lunch programs.

Universal programs help people in need by eliminating arbitrary cutoffs

For SNAP, the income eligibility threshold is 130% of the poverty line, or about $27,700 annually for a family of three. People who make less than that amount (provided they meet other requirements – SNAP also has an asset test and restrictive eligibility rules for various groups of people including immigrants, individuals aged 18 to 49 who don’t have children, and students) can access benefits; people who make more than that amount cannot. Under Buttigieg’s higher education plan, college is free only for families making less than $100,000 a year (and discounted for families making between $100,000 and $150,000).

Means-tested benefits typically phase out slowly – that is, benefits get gradually smaller as beneficiary income gets higher – to ensure that the sum of pay plus benefits continues to increase when people pass eligibility thresholds. But why shouldn’t a family of three making $30,000 a year get food assistance? Why should $100,001 be the level at which a family starts having to pay for college? Eligibility thresholds in means-tested programs are arbitrary and inevitably create strange, difficult-to-justify divides between people right above and right below them. Universal programs avoid this problem completely by providing the same benefit to everyone.

Universal programs help people in need by reducing usage barriers

Means testing requires some form of testing, as the name implies, to determine whether or not someone is eligible for benefits. Depending on the complexity of a program’s eligibility rules, that testing might require a form of identification, proof of residence, proof of income, or any number of other things. Eligible beneficiaries may need to mail, hand-deliver, or electronically submit one or more forms, which, as Sanders accurately observed during the December debate, “people are sick and tired of filling out.

Filling out forms and proving eligibility is much more than an annoyance for many eligible people in need. Some may not know how to read or write. Some may move and/or change jobs frequently. Some may lack an official ID. The more hoops people have to jump through to access benefits, the fewer eligible people will actually end up receiving benefits.

Government agencies can mitigate this problem with outreach efforts and assistance programs, of course. But even well-administered means-tested programs like SNAP that continue to improve in these areas don’t catch everyone they should, in part because of the access barriers means testing inherently creates – in 2016, the most recent year for which we have data, about 15% of people eligible for SNAP did not participate in the program.

Universal programs improve efficiency by reducing administrative costs

In addition to creating an obstacle for eligible beneficiaries, the complexity introduced by means testing presents a challenge for efficient government. Every form that needs to be filled out has to be processed. Eligibility has to be verified. Complex rules have to be actively managed. Means-tested programs spend a larger share of their money on administrative overhead than universal programs do.

Administrative costs for Social Security, for example, are only 0.7% of total expenses. For SNAP, one of the most efficient and effective means-tested government programs, administrative spending comprises 7.7% of its total budget. Over three-quarters of those administrative costs are “certification-related,” meaning they’re “associated with determining household eligibility.”

To be clear, the overall cost of SNAP and other means-tested programs would be many times higher, even with substantially reduced overhead costs, if they were more universal. Increased overall cost is the only real potential downside of universality. And if one were forced to choose between increasing benefits for people in need and extending benefits to higher-income people who don’t currently receive them, increasing benefits for people in need would be the clearly correct choice.

But as noted above, that choice is a false one. There is no question that the US government has the money to offer increased benefits through universal programs. The only question is whether we will choose to spend it on the worthy goals of helping people in need and improving government efficiency for everyone.

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Filed under 2020 Election, Education, Health Care and Medicine, Poverty and the Justice System, US Political System

How Mainstream News Coverage Distorts the Policy, Politics, and Polling on Medicare For All

Jonathan Martin and Abby Goodnough discuss a brewing Democratic Party debate about Medicare For All in The New York Times. Does it mean a single-payer system in which the government covers everyone’s health care costs? Or is it just rhetoric intended to mean “I support a better health care system” without a commitment to challenging insurance industry power?

Martin and Goodnough helpfully note that only one of the five likely 2020 presidential candidates they discuss* is committed to a single-payer system: Bernie Sanders. But their article is also misleading in its discussion of Medicare For All policy, politics, and polling. Their errors are all too common in news articles and anyone wishing to responsibly cover politics over the next few years needs to correct them.

First, when it comes to the policy implications of Medicare For All, Martin and Goodnough characterize single-payer health care as a system “in which many would lose their current insurance options and pay higher taxes.” They fail to mention that the policy replaces people’s “current insurance options” with more expansive coverage that (under Sanders’ plan) eliminates premiums, copays, and deductibles. As pretty much every distributional analysis of proposed single-payer plans show, the vast majority of people will pay substantially less money in taxes plus health care costs under Medicare For All than they currently pay. The omission of these details is akin to implying Martin should have felt “uneasy” about losing his health insurance options and paying higher taxes in 2013 – without mentioning that he was replacing his insurance and making a higher income by moving from Politico to The New York Times.

sanders-tax-and-transfer-distributional-analysis

Similarly, in an attempt to support Michael Bloomberg’s claim that single-payer health care will “bankrupt” America, Martin and Goodnough cite a study from the Mercatus Center that “predicted [Sanders’ plan] would increase federal spending by at least $32.6 trillion over the first decade.” That study also predicted that combined private and public spending on health care in the United States – the most important number in health care cost estimates – would fall by $2 trillion, but Martin and Goodnough don’t mention that fact. As Matt Bruenig has documented extensively, it’s hard to read the numbers in the Mercatus report as anything other than an endorsement of Sanders’ plan.

Mercatus doesn’t want us to read their study that way, which brings us to the second way in which the Times article is misleading. Martin and Goodnough describe Mercatus as the “Mercatus Center of George Mason University,” giving it the imprimatur of impartial academic institution, when Mercatus is in reality a Right-wing think tank funded by the Koch family foundations. This neutral description is inconsistent with how the Times news pages describe other think tanks – they routinely call my old employer, the Center on Budget and Policy Priorities, “liberal” or “liberal-leaning” – and erroneously suggests to the reader that the concerns Mercatus raises come from an objective source.

Martin and Goodnough fail to provide key context for other political opinions, too. They write about how “moderates believe” that Medicare For All will “frighten” an important crop of general election voters, for example, but don’t note that these moderates have been consistently wrong about what voters care about. If there’s any lesson to learn from the 2016 election result, it’s that people’s beliefs about what makes politicians electable should be discounted – especially the beliefs of people who ignored electability evidence the last time around.

Third, Martin and Goodnough cherry-pick the Medicare For All polling data that makes their preferred case. They acknowledge that the term itself “has broad public support,” but they highlight how support for the policy drops “when people hear that it would eliminate insurance companies or that it would require Americans to pay more in taxes.” A result from the same poll that goes unmentioned? That support for the policy rises when people hear that it would “guarantee health insurance as a right for all Americans” or “eliminate all health insurance premiums and reduce out-of-pocket health care costs for most Americans.” Martin and Goodnough also cite a Gallup poll finding that “70 percent of Americans with private insurance rate their coverage as ‘excellent’ or ‘good’” without pointing out that the number jumps to 79 percent for Americans on Medicare or Medicaid.

What Martin and Goodnough get right is that “attitudes [about Medicare For All] swing significantly depending on…the details.” If you tell people that the policy will result in them losing their current insurance, paying higher taxes, and interacting with a bankrupt federal government, they’re less likely to support it. If you tell people the truth, however – that public insurance in the United States is well-liked and more cost-efficient than private insurance, that other countries with Medicare-For-All-type systems spend way less money while covering a much higher percentage of their populations than we do, and that, under a Medicare For All system, all but the richest among us will get better coverage while paying less than they do today – people are fully on board. We need our news media to start telling the truth.

*Update (2/4/19): Thanks to a reader comment, I updated this sentence post-publication to clarify that the Times did not discuss every likely 2020 candidate. Tulsi Gabbard, for example, may also be committed to a true single-payer system.

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Bernie Sanders-Style Health Care Would Be a Big Win for Low- and Middle-Income Americans

Bernie Sanders just released his new proposal for a single-payer health care system.  As former US Labor Secretary Rob Reich notes, Sanders’ plan would be “a huge advance over what we have now.”  Reich’s summary:

It builds on the strengths of Medicare. Like Medicare, it’s universal — separating health insurance from employment, and enabling people to choose a health care provider without worrying about whether that provider is in-network: All they’d need do is go to the doctor and show their insurance card. No more copays, no more deductibles and no more fighting with insurance companies when they fail to pay for charges.

Through a single national insurance system, we’ll no longer be paying for the marketing and advertising of private for-profit health insurers, nor their giant executive salaries, or their complex billing systems. Government will negotiate fair prices with drug companies, hospitals, and medical suppliers.

The plan’s release came right before the fourth Democratic debate and after a week of attacks from the Hillary Clinton campaign, which had been simultaneously complaining about not having plan details and distorting the details of a similar proposal Sanders introduced in the Senate in 2013.  Even those sympathetic to Clinton have labeled these attacks “questionable” or “genuinely strange,” while those willing to more accurately describe her team’s “GOP fear tactics” have noted that they are “wildly misleading,” “flagrantly mischaracterizing,” “mostly false,” “nonsense,” “disingenuous,” “stupid,” and “dishonest.”  Sanders’ plan would expand Medicare, not “dismantle” it; cover more people, not “strip millions” from coverage; ensure that insurance is provided in every state, not “empower” governors to “take [it] away;” and save most Americans lots of money, not “cost” them.

That last point in particular deserves more emphasis, as it’s one about which Clinton appears to have been lying outright.  Speaking to George Stephanopolous about single-payer health care on Wednesday, January 13, Clinton said: “Every analysis that I’m aware of shows it’s going to cost middle-class families and working families.”  Yet I have never seen such an analysis, and every analysis I am aware of says the exact opposite: that most families would gain big from a switch to a Sanders-style health care system (as Sanders explained at the debate, their savings from not having to pay premiums anymore would outweigh any increased taxes they would have to pay to fund the program).

Consider, for example, a 2013 analysis of the Expanded and Improved Medicare For All Act from UMass-Amherst economist Gerald Friedman.  Physicians for a National Health Program called this bill and Sanders’ old plan (which, despite Clinton’s suggestion to the contrary at the debate, is not all that different from his new one) “simply two expressions of the one single payer concept;” Clinton spokesman Brian Fallon agreed that the two bills were “similar” in a recent interview.  As shown in the graph below, Friedman estimated that everyone in the bottom 95% would see their after-tax incomes rise under such a proposal.  Fallon is clearly familiar with this analysis – he selectively referenced parts of it in the interview linked above – and it’s been the most common citation for cost estimates that Clinton herself has used; it’s near impossible to believe that Clinton was not “aware of” it.

Friedman HR 676

Distributional analysis, from UMass-Amherst economist Gerald Friedman, of a 2013 proposal for single-payer health care.

Friedman now estimates that, “[f]or a middle-class family of four with an income from wages of $50,000 and an employer-provided family plan of an average price, the Sanders program would save $5,807, or 12% of income.”  Similarly, the Sanders campaign had previously estimated that his old plan would have saved a typical family between $3,855 and $5,173.  PolitiFact argued that employers might respond to the financing scheme in that plan by reducing workers’ paychecks, but still estimated, even under pessimistic assumptions, that “the average family would save $505 to $1,823 a year.”

There have also been analyses of proposed state-level single-payer health care plans.  A proposal in Vermont in 2001 would have saved an estimated $995 on average for families making between $50,000 and $75,000 a year, while a proposal in California in 2006 would have saved families in that same income range an estimated average of $2,942 (the poorest families – those making less than $10,000 a year – would have saved an estimated average of $608 in both states).

Each of these analyses indicates that Bernie Sanders-style single-payer health care is a major win for low- and middle-income Americans.  It’s theoretically possible that Clinton both isn’t “aware of” any of them and that she and Fallon are sitting on credible analyses that say something different, but I’d give that possibility much lower odds than Martin O’Malley winning the Democratic nomination.  And while Clinton shifted gears slightly at the debate in response to Sanders’ new plan, many of her comments, like the assertions that Sanders would “tear [the Affordable Care Act] up” and that Democrats “couldn’t get the votes for” a public option during the ACA debate, were still extremely misleading.

This conversation about single-payer health care has become a perfect window into the choice facing Democratic primary voters.  After receiving millions of dollars from the health insurance industry, Hillary Clinton no longer supports the type of truly universal health care coverage she backed in the early 1990s.  Instead, she has attacked Bernie Sanders’ support of such a plan with very similar tactics to those she herself decried in 2008 as “right out of Karl Rove’s playbook” (see video below).  These attacks, besides being dishonest, undermine key Democratic values.

On the other hand, Bernie Sanders has a consistent record of fighting for those values.  He rejects money from special interests and believes, as his new proposal reiterates and he said at the debate, that health care is a right that “should be available to all of our people.”  As he also pointed out, the real question isn’t whether single-payer health care is desirable – it’s quite clearly “a pretty good deal.”  The more pertinent question is “whether we have the guts to stand up to the private insurance companies and all of their money, and the pharmaceutical industry.”

Sanders certainly does.  Let’s hope the voters choose wisely.

Update (5/29/16): The Tax Policy Center issued an analysis of Sanders’ overall proposals on May 9.  While headlines have tended to focus on their estimates of how much the plan would increase the national debt – estimates which other analysts sharply dispute – less attention has been paid to the fact that the Tax Policy Center also found, consistent with every other analysis above, that Sanders’ plans would bring large benefits for low- and middle-income families.

Sanders Tax and Transfer Distributional Analysis.png

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Big Pharma: Don’t Hate the Player, Hate the Game

Martin Shkreli is a man I admire in an odd sort of way.

The recent controversy involving Mr. Shkreli and his price hike of the toxoplasmosis drug, Daraprim, seems to have caused misguided furor towards the 32-year-old CEO of Turing Pharmaceuticals. He may epitomize a major problem with the pharmaceutical industry but he is simply playing by the rules his pharmaceutical executive contemporaries and predecessors have helped set in place. Much like Donald Trump and his history of bankruptcies, he’d be foolish not to take advantage of every oversight weakness or loophole set up by a corrupt system that affords advantages to those who are shrewd enough and willing to exploit them. The public’s anger is directed at the man and not the system.

If Shkreli were to step down or be forced to resign, do people think that the next CEO of Turing Pharmaceuticals won’t be as zealous or brash in exploiting the system? People dislike him for the price hike, but loathe him for the way he defiantly acted in response. If I were a board member I would demand that my CEO rigorously investigate every pathway to make the company more profitable and therefore more financially stable, but I would also want them to exhibit a measure of temperance so as not to attract unwanted public spotlight. It seems as though people would be willing to forgive and forget a less brazen pharmaceutical executive. Every public dollar not claimed by Turing Pharmaceuticals is a dollar that will be spent elsewhere, or heaven forbid end up in the coffers of the competition.

As for the relationship to medical students, pharm and biotech industry sales reps are not seen or heard from during the first two years of our schooling. We are in the classroom and there is no official school-sanctioned time allotted to these groups unless specifically invited by a student organization. There are no events or talks sponsored by companies, and all faculty must divulge any real or perceived conflicts of interest when lecturing.

This changes in the clinical years (third and fourth year) when the students are out and about amongst the physicians, nurses, and patients in the hospitals and clinics. Students are left to their own devices and are sometimes in rooms with Big Pharma reps during presentations for a new product or during demonstrations of a new surgical device. The “good” reps will gravitate towards the students after they’ve made their pitch to the higher-ups and start chumming it up with those at the bottom of the totem pole and those with the least decision-making capacity.

My first encounter with a sales rep was right before entering the operating room (OR). Gowned in scrubs, all entrants into the OR look nearly identical and no hierarchy can be discerned readily, like it can be up on the patient floors. There doctors wear long white coats, nurses wear scrubs, and students wear short white coats paired with a look that can only be described as confident confusion. There the pecking order is clear. The OR is murkier—we’re all wearing blue scrubs so the nurses and students are dressed like the doctors are dressed like the students. The man approached me and asked if I was a student and we began chatting. I assumed this guy was of some import—he was tall, he spoke confidently, and he knew everyone’s name entering the OR. As the conversation shifted from what my first few days at the hospital were like, he started extolling the sophistication and ease of use of this new surgical device that would be employed for this particular operation. Then it hit me that this guy was just a salesman.

He knew who I was, right? Him selling me on his product would do absolutely nothing for his company’s bottom line and his quarterly sales wouldn’t see the slightest uptick whether or not he had ever spoken to me. He gave me his card and told me to be on the lookout for his company’s reps in all my future endeavors. Man, I thought, he was such a nice guy. As the weeks went on I encountered other reps while in the hospital. All of who were just as nice. What an endearing industry.

Drexel had done a superb job at shielding its first and second year students from the influences of third party companies. We had almost no exposure to the sales pitches coming out of the mouths of these charismatic salespeople. We were being released to the world as naïve students. Were these reps being nice for the sake of being nice? Of course that’s a possibility. What’s much more probable, however, is that they are all planting the seeds of merchandising as soon as they are able. I wouldn’t be advising any hospitals to buy any new surgical devices, nor would I be prescribing any meds for a few years, but when the time comes, I will already have that brand recognition stored somewhere in my brain.

As students we are never given formal training in how pharmaceutical companies operate and what we can expect to deal with for the rest of our careers, regardless of our specialty. We have a Business of Healthcare course that does a great job of outlining the history of US healthcare, how it came to be the way it is, and how insurance companies fit into the puzzle that is the US healthcare system. I once believed that it was a good thing that med school limited exposure to Big Pharma, and that this limited access to its students would offset some of the pernicious effects of physicians becoming beholden to a drug company. As our system is set up now, students or recent med school grads will be inundated with free luncheons, demonstrations, and gifts that are designed to both inform and persuade physicians and future physicians to prescribe certain medications. There seems to be real value in these demonstrations, as it is a way for those in healthcare to stay current with advances in research and technology.

The FDA and Big Pharma continue to battle about how much free speech the for-profit pharmaceutical companies can claim when marketing their drugs and devices. Students are not given much information regarding the politics of what is going on in Washington, D.C. It is important to learn about how our healthcare system works and to truly be advocates for our patients, doctors need to be versed in the discussions going on in the capital. Perhaps to steer clear of politics and controversy, medical schools opt to leave this discussion out altogether.

Or perhaps not; in order for physicians to best advocate for our patients and their health, we need to know the rules of the game. Med schools need to find the balance between creating competent, knowledgeable physicians who understand their field very well but that are also aware of all of the players in the game and what’s at stake. I’ve found that many of my colleagues find the political aspect of medicine tedious, boring, and too time consuming to delve into the intricacies of policy creation. It is this lack of knowledge or fundamental misunderstanding of the relationship between physicians, pharmaceuticals, and the government that makes doctors more susceptible to persuasion by the sales reps as conflicts of interest in the health practitioner field aren’t readily apparent.

The relationship between pharmaceutical and biotech companies with medical schools shouldn’t be adversarial, but when the goals of the healthcare provider and healthcare-related companies don’t coincide, the physician and the patients need to be made aware. Talks by prominent physicians that are on the payroll of drug companies need to be scrutinized. Papers applauding new breakthrough treatments need to be rigorously investigated because even peer-reviewed journals are not free from bias. There is no ideal time during the course of our education that this information would naturally fit, but it is vital and it should be taught early on so that when we are released into the hospitals we will have practice with critiquing sources and being mindful of current legislature concerning what parties are spending money and where they are spending it. If you set up a system that can be exploited you will attract those that are the best at this exploitation.

It is easy to set the ire and pent up aggravation at a wasteful system onto the figurehead with the likeness of a James Bond super-villian, but the release of the collective frustration still does not change the underlying current of how our healthcare system is run. If we’re not educating future doctors on how to effectively combat an (at best) unfair or (at worst) corrupt system, then who can we rely on to give patients a better handle on their own health?

As far as Mr. Shkreli is concerned, he’s just a example of what can happen when an arrogant, young, former hedge-fund manager gets his hands on a product that people need. He’s willing to be the face of a controversy and actually exemplify to the public how screwy the system is. Like Donald Trump proclaiming to donate heavily to both parties in order to personally benefit, Shkreli is opening our eyes to the nature of business side healthcare. Rather than being angry at why someone would do this, be angry at how someone could do this. Don’t hate the player, hate the game.

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Filed under 2016 Election, Business, Health Care and Medicine, US Political System

Anti-Vaxxers: Why Medical Students Aren’t Being Trained to Weigh-in

With increasing frequency I have been asked by friends and well-wishers about how “anti-vaxxers” are being broached by my medical school professors. Simply put, we aren’t being taught anything on the matter. This is insight on how future physicians are being groomed to handle public misinformation and media outcry. Obviously we are given the molecular biology and public health angles as to how vaccinations work from the micro to macro scale, but we aren’t supplied with the tools on how to discuss these seemingly controversial topics with our patients. This could be for a few reasons.

First, the rising trend in vaccination refusals and recent measles outbreak, coupled with subsequent media hysteria, will raise awareness of the harm of not vaccinating children—and this trend will correct itself. After all, it seems affluent Millennials are seeing the greatest raise in foregoing vaccinations. They understand that chemicals are pervasive in today’s world, and while they might not buy that vaccines cause autism, they certainly don’t believe that injecting children with man-made concoctions at an early age increases their biological fitness. Therefore, when the educated anti-vaxxers see the harm they may be causing society as a whole, let alone their own kids, the trend will inevitably correct itself. One would hope.

It isn’t only the Millennials; some of the unvaccinated come from isolated religious communities, and the poorer counties within a state tend to have lower levels of vaccination rates. Each patient is unique and asks questions regarding vaccinations with different levels of background knowledge. Therefore different ways to convey the same message about the effectiveness of vaccines would need to be employed by the physician. This is a technique developed more during third and fourth year of med school (I’m still in my second year which is primarily classroom-based) so maybe it is more appropriate to have these discussions later in schooling. Sometimes a patient’s anecdotal evidence (e.g. “My friend’s sister had a normal child until they got vaccinated and then the child became autistic”) is too ingrained and no amount of sound evidence can dissuade them from their preset justification. My school might just be trying to allow its students to form their own ways of picking and choosing their battles when it comes to handling these issues with the patients.

Lastly, perhaps doctors feel that by and large they are above the entire “debate” about whether vaccinations are good or bad. Let the 24-hour news cycle run its course. Football just ended, it’s too early for 2016 elections, Russia and Ukraine’s ceasefire is mildly interesting, and by national news standards there’s not really much going on besides the latest ISIS comings and goings. By physicians engaging in a discussion about the merits of vaccinating your kids, it may lend credence to the extreme minority’s position as a legitimate conversation starter. Last year, noted scientist Bill Nye entered a debate with noted Amish-look-alike Young Earth Creationist (YEC) Ken Ham on whether creationism and a 6,000-year-old Earth is a viable model for our origin. Many people felt that Nye showing up to the debate was essentially giving YECs publicity and a form of legitimization, even though they are an extremely small and vocal minority without the backing of any evidence or scientific merit—much like the anti-vaxxers. The biggest difference being that someone believing Earth is 6,000 years old won’t necessarily raise the chance that my child gets a debilitating illness.

As far as med school teaching is concerned, we are urged to strongly recommend for vaccinations for inquiring patients, but maybe we should also be discussing issues on a larger scale and how it relates to public health. Although we have a bioethics course, which excels at giving students the facts regarding the law and why and how the law was passed, we are never given the tools for how to make more permanent change in the community. We are not instructed on how to engage in ethical discussions about whether or not something like vaccinations should be mandated by the government. In the last decade there have been failed or short-lived attempts at making HPV vaccinations mandatory throughout the U.S. The issue has been up for legislation in nearly half of the states and has failed in all but Virginia and D.C. (it was passed and later repealed in Texas). Perhaps not surprisingly, people would prefer to have the opportunity to make the wrong decision rather than having the right decision forced upon them.

I believe that people are very much products of their environment and will naturally gravitate towards the path of least resistance. Change on a macroscopic scale, like how society views public health mandates, can be unnecessarily slow to develop, except in rare cases like the polio vaccine—which was almost literally an overnight sensation. If many of the medical aspects of how we treat our bodies are dealt with in an “opt out” fashion I believe that we may see a significant increase in the quality of life across all strata of society. A great example of this is Spain’s organ donation rates. They have the highest rates of organ donation on the planet primarily due the country’s policy that each individual is automatically enrolled as an organ donor. If you want your organs to stay in your body to take them with you to heaven (or hell) after you die, you would have to fill out some paperwork. Well guess what? People generally find paperwork to be a nuisance and a tedious endeavor. You want me to fill out these forms just to be able to fill out more forms like we’re in some bureaucratic Soviet state? I’d rather just let you have my organs.

And that is the idea: create a society in which it is commonplace for people to generously donate their unneeded organs and they will eventually do so, not because it is the path of least resistance because it is the right thing to do to save other people’s lives. I envision after years or perhaps generations with a certain policy in place (like having to opt out of donating blood) that when the opt out policy is removed people still donate at the same rate because donating blood is something that people should feel compelled to do to help their fellow man. In the meantime, don’t incentivize performing a positive action, simply tack on some form of negative reinforcement to make a negative action (such as not donating blood or organs) more difficult. This way only those who have a true objection to the task will take these necessary steps.

In all likelihood there is no formal teaching for medical students on how to deal with anti-vaxxers in our pre-clinical years because it may not come up in doctors offices as much as the cable news-watching public may think. According to the CDC, vaccination rates have only had a very modest dip over the past decade and it should be far down the list of concerns doctors have for their patients. Some combination of it being a trendy topic, each patient’s situation being unique, and that it’s just beneath us as physicians to discuss, is what’s most likely being employed by our professors. There is already so much packed in our ever-expanding curriculum that we simply might not have time to really delve into the issues surrounding medical trends. Plus, by the time I actually become a doctor seeing my own patients, the medical landscape could be so vastly different that people questioning vaccinations would be a relic of a bygone era.

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A Person Among Machines

34justice’s first guest author is David Fischer, a student at Harvard Medical School and a Howard Hughes Medical Institute medical research fellow.  In this piece, David discusses how physicians navigate “the gray zone between life and death” when they interact with patients on life support.  David studies the effects of noninvasive brain stimulation on movement and cognition and has authored several articles pertaining to neuroscience research, philosophy, and medicine. He has a B.S. from Haverford College, where he studied psychology and philosophy.

David Fischer

David Fischer

The attending physician sat at the foot of the patient’s bed, while I stood watching. He was smiling, but the look in his eyes conveyed far more kindness than his mouth or words could. He reached for the patient’s hand, which was contorted into a strained position, and took it in his. “You’re a lovely gentleman,” the doctor said, his voice quiet but firm. “It’s my pleasure to meet you.” The patient turned his eyes to meet the doctor’s gaze, his neck twisted and cocked at a sharp angle. The patient said nothing, and could say nothing, but kept his eyes fixed on the doctor’s. Several moments passed in silence, punctuated only by the mechanical sighs of the patient’s ventilator and the rhythmic beeping of nearby monitors. The doctor gave the patient’s hand a final squeeze, smiled, and led me from the room.

There was something remarkable about this encounter. It was, in some sense, a mundane scenario: a physician evaluating a patient with spastic paralysis, altered level of consciousness and dependence upon a ventilator. So what made the doctor’s attitude towards the patient so striking?

Treating patients with diminished consciousness and dependence upon life-sustaining technology poses unique challenges to the cultivation of humanity in patient care. In many areas of medicine, the distinction between life and death is roughly dichotomous. When alive, patients can often interact, remember past experiences, and demonstrate their personality. Following a fatal event, the transition between life and death, from a person to a body, often occurs quickly, save for relatively brief alterations in mentation. However, the technology that has permitted modern life-sustaining treatment, such as mechanical ventilation, has complicated this distinction. Following a severe neurologic insult, patients such as the one we encountered can remain in this transition for prolonged periods of time. Patients with disorders of consciousness or severe dementia may appear to lack the memories and personality that made them who they were in life. Yet, by mechanically preserving basic physiologic functions, we can ward off death. In this way, these technologies, though undoubtedly important, can suspend patients in a gray zone between life and death.

For physicians who care for patients in this gray zone, the encounters can be uncomfortable. The ability to interact with people, a skillset developed through years of human experience, is difficult to apply in these circumstances. The moments alone with such patients can be haunting, as one greets the patient by name and then awaits a response. As the silence lengthens, the patient may seem neither alive nor dead, like a ghost of his or her formal self. When the expectant silence is broken only by the mechanical sounds of equipment, technology can feel like the only presence.

Doctors who regularly encounter experiences such as these may come to treat these patients like bodies, like sets of physiologic processes as inanimate as the technology the patients rely upon. This is not to say that such patients are not treated with respect, but that the respect is similar to that paid to a body in a funeral home. This is an approach that protects the doctor’s psyche in several ways. For one, the doctor must often purposefully inflict pain on patients in order to gauge the extent of neurologic impairment. To summon the strength to deliberately injure a fellow, vulnerable person requires a forceful violation of empathy in what can be an emotionally harrowing task.  To do so to a human body – to transform the ‘experience of pain’ into a ‘noxious stimulus’ – is much more manageable. Moreover, the prognosis in disorders of consciousness can often be poor, and the range of therapeutic options is often limited, rendering the physician largely powerless. With patients viewed as bodies, however, the physician is afforded emotional distance from these tragedies, and the instances of clinical improvement are all the more gratifying. Ultimately, for many physicians, eliminating humanism from these interactions is emotionally protective in the care of these patients.

This context is what made the encounter between the doctor and his patient so powerful. It was not merely that the doctor sat at the patient’s side, was polite, or maintained eye contact. We have all learned to do these things. What was striking was the attitude that appeared to underlie these behaviors: despite the patient’s altered level of consciousness and dependence upon life-sustaining technology, the doctor treated the patient like a full person. The doctor, with no expectation of reciprocation or gratitude, was willing to take the time to speak to and hold hands with a person who may not have understood these gestures. The doctor’s time, however, was the least of his sacrifices; by approaching the patient as a person, he rendered himself vulnerable to the emotional hazards of care, from the discomfort of inflicting pain to the powerlessness associated with management.

In addition to emotional fortitude, the doctor’s willingness to treat the patient as a person reflected a poignant wisdom. Much of the discomfort associated with treating patients in this state stems from confronting the gray zone between life and death. Our binary concepts of life and death provide us comfort, distancing us from the thought of mortality. However, life-sustaining technologies challenge this dichotomy, and threaten the view that the line between ourselves and death is a sharp one. In such cases, it can be easier to circumvent these existential discomforts by treating these patients as bodies, dedicating more attention to the monitors and ventilation settings than to the person before us. This doctor, however, was able and willing to appreciate the spectrum between life and death, and in doing so could comfortably recognize, within that spectrum, an ill person in need of compassion. He could recognize someone who was more than the mechanics upon which he relied. This wisdom ultimately empowered him to accept the emotional sacrifices of care and, as was clear to me in that room, allowed him to see a person when few else dared to see more than machines.

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What Did I Just Pay For?

One year down and the greater part of a decade to go. As a first year medical student, having finished class for a couple months has allowed for ample time to digest much of what happened to me over the last twelve months, I can’t help but ask the question: what did I just sign up to pay for?

Students aren’t afforded the time to process the new information, surroundings, and lifestyle that comes with being a med student—it just sort of happens to you whether you like it or not. Medical school confronts students with a unique problem from the very first day of class: too many teaching resources to learn from and not enough time to use them all. It is up to the student to determine the most efficient way to retain information and stick with it for the year. The problem is that different subjects require different types of learning—some rote memorization, others require more critical thinking and problem solving—so there isn’t a magic bullet for getting by. Most students would agree that the material offered in medical school is not particularly difficult, there is just a lot of it. A policy at my school, along with many other medical schools, is to record all lectures and to ease restraints on mandatory attendance. This decision has deep ramifications that may end up changing the face of not only medical school, but higher education in its entirety.

The motivation behind recording all lectures with the professor’s corresponding notes is presumably to make life easier on the students, and in doing so, move medical education into the 21st century. The theory is that if all students have the ability to go back and listen to old lectures surely test scores will rise, as will the scores for the all-important and ever-looming United States Medical License Exam (USMLE) Step 1, which is a national standardized test given to all medical students following completion of their second year.

I’m not complaining. Streamlining content and making it accessible from anywhere on the planet is certainly more beneficial to students than having to attend each lecture and furiously scribble notes while simultaneously attempting to comprehend what is being dictated. I have it easier than classes before me and classes after me will have it easier than me. This is a good thing.

Not all courses involve professors standing in a lecture hall speaking to students. There are several courses in which students are taught how to interact with patients, colleagues, and peers, as well as using small groups and teams to discuss and work through cases. These require the students to be present because some things—like interviewing patients and teamwork—just don’t translate to the digital world yet. While watching lectures at a time and place of my choosing I can pause, rewind, and increase the lecture speed to ensure that everything I need to spend more time on I can go over slowly, and material that I know well I can just skim through.

Every now and then a lecturer will get called into an emergency and cannot attend class, so the lecture from last year on the same topic will be posted online. This is also good. No classes are ever really canceled or postponed due to unforeseen circumstances because there is always the previous year’s lecture ready to be posted at a moment’s notice. Lectures that were canceled but would have discussed updated material to reflect new findings in the field would have an emailed addendum with the additional slides or lecture notes to reflect such changes.

During this year alone our class had over 20 lectures used from last year (out of over 450), most of which came during the unusually snowy winter. I appreciate the option to learn medicine while in my pajamas and not having to go to campus each day, but what if every class simply used the previous year’s recorded lectures and then addenda were sent out addressing the newest research or pertinent clinical findings so that students are current on the given topic? Since the vast majority of students don’t attend lectures anyway this would only affect 2 groups: the professors themselves and the students who do attend lectures in person. I am usually hesitant to call for automation at the expense of other people’s labor, salaries and livelihoods, but if it can be shown that the cost of paying the salaries for lecturers can be used on other important learning tools then I believe it is an interesting proposition. The average medical school tuition is over $40,000 per year with an average class size of 135 students, meaning about 8 full-time professors/faculty making $85,000 a year would need to be laid off in order to reduce tuition just $5,000/year per student. Keep in mind the cost of medical school is far greater than just tuition, and more accurately comes to $60,000 and upwards each year (with many students coming out owing well over $200,000) and does not even include interest. All of this to say that saving $5,000 or so on tuition each year is really only a drop in the bucket from a student’s perspective and money should be spent on technology and facilities that find innovative ways improve learning. Additionally, most of the professors do not teach full time but perform research on campus and use teaching as supplemental income (or it’s part of their contract), or hold other positions on the medical school staff such as advisors, committee members, etc. I’m sure many of the professors would prefer to spend more time in their laboratory and less time in front of students teaching, but would they really wish to do so at the expense of a decreased salary?

However, the real question is: if the vast majority of lectures are posted online, how far away is medical school from becoming an online degree? Facilities such as the simulation laboratory (a robot patient that interacts with student doctors and responds to treatments given), and micro and gross anatomy laboratories have difficulty translating into the virtual world, but with new technology we are not far from having a fully interactive human body that looks and responds to our scalpels in the same way that our actual cadavers do. As technology streamlines education, how will this affect students’ abilities to learn the required material? Most schools have the same core curriculum that covers standard topics that are required for the USMLE. Doesn’t it make sense to have a centralized database in which there are only a handful of professors lecturing on topics to every med student in the U.S.? This somewhat exists already for students studying for the USMLE exams. The vast majority of students use only a handful of resources to prepare for the test. Couldn’t this be adopted for actual school material throughout the year rather than only for USMLE prep?

Curriculum for U.S. med schools is not completely uniform, however, as a school in a rural area will be more likely to have classes that are geared towards illnesses afflicting the surrounding population than a school in an urban environment. This variation can also be accounted for in recorded lectures and shouldn’t deter the schools from adopting more online-only content.

The reasons for having a physical campus for medical school is to be able to put in face time with peers to create a sense of community and attend the occasional classes in which groups of students are required debate and discuss case studies. Extracurricular activities and student groups also need places to meet. Students should meet with their advisors and professors for office hours, although I will admit that the increasing ease and frequency of video conferencing programs such Skype makes this less pressing. Students need to be face to face with their “mock patients” when conducting interviews and physical exams, but even the traditional doctor-patient relationship is becoming a thing of the past. As of this point, learning the hands-on aspects of becoming a physician cannot be substituted for an internet connection. In the same vein, gross anatomy needs to be attended by students because getting close to the cadavers is an important experience that means more than just learning to cut flesh and identify organs. It is important to strip away much of the excessive or redundant amount of information coming at the student, yet keep the humanistic and emotional aspect of learning to become a more complete physician intact.

The physical med school will require adequate study space, but a library with books is certainly not as necessary as it once was. As a matter of fact, I recently received an email from my school notifying all students that librarian hours will be cut to 20 hours per week due to the lack of student demand. Of course the library will remain open 24/7 but faculty and staff will no longer be available for as many hours. With almost all textbooks having digital formats, less and less space will be needed on bookshelves but students should have the opportunity to order physical books through their library, or a central library in a city or region. I began college in 2004 and all textbooks in biology were over 500 pages, weighed 10 lbs. and cost hundreds of dollars with a new addition of the book arriving every other year, making the books resale value almost nil. My younger brother recently graduated from college studying biology and all of his textbooks were digital, much cheaper, contained animations of biological pathways and reactions, and have the added benefit of being able to download updates so that the book always has the newest material. This is how the new generation of doctors will be studying. I still like the feel of paper between my fingers but there’s no reason to prefer it beyond familiarity and nostalgia. Digital formats are superior in every aspect except maybe they’re a little harsher on the eyes (but that could also be because I didn’t grow up staring at monitors).

The med school of the future still needs to contain conference rooms and an auditorium for notable lecturers or guest speakers so that more ears can be reached rather than speaking to a mostly empty room but with a digital camera pointed at the speaker. Something needs to be said about being in the presence of a great speaker who can advocate passionately about their novel ideas, and the sound of clapping that gives energy to a room can really make their notions hit home.

Ultimately if students are doing 80% of their learning in front of their computer screen is there a point where administrators have to be careful so that students don’t start to ask, “am I getting my money’s worth?”

If more schools develop online-only learning tools, how will teachers and professors be viewed by society? Will they be marginalized in their own classroom and become relegated to only answering the sparse questions from the student that can’t find his answer on Google? Will this shift free up more time for professors at higher institutions to pursue their own research or projects regardless of the field? These are the questions that medical schools will begin to face as more universities begin to shift their content into online databases that can be accessed by enrolled students as well as the public.

As tuition skyrockets and students are saddled with hundreds of thousands of dollars of debt, many feel as though they need to make up for lost time not spent earning a paycheck in the workforce and become highly specialized physicians. Highly specialized physicians are great when there is a pressing need for them, but the Association of American Medical Colleges (AAMC) reports that there will be a shortfall of 45,000 primary care physicians by 2020 so more needs to be done to incentivize students to pursue more broad (and often lower paying) types of doctors. There is also projected to be a shortfall of specialty physicians, but if primary care is emphasized in America, the use of specialty physician will wane as diseases and other illnesses will be caught and treated earlier rather than being able to progress to more difficult-to-treat stages which ends up increasing health insurance premiums across the board.

Another effort to lower costs of medical school is being explored by New York University, and having a 3 year medical degree. Although this is a new frontier for U.S. schools, where is the incentive for a private university to completely forego millions of dollars from its students by axing a year of payable tuition? This is another example where the profit-motive and efficient and effective healthcare do not coincide. The medical school industry, much like healthcare in the U.S., needs to reduce costs but maintain its efficiency in pumping out quality physicians. There is a difference between taking shortcuts and cutting corners and right now medical schools in the U.S. aren’t doing either, which is hurting both medical students as well as the future delivery of healthcare in America. The shortsightedness of the medical education system is forcing students to rack up enormous amounts of debt which ultimately will end up harming the population decades down the line either because the debt will discourage enrollment, or students will feel compelled to pursue higher-paying specialties rather than serving in a more utilitarian role. Medical schools would be wise to implement cost-saving measures that may prove to enhance student training while by embracing the latest technological advances. In many circumstances bloated industries and less-effective methods would be phased out by new and cheaper start-ups. In the highly regulated medical school field this type of progress is impeded by old ways of thinking and layers upon layers of bureaucracy. The last thing anybody wants to think walking out of the supermarket, a car dealership, or a campus is, “What did I just pay for?”

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