Saturday, June 20, 2009

Protecting Your Job While Coping With a Chronic Illness -

It started with an odd sensation in her right hand and a feeling of exhaustion so profound she could hardly get through an hour of work, let alone a full day.

After numerous tests and countless doctors' visits, Natasha Frechette, then 27, learned she had multiple sclerosis, a disease that attacks the central nervous system and can cause numbness, blindness and eventual paralysis.

In addition to grappling with the diagnosis, Ms. Frechette was concerned about keeping her job as a data manager for a small research organization in Brooklyn Park, Minn. "I didn't want to have to depend on someone to take care of me," she said. "But I know that I could wake up tomorrow and not be able to walk."

Workers with chronic illnesses face chronic uncertainty, forced to worry not only about their health but about their jobs as well. The protections afforded chronically ill workers in the United States are thin and somewhat vague. To protect their health and their jobs, workers must navigate employers' policies, which may include short- and long-term disability plans, as well as a patchwork of federal laws and regulations.

A recent study by the Center for Economics and Policy Research, a Washington research organization, found that among 22 rich nations, the United States was the only one that did not guarantee workers paid time off for illness.

Most other countries provide their workers not only with paid sick days, but also time off for cancer treatments, the study found. German citizens, for example, are allowed five sick days and 44 days for cancer treatment, if needed, in addition to vacation days.

Most employers in the United States allow employees to take days off for minor ailments, like the flu or outpatient operations, without docking their pay. And 41 percent offer employees days off — nine, on average — for illness or other reasons, in addition to vacation days, according to a 2007 survey by Mercer, a benefits consulting business based in New York.

But when an employee has a serious or chronic illness, like diabetes, major depression or lupus, the rules about time off become murky.

Two laws offer workers some relief. The Family and Medical Leave Act allows employees to take up to 12 weeks off each year for medical or family emergencies — but without pay. And the Americans With Disabilities Act requires employers to make reasonable adjustments for disabled workers, often in the form of additional time off.

Ms. Frechette explained her condition to her supervisor and said she would need time off for physical and occupational therapy. Her boss readily agreed, and Ms. Frechette, who plans to marry this fall, continues to work full time.

"I'm careful," she said. "I don't want my disease to be seen as a cop-out."

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Why do doctors wear white coats?

The American Medical Association voted Tuesday to recommend that hospitals ban doctors' iconic white lab coats, citing evidence that the garment contributes to the spread of infection. Indeed, a number of studies have shown that the coats harbor potentially harmful bacteria (and may cause "white coat hypertension"). If white coats are so bad, why do doctors still wear them?

Because a white lab coat says "I am a scientific healer." The knee-length coat in medicine crossed over from the laboratory sciences at the turn of the 20th century. Before that time, medicine was generally seen as the haphazard province of quacks and frauds, and physicians wore street clothes even in the operating room. As the field developed into a respected branch of applied science in the early 1900s, doctors adopted the costume of the laboratory as a way of bolstering their scientific credibility.

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Friday, June 19, 2009

Health-Care Reform 2009 - Tracking the National Health-Care Debate

Primary-Care Doctor Shortage May Undermine Health Reform Efforts -

Fifty years ago, half of the nation's doctors practiced what has come to be known as primary care. Today, almost 70 percent of doctors work in higher-paid specialties, driven in part by medical school debts that can reach $200,000.

"We need to rethink the cost of medical education and do more to reward medical students who choose a career as a primary-care physician," President Obama said in a speech to the American Medical Association on Monday.

The average annual income for family physicians is $173,000, while oncologists earn $335,000, radiologists $391,000 and cardiologists $419,000, according to recent data compiled by Merritt Hawkins, a medical recruiting firm.

The disparity results from Medicare-driven compensation that pays more to doctors who do procedures than to those who diagnose illness and dispense prescriptions. In 2005, for example, Medicare paid $89.64 for a half-hour visit to a primary-care doctor in Chicago, according to a Government Accountability Office report. It paid $422.90 to a gastroenterologist who spent about the same amount of time performing a colonoscopy in a private office. The colonoscopy, specialists point out, requires more equipment, specialized skills and higher malpractice premiums.

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Obama's Doctor Knocks ObamaCare-

David Scheiner, an internist based in the Chicago neighborhood of Hyde Park, has a diverse practice of lower-income adults from the nearby housing projects mixed with famous patients like U.S. Sen. Carol Mosely Braun, the late writer Studs Terkel and, most notably, President Barack Obama.

Scheiner, 71, was Obama's doctor from 1987 until he entered the White House; he vouched for the then-candidate's "excellent health" in a letter last year. He's still an enthusiastic Obama supporter, but he worries about whether the health care legislation currently making its way through Congress will actually do any good, particularly for doctors like himself who practice general medicine. "I'm not sure he really understands what we face in primary care," Scheiner says.

Scheiner takes a few other shots too. Looking at Obama's team of health advisors, Scheiner doesn't see anyone who's actually in the trenches. "I have a suspicion they pick people from the top echelon of medicine, people who write about it but haven't been struggling in it," he says.

Scheiner is critical of Obama's pick for Health and Human Services secretary--Kansas Gov. Kathleen Sebelius, who used to work as the chief lobbyist for her state's trial lawyers association.

"He doesn't see all the pain, it's so tragic out here," he says. "Obama's wonderful, but on this one I'm not sure if he's getting the right input."

What should the president be focused on? Scheiner thinks that a good health reform would be "Medicare for all," a single-payer system where the government would cover everyone and pay for it by cutting out waste in the system. "A neurosurgeon gets paid $20,000 for cutting into the neck of my patient. Have him get paid $1 million a year instead of $2 million or $3 million. He won't starve," Scheiner says.

Scheiner thinks that Obama's "public plan" reform doesn't go far enough. He supports the idea of that option for people who don't like or can't afford their HMO. But he worries that it will be watered down or not happen at all. "It's nonsense that the private insurance companies need to be protected," he says. "Why? Because they've done such a good job?"

He thinks that Americans have been scared into believing that they will lose the coverage they already have if a public plan is created. And he worries that nobody cares about the 50 million uninsured. "I have people who have lost their jobs and come to me and I give them drug samples," he says.

Scheiner says he thinks that Obama probably sees the virtues of a single-payer system but has decided it would be politically impossible to create one.

Reid Cherlin, an assistant White House press secretary who covers health issues, wrote in an e-mailed statement, "The President has been clear that while a single-payer system may work in some countries, it makes the most sense for us to build on what works in the system we have and to fix what's broken.

"He would certainly agree that there's too much waste in the system--where families, businesses and governments pay too much for too little," he added, "and that's why he's committed not just to expanding coverage but to reforming the health system to provide high-quality care at a lower cost to more Americans."

Scheiner says he never thought it was appropriate to talk about health policy with Obama, especially once he became a U.S. Senator. The one exception was medical malpractice reform. "I once briefly talked to him about malpractice, and he took the lawyers' position," he says.

Obama reiterated his opposition to caps on medical malpractice-related damages when he addressed an audience of doctors earlier this week at the American Medical Association's annual meeting. (See "Will Doctors Buy Obamacare?")

Scheiner, like most others in his profession, thinks that it should be harder to sue doctors and that awards should be capped. He says that he and other doctors must order too many tests and imaging studies just to avoid being sued.

Scheiner graduated from Princeton and then started at Columbia University's College of Physicians and Surgeons 50 years ago. After training in internal medicine in Chicago he joined a practice in Hyde Park. His partner was Quentin Young, a doctor known for supporting universal coverage and for briefly being the personal physician of Martin Luther King Jr.

Before selling his practice, he watched his income decline over the years to what he calculated to be $22 an hour ($2,100 every two weeks after withholding for taxes, health insurance and malpractice insurance.)

Scheiner thinks that any health reform should involve paying primary-care doctors better so they don't have to rush through appointments to make ends meet. He says that the medical students he encounters are no longer even taught how to do a patient history and physical exam. Patients get imaging studies and lab work instead of actual work-ups. "It's like in Star Trek where Bones had the thing he would wave up and down. They don't even talk to patients," he says.

Thursday, June 18, 2009

Taking Time for the Self on the Path to Becoming a Doctor -

Over the next two weeks in hospitals and medical centers across the country, new medical school graduates will begin their internship. Among their many worries — moving to a new city, meeting new colleagues, adjusting to medical training — is a more profound, existential concern that had once plagued me.

Do I have to lose my self in order to become the doctor I want to be?

I learned the answer to that question partway through my internship. Not in the hospital but in the checkout line of a local grocery store.

The customer in front of me was an older woman — she wore a faux camel-hair coat and had hair dyed a matching color. I remember that she had wanted her groceries bagged in a particular fashion, but the sales clerk, a young woman with impossibly long pink acrylics, was perplexed by the woman's demands.

I felt as if I had stepped into an avant-garde theatre production. Each time the young woman bagged the groceries, the older woman admonished her and asked her to go through the process yet again. The muscles of my jaw tightened with each round of bagging, and even though I was off for the day, all I could think was: I've got sick patients to take care of, I can't wait for this!

Unable to bear it any longer, I stepped forward and bagged the woman's groceries myself, shoving the plastic bags into her arms while resisting the urge to push her on her way. I imagined steam rising from my head as I ranted. But a part of me was as shocked as the people still standing in line. I had never lost my temper in a store, and I had never raised my voice in public. Now, a few months into internship and with a three-minute provocation, I had the capacity to act like a grizzly bear sprung loose from a trap.

I walked out of the store horrified. That night thinking back on the event, I grew more ashamed of my behavior. But I also realized that it was not the first time I had snapped. Over the previous months, I had thrown myself into my work and shunned everything I once enjoyed and nearly everyone I loved. I believed I needed to do so in order to become a surgeon.

But I had lost my self in the process, and the stress made me irritable. I was no longer the nonconfrontational person I once was.

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Why must health reform be isolationist? - By Timothy Noah - Slate Magazine

The political establishment's hubristic refusal to consider how other countries manage health care is encapsulated in the cliché "uniquely American," which is what Sen. Max Baucus, D-Mont., the lead legislator on health care reform, says he wishes his bill to be. It therefore goes without saying that the finance committee Baucus chairs could find no place in this year's exhaustive health care hearings for a single expert on how other countries achieve better health outcomes for their populations while typically spending, on a per capita basis, half what we do. When the finance committee releases its draft bill this week, it will be almost completely free of foreign influence.

Given this circumstance, I am sorry to report that T.R. Reid's superb new book, The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care, won't hit bookstores until August, by which time the Obama White House and Congress hope to be finishing up their work on health reform. In the meantime, I would urge Penguin Press to sprinkle advance copies liberally throughout Congress, the White House, and the Health and Human Services department.

Ignore the title (which, apart from being Sunday-schoolish, was used 12 years ago by New Age spiritualist Marianne Williamson); a better one would be Sick Around the World, which is what Reid called the excellent Frontline documentary he hosted on this topic last year. Even better: Around the World With My Bum Shoulder. Engagingly, Reid frames his inquiry by seeking relief for his aching right shoulder, which he injured while serving in the Navy in 1972. A surgeon at Bethesda Naval Hospital fixed it by inserting a stainless-steel screw into his clavicle, but three decades later Reid could no longer swing a golf club and could only just barely replace a hanging light bulb. In a show of the same sunny resourcefulness he displayed as a foreign correspondent for the Washington Post, Reid uses his ailment as a vehicle to explore the world's health systems.

Reid helpfully divides health care systems into four models:

Bismarck. As the name suggests, the Bismarck model is found in Germany—and also in Japan, France, Belgium, Austria, and, "to a degree," in Latin America. Doctors, hospitals, and insurers are all private, and insurance is funded jointly by employers and employees, as it is in the United States. But the insurance companies are nonprofit, and coverage, fees, and medical services are all tightly regulated by the state.

Beveridge. Named for Lord William Beveridge, who with Aneurin Bevan created Britain's National Health Service. Also found in Spain, Italy, Hong Kong, and much of Scandinavia. Instead of private insurers, the government pays all medical bills. Hospitals are typically owned by the government, and doctors are usually (though not always) salaried government employees.

National Health Insurance. A blend of Bismarck and Beveridge found in Canada, Taiwan, and South Korea. Hospitals and doctors are private, but the government pays.

Out-of-Pocket. The de facto system of the Third World. Since most of the population can't afford health insurance, medical care is typically achieved through international charity or (most often) not at all.

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Wednesday, June 17, 2009

Peanut Allergy Kid: Review of "Binky Goes Nuts"

It is hard for kids of any age to fully comprehend a peanut allergy. Part of the problem is speaking on a level they can fully understand. So, when I heard there was a cartoon that was about a peanut allergy, I had to get it for Tyler!

If you have seen the "Arthur" series on PBS, you know what a high quality show it is. Tyler already liked it before we found "Binky Goes Nuts."

The story is simple and opens with Binky being diagnosed (via a skin test) with a peanut allergy. Binky does not fully understand all of the implications of the allergy but his mother does.

His mother teaches him the importance of reading all labels (she finds peanut oil in chili!) and talks about all of the precautions he must take to keep himself safe.

One important moment in the show is when Binky picks out a snack for himself at the store. His choice is cashews. Since he does not have a cashew allergy he does not give it a second thought. However within moments of eating his snack, he breaks out in hives. After a trip to the ER, he discovers the very real possibility of cross contamination.

This show is fairly short (maybe 10 minutes?) and could easily be shown to a classroom or a group of friends. Its interesting enough that they would stay engaged but truly learn something valuable about peanut allergies.

Tyler's Opinion

Tyler loved the fact there was a show about peanut allergies! He watched it several times in a row (it's very short). He kept saying, "I want to watch the peanut allergy show!"

The show also gave us a great opportunity to talk about his allergy. This child was in school and we talked about how to deal with his allergies at school.

There was one part in the movie that was a little unnerving to Tyler. (He is 4 and a rather sensitive child.) Binky has a nightmare where a peanut butter sandwich is trying to attack him. In the end, a super hero rescues him. This would probably not bother a child ages 5 and above, and might not even bother some younger children.

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Monday, June 15, 2009

U.S. Births Hint at Bias for Boys in Some Asians -

The trend is buried deep in United States census data: seemingly minute deviations in the proportion of boys and girls born to Americans of Chinese, Indian and Korean descent.

In those families, if the first child was a girl, it was more likely that a second child would be a boy, according to recent studies of census data. If the first two children were girls, it was even more likely that a third child would be male.

Demographers say the statistical deviation among Asian-American families is significant, and they believe it reflects not only a preference for male children, but a growing tendency for these families to embrace sex-selection techniques, like in vitro fertilization and sperm sorting, or abortion.

New immigrants typically transplant some of their customs and culture to the United States — from tastes in food and child-rearing practices to their emphasis on education and the elevated social and economic status of males. The appeal to immigrants by clinics specializing in sex selection caused some controversy a decade ago.

But a number of experts expressed surprise to see evidence that the preference for sons among Asian-Americans has been so significantly carried over to this country. "That this is going on in the United States — people were blown away by this," said Prof. Lena Edlund of Columbia University.

She and her colleague Prof. Douglas Almond studied 2000 census data and published their results last year in the Proceedings of the National Academy of Sciences.

In general, more boys than girls are born in the United States, by a ratio of 1.05 to 1. But among American families of Chinese, Korean and Indian descent, the likelihood of having a boy increased to 1.17 to 1 if the first child was a girl, according to the Columbia economists. If the first two children were girls, the ratio for a third child was 1.51 to 1 — or about 50 percent greater — in favor of boys.

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Sunday, June 14, 2009

The Disease & Illness Blog

Diagnosis - Were Panic Attacks Causing a Loss of Consciousness? -

“Mommy, I’m afraid. Tell me what to do.” The child’s mother looked up at her 8-year-old daughter. “It’s going to be O.K.,” she said. “Just go get some help.”

The woman watched as her daughter left the public bathroom, where she now lay. She and her daughter had come to this store to pick up some new towels. But once inside the mother began to feel hot and dizzy. Her heart fluttered in her chest, and she felt as if she was going to be sick. She grabbed her daughter’s hand and hurried to the bathroom. Once there she suddenly felt as if she was going to pass out and laid down on the bathroom floor. That’s when she sent her daughter to get help.

Finally a store clerk came into the bathroom holding the little girl’s hand. The last thing the woman remembered was the look of horror on the clerk’s face as she saw the middle-aged woman lying on the floor in a pool of her bloody stool.

When the E.M.T.’s arrived at the store, the woman was unconscious. Her heart was racing, and her blood pressure was terrifyingly low. She was rushed to the emergency department of Yale-New Haven Hospital.

By the time she arrived at the emergency room, her blood pressure had come up and heart rate gone down, and she was no longer bleeding from her rectum. A physical exam uncovered nothing unusual, and all of the testing she had was normal, with one important exception: her blood seemed to have lost its ability to clot. If that problem persisted, she would be in danger of bleeding to death after even the smallest cut or abrasion.

The patient told the E.R. doctors that her only medical problem was anxiety that caused occasional panic attacks, and she had recently started taking an antidepressant for that. She didn’t smoke, rarely drank, worked in an office and was married with two children. She had been healthy her whole life until almost two years before, when the exact same thing happened to her; one day, out of nowhere, she had sudden, bloody diarrhea, her blood pressure dropped and she lost consciousness. Then, when she got to the hospital, doctors found that her blood would not clot.

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More Young, Single and Pregnant - Motherlode Blog -

I have read every one of the more than 600 responses to Emmie, the young woman — 22, single, unexpectedly pregnant and about to start a prestigious, difficult graduate program — who wrote asking for readers’ advice on what she should do. Emmie tells me she has read every word, too.

Spending two days scrolling through those responses, I have been struck by two things. First is the complexity of the decision to become a parent. So many of your comments were about your own decision trees — about what you needed to feel ready, about whether you can ever completely feel ready, about how markedly different this choice is for men and for women, about balancing your own needs and those of a baby who still exists mostly in the abstract. About health insurance, and child care, and support systems, and the role of race and money, and of educational dreams and fears of infertility, and the complications of adoption, and the relief and regret of abortion.

For days I have been pondering several comments in particular:

Nancy wrote: “In my opinion, the question ‘when does life begin’ can be answered most closely with the answer ‘when it is intended.’ ”

RogerR wrote: “I think the young woman’s very moving e-mail is testament to the difficult decision-making all women go through in their lives relative to unplanned pregnancy. No woman makes a callous, unthinking ‘choice.’ ”

StarryNightFish wrote: “…the world is still set up to assume the ‘normal’ worker or student is a man. If the world accepted that normal people are women and get pregnant at times that the world may not think are the best times, we would have paid maternity leave, quality affordable day care, etc. It’s not fair that due to the lack of these things, so much of one’s life is ‘the wrong time’ to be pregnant.”

And, in an echo of StarryNightFish, Hugh wrote: “What does it say about the future of our modern culture based upon ‘economic progress’ when, as we can see in Emmie’s agonized choice, when the choice to reproduce is such a burden upon one’s ability to survive and prosper?”

I have also been reminded while moderating the torrent of comments of the power of the Internet. I worried when I posted Emmie’s e-mail that it could bring out the worst in readers. Instead it brought out the best. Your answers were compassionate and wise. You differed in what you thought she should do, but you all began with the assumption that she was doing her best to make the decision that was right for her. Out of more than 600 comments, I deleted only four, because of language or blatant incivility. So what you see is an accurate representation of what was sent. And it is breathtaking.

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Policy and Profit - Following the Money in the Health Care Debate -

Congress appears ready to confront one of the nation’s most contentious issues — health care reform — and arguments will fill the air in the coming months.

Much of the discussion so far has focused on President Obama’s proposal for a government-sponsored health plan that he says will reduce costs. Insurers and doctors argue it will limit patient choice. Drug companies warn that the quality of care could be compromised.

But Mr. Obama’s proposal is only one of many that await Congress as it wrestles with how to rein in exploding health care costs while taking care of the country’s nearly 50 million uninsured. The size and complexity of the issue are daunting. To help understand what’s going on, you need to follow the money.

Roughly $2.5 trillion is at stake, the amount the nation spends each year on health care, nearly a fifth of the American economy. How that money is divided up — or prevented from rising at its current pace — is at the center of the debate. Many doctors, insurance companies and drug companies say they fear that their revenues could shrink significantly and patient care could be threatened.

Their arguments may prove to have merit. But “people are voting with their own economic interests,” said Les Funtleyder, a Wall Street analyst who is following the debate closely for Miller Tabak & Co. in New York.

When you hear nothing from one of the interest groups on an issue that is part of the larger debate, you can assume the silence means it has no financial stake in the outcome, he said. “You wouldn’t probably weigh in if you don’t have any skin in the game because if you weigh in, it makes you more of a target,” Mr. Funtleyder said.

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