Thursday, August 23, 2007

Physician Heal Thyself

Last year, I was faced with a myomectomy for a fast-growing fibroid on my uterus. I want to use my experience to present a comparative assessment of two different health care systems. The two systems are the nationalized health care plan of the UK (the NHS) and the privatized health care plan of the USA.

I was in the UK when I started developing symptoms that indicated that something might be going on in my reproductive system. I was registered with a GP in Birmingham city center but I had moved to a different address. I went to the GP and she carried out an external examination and determined that I might need some tests but when she found out that I had moved, she told me that I really had to register with a GP where I lived because otherwise there would be lapses in my care. So off I went to find a GP near my place. A new GP carried out an internal exam and he thought I had fibroids and needed to get an ultrasound and see a GYN specialist. Since the system uses electronic medical records, the new GP could easily access my previous records without undue delay. He made these referrals for me. This was in August 2006. He said I should hear from the specialist and the ultrasound clinic about an appointment. The appointment would likely be 6 weeks away.

I did hear from the clinic in six weeks but only to say that I should call them to set up an appointment. The earliest appointment I could get was in November 2006 for an ultrasound. In the UK you are triaged for specialist appointments based on urgency and it seems there were many other people requiring or already signed up for ultrasounds. My GYN appointment was scheduled for a week before the ultrasound. As it turns out, this was not ideal but the specialist's office was accommodating and saw me, not only at the original appointment but also, a week later in order to interpret the ultrasound and answer my questions about treatment options.

I have written, in an older post, about the fact that I never saw the specialist himself but rather a nice registrar he was training. Not seeing the specialist made me feel like he was not as invested in my care as he should be and this bothered me a bit. Another thing that bothered me was that my specialist was telling me to undergo gonadotropin therapy. I would be on Prostap (known as Lupron in the US) for 3 months and be menopausal so that during and after surgery, I would have less bleeding and not need transfusion.

To begin with, I hated to think about the kinds of severe hormonal changes the therapy would induce in my otherwise healthy body. So while I was still in the UK, I called a couple of physicians in the US to find out what they thought. I was still covered by my husband's health insurance. One of the doctors I called was a female doctor and the other was a male OB-GYN recommended by an acquaintance. Both asked me whether I was anemic. I wasn't. At which, they both said that in a healthy, non-anemic patient they would not recommend the gonadotropin therapy as unshrunken uterine tissues would be easier to operate on for the surgeon and should not unduly hamper the patient's post-op recovery.

Armed with this knowledge, I got back in touch with the UK specialist's registrar to find out what their rationale was for recommending this therapy and if I could avoid the 3 month treatment and get my surgery sooner. The registrar couldn't answer my question but she passed on my question to the surgeon who wrote me a letter explaining that the gonadotropin therapy was standard and not only prevented blood loss but also made the surgery incision smaller and less obtrusive. He also said that if I chose not to undergo Prostap therapy he would still operate on me but it wouldn't change the date of the surgery as he was fully booked for the next 3 months.

At no point, did we discuss costs. Everything would be covered and I would be in a nice university based research hospital which I had visited during my consultations. However, I felt like I wasn't getting personalized attention from the surgeon and also I felt like I shouldn't have to wait 3 months for surgery. The American doctor told me that he could fit me in sooner. I told my employers that I needed medical leave. That was all it took and I went off on paid leave.

In the States, I called both the female and the male doctor. The female doctor couldn't even see me for an initial consultation for a month (waiting periods vary from doctor to doctor in the US as we know) which made my choice easier and I chose the male surgeon. I went to see him and he scheduled me for surgery about 3 weeks from initial consultation. He thought everything would go off just fine, nothing to worry about and no complications. He seemed so magical after the elusive UK surgeon.

I went into surgery and when I came out a few hours later the surgeon told me that everything had gone off well and I should be recovering quite well. I was in good spirits and decided to start walking around as per the advice given me. However, within a few steps, I'd lose all energy and wilt. My blood pressure which was being monitored every few hours, started to creep lower. The next day the same thing kept happening. I would wake up in good spirits every few hours but any movement and I'd start to wilt without energy and my BP kept getting lower till I was about 70/40. It took the doctor till the next day, i.e., 2 days after surgery to hit upon the fact that I was losing blood internally and needed a transfusion. I was put in the position of signing documents when my mental capacities were not at their sharpest. I chose the transfusion as otherwise my recovery would have been even longer and since I was being discharged from the hospital (I was already slated to stay a day longer than the doctor originally planned because of my post-op complication) and going home to be alone (my husband was going to travel the day after I got out), I felt I could use all the boost of a transfusion.

Anyone with any inkling of human physiology and medicine, let alone a trained GYN specialist, should have thought of the eventuality of a complication and the surgeon had 3 weeks before my surgery to do so and think of having me donate my own blood to be held in case I needed it. It also took the doctor well over a day and a half to think of bleeding as the cause of my sinking diastolic pressure. It seemed like once the surgeon had me signed on as a patient, he divested himself of any more special interest in me as a patient. It did not occur to him to spend a little bit of time thinking through a procedure like this and saying to the patient, let's collect some of your blood just in case; let's think about what happens in case there are any complications needing your approval. No sirree, we were signed on for an expensive procedure that was going to put a substantial amount of money in the doctor's pocket but to him I was still one of his "routine" patients.

After the fact, I have thought long and hard about the differences in the system. There were many pressures on me in the American system which I had not expected. Once I had chosen a doctor I had assumed myself to be in good hands and absolved of the need to collect my own medical information. This is not true as not all doctors in the privatized system are invested in patient care as detractors of nationalized systems would have you believe. Further, my doctor not only did not think of the possible medical consequences and complications of abdominal surgery, he also did not bother to pick other specialists who were covered by my health plan. Post-surgery, I started receiving large bills from an out-of-plan anesthesiologist and surgical assistant.

Unlike the nationalized health system, hospital stay is really expensive in the States, and the pressure was on post-surgery to get me out of the hospital. I was given one extra day past my discharge date because of my blood-loss complication. The transfusion was my only option to not go home completely weakened and try to recover alone.

The quality of a health care system is not determined solely by how much money is invested in that system. By that measure, the US ranks number 1 as more is spent and yet more is reaped in the medical system here. And yet, we are not able to provide health care for all. But we tout very loudly that the health care we do provide is top-notch. Well, no, we don't provide top-notch care across the board. As more and more studies are showing, the record is quite spotty and inconsistent. There are some centers of health care which do provide cutting-edge health care better than anywhere else in the world. But overall care and coverage are worse than most developed nations of the world.

I have presented here an objective account of the service and care I received in 2 different systems. In both cases, the surgeons were men who were not showing due diligence and were not invested properly in my care. But in one system, I had to pay for the same level of shoddiness.

Wednesday, August 08, 2007

Corny Economix

I did not think I'd have to follow up my last blog about Ethanol quite as soon as this. I wrote that biofuels, as they were being manufactured and utilized currently, were ill-conceived and short-sighted. I had thought that in the near to medium future I would be writing once again about the effects of ethanol farming as they became more visible and undeniable. I am compelled to address this issue again in the face of unmistakable dynamics that are already manifesting themselves and affecting various aspects of the economy.

Corn is one of the five major crops for which American farmers receive huge subsidies. This creates perverse incentives all around and is as harmful to poor farmers around the world as to the American farming culture. The recent popularity of ethanol as a fuel has seen an upsurge in corn prices as well as land prices. Since the ethanol fever shows no signs of abating in the near future, more people want to grow corn for which they can receive subsidies from the government and sell it at the rising prices to the ethanol producing facilities (see adjacent picture). This has lead to land grabs in states such as Iowa and Nebraska where land prices are at an all-time high. More and more land is coming under corn production.

This creates multiple unhealthy dynamics. It discourages the small farmer who concentrates on other crops. They don't receive subsidies and have to labor to bring fresh vegetables, fruits and other crops to the market. And this at a time of a growing obesity crisis in this country. We are telling people to eat healthier by incorporating more diverse produce, fresh fruits, vegetables and whole grains in their diet. But we still continue subsidies to big farmers practicing corn mono-culture which is also the mainstay of the processed food industry with its reliance on fructose.

By subsidizing corn the government encourages farmers to produce a lot of it which used to get dumped on other countries at an artificially low price, thereby hurting indigenous farmers globally (this continues for the other subsidized crops). In corn's case, in addition to the creation of fructose, we now have a new internal outlet for all the excess farmers can produce- Ethanol! Subsidies make the big rich mono-culture farms richer. They do not, in general, open up the market to small farmers who are held out of the market because they cannot afford the escalating land prices or because the big farmers, who own most of the land, charge high rents for it.

On the one hand having an additional outlet within the country for all the excess corn, means it won't be dumped on the rest of the world at lower than cost. However, this may make corn everywhere more expensive as demand for corn to make ethanol continues to outstrip supply and may eventually make corn costs too much as food and feed.

A researcher at Berekely, Tom Patzek, has written a technical paper on the corn biofuel and all its implications. He quantifies the sustainability and the renewability of this resource and finds that it falls short.

I wonder if demand for corn as a biofuel source will forcibly change the processed food industry when fructose becomes scarcer. I hope at least one good thing comes of it but I fear even that one good thing won't balance out all the negative outcomes that will result if we continue down this path of converting food sources into fuel. We don't need more subsidized resource-intensive mono-culture farms. The focus should not be on creating alternative fuel sources. The focus should be on reducing consumption of fuel altogether and finding alternative, energy-efficient and cost-effective ways of accomplishing growth and progress with good health.
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