Tests, round 1

I can't believe that I've already been in school for five weeks. It seems like it's been forever, but it also seems like it just started -- that's the wonderful dichotomy of medical school, I guess. I have the next week off to study for my first round of exams -- we call it block testing. We have a week off to study, then we test for about 7 hours straight on Friday. Each block lasts about an hour and has about 45 questions, all mixed up from each of the three subjects we're being tested on (Path, Micro/Immuno, and Intro to Clinical Medicine) -- it's supposed to emulate board testing, and it's supposed to be good for us. I like it, actually. It's nice having the week off to catch up, as opposed to having to cram test studying into the week while classes are still going on. Unfortunately, I have a lot of studying to do this week. I was caught up for the first 2-3 weeks, then the last two have been just crazy, and I'm a little behind right now. In addition, I've already forgotten the stuff I knew two weeks ago :( This isn't going to be a very fun week.

On the other hand, I really like this year better than last year. Over and over, I had heard that second year was much harder, but everyone likes it because it's more clinically relevant. Boy, is that true. It's MUCH harder -- the workload, mostly, not that it's conceptually that much harder -- but it's MUCH more enjoyable, as well. I like learning about diseases in Path -- putting together clinical scenarios with underlying disease processes. I wasn't a huge fan of the memorization aspects of immunology, but I like it conceptually. And I love microbiology, so the rest of the semester will be fun (we just started it). Even ICM, which I've always stuck up for, has gotten better. We just finished a whole section on medical ethics (fascinating stuff!) and healthcare financing (obviously, an issue I feel strongly about).

Speaking of healthcare financing, I got a chance yesterday to meet two really cool people: Dr. Steffie Woolhandler, and John Yarmuth. Dr. Woolhandler is a Harvard primary care physician who is one of the co-founders of Physicians for a National Health Program. She came to Louisville to give a public lecture on single-payer health care and to give a lecture on single-payer systems at the Kentucky Medical Association annual convention. In fact, the focus of this year's KMA meeting was covering the uninsured and underinsured, which I found really surprising, because I've always thought of the KMA as a much more conservative group -- it shows how much the problems with the current healthcare system have resonated across all groups, patients and physicians alike.

John Yarmuth is the democratic congressional candidate for our district here in Louisville. I like the guy a lot, mostly because he has extremely strong views on healthcare -- as a first-time candidate and unknown, he's really been pushing the single-payer cause hardcore, which is very impressive. He told me that his opinion, from speaking with people, is that the people are very much ahead of the politicians on this issue. The politicians are the ones preventing this from going forward at this time, but hopefully that will change. (The other cool politician who was in town this week was Barack Obama -- he spoke at Slugger Field on Thursday, and I heard he was awesome, but I wasn't able to go.) Here are the interesting things I learned at the KMA conference and Woolhandler lunch yesterday (plus some additional things that I already knew but maybe you didn't):

-In the 1960s, the pre-Medicare average physician salary was 2x that of the national average salary. After Medicare was enacted, it was such a good payer that the average physician salary became 5x that of the national average salary. (My new argument for people who keep countering me with the fact that Medicare is a bad payer; yes, there are currently Medicare cuts in the works, but we still need to fight those, even if we go to a single-payer system.) When Medicare was enacted, it created a whole new pool of patients/customers: the elderly, who had previously not been seeking medical care.

-If we create a single-payer system, there will be 46 million new customers who now have insurance. If we create a single-payer system, there will be an estimated additional 40 million new customers who now have good insurance. (There are currently 46 million Americans without insurance, and probably another 40 million who are underinsured.)

-Underinsurance is a big problem: In 2005, 22% of insured Kentuckians reported not going to a doctor even though they thought they needed to, because of cost. Twenty-one percent did not take a medical test, medical treatment, or complete follow-up visits recommended by their physician because of cost. An astounding 26% did not fill a prescription they needed because of cost (or filled it incorrectly -- "stretching" a month's supply to last two months, which can be a serious problem). And 15% did not see a specialist when they or their doctor thought they needed to. These are people WITH health insurance who cannot afford health care!

-Anecdotally, one of the largest groups opposing universal health care is medical students (surprise, surprise!). Apparently, we apply to medical school claiming we want to help people, but then we get greedy and think a single-payer system will create paycheck cuts for physicians. Or, to give us the benefit of the doubt, we get scared at how much debt we're in and are worried we'll never be able to pay it back (I myself am going to graduate with about $250,000 in medical school debt. Add on undergrad and my master's degree, and it will probably be about $300,000). Then, we graduate from med school and residency program, go into practice, and see the reality of how little we get paid under the current system and how wasteful it is, and sign onto the cause. (I heard that from someone who heard it from someone -- I have the attribution, but I can't verify it, so don't hold me to it. However, it does agree with the reactions I've gotten from medical students as opposed to physicians when discussing universal health care.) And yes, a few physician salaries are likely to decrease if we go to a single-payer system. But if you're currently making $600,000 and you get cut to $500,000, I think you'll survive. The current average salary for a primary care internist is $160,000-180,000. That's not a small chunk of change, by any means, and that's pretty much the bottom of the barrel. The highest-paying jobs in this country are physicians, and they still will be, even under a single-payer system.

-Nearly 1/3 of medical expenditure in this country goes to administrative costs. If I have a primary care practice, I might be paid $40 for a typical patient visit. Say $10 comes from the patient as a co-pay, and I need to track down the other $30 from the patient's insurance company. I pay an office person (who needs to be qualified and educated in this field to know what they're doing -- it's not a minimum wage job) to fight the insurance company for my extra $30, and God forbid it becomes a real fight and the insurance company doesn't want to pay. It's very likely that what I'm paying my office person to get that $30 comes very close to $30 itself. At some point, it becomes not worth it, and that's why more and more physicians are moving to fee-for-service systems. Sad. (That particular story came from a lawyer who gave us a lecture yesterday; it was about his wife, a psychiatrist, and what she actually went through.)

-Only about 50% of employers offer health insurance to their employees. Many small businesses can't afford it. Ford is offering $140,000 cash to employees if they'll sign away their rights to lifetime health coverage, which they were initially offered when they started working there 30 years ago -- that's a sign that even the top employers can't afford health coverage. Apparently, the president of GM and Hillary Clinton were talking recently (this is supposedly in the Congressional Record but I haven't checked) and GM said that health care was killing them. Clinton asked why they didn't push for universal health care and then she'd sign on. GM asked why SHE didn't push for universal health care and then THEY would sign on -- I guess at this point, the manufacturing industry doesn't want to break with Bush, but the time is going to come. Right now, everyone is waiting for someone else to say that the emporer isn't wearing any clothes -- let's see who finally says it. It's dumb for health insurance to be tied to employment. It's done that way for historical reasons (I'll tell you the story if you like), but it doesn't make sense anymore.

-And the bottom line is, there are plenty of things that work in a market system. Electronics, groceries, clothing stores -- these should all function in a supply-and-demand system. But health care is a basic human right, and everyone should be on a level playing field. There's no reason that health care should be fought out in a market system. Market systems have winners and losers, and that's all well and good. People should not have to fight to be winners or losers to ensure a healthy life.

So that's my re-affirmation of the single-payer cause. If you want more information, you can check out Physicians for a National Health Program; www.kyhealthcare.org, which is a joint project of PNHP-KY and Kentuckians for Single Payer Healthcare, a layperson group; the source for those percentages I quoted up above; AMSA's section on universal health care; and, to be fair, the AMA site on the uninsured, although the AMA is only supporting Bush's system of tax credits and health savings plans (if you don't know anything about these, you can find plenty of sources yourself. I think they're one of the dumbest ideas in the world.).

Now, here's to a productive week of studying! There's no point in championing a cause if I don't graduate!