Summertime and the Livin is Easy

June 13, 2007 at 12:41 pm (Michael's Posts)

Hey folks
I’m going to be awol (some more) over the summer. Med school starts in the fall and I expect to get back on track with the blog then. I may post occasionally and all other contributors may post as well. I’m just headed out for a bit of a vacation.
Til then!

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A System of Incentives?

May 21, 2007 at 1:42 am (Michael's Posts)

I’m reading this book Hospital by Sydney Lewis (as I mentioned previously) and it’s raising interesting questions. One of the things that came up today is how we get doctors to take care of poor people. The doctors’ testimonies in the book seem to indicate that the only way they got the system of care to work at County (at least in the 60s and 70s and 80s) was to employ a large number of interns and residents whose goal was to further their education by working at County. The idea was that if you could make it through County, you could make it anywhere. In the most sceptical light, it was a super resume boost. The overwhelming majority of them didn’t remain in practice at County and they didn’t remain in practice in the service of poor people, either. Now this may be the bias of the interviewed doctors (because they often did spend a lot of time there) but it also raises an interesting question: without plenty of money, how can you get quality people to provide care to poor people? What other incentives might draw people to these situations? Is the incentive of an education-in-the-trenches morally okay? I mean, are the people who are providing care in those circumstances doing so for the right reasons? Does that matter?

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Class Consciousness!

May 15, 2007 at 2:51 am (Michael's Posts)

Huh! What is it good for!

Well, I don’t know yet. However, I’m reading a book by Sydney Lewis about Cook County Hospital (It’s called Hospital. I added it to my book list post) and various people have brought up the issue of class.

Even though this book is about a hospital in Chicago, this question applies to all of the work that we have talked about in this forum. It’s an uncomfortable question (talking about money is never easy) but it is really necessary to address for all global health folks.

A lot of people have said that the issue of class in this public medicine mecca is always there. This may seem obvious, but it’s important (maybe?) to remember. The interns are mostly from the middle or upper class and surely the doctors are mostly from a similar background. Class awareness plays a prominent role in the questioning of new interns, according to one attending physician who discussed the important questions for candidates for residency. He wants people to at least be honest and aware of the fact that there is a huge gulf between provider and patient.

Some of the time the question of race division is raised and people choose to rephrase it as a matter of class. I think that in America the two are linked deeply, if not inexorably. So we must address both and we ought to understand that they ought to be addressed together. Or must we? In my experience, it’s been a mixed bag as far as what works the best as an approach to these issues. However, I have been finding (and other race-conscious white folks I know find this as well) that if you look through all that stuff and simply be in contact with the humanity of the person you’re talking to, it works pretty well. But does this mean ignoring the differences? Does it mean discounting them?

As far as provider-provider divisions are concerned, it seems that the bottom line for the black people I have read interviews from is whether or not the white intern or doctor or fellow nurse has a funky attitude or not. I find this to be true in my own experience as a volunteer.  However, I have witnessed otherwise and I’ve talked to some of the attendings I work with now about a racial division in the clinic. They have said it’s alive and well and troublesome.

Are these divisions important to recognize? Well, doctors from well-to-do backgrounds can think that a patient’s inability to rustle up bus fare or find a caretaker for a child are poor excuses for missing a clinic appointment. In reality, these are life truths for the patient that appear as very real barriers to getting care. According to some of the health workers interviewed in the book, poor people complain about discomfort less than the more well-off. This might contribute to a tendency to report feeling “fine” when they are in pain, which in turn can make it hard to know if a medicine is working or appropriately dosed. In these cases, a class awareness contributes to respecting and working with a patient’s life difficulties instead of getting impatient with them for missed appointments.  It also helps a doctor think about how to ask better questions of their patients so as to get the best information from them.

I have also been reading that people are people are people and that we should treat everyone like a human being.  With equal compassion and care, is all this discussion of class really all that important?  That sounds flip, but if we really think about it, what part of the class discussion do we need and what part do we not need?

I’ll probably post on this more as I read and think.  Please comment!!

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Advocates Wanted

May 7, 2007 at 1:22 am (Michael's Posts)

I hope to never be at a party as sad as the one I attended at Cook County a couple weeks ago. The medicine Division Head was there as was the director of the clinic I work in. As were most of the doctors who were in clinic that day. As were a few of the doctors and nurses who were being fired.

As I have mentioned before, Cook County (Chicago and a few of its surrounding suburbs) is downsizing its health operations. What this means is the county is over-budget and they’re cutting jobs to bring balance to the fiscal situation. Never before, however, have the doctors who sacrifice more lucrative practices to treat needy patients had their positions in the county in danger. Many doctors and nurses were sent pink slips this spring and many more will recieve sad mail in the fall.

The really awful part about this method of budget-balancing is that it occurs not on the backs of the doctors (it’s hard to be unemployed for a very long time as a doctor. At least as far as I can tell). I’m not worried about these people, at least. They are compassionate, wonderful doctors and will find gainful (and most probably much more lucrative) work elsewhere. The sad part of this story is the people who they serve will continue to see the little bit of assistance they recieve from the county dribble away.

Richard J Daley and his cronies have screwed the poor people in this city over and again and they always get away with it. This is the same attitude that saw the destruction of public housing along with exuses that were was no money in the budget to rebuild. However, there’s money to build an olympic village, apparently (we’re the US bid for the 2016 games) and money to go forward with the beautifucation of downtown (everyone who visits here says that it’s a very beautiful city. Well, it is. The part of it you’ve seen, at least.) They’re doing it again and getting away with it again. How? How can the county government cut services to thousands of people and not have some kind of backlash?

This is an important topic to discuss as the questions of “Global health” hinge greatly on the willingness of governments to help the disenfranchised. Chicago’s government is doing, well, a piss-poor job of standing up for the destitute in its boundaries. Why? Whose job is it to stand up for them if the state won’t? How can we make them change their minds?

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Google Acquires Public Health-Oriented Statistics Tool

March 22, 2007 at 11:37 am (Links, Michael's Posts)

The story: some Swedish folks, with the health of the globe in mind, designed a cool tool for gathering statistics so as to make the plight of the poor in the world more powerfully factual in hopes of raising awareness and building strength in the discourse. Google recently bought that tool.
Is this a good or a bad thing?
Good: increased exposure and power is imbued in the tool via association with the WebGiant Google.
Bad: corporatization and the subsequent dulling of the social justice side of the tool.
Another health blog, Public Health Matters, has posted an article that I read and found interesting.
A call for action may be in the works.

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More on Racial Disparity in the USA

March 21, 2007 at 12:26 pm (Michael's Posts)

Below is an article I found in the New York Times Health Section a couple weeks ago. My reading of it points to the deep and hidden racism in America. If doctors are singling out Black and Latino patients for alcohol abuse, it’s a sign of their internal biases about the habits of their patients. Especially in light of the statement that the article makes about the lack of evidence to support such an assumption. This is most disturbing in light of the fact that minority patients are screened less for biological illnesses.

One of the issues I take with the researcher’s stance is with their statement that the increased alcohol screening rate could be due to theincome level of the patients being screened. Of all the patients I see at County, very few of them drink much. Granted, many are diabetic and many are older. However, the poor folks I see who are in their late 40s and mid 50s and not diabetic are often not drinkers. To top it off, the few really serious alcoholics I’ve seen have been white. Now, my patient exposure has not been enormous, but I’ve been working in this clinic for 6 months and I’ve seen enough to start making a few assertions.

Like I said before, by working on racism and pointing it out and watching ourselves and our colleagues, we can raise the quality of health in our country.

Disparities: Singling Out Minorities for Alcohol Counseling

By ERIC NAGOURNEY
Published: March 6, 2007

At last researchers can point to an area of medicine in which African-American and Hispanic patients get more attention than white ones do.

Whether that is a good thing is another matter. The care in question is counseling from doctors about alcohol abuse. And given that there is no evidence that blacks and Hispanics drink more than whites, the researchers ask why they seem to be singled out for the advice.

“Our results raise questions about whether physicians apply preventive screening practices systematically, and whether they inaccurately tie race to problem drinking,” wrote the author of the study, Dr. Kenneth J. Mukamal of Harvard. The report appears in the March issue of Alcoholism: Clinical and Experimental Research.

As a general rule, numerous studies have found, minority patients are less well served than whites by the medical system. They receive less screening, for instance, for cancer and other illnesses.

The new study drew on information gathered in a federal survey of more than 15,000 people about their health. Among other questions, those surveyed were asked how much they drank and if they had been counseled by a doctor about alcohol.

The study found that blacks and Hispanics were about twice as likely as whites to report having been counseled about alcohol. But when it came to counseling about diet, the differences largely disappeared.

Part of the explanation, the study said, may lie in the fact that minorities tend to see doctors whose practices focus on low-income populations. So it might be less a matter of an individual doctor treating black and white patients differently than how minority communities over all are served.

In any case, the study says, given how effective alcohol counseling has been found to be, the answer is not to give less of it to minority patients but to give more of it to all patients.

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Entitlement and the Poor

March 15, 2007 at 10:59 am (Michael's Posts)

I was shadowing one of the very senior attendings in the department of medicine at Cook County Hosptial a week ago. His reputation is well-established as a thorn in the side of those who would rather turn a blind eye to the bureaucratic waste and BS that the poor who utilize the Big Public Hospital have to put up with. He fights for them in every way he can every day. Because of his fierce advocacy, he has been passed over for promotions that he absolutely deserves. He’s not popular with the higher-ups. But the work he’s been doing for the last 30 years is indispensable. Truly an inspiration.

As we were coming out of one patient’s room, Dr Schiff commented that he was a “Classic County patient. Never worked a day in his life. Just sitting around waiting for a handout.” Now listen for a minute to this guy’s story. And imagine that everyone we talked to had a similar one.

When Dr Schiff asked this man what he had done for work in his life (he was 81 and built like a horse except his heart was fluttering like a drunk butterfly), the man looked at him with a weary smile and said, “Everything.” He worked construction during the week, bartended at night, drove a cab on the weekends, did upkeep work for various churches, etc, etc. He put FIVE of his eight kids through college. In short, he lived a busy, stressful, and very productive life.

Dr Schiff was obviously kidding when he said what he did. And with a lot of bitterness in his voice. He made me realize consciously what I knew about the people I saw in the outpatient clinic: all of these people worked hard and they’re still poor.

This idea we Americans have about “Bootstraps” and the ability to pull oneself up by them is maybe partially true but is way more conditional than we’d like to think. It depends on what you have to fight against to get upward motion. It depends on if you even have bootstraps to pull on. Think about our 80 year old friend who, with the most dignity I can imagine, submits to the whims of an inefficient bureaucracy whose higher-ups could care less about him for his medical care. Think of his grandchildren whose lives he made better. How can we treat him the way we do?

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The Importance of Local Health Data (Plus a v. Brief Comment on Race and Health)

March 7, 2007 at 2:15 am (Michael's Posts)

Today I was reading a paper by Shah, Whitman, and Silva from the Sinai (Chicago) web archive of papers on Urban Health (archive found here) and I just had to share it. Very common sense but also very good to read it in study form. It’s short and not too dense.

The main point of the paper is that to properly understand what’s going on in the health of communities, we need to look not at provincial or city levels, but rather at community levels (zip codes/neighborhoods, not just counties). The blend of all neighborhoods’ data together in a city- or county-wide survey (much more common than neighborhood-based surveys) masks disparities. And if we want to address the needs of communities, we have to understand where those needs lie.

“As urban settings become increasingly diverse and certain populations are disproportionately affected by disease, variations in the health status of these smaller geographic areas may be substantial, and such variations must be considered if true advances in disease prevention and control are to be achieved.” (Shah, et al, 1)

In the study, it was found that very distinct health patterns in some indicators arose depending on the racial and socioeconomic makeup of one neighborhood versus another. For instance, two adjoining neighborhoods with different racial makeups had vastly different rates of tobacco use (39% compared to 20%).

“If data are examined in an aggregated fashion, contextual differences in the demographic and health profiles of specific communities will not be identified, leading to difficulties in identifying and mounting effective community- based public health and public policy programs.” (Shah et al, 5)

In other words, as an example, the two above neighborhoods have different needs when it comes to smoking cessation work and one would benefit more from such work. The argument naturally follows that it would pay to focus the work where it is most needed so as to make the best use of scarce resources.

Their methods are quite good but are also time and money intensive. This is a shortcoming. However, if a philanthropic body can be plied for funds, it may be well worth it to public (state-run and community-supported) health workers to organize such data collection.

When reading this comment on race and health, recall that Chicago, like many American cities but probably more so than its peers, is extremely racially segregated. That is to say, neighborhoods are divided along racial lines. The study also highlights the rift between black and white, underscoring that even the more affluent black neighborhood in the study had much more in common in terms of low health outcomes with the poor black neighborhood in the study than it had in common with the relatively affluent white neighborhood. I found this an interesting, though not surprising, conclusion and one that adds to my understanding of the continuing inequality based on race in this country of ours. This can assure us that if we dedicate ourselves to curing racism in America, while working to heal a social ill we are certainly simultaneously doing important health work.

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Book List

March 5, 2007 at 9:18 pm (Michael's Posts)

Hey all. Sorry about the hiatus. My internet access has been spotty and I’ve been preoccupied. But you’ll hear from me in a couple days in a more expanded format.
I’d like this post to be a little book list . Add books in your comments, second reccommendations, and/or rebut reccommendations. Really, just add your books, though. 🙂 And include a little description.
Mine tend to be a little social-science theory-heavy. I miss my social science major and I really love theory. The bent of my reading has been to improve the theoretical framework with which I will be approaching care for the vulnerable in society.

-Michel Foucault, The Birth of the Clinic
(regarding the overarching structure of medical view in western culture. As Foucault tends to be, this is thick stuff but once you get the hang of his lingo, it’s really amazing insights into how doctors think, how they ought to think, and how we ought to think about health in general. He takes a historical-philosophical approach)

-Kwame Ture (formerly Stokeley Carmichael), Black Power
(Read a while ago but really amazing ideas about how how Black Americans in particular need to think about power structures and social organization in order to bring about change. Helpful for me because it showed me better than a lot of commentaries on the black-white problem in the US where I can fit in and be helpful. Possibly ideas that apply to other minorities/vulnerable groups in the world but is probably limited to American Blacks.)

-Sydney Lewis, Hospital
(In the middle of reading this oral history of Cook County Hospital and it has raised some interesting issues, some of which are probably unique to the County but most of which I am pretty certain apply elsewhere, as well. An interesting look at the stories of people who try to provide quality care to poor people in the midst of a prosperous society.)

Hit this up!!!

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Sarah, I See Your Rant and Raise You an Anguished Cry For the Poor of Chicago

January 30, 2007 at 4:21 pm (Michael's Posts)

Sarah’s question in her previous post made me think of bureaucratic reform and at work at the clinic I am surrounded by the rumblings and turmoil of budget cuts. In other words, the gutting of the health system. So, I was just thinking about this crisis in light of bad bureaucracy. One of the biggest issues that i’ve heard mentioned around the campfire is that the county healthcare administration is bad at billing medicaid and medicare. As in they only get some tiny amount of the money that there is alloted for the care they offer. And that’s only for documented medicaid/medicare folks. There are thousands who qualify but who have not applied or been approved for one reason or another. Why is it not a chief priority in the clinics and hosiptals to get people signed up for these services?

A: It costs the feds money and there’s a conspiracy to prevent people signing up.
B: There’s no good reason.

I’m a down-to-earth guy (even though I am an economic radical of sorts) and I go with answer B. At least there’s no good reason the doctors I work with can think of. So it must be a failure of a bloated, inefficient bureaucracy. And since I don’t actually get paid by them and my volunteer job is not on the line, I feel free to say that. And if it be false, please, do let me know.

So it looks to me that there’s money and we’re not using it. Instead we’re contributing to the myth that there aren’t enough resources in America to go around (read: no one wants to take responsibility for the care of the poor). And this makes it look like it’s impossibly expensive to care for everyone in this country. How will we know if we don’t use the systems we have set up? We’re just going to give up on it like that? It’s a damn shame.

See also: Bureaucratic reform. (Sarah’s post on polio)

See also: public accountability. How do we make THAT work?? How can people who are as disenfranchised as the poor hold a machine as famous as the political system in Chicago accountable when it screws them over? Especially when it screws them by not charging the federal government for the medicaid and medicare it’s owed. Absurd. And if I’m totally off base with this accusation, someone set me straight). Any ideas from political type people on how to empower the poor to hold powerful government entities accountable? I know it’s a very uphill battle.

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