16 December 2010

Back to Kenya

One month from today, I'm headed back to Kenya.  And I'm taking Mom with me. 

I first traveled Kenya and sub-Saharan Africa, as part of the three-week SHARE Kenya medical mission during my fourth year of medical school.  I'd been interested in medicine in developing countries before starting medical school and this was my first such experience.  Now, I'm returning, structuring my trip as an elective rotation during my last year of residency.  We'll be there from January 17 through February 9, 2011.  I'll be working in a clinic in the village of Masara most of the time, with some time spent rotating in an Aga Khan Hospital in Kisumu.  I plan to train Mom to assist in the clinic amongst other social learning encounters around Kisumu.  We aim to go on a short safari through the Maasai Mara at the end of our time.  Afterwards, I'll head (solo) to Morocco for 10 days on my way home. 

Please see my mother's letter (below) to our friends and family, asking for support.  This year, I've only asked Santa for support for our trip, and I ask the same of you.  We look forward to hearing from y'all via Facebook or this blog.  Please be in touch, and keep our trip and Dr. Bonyo's Kenya Mission in your prayers.

From Mom:

Dear Family and Friends,

On January 17, 2011, Travis and I will be headed to Kisumu, Kenya for a 3.5-week medical mission trip. Travis has committed one of his elective rotations during his last year of residency to returning to the Mama Pilista Bonyo Memorial Health Centre in the village of Masara, roughly one hour from Kisumu. During this time, he will be the sole physician at this clinic working alongside its one full-time nurse. He will also spend some time rotating with one of the staff physicians at the Aga Khan Hospital in Kisumu. And I am beyond thrilled to be going with him to assist in any way possible.

We’re very excited to have this opportunity to serve together. I’ve always wanted to experience life as a missionary, so when Travis traveled to Kenya three years ago on his first true medical mission I mentioned how cool it would be for us to go on such a trip together in the future. When Travis decided to return to Kenya, Randolph suggested I go with him. I’ve booked my flight and have finished my series of 10 vaccines in preparation for the trip.

The purpose of this letter is to inform you of our trip and to ask for your support. It is going to cost us each about $3000 for our transportation, vaccines, and housing. We will also be purchasing supplies once in Kisumu, including medications, toothpaste, and multivitamins. We would appreciate any contributions you would feel comfortable making to defray these costs. Donations made directly to us will not be tax deductible, but even the smallest donation can provide life-saving medications and a fresh opportunity for those in extreme need. If you would prefer you could make tax deductible donations to Bonyo’s Kenya Mission, the non-profit organization that serves as the primary financial backer of this clinic.

Two other ways you might support our trip is with supplies and prayers. Travis says we will take with us multi-vitamins, tooth brushes, toothpaste, gently worn prescription and reading glasses, and gently worn children’s clothing; any of these you would give us we’ll take with us to Kenya. Or again, monetary donations we receive will go in part towards such supplies. Finally, we (and the people of Masara) would deeply appreciate your prayers, this January and beyond.

While we are in Kisumu, we will be sharing our trip with you as we can. Please find us on Facebook, or on Travis’s blog.

We hope you’ll start the New Year by supporting and following our trip with your prayers and your gifts.

In Love and Gratitude,

Cheryl Bias
1329 Braided Rope Dr.
Austin, TX 78727
Mobile 512.750.0845

10 October 2010

Pay the Primary Care Physician More

Throughout my involvement in organized medicine, I’ve met friends who I hold in high regard, and colleagues for whom I hope to one day work.  One of my favorites, a Neurosurgery resident buddy of mine, claims specialists should be paid more than primary care physicians.  But, I am a third-year Family Medicine resident, preparing to enter the practicing world.  And thus, it is with great respect that I offer this counterargument:
The primary care physician is the quarterback.  In more ways than one.  The primary care physician shoulders the responsibility of making numerous initial diagnoses, treating and managing all cardiac risk factors, and ensuring patients are directed towards the right levels of care.  We are also the center of chronic disease management, the source of 75% of health expenditures in the U.S.  Primary care visits save money by preventing poor outcomes and maintaining health.

For this very reason, we need more primary care physicians in the face of a
45,000 physician shortfall anticipated nationwide by 2020.
How do we meet this demand?  It’s very simple.  Pay primary care physicians more.
The first argument against this is that specialists undergo longer, more extensive training.  I absolutely agree that a physician whose residency is longer should be paid more.  Hands down.  My friend the Neurosurgery resident will train for 7+ years after medical school, compared to my three.  He trains an additional four years that he can’t be making significant strides towards paying off his educational debt.  He is the king of delayed gratification, more so than the rest of us.
But how much more should he make?  
Currently, he will make at least four times as much.
His training also may be more difficult at times, but all residents undergo the same stressors.  We experience stress on our relationships, both romantic and with our family.  We undergo sleep deprivation.  We miss friends’ weddings.  The life stress is comparable.
The next argument is that subspecialists are subject to greater risk.  Currently, physicians are reimbursed for procedures.  Procedures inherently carry with them a great malpractice burden - if the surgeon’s technical skills aren’t up to speed, or his/her judgment is flawed, life-threatening mistakes can be made.  But how does this compare to the missed or delayed diagnosis, the cause of many primary care lawsuits?  Or how does this compare to not adequately covering every single medical problem for the patient with an extensive medical history?  Even when a patient is referred to a specialist, they are generally referred back for the primary care doc to manage the treatment or monitor its effect.  
Not only does a primary care practice not generate revenue from a high number of procedures, but we are not paid a dime for the skills we are trained to do best - think, communicate with patients, communicate difficult diagnoses, communicate with difficult patients, e-mail patients, call patients - you get the point.  None of the aforementioned skills are reimbursed by insurance companies, and the only one you might make an argument for is “thinking,” yet this is at a far inferior rate than that of a procedure.  I get paid much more for taking off a mole than just talking to my patient. 
When in medical school, most of us just see the Family Physician as the one dealing with coughs and colds, and the one referring out to specialists for the real treatment.  But only deep into Family Medicine residency and practice does the Family Doc appreciate the depth of care delivered in the primary care setting.  We manage COPD, Diabetes and other cardiac risk factors.  We deliver babies, give flu shots, do pap smears, and help our patients to quit smoking.  We remove suspicious moles, evaluate knee pain, and manage anxiety.  
And most importantly we take the time to listen to our patients to get to the root of the problem.  Treating abdominal pain with expensive CT scans, antibiotics, and hospitalizations does no good if the patient is simply depressed.  Simply knowing your patients can save money and maintain a high level of quality.  My parents’ family doc of over 30 years knew them, and thus instead of the Hospitalist admitting my father to the hospital one Thanksgiving Day, we simply called his family physician on his cell phone and, the following week, commenced the appropriate work-up in the appropriate setting - outpatient, and not in the hospital over the weekend.
Properly reimbursing primary care physicians for their coordination, communication, and quarterbacking skills will in turn incentivize medical students to enter the field of primary care.  This is how we will appropriately meet the primary care demand and shortage in the next decade.  It’s that easy.

23 March 2010

Health System Reform?

The bill was signed today. The Republicans are offering amendments in the Senate, which will likely be futile. Was this really health system reform? That was the initial goal, but ended up as health insurance reform. Was the change in nomenclature simply a change in course to only reform one part of our system? Or was it just a cloak, a change in the title instead of the substance, to settle down the masses? Our entire system needs reform.

Where were the medical liability reforms? Where was the change from an employer-based system, to a system of individuals buying portable insurance? Where was the overhaul to allow Medicare to negotiate with pharmaceutical companies for cheaper drugs? Not only did we not just accomplish health system reform, but we did not accomplish it in the manner promised us by the candidate Obama.

Worse than anything, watching the debate on C-Span Sunday night made me think - this was not the way it was meant to happen. Democrats ignoring Republicans. Republicans shouting on the House floor. Instead of legitimate open-minded debate, we saw political theater at the primetime showing. Democrats wrote the bill with little Republican assistance, and there was little teamwork to produce this sausage.

Some of my fondest memories throughout my medical training have come during heated debate at American Medical Association meetings. The back-and-forth, usually led by my liberal-leaning fellow medical students and physicians-in-training, and generally enhanced by the fatigue that comes from a day of discussion and panels and meetings, topped with a touch of wine, generally led to a powerful consensus: Our healthcare system needs a life-saving operation. While the views of my friends out in the pacific northwest typically didn’t align with those of my own more conservative camp from Texas, we almost always found common ground. Each time we ended with a heightened sense of mutual respect for the others’ views and goals, and our friendship grew. What harmony.

Where was this agreeable attitude amongst our Congress? Have the last few administrations and elections, and most importantly the media, this effectively polarized our country and its leaders?

In the end, what are we left with? Health system reform (or was it health insurance reform?) that was passed - squeaked by the House, and Reconciliation that will survive the Senate only with the help of the Vice President’s vote. And to slap the exclamation point on the end, the Vice President demonstrated powerfully just how much of an accomplishment he felt this was.

This entire debate has left me confused about what “side” I’m on in this debate, in this polarized country, where everyone is forced to choose. Black or white. For the uninsured or against the uninsured. For lawsuits or against them. Expensive medication or cheaper medication. Tax Cadillac insurance plans, or not. And finally last night I was asked, “Can anyone really be just ‘for’ or ‘against’ healthcare reform?” Brilliant question.

No. The answer is no.

The 2700-page bill, the health system, the debate, has many aspects, many working parts. You can support parts, and want revisions to others. Truthfully, our system needed a change. Not only a facelift, but a transplant – in most areas. We needed drastic changes, but in this climate severely lacking in compromise and the ability to work in the grey zones, this wasn’t politically possible. (Whether that’s the media’s fault, or the fault of the politicians themselves, I’ll let you be the judge.) In the end, I want what’s best for the patients in our country. I want for everyone to have access to quality healthcare. And if that makes me liberal, then I guess I am.

And finally, my favorite quote from the grand finale Sunday night comes to us from Paul Ryan, Republican from Wisconsin: "The philosophy advanced on this floor by this majority is so paternalistic and so arrogant - it’s condescending.” This debate has forced me, and many of us, to reach deep down and ask what we believe and why we believe it. At my core, I believe the government is not itself the answer to our greatest problems – and if that makes me conservative, then I guess I am.

So, if you’ve had trouble picking between the two sides in this debate, don’t worry: You don’t have to, and you’re in good company.

27 January 2010

The State of the Union Address

“[The President] shall from time to time give to the Congress Information of the State of the Union, and recommend to their Consideration such Measures as he shall judge necessary and expedient...”

The State of the Union Address is my all-time favorite part of politics. The ceremony. The fanfare. It happens only once a year. The President has everyone’s attention. The Senate and House, both convened in one room, all representatives listening to the words of their President – deciding when to give their applause of approval.

The Address is largely symbolic. But it can translate into political victory. And it’s the President’s key chance to take "it" to the people. Whether that "it" is a campaign for the presidency, or a push for a policy provision, this is his designated biggest shot of the year.

JFK was the first to take it to the people. He argued on behalf of Medicare. Harry Truman made numerous train stops throughout the country in an effort to win the White House. And of course, Barack Obama has given more speeches in his first year than any president ever.

So, whether you’re playing the
State of the Union Drinking Game, pulling for the first person you voted in as President, or just putting something on while you cook dinner, please enjoy the show.