A New England Journal of Medicine article, Cost Implications of Reduced Work Hours…, placed the cost of of the recent IOM recommendation to limit medical resident shifts without naps to 16 hours at $1.6 billion dollars. The study argued that the the benefit to patients would be low and that the shift in costs would be a burden to teaching hospitals. But if $1.6 billion were to shift onto hospitals, who would those costs be shifting away from?

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Medical residents, doctors in their first few years out of medical school, make an average salary of $35,000 per year. Under the current ACGME limit, medical residents can work a maximum of 80 hour work. Studies show, however, that the limit is loosely adhered to. Regardless, assuming an 80 hour work week, medical resident wages average out to $8.65 per hour of service.

After four years of undergraduate education, four years of medical school, and $250,000 of debt from student loans, why are medical residents forced to endure further financial burden? Why do they earn such a meager amount that barely tops the average national minimum hourly wage? Despite the shorter duration of educational programs and smaller financial burden, health care workers in other fields (nursing, for example) can expect a much higher salary in their first years.

If the maximum shift length for residents was reduced to 16 hours, it would cost $1.6 billion dollar to have other health care workers fill in the gaps. That also implies that medical residents are already shouldering the weight of subsidizing the health care system to the amount of $1.6 billion dollars a year.

Upon reaching residency, medical students are essentially 'all-in' — completing residency is a prerequisite to becoming an independent physicians — so they have no leverage with which to bargain for wages. If other health care providers are paid more for providing a similar service, doesn't that mean that residents are essentially forced to work at a charitable level? And, assuming so, is it fair to expect medical residents — as opposed to the government, hospitals, insurers, employers, etc. — to shoulder costs of subsidizing the health care system?

Americans with health insurance are generally used to having open doors when it comes to medical care. Patients with terminal conditions often pursue treatment up until the very end — even when the benefits are negligible. But should that necessarily be the case?

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A recent New York Times article, “Fighting for a Last Chance at Life”, exemplified this issue. Iplex, an experimental drug developed to treat muscular dystrophy in children, was the last glimmer of hope for a group of patients suffering from Lou Gehrig’s disease (also known as A.L.S.). However, they had no scientific evidence to back up their hopes — anecdotal accounts of successful treatments were all they had to go on.

Iplex isn’t cheap. Even at $100,000 per year, the patients faithfully used Iplex as a last resort. While the patients in this case were taking the financial burden upon themselves, the situation still poses a question: in cases of terminal illness, at what point should treatent stop?

In a system where financial risk is spread across all participants, spending endlessly raises costs for everyone. Increased spending leads to higher premiums and fewer individuals being able to afford health insurance.

In the UK, the National Institute for Health and Clinical Excellence (NICE) uses the Quality Adjusted Life Year (QALY) to determine their spending limit. For example, if Iplex extended an A.L.S. patient’s life by 1 year (assuming 100% quality of life), the cost per QALY would be $100,000. NICE denies therapies that exceed a cost of £20,000-30,000 ($30,000-46,000) per QALY.

To make health care more accessible and affordable for the 45 million Americans without insurance, Congress will eventually have to find ways to control health care spending. But, even in a system wrought with runaway costs, at what point should spending stop?

Should insurers have to fund endless interventions up until death, should the terminally ill have to settle with palliative measures, or should they eventually have to take on the financial burden themselves? And who can even make that decision?

I think doctors should get comfortable with being realistic. If it is the case, the doctor should bring up the idea that this disease process might be fatal. Right now, we say, “I can’t take away a person’s hope,” as if doctors were bestowing life. You have to support those hopes that are realistic, not this fantasy land.

-Dr. Robert Martensen

Employers get a tax break for providing health insurance to their workers, and the health benefits employees receive don’t count as taxable income. This tax benefit is the main reason why the majority Americans have employer-provided health insurance. But what started this trend? And are the unemployed left out?

During World War II, federally mandated wage caps prevented companies from offering higher salaries to attract new employees. As a work around, companies started providing health insurance as a fringe benefit. And in 1943 the IRS deemed those benefits non-taxable for both the employer and employee.

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Was their move successful in expanding American health coverage? Well, more than 158 million Americans now rely upon their employer for their health coverage. Employer provided health insurance does a great job of providing coverage for the employed, but not everyone keeps their job forever.

Is your employer downsizing? Need to go back to school? Want to quit and start your own company? You’ll have to try your luck in the individual insurance market. And switching to a plan in the nongroup market means giving up the tax benefits that employer based coverage provided.

Yes, people who have nongroup insurance plans have to pay income tax on the money they used to pay for their plan (about $750 per anum for a family in the 15% tax bracket). The premiums for nongroup insurance plans are also nearly double the dollar amount that the average employee contributes towards their health plan. (For a family, the average nongroup insurance plan was $5,800 in 2007. The average contributions for employee and employer in 2008 towards employer-provided coverage were $3,350 and $9,325 respectivly)

If companies can tend to be overly generous with their non-taxable health plans, providing plentiful and luxurious ‘Cadillac’ benefits, then those using nongroup insurance can tend be overly frugal. With all the added economic burden for the individual outside of the realm of employer-provided coverage, it’s not surprising that nongroup policy holders tend to be extremely price sensitive.

Underinsurance is common for nongroup policy holders — high deductible plans with low lifetime benefit limits are all but ubiquitous in the nongroup market. Why? While they offer only bare bones benefits and leave their benefactors uncovered for many catastrophic health problems, they still manage to satiate the price sensitivity of the consumer by offering relatively low premiums. Even though they offer very little in terms of protection risk, the consumer leaves feels protected.

Our system is stretching to cover everyone and failing miserably at it. Much of the population still uninsured, unemployed, or both. There are huge deficits in health coverage when it comes to these groups.

Why should a tax break that has evolved to become the primary stimulus for providing health care to Americans only apply to the employed? Max Baucus, chairman of the Senate Finance Committee, has already call the tax break “too regressive” and stated that it “skews the system”.

The health system has a multitude of problems, and America’s 45 million uninsured are evidence of the system’s dysfunction. One of the first steps towards reform needs to involve making coverage more available to these individuals. In order to level the playing field, Congress needs to rework the tax break for employer-provided insurance. Employed or not, everyone should have the the same economic incentive for purchasing health insurance.

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As beacons for good health, doctors don’t need constant reminders to promote healthy lifestyle changes in their patients. Encouraging better health part of the job description, right? Well, a study from the Archives of Internal Medicine found that giving doctors a small reminder can make a big difference for patients who smoke.

In a one-year randomized trial of 26 primary care practices, researchers implemented smoking status icons and tobacco treatment reminders on electronic patient records. A “Tobacco Smart Form” was also implemented into the record system to encourage patient coordination with smoking cessation counselors.

A total of 9,589 patients were enrolled in the study, half of whom were in a control group. Patients whose doctors received the reminders were 13 times as likely to meet with a smoking cessation counselor, and 2.8 times as likely to quit smoking by the end of the one-year study.

Small behavioral changes, like increasing activity and quitting smoking, bestow long term health benefits. As electronic medical records work their way towards prevalence in the health care system, strategies like ’smoking status icons’ can be implemented cheaply and easily, thus facilitating cost-effective and favorable heath outcomes. Sometimes a simple reminder can go a long way.

Source: Archives of Internal Medicine, April 27, 2009.

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It’s almost impossible to converse about influenza A / H1N1 without touching on the 1918 Spanish Flu. Why is that? Worry-filled observers try to draw parallels between the two. “This will be another 1918 Spanish Flu,” they say. “Wait until the fall,” they warn. But are they right?

Yes, swine flu and the Spanish flu are both of the influenza A / H1N1 subtype. And, yes, it’s true that the 1918 Spanish flu began its initial spread during spring, reaching it’s peak virulence the following fall. However, the current influenza A / H1N1 is not showing the deadliness that the 1918 Spanish flu displayed during its spring upstart.

But some still contest that as influenza A / H1N1 didn’t have the opportunity to reach its deadly potential–it didn’t appear until the tail end of flu season. Influenza has little ability to spread during the summer months, so influenza A / H1N1 will likely lie dormant until next fall. But most experts suggest that future infections will continue to be relatively mild.

However, with so little observational data available, completely refuting the doomsayer theory of a deadly fall outbreak proves difficult. So should we err on the side of caution, stockpile anti-virals, and hunker down until it all blows over? Just in case?

In the norther hemisphere, with little collateral damage, influenza A / H1N1’s spread is slowly dropping off as summer approaches. But fearfully waiting until fall to see if it has any unknown deadly potential wont be necessary. Influenza A / H1N1 has already been confirmed in New Zealand and Brazil.

The flu season in the southern hemisphere is just beginning, and swine flu already has a running start. If the doomsayers are correct, they’ll be all over the media in the next few weeks. For those living in the northern hemisphere, don’t worry about canceling any spring or summer plans. Take out the sun shades, hit the beach, and relax.

Most Americans die in hospitals or nursing homes, and neither is configured to take care of dying patients. There’s little palliative care available, and often the payment structure of health insurance doesn’t support it.

So you end up with situations where a 90-year-old with organ failure is brought to an emergency room and the doctors go, “Let’s tune her up.” Or if the patient starts failing at the nursing home, they’ll say: “No one dies here. Let’s get her to the emergency room.” It’s not unusual in the last six months of a patient’s life that they’ll be shuttled between the nursing home and hospital 6, 8, 10 times and subjected to a lot of painful and expensive interventions.

-Dr. Robert Martensen, NY Times Interview

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Egypt decided to slaughter all of their nation’s 300,000 pigs, President Obama asked Congress for $1.5 billion for flu preparedness, and China herded and quarantined 70 healthy Mexican nationals. But why? Is all the fear and preparation justifiable?

The initial numbers seemed to suggest so as reports highlighted the deaths in relation to the relatively few confirmed cases. But we now know that this new influenza A/H1N1 strain is currently no more deadly than the normal seasonal flu. As the hype is starting to wear down the focus in the media is switching from new infections to speculations regarding how the virus could change.

Influenza is a volatile virus. Its genes change rapidly through regular mutations. And when two different influenza strains infect the same host, they can swap and borrow bits of genetic material. This process, known as reassortment, compounds influenza’s unpredictability.

Sometimes reassortments led to new pandemics. It is possible that reassortment enables flu viruses to escape the immune system so well that they can make people sicker and spread faster to new hosts.

Reassortment also played a big role in the emergence of the current swine flu. Its genes come from several ancestors, which mainly infected pigs.

-New York Times, “10 Genes, Furiously Evolving”

When the reassortment occurs between two strains already endemic in the human population, the results tend to be less than extraordinary. But when unlike strains come together, just as bird, pig, and human strains formed the 1918 Spanish flu, the result can be extremely virulent.

So it’s a fair question to ask: what if this new strain of influenza A/H1N1 becomes more deadly? Even though there have only been 1490 confirmed cases and 30 deaths globally (WHO, 5 May 2009), governments continue preparations as if a deadly outbreak were imminent.

Should the outbreak take a turn for the worse, any government taking a more conservative stand would be hard pressed to justify any inaction. Erring on the side of caution, governments more readily hedge their bets.

Will this new influenza A/H1N1 virus become more deadly? It seems unlikely, but certainty tends to be a luxury of hindsight.

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In a race to the finish, it’s usually anyone’s game. The margin between winning and losing might only be seconds. And when seconds count, even the smallest detail can make a difference. While training best determines success, athletes also have something else they can turn to for an extra edge. And it’s not a new medication–it’s something we’ve been using for thousands of years.

Caffeine, found primarily in coffee and tea, is best known for its use as a stimulant. The mental effects are undeniable, and studies on the musculoskeletal benefits of caffeine date back to the 1970’s. However, recent studies are consistently showing that caffeine can boost performance across a range of athletic activities.

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Have you ever heard that your brain is like a muscle? As in, if you stop using your brain, it will stop working as well. A recent study covered by WebMD definitely suggests this to be the case. Here is a quick excerpt to summarize the point:

Lab experiments show that if you put brain cells in a Petri dish, “they will form connections and survive. But if you put just one cell in the dish, it will die,” Jicha says.

Reading, playing games, and other activities stimulate brain cells to connect and flourish, he explains.

-WebMD, “Brain Exercise May Delay…”

In the study, participants cognitive abilities were compared to the level of mental activity they underwent on a day to day basis. Researchers noted a strong correlation between high levels of mental exercise and decreased memory loss.