Sunday, January 23, 2011

Do Medical Students Know How It Feels to Be Uninsured?

Up in the Ivory tower, do tomorrow's doctors know what it feels like to be without insurance?  About one in three Americans between the ages of 18 and 24 is currently uninsured, and about one in four of those ages 24-64 is.  Harvard requires us to have insurance while we are in school.  Have our classmates ever been without?

N=55 for this survey.

Age (N=53)
The mean age of the respondents was 23.75 years, and the median was 23 years.  About 90% of those who answered were between the ages of 22 and 25.  The oldest student was 33.

Types of Insurance (N=55)

Respondents were not restricted to a single choice, and no time period for a type of coverage was specified.  Thus, coverage types may or may not have overlapped.  All students had had at least one type of insurance: 11 students had had one type, 22 had had two types, 19 had had three types, and 3 had had four types.  Age did not correlate with how many types of insurance a student had had.

All but one student (with private non-group) had been on either dependent or school-based coverage at some point.  All three students on Medicaid had also been on school-based insurance at some point.  One student ("other") had received coverage via an international organization during an internship.

Uninsured at any point? (N=55)

Since Harvard requires that we have health insurance to attend (and Massachusetts has an individual health insurance mandate), the base assumption was that all students are currently insured.  Only one student mentioned in the free-response that s/he was between insurance plans and was planning to get insured soon.

Just over one-third of students had been without insurance.  The average age of this group was 24.5 years, and the median was 24 years.

Regarding the two-thirds of students who had never been without insurance: the average age of this group was 23.35 years, and the median was 23 years.

An F test revealed equal variance between the two groups (p=.00015).  A two-tailed homoscedastic T test revealed a significant difference between the ages of the two groups (p=.039).

Characterization of uninsured period (N=20)

To determine the nature of the uninsured period, I asked two questions: 1) How long total have you been uninsured, and 2) Why were you uninsured?

Answers ranged from one month to 10 years, so a strict average would not be helpful for characterization.  Instead, I will divide time periods into short- (<6 months) and long-term (>1 year) periods.  The reason I chose this classification is that no one was uninsured for a time between 6 months and 1 year, suggesting a natural break in the data.

Short-term uninsured period (N=9)

Three students answered one month; the rest answered "several" or answers between 2 and 6 months.

Six of the nine students described the reason as being in an "in-between" period: either between schools, jobs, or plans.  Two more mentioned simply not buying a plan, and one mentioned being unable to afford private non-group insurance.

Long-term uninsured period (N=11)

All three students who had been on Medicaid were in this group.  Six students mentioned cost, four students mentioned that their parents did not have coverage, and one student mentioned having a part-time job without health coverage.

Revised graph of insured vs. uninsured

No other questions about demographics or attitude were asked.  This is simply a snapshot of 55 first year HMS students.  Slightly over one third of them have been without insurance at some point, and one fifth of them have experienced being uninsured long-term.

Wednesday, January 19, 2011

Sufficiently Indoctrinated

Rather than teaching physiology or immunology, our school devotes this entire month to population health, epidemiology, and health policy. The three subjects complement each other well: we learn statistics to analyze epidemiology papers and use such studies to devise policies that affect population health. The most eye-opening course for me so far has been health policy. I didn't realize how little I knew about health care economic infrastructure and payment schemes until they were explained to us in great (and sometimes tedious) detail.
Health care coverage is relevant, nonintuitive, and downright confusing. Economics, policy, and politics are certainly not topics I have learned much about from sources other than the media. Every day, for four weeks, we learn about geographical variations in health spending, insurance, Medicare and Medicaid, cost growth, managed care, medical malpractice, health care quality, and health care reform.
If the purpose of a mandatory health policy course is to get future doctors to think about costs more frequently and intelligently, the short-term results seem pretty good. Now, during our population health lectures, it is not uncommon to hear a student ask the lecturer about the cost-effectiveness of an intervention--and then apologetically explain the fiscal interest as, "It's just that we're taking health policy now..."
I don't remember these sheepish questions ever surfacing before.
Additionally, I have wondered if my classmates--and tomorrow's doctors--know what it feels like to be without health insurance. About one in three Americans between the ages of 18 and 24 is currently uninsured, and about one in four of those ages 24-64 is. We are required to have insurance while we are in school. But have we ever experienced any time without it?

Thursday, January 13, 2011

Body Donation Preferences After Taking Anatomy: Take 2

Medscape's The Differential is a collection of medical student blogs. Garnering about 1000 views each day, the international audience is (presumably) composed mainly of medical students of all years, with a smattering of residents and higher-ups.

We (the bloggers) are allowed to create a single-question poll with our post.  So, how does national/international medical student/resident opinion on body donation compare with that of Harvard first years' fresh out of anatomy (original post here)?  The results are fairly similar.

Dear The Atlantic, We Have Opinions

When I was applying to medical school, a big part of my spiel was on the importance of connecting the medical profession to the outside world by those inside the community (in my case, I wanted to do it via writing).  It's quite easy and tempting to speak candidly and frequently with colleagues, who by definition share our professional backgrounds: we are trained similarly, learn similar material, undergo similar challenges on the job, face similar frustrations, and basically just "understand" what it's like in fewer words.  It's more of a challenge to communicate to those without a similar professional currency.  It's time, it's effort, it's frankly patience that can sometimes be difficult to muster.

But the alternative is to have those outside the community describing to others outside the community what it's like from inside the community.  And sometimes it's misleading, or hits on precisely the wrong points... or both.  If we do not have the time to write, we should at least correct such misinterpretations:

In September 2009, The Atlantic published a piece on teaching ethics to medical students.

The premise was that medical students were getting a surprisingly inadequate foundation in ethics, buttressed by a study published in JAMA by Mayo researchers.  Used as major support for the article's premise was a startling statistic apparently found in the Mayo study:
Also surprising was the study's finding that only 14% of those students had an opinion about "appropriate interactions between physicians and pharmaceutical companies." How could 86% of medical students not even have an opinion on such a hot subject? 
The short answer is, they don't.  The study did not find that students did not have opinions on these issues; rather it found that students "frequently had opinions inconsistent with the AMA policy on conflicts of interest in relationship with [pharmaceutical] industry."  When researchers presented scenarios to students, "only 14%... of students' opinions on relationships with industry aligned with the AMA policy of all 6 scenarios."  Only about 5%--not 86%, as the journalist claims--did not answer at least one of the industry questions.  So, about 5% of students have at best "incomplete" opinions and at worst no opinions on industry.

We may not agree with the AMA, but we do have opinions.  Quite a difference.

Perhaps most disheartening is the fact that this result was in the abstract of the paper, right under Results.  It is accessible to all and is a mere 342 words long.  (This blog post is 417 words long.)

Saturday, January 8, 2011

We're Not Taught to Do That in Medical School

Doctors vs. nurses (or doctors vs. nurse practitioners, or doctors vs. physician assistants, or what have you). The debate over superiority is old, tired, unimaginative, divisive, and wrong-headed--for reasons that are too obvious even to list. Does it get perpetuated because it garners comments?  

The New York Times recently ran a column by one of its editors, "In Praise of Nurses."  Nothing wrong with gratitude for nurses, who are certainly under-appreciated or mistreated, both in real life and in media portrayals of them.  Where it gets gnarly, apparently, is how to praise nurses in a vacuum, without comparing them to physicians, and without the snarky jabs.

To generalize: Nurses are warm, whereas doctors are cool. Nurses act like real people; doctors often act like aristocrats. Nurses look you in the eye; doctors stare slightly above and to the right of your shoulder. (Maybe they’re taught to do that in medical school?)
The rhetorical question begs a response.  So... this is what we learn in medical school about how to interact with patients.  Keep in mind this highlights solely psychological factors.  How we learn to put together the relevant information to generate a differential is another story for another time.

-Consciously keep "patient as a person" in mind while we conduct our interviews. While starting, we even had a separate category entitled this, which would often include vocation, home life, and hobbies.

-Ask for a patient's explanation of his/her illness. "Why do you believe that?" is usually a good question and leads to better care.

-It's not an interrogation.  Seat ourselves during the interview at a slight angle to 180 degrees, so that we are not directly facing the patient.

-Body language, body language, body language.  It's like a first date.  Encourage conversation; it's information you need.  Make direct eye contact, nod, say "mmhmm" or "go on."

-Attend an AA meeting.  Watch alcoholics who have been sober for decades counsel alcoholics who have decided yesterday to quit.  "Today is a new day."

-Listen to victims share their domestic abuse stories. Ask questions. Listen some more. It happens at the most unexpected times to the most unexpected people.

-Learn how to take an appropriate and sensitive sexual history.  Don't assume anything--married or not, "straight" or not, "educated" or not.

-Make a home visit to a patient.  We see "disease"; he experiences "illness."  What is it like?

If something is going wrong with the author's doctors, unfortunately it is in spite of what our dedicated and caring preceptors teach us in medical school.

Thursday, January 6, 2011

Another Quick-and-Dirty Survey: How to Finance Health Care?

Thank goodness the Health Policy course at Harvard is not optional.  Health care coverage is relevant, nonintuitive, and downright confusing.  Economics, policy, and politics are certainly not topics I have learned much about from a source other than the media.  Every day, for four weeks, we learn about geographical variations in health spending, insurance, Medicare and Medicaid, cost growth, managed care, medical malpractice, health care quality, and health care reform.  This is week one.

I am curious about our class's sentiments about how health care should be funded.  I am also interested whether that sentiment will change after we are (presumably) better educated by the end of this month.  (I plan to send out an identical survey at the end of the course.)

The survey simplifies almost to the point of ridiculousness.  Should funding for health care head in a private or public direction?  Of course, there are many, many different and complicated models of coverage: for example, "universal coverage" does not necessarily entail a single payer or even completely public funding.  I intentionally left out the concept of mixed (public and private) funding, since that is what exists today and I suspect most of my classmates would fall into that camp.  I am more interested in the direction that they think health care coverage should go--should we encourage private or public entities to fund it?  Which way do we lean, on a very superficial level?  Does it correlate with self-reported knowledge of policy?  Will it change after this course?


Correlation between "self-reported knowledge" and leaning?  Size of private funding group (N=7) is too small to draw any conclusions.

Caveat: "Self-reported knowledge" is an incredibly subjective measure.  It could also reflect ego more than knowledge.

The average knowledge score for those who leaned toward private funding was 2.9, and for those who leaned toward public 2.3.  

No one who self-rated a 1 on knowledge leaned private.

40% of those who self-rated a 4 on knowledge leaned private.

Idioms That Are Now Off the Table

Now that we are in medical school, stereotyping specialties seems unsavory.  So long to brain surgeons as an off-the-cuff representation of intelligence.

From our Population Health lecturer today (emphasis added by me):
"What do we do to reduce the harms of tobacco? It doesn't take a....[pause] rocket scientist.... People shouldn't start smoking, and if they do smoke, you should help them quit."