February 2013
2 posts
Addictions in the primary care office
As with any disease, prevalence of this narcotics abuse is region-specific; an hour north of the office where I practice, Rio Arriba County in New Mexico is home to one of the highest opioid overdose rates in America – up to five times higher than the national average. Our patients routinely lose family to addictions; our clinic has been home to a near-fatal overdose within the walls of the...
A brief side note
Recently two friends and I were mulling over some of our more taxing workplace interactions and finding common struggles in our most difficult patients: those suffering from addictions, uncontrolled pain, and the overlapping arena between the two. Out of this discussion came the notion of opening up a discussion forum for practitioners and the general public looking to find innovative solutions...
December 2012
1 post
Our daily neuroses and occasional psychoses
The dust had hardly settled on the Sandy Hook elementary school when the most futile of all debates began: is the lack of mental health infrastructure at fault for Sandy Hook, or are the mentally being unfairly blamed for violence? Both positions are both right, and they are both wrong. Mostly, it’s a matter of definition: what does it take to define someone as “mentally ill”?
If you read the...
October 2012
1 post
Prescription narcotics crackdowns and the law of...
With prescription narcotics abuse reaching epidemic levels across the United States, federal and state authorities are struggling to reign in opioid addiction. The narcotics crisis was cross-bred accidentally from good intent - the push to make pain the “fifth vital sign” - and extremely poor foresight, as physicians were mandated to treat pain without increased training in appropriate...
July 2012
1 post
The Limits of Customer Service in the Exam Room
Under the heading of “Value-Based Purchasing,” Obama’s Accountable Care Act includes measures to link hospital reimbursement to patient satisfaction measures. Through both public and private insurers, this trend is likely to spill over into the outpatient setting in the very near future. Aside from creating redundancy in the market (with some very rural exceptions, patients can act as agents...
December 2011
1 post
Avastin: The Pursuit of Last False Hopes,...
In the past month, the Food and Drug Administration yanked its formal stamp of approval on Avastin – a chemotherapy drug designed to starve tumors of their blood supply – for the advanced stages of breast cancer. Because the drug still carries approval for other indications (especially late-stage colon cancer), patients can still obtain the drug by prescription for off-label use. But because...
November 2011
1 post
Cheaper generic medications: Not coming to a...
The New York Times reported Friday on a move by Pfizer – the makers of the blockbuster cholesterol drug Lipitor – to manipulate the market to limit generic supplies to a number a major drug management agencies after Lipitor goes generic in the coming months:
“Pfizer has agreed to large discounts for benefit managers that block the use of generic versions of Lipitor, according to a letter from...
October 2011
3 posts
I stand with the 99%.
I stand with the 99%.
I have a choice, you see. I don’t have to stand with the 99%. I have an advanced degree, make a low six-figure income in an extremely high-demand field, and if I wanted, could double or triple my income without much thought beyond having to move somewhere I wouldn’t too much like. I have a rock-solid job with even greater future opportunity, as well as health coverage and a...
Against Medical Marijuana: A civil liberties...
In 2007, medical marijuana became legal under a physician’s directive in New Mexico, one of sixteen states allowing some variation of medical use of Cannabis sativa. Since then, regulation of medical marijuana in the state has swung with the political tides: founded and liberalized under former Democratic governor Bill Richardson, then tightening under current Republican governor Susan...
Efficiency in the health care market: A short...
On any given day, you can hear talking heads on a dozen sides of the health care reform debate arguing about which version of health care delivery is the most efficient. Many lay claim to this holy grail of financing, they cannot all be right, so who is doing the truth-telling and who is doing the lying?
“Efficiency”, like many jargon-able phrases, has different meanings to different people...
September 2011
3 posts
GOP Scrapes Bottom over the HPV Vaccine
Struggling to regain her position as heir-apparent to the dubious legacy of Tea Party darling Sarah Palin, Michelle Bachmann took the opportunity at the recent Republican debate to let the crazy out of the GOP closet on topic of Gardasil vaccine. Bachmann railed at Perry for making the vaccine mandatory for sixth grade girls in Texas; Perry waffled on the issue, guessing that maybe he...
Against Medicare: A populist argument against a...
In 1965, a decades-long legislative and social battle culminated in the passage of one of America’s most enduring and populist social programs: government-sponsored health coverage for the elderly and disabled that you know by the name Medicare. So devastatingly popular is this subsidized coverage that it has spawned one of the iconic moments of irony in the decades-long battle over the...
Karma: A bitch
You never want to point fingers and say I told you so when someone up and dies all young and tragic-like on you. But then, every once in a while, ya know, you do.
The spectacle of Ron Paul’s performance at last week’s GOP debate was chilling, to say the least. To Wolf Blitzer’s questioning, Paul implied that an uninsured 30 year-old man without insurance should be let to die rather than rely on...
August 2011
4 posts
The “Individual Mandate” Struck Down by Court of...
Last week another court decision by 11th circuit Court of Appeals came down against a key provision of the health care reform bill: the individual mandate. The individual mandate states the obvious and the somewhat subtle: that all people must buy health insurance of one kind or another. It is a key portion of the health care bill, and it is an unstated fact that if this portion is struck down,...
Contraception in the milieu of health care reform:...
Not long ago, during a yawn-inducing day of medical review lectures, a particular speaker threw a PowerPoint slide onto the screen with a three-part photo montage of a bottle of European-label wine, a suspiciously malodorous-appearing cheese, and a copper IUD. Underneath was a caption: “Three things that cost under $10 in France.” In the United States, a copper-based Paragard IUD will run you...
The gambler against the house: Fundamental flaws...
Last time the brakes on your car wore thin (or in my case, the last time I blew an aneurysm into the sidewall of my snow tires on last year’s pothole and had to replace all four of them), you probably reached into your wallet for a credit card, a wad of cash, or a check, and paid out of pocket for the expense. Last time you got your oil changed, you probably did the same. It is notably unlikely...
Special interests in the common risk pool
Last week – amidst the debt crisis meltdown that seemed invented to distract America from any substantative topic on the horizon - the Obama administration proved that congressional dog-and-pony shows do have some function in the reality-osphere: to allow a space for unpopular but well-deserved policies to be implemented almost unnoticed by the rank-and-file mud-slingers. While the GOP was busy...
July 2011
3 posts
The reduction of harm
Twenty miles up the road from my adopted home, the Espanola Valley fans out between the wealthy enclave of Los Alamos and the forests of the Sangre de Christo mountains. The main street of Espanola looks like any dry, dusty burnout of a town west of the Rockies; except for the Indian casino plunked down on the main drag, you might as well be in Barstow, Bakersfield, Yuma, or Calexico. Turn right...
A rainbow of pills and potions
The New York Times this week reports on a phenomenon that you’ve likely experienced if you take more than a couple of prescription drugs, or especially if you care for an elderly parent who juggles a rainbow of blood pressure meds, statins, prostate shrinkers, memory enhancers, and other sundry pills and potions: all that confusion that happens when one generic pharmaceutical is substituted for...
In the shadows of Las Conchas
A short diversion from the topic of health care reform…
Two weekends ago, on one of those glittery bright, hot mornings that New Mexico is known for, I drove up to Los Alamos to have breakfast with a friend. The most notable event on the horizon was a plume of smoke from the Pacheco fire on the opposite side of the valley, by afternoon nearly obliterating the view of the east-side Sangre de...
May 2011
6 posts
Squinting through the looking glass: Finding...
How much did you pay for your last prescription? How much was your copay? How much did your insurer (should you be so lucky) cover? How much did the insurer bargain the pharmaceutical provider down before they paid their share? How much of that net difference did they tell you about? What is the difference between what would have been paid on your behalf if you had been insured and what you...
Deductibles, copays, profits, and the deep end of...
Once upon a time, if you wanted to see a doctor you shelled out cash, a chicken, a handful of gold coins, a promise of future services in return, whatever the exchange medium du jour, and you saw a doctor. Then along came medical insurance, wherein you bet ahead of time on the probability that you might need services in the future. Then along came HMOs, PPOs, and finally today: the highly...
Med school admissions in milieu of reform
Every year, medical school hopefuls sit down to endure a grinding six-hour hazing ritual known as the MCAT: the Medical College Admission Test. For the fourth time in its history, the committee that oversees the exam is considering a major overhaul of the exam.
So if you’re not in the line-up to apply for medical school, what interest could this possibly hold for you? The training of medical...
Nostalgia and the small-town GP
In the era of rapid change in the medical field, not more than a few days go by before another major news outlet produces a heartfelt ode to the dying breed of the small-town family GP. Hard-working, ever-suffering, delivering babies from their mothers and the elderly from the bonds of the earth, this backbone of America is as vaunted as a Norman Rockwell painting and – sometimes – only slightly...
From the archives...
I am slowly gathering up all my previous posts from different sources on the topic of health care reform, and eventually they’ll all be found here - click on the “Archives” button for preview of those to come…and stay tuned!
America, love it or heal it
Love it or leave it. The old war-hawk slogan declared that we could love America or we could pack it in and leave for other shores. That was a generation or two ago, and the polarized opposites of the political spectrum have hardly learned to play nice with each other in the decades since. But whether you cheered or shouted down the passage of the Obama health care reform, whether you are...
August 2010
1 post
From the archives: Presidential charity and AIDS...
Next summer, just before independence day, a somber anniversary will mark the third decade since a handful of doctors in New York and Los Angeles noticed a peculiar constellation of pneumonias, skin cancers, and intractable diarrhea in otherwise healthy young male patients - patients who would go on to die as their immune systems withered into the dread affliction that we would come to call AIDS. ...
December 2009
1 post
From the archives: The horse and the cart
There is an undercurrent to the current health care reform debate – a sneaking undercurrent of suspicion – that wonders if this nation can successfully insure every American when the health infrastructure does not exist to take care of every one of those individuals. Primarily among the deficits in the medical workforce are loci of primary care: family doctors, general internists, pediatricians,...
August 2008
12 posts
From the archives: Where do we go from here?
If you’re still with me, fifteen wordy posts later, you may feel buried beneath an avalanche of priorities and issues and complexities. Out of a whole heap of information, there is always the lingering question: where do we go from here? What conclusions can we make from all this quagmire of complication and controversy?
So here’s the post-game, the recap, the proverbial twelve steps...
From the archives: The Bridge to EPT
Where the dusty border town of Juarez butts up against the jutting mountains to the north, there is a bridge. On one side of this bridge lies Mexico, and on the other lies the city of El Paso, Texas. A place whose name itself invokes journey, transition, a throughway to greater things: The Passage.
Women on the south side of the river that divides the wealth of the north from the ...
From the archives: Paying the Piper
Today, you’re going to hear something new and different. Today you are going to hear this bleeding heart, tree-hugging, west-coast, San Francisco-born progressive make a neo-conservative argument. Free market, pay-your-own way, private enterprising, classical neo-liberalism. Hold on to your wallets, we’re going for a ride.
This argument concerns the question that underlies everyone’s...
From the archives: Down on the Pharm
A virile sixty-ish male chucks a football through a tire swing, raises a couple of fists in victory, and manhandles his comely wife; the final voiceover lists headache, flushing, dizziness, rash, cognitive dissonance, sudden loss of conscience, and pernicious priapism as possible unintended consequences of the little blue pill that made this moment possible. I might have just made up...
From the archives: Burden of debt
Becoming a doctor, it turns out, is all kinds of expensive. Four years of medical school, one year of graduate school to obtain a masters in public health. Fifty-something thousand a year, add on five years’ worth of accumulated interest (capitalized twice when I lost eligibility for deferral due to quirks of the federal loan program), and you have my total school debt: just over three hundred...
From the archives: End of the road
In a teaching hospital, it is often the intern’s job – when admitting a new patient – to ask after a topic that is gently and euphemistically referred to as “code status”…that is, if one were to stop breathing or generating a useful pulse during their admission, should the covering physicians make all attempts at resuscitation or let you go quietly into the night? More times than you might think...
From the archives: Overuse, underuse, barriers,...
There are a few folks out there who overuse the medical system. Every emergency department has its “frequent fliers,” and every clinic has its quota of disordered personalities on the rolls that require an individualized level of energy that could otherwise fulfill the needs of ten patients in the same time span. These patients are often the bane of primary care and emergent care ...
From the archives: The opt-out crisis
I was a sophomore in college, studying abroad, when my parents called me up to tell me my father was retiring. And so, at age nineteen, like middle-class post-adolescents all over the nation, I got booted off my parents’ cozy medical insurance plan and out into the nebulous world of the marginally insured. They did their best by me for a year or two; they qualified for COBRA, and since I was in...
From the archives: Unfunded mandates
The arrival of my intern class at the university hospital was occasioned by the opening of the brand spanking new emergency department. I never had the pleasure - or the horror - of seeing the old department, though its mythology remains. Occupied beds lining the hallways, bleeding patients begging as you passed anonymously on your way to find the one you were assigned to admit, and dingy, always...
From the archives: OHP, a bold experiment in...
Local newspapers are a funny thing - half pulpy fiber ready-made for the recycling bin, half voyeuristic insight into quirky local ways. When I first moved to Oregon several years back, I picked up the local rag one day, intending to peruse the low-end rentals section. The front page caught my eye; on it was a lengthy list of medical conditions, some five hundred or so altogether. Somewhere on the...
From the archives: Fifteen days of blogging for...
Doctors battle out the flaws and foibles of the American health care system every day. No matter what their opinion on the solution, few will disagree that we indeed have a problem in this country. Some will tell you we need more free marketeering, less government interference; others lean to the far opposite side, demanding reform toward single payer coverage or even a government-run ...
From the archives: Health care reimbursement - a...
Ever wondered how your doctor gets paid? It’s not something that most patients put much thought into, beyond a cursory glance at the vehicles parked in the physician parking lot and the realization that you’ll probably never drive a car quite like those. But it’s a rather germane topic when it comes to understand how your doctor treats you, and how satisfied you’re going to be with that care, and...
September 2006
1 post
From the archives: Profit, Ethics, Big Pharm, and...
Cassie* was just six years old last January when she started to turn pale and feel an unfamiliar ache in her bones. The change was so gradual that months passed before her parents became worried enough to take her to the pediatrician. But before the appointment was scheduled, she was rushed to the emergency room, so weak she could barely stand; by the end of the evening Cassie was diagnosed with...
