Why pre-existing conditions are like small pox

As a doctor, I have never diagnosed a patient with a “pre-existing condition.” When I took my medical licensing exams, I don’t recall a multiple-choice question asking me the most important risk factor for pre-existing conditions. Pre-existing conditions don’t show up on CT scans or biopsies. I’ve never heard of a British or Canadian citizen coming down with the affliction. Yet this strange illness is all we seem to hear about in contemporary political discourse.

Pre-existing conditions have no natural correlate. They were an actuarial invention that addressed the needs of insurance companies: pricing individual premiums, cream-skimming the healthiest, lowest-risk patients, and finding clever ways to avoid paying for care. The Affordable Care Act, which I am politically required to tell you is far from perfect, essentially cured this condition. The ACA requires insurers, with few exceptions, to sell their insurance plans to all those who wish to purchase them, regardless of their state of health. Further, the ACA requires community rating, so insurers can’t charge the sick unaffordable prices. To balance out these increased costs on insurers, the ACA instituted an “individual mandate” and coverage requirements for businesses in the hopes that healthier people will purchase insurance and dilute the risk pool.

So in 2017, the pre-existing condition has been eradicated. Its elimination may rival that of smallpox for impact on morbidity and mortality in the United States. When President Trump or the GOP promise to cover all those poor souls who suffer from this disease, we must remember that politicians aren’t promising to cover the sick, but to commit an act of political bioterrorism by re-introducing an eradicated condition. Once we recognize that there is no human reservoir for the pre-existing condition, the only vector that remains is the political invertebrate, who finds the complexity of ensuring health insurance for the sick too onerous a task.

People don’t have pre-existing conditions. People have illnesses. As a country, we have to decide if allowing sick people to have affordable health insurance is important to us.

Immigration and pathology

My letter in the Los Angeles Times.

To the editor: Your articles have mentioned the effect this ban may have on teaching hospitals and training new physicians.

I am a resident physician at Yale-New Haven Hospital and I train alongside Syrians, Iranians and other immigrants. Let me be clear: They make American healthcare better. America’s finest hospitals rely on the brightest doctors from around the world. In pathology, my field of medicine, more than half of all new residents went to medical school outside the U.S.

This policy is deleterious to American healthcare but also has a human cost. Some of my colleagues have spouses working in other countries. They may no longer be able to see them under this ban. Other immigrant residents fear they too may be the next victims of an executive order.

It pains me to watch my colleagues, as well as my patients, suffer under this anti-immigrant agenda of the White House.

Benjamin Mazer, MD, New Haven, Conn.

Reactionary politics and alternative medicine

Looking back, 2016 could be called the year of reactionary politics. Donald Trump was propelled to the presidency through widespread populism, helped by the fringe, conspiracy-theory laden alt-right community. A reactionary, antiestablishment sentiment prevails. The equally dissatisfied alt-med movement aims to have a similar disruptive effect. It certainly has some high-profile proponents: President-Elect Donald Trump has courted the community by tweeting about vaccines and autism while Jill Stein, the third-party presidential candidate and a physician, has explicitly attempted to merge alternative medicine culture with populist politics.

Alternative medicine is an innocuous, even attractive, term, framed as a healthy, natural option other than conventional medicine. What could possibly be bad about alternatives and nature?

The truth is, there’s little unconventional or natural about the factory production lines and multibillion-dollar industry behind most of the so-called alternative products used by millions of Americans.

Instead, much of alt-med is based on a deep distrust of for-profit medicine and science. Just as the alt-right community reacts broadly against the political establishment, the alt-med community seems more interested in reacting against the corporatization of medicine and nutrition and less about proposing its own reasonable, evidence-based alternatives.

You can read the rest on STAT.

Overdiagnosis awareness month

September was Prostate and Thyroid Cancer Awareness Month, October was Breast Cancer Awareness Month, and November was Lung Cancer Awareness Month. We should designate December as Cancer Overdiagnosis Awareness month, because a lot of cancers diagnosed by screening tests will never kill you.

Through decades of advocacy by patients, family members, and doctors, the public has never been more aware of the dangers of slow-growing, yet sometimes deadly cancers like thyroid, breast, and prostate cancer. Newer, more sensitive tests are promoted to encourage early detection and treatment. These interventions, it is said, “save lives.”

Undoubtedly some lives have been saved by the increased early detection and treatment of symptomless cancers. Yet there is another side: the problem of overdiagnosis. That’s when doctors diagnose a disease that won’t cause the death of a patient during the patient’s lifetime. And it is a complicated problem: Many diagnoses and treatments doctors provide today simultaneously have the ability to be either life-saving or unnecessary but nonetheless life-altering.

You can read the rest at The Boston Globe.

Editorial about gay blood donation

Public policy can have a profound affective role in our society. Law professor and bioethicist Dov Fox refers to this concept as the “expressive dimension” of public policy. He contends that a policy can be discriminatory and harmful if “the policy communicates a social meaning — independent of any bad intent or bad effect — that erodes worthy forms of public recognition.” Banning a stigmatized group from participating in the social good of blood donation, independent of any rational merits of the policy, signals to the public a sense of that group’s social undesirability.

An honest, ethical evaluation of our blood donation policy must acknowledge that gay men are far more likely to live with fears of HIV, violence, and ostracism than straight people. Instead of valuing the outsized fear that straight people have of homosexuals, we could instead reintegrate gay men into charitable society through a science-based blood donation policy.

You can read the rest on STAT.

Hippocratic capture: Thoughts on the undisciplined physician

This post originally appeared on KevinMD under the title “What is the proper way for physicians to be leaders?”.

In medical school you learn very quickly that you can’t know everything. By the end of your first-year anatomy course, you’ll probably give up on learning the names of every part of the body, let alone the intricacies of how they function. As physicians, we must grow comfortable with our limitations. We seek help from our colleagues and try not to let our egos get in the way of patient care. We accept that no physician will ever master the entirety of his or her discipline.

But are physicians now expected to master other disciplines, such as software engineering and social work? If you read the popular press and even academic journals you may think so. I like to call this phenomenon, this growing body of subjects doctors “should” master, Hippocratic Capture.

I was reminded of this new pressure most recently while reading this article in a New York Times blog. The author makes some excellent points. Medical curricula are relatively stagnant while our world rapidly changes. The best medicine will incorporate modern technology and respect for the socioeconomic factors that influence patients’ health. The author also complains that he sometimes feels as if he has only one tool in his toolbox — the biomedical framework. For many health problems, this feels like simply not enough.

It’s hard to imagine any physician not empathizing with this struggle. But is the solution for medical students to take design courses from a Fine Arts school, as the new Dell Medical School is planning (according to the NY Times blog)? Should doctors also become designers?

Doctors face the paradox of being among the most visible and respected members of the healthcare field. While this authority provides many rewards, it also places an enormous expectation on us as leaders of healthcare. Doctors are expected to heal the sick (and we want to). If socioeconomic struggles are leading to sickness, doctors are expected to fix that. If technology provides the opportunity to democratize healthcare, then doctors are expected to lead the charge. We’re even supposed to design better hospital gowns, at least according to Dell Medical School’s example of its innovative new curriculum.

But to point out the obvious: we can’t do it all! Doctors have already come to terms with our inability to master the entirety of biomedical knowledge, and we need to come to terms with our inability to personally fix every social determinant of health or poorly-designed health system. In fact, we can better provide these influencers of health the respect they deserve by allowing the true experts to take charge.

There are millions of social workers, public health professionals, software engineers, designers, and others who have the ability and desire to improve people’s health through their respective disciplines. The solution isn’t for physicians to master yet another subject, it’s to build powerful interdisciplinary teams that can address these aspects of healthcare in an egalitarian manner by including many kinds of experts. Doctors and other providers can no longer be the only ones responsible to the public for creating the best possible healthcare system. This physician-dominant model is regressive and inefficient.

I am not suggesting that doctors should ignore problems outside of the biomedical framework. I personally attended business school in addition to medical school because I was excited by the opportunity to improve patients’ health through innovative healthcare delivery. But I went to business school precisely because I didn’t expect the intricacies of management and economics to be taught in medical school. I don’t expect all physicians to master this part of medicine.

I am suggesting that if doctors are expected to master the multitudinous disciplines that are relevant to health, then eventually the biomedical aspect of medicine will suffer. After all, despite the need to address the social determinants of health, you still need someone who knows how to take out an appendix. In forward-thinking health circles, the “biomedical framework” has become an epithet. It represents the myopia of past physicians, who thought scientists in a lab would cure every disease, ignoring issues of poverty, education, and behavior. But biomedicine is still a vital part of good care delivery and should remain at the center of medical education.

While many types of professionals can address healthcare policy, good design, and innovative technology, only physicians have the duty to provide medical care under the biomedical framework. When someone requires a surgery or drug for their illness, it is doctors who are responsible for ensuring the proper selection and delivery of that type of care. We can dilute our education, but we cannot dilute that responsibility.

Doctors should have some familiarity with the many disciplines that affect health. This isn’t a new idea despite what the popular press would lead you to believe. I attended the University of Rochester’s medical school, which since the 1970’s has been home to the “biopsychosocial model” of medicine. I greatly value the broad experiences I received from learning under this medical model. Even in this environment, however, I spent plenty of time learning the pathophysiology and technical skills that are traditional parts of medical education.

I personally look forward to addressing the business side of healthcare in addition to providing good medical care under the biomedical framework. When I do work on issues outside of this framework, however, I expect to succeed not by knowing everything there is to know about healthcare delivery, but by engaging administrators, engineers, and others through interdisciplinary teamwork. If physicians are expected to be leaders of the healthcare system, then this is the proper way to lead. Hippocrates, after all, didn’t need an MBA or MSW to be a good doctor.