Do You Have Any Guns In The Home?

If this Florida legislator has his way, asking that question could cost up to $5 million and/or 5 years in prison.  I presume this is at least in part a result of the recent calls for increased gun control in light of the shootings in Arizona just over a week ago.

The legislator who introduced the bill has built his argument upon his worries that physicians who ask about guns in the home will report this to the insurance company, who could report them to the government, who then could come after your guns.  This argument is flawed: most docs who ask about guns do *not* report that to the insurance, and therefore the chain of feared consequences is never even begun.

So: why would physicians ask about guns in the home?  A few quick examples:

• If there are children at home, a physician could ask about guns in order to discuss safety, accident avoidance and proper gun storage.  Evidence is clear that guns are much more likely to kill a family member than an intruder, so asking about gun safety and storage is a necessary part of well-child care.
• If someone is suicidal or homicidal, the presence of a gun in the home increases the risk of completing a suicide attempt or severely harming (or killing) another person.  If a gun is available, then a mentally ill person has much more probability of hurting themselves or others, and a physician would be ethically and legally bound to approach that person's care more aggressively in order to avoid that harm.
• If one person in household is being abused by another, the presence of a gun would increase the potential lethality of the situation.  A physician may need to know this information in order to provide the necessary guidance to the victim of abuse in order to see to their safety and protection.

Physicians have legitimate and necessary reasons for asking about the presence of guns in the home.  This law, as proposed, would severely undercut doctors' ability to care for their patients and could penalize what most would see as proper medical care, and would place more government controls on what can be discussed in the privacy of the doctor/patient interaction.

Let's hope this bill ends up in the trash pile, where it belongs.

Is There A Right To Health Care?

As part of an online community, a colleague presented this article to the group in order to further discussion and debate of the issues surrounding health care reform.  The article aims to discount claims that there is any sort of right to health care.

Not surprisingly to anyone who reads this blog, I disagree.  I'm posting my reply below.

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This might not surprise anyone, but I find the article less than compelling.  If anything, the author has noted that England's approach to universal health care isn't idea, but he has not shot down the idea of universal health care overall.  In other countries (and in certain communities in our country), universal coverage is provided in ways that make health care available to all: there is England's national system, Canada's provincial systems, Switzerland (where everyone has coverage via an individual mandate and tight regulation of insurance company practices and profits--sound familiar?), Germany's combination of private/public coverage, Medicare (which dramatically changed the lives of elderly Americans), the Veteran Administration system (which some argue is among the best systems in America), etc.  The one question that can be fairly asked is how universal coverage should be paid for, but there are multiple arguments that the coverage can be provided.

From the standpoint of whether there is a right to health care, I don't think the article's author really, honestly addresses the question.  This is a complex question, and one that seems glossed over as the author moves on to attack the means of delivering universal care (as opposed to the perceived right to access care).

A few points:

1. The rules of medical ethics can be used to argue that access to health care should be available to all: the principles of beneficence, non-maleficence, justice, and autonomy would suggest that a) access to care is good; b) lack of care is bad; c) it is unjust that some have access to care while others do not (often for reasons that are not in their own control); d) one cannot be a fully autonomous individual if one is not healthy.
2. Religious guidelines can also be used in favor of the right to access: so much as religious faith compels one to help those less fortunate and to provide aid to the ailing, then faith can guide a right to health care.  The argument could be made whether such care should be provided in faith-based institutions, charitable organizations, or through government programs, but any faith that concerns itself with caring for the ill and the poor would have a hard time claiming that access to health care is not a right.
3. Civil institutions can be used to argue for a right to health care: If we are seeking rights to "life, liberty, and pursuit of happiness", it is easy to argue that one cannot have any of the three if one does not have health as a necessary precondition.  The connection of health to life and the pursuit of happiness is clear, but is also applies to liberty.  How can anyone be an active citizen and take advantage of our cherished liberties if one is not in good health?
4. Philosophical constructs exist that suggest that as individuals and as societies we should be working for the greatest good for the greatest number.  Kant's categorical imperative states that each of us should act in ways that we would like to see become universal law.  In this context, the argument I could make is that a)if we all agree that health care is a good thing, then b) we should seek to make health care available.  I think the argument could again be made as to the best way to reach that goal, but I think the goal itself can be easily agreed upon.

Regarding the author's question as to why a right to health care didn't exist in 250 BCE or 1750 AD, a quick answer could be this: in those years, medicine had fewer proven benefits and engaged in practices that actively caused harm (bloodletting, laudanum for anxiety, etc), whereas today's medical practice offers a much stronger balance of benefit vs. harm.  The argument could be made that increased access to medicine in the 1500s hurt more than it helped--maybe that is why societies did not seek to establish that harm.  Of course, in those years one could be enslaved and treated as chattel: maybe our society has advanced and moved forward to a more enlightened place?

Regarding other needs that the author addresses--food, shelter, clothing--many of us feel that there should be mechanisms to assure at least basic needs in all three areas.  Even if one does not feel that way, though, I would argue that good health is a necessary precondition for meeting these other three needs.  So in that perspective, health (and, by extension, access to health care) is a primary need for all.

I apologize this has run on for a while, and I thank anyone who has read this far.  I am not a philosopher, and so I am sure that I haven't been 100% on-target with my statements above--please feel free to point out if I am in error.

The author of the article argues that there is no right to health care because he believes that there is no right to health care.  He doesn't back up his claim in any meaningful way, and chooses to attack the *right* to health care by focusing on problems with the *delivery* of health care--two very different arguments.

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If anyone who reads this would like to point out flaws in my argument or take a different position, please do.  I really do think that engaged, intelligent, civil discussion is an important part of our democratic process.  Please comment!

Physican Educators Should Avoid PhRMA Contacts

(Note: this post is slightly modified from my post at www.npalliance.net/blog.)

Evidence has suggested that physicians are influenced by contacts with PhRMA--via drug reps, conferences, advertising purported to be educational, etc.  As I've previously noted, I think this is a strong reason why physicians should avoid industry contact/influence.

Recently, ProPublica launched their Dollars for Docs reporting series.  This series of stories (and a searchable database) intends to bring light to the relationship between PhRMA and physicians.  It's a very revealing (and fairly unpleasant) overview of how tight these connections are and how much influence industry wields on and through physicians.

A recent article describes how poorly medical schools perform in keeping medical school faculty from joining industry speakers bureaus.  High-ranking faculty at medical schools participate in these activities and give industry-sponsored talks, even though school policies officially forbid that.  In many cases, the physicians' excuses were lacking.  A major failing appears to be that medical schools' policies rely upon voluntary reporting and the honor system.  Considering that some speakers can make over $100,000 yearly through their speaking activities, it is clear that voluntary reporting is insufficient and significant penalties may be required if faculty violates their school's policies.

Considering that companies are seeking to exert more control over what speakers say, it is increasingly evident that PhRMA and other industry-sponsored talks are NOT educational endeavors--no matter how much participants might believe and no matter how much industry insists that they are.

Physicians who speak on behalf of industry are both targets of companies' advertising efforts and a key part of those companies' advertising campaigns.  Continuing this activity is questionable at best.  For our physician educators, who influence other physicians and who teach and mentor future physicians, this is unacceptable.

Repealing the PPACA Could Harm Vulnerable Communities

I have already posted some observations that, in my opinion, the calls to repeal the Patient Protection and Affordable Care Act (PPACA) are politically motivated, and that the public does not agree with the call for wholesale repeal.  I thought it would be interesting to look at how the proposed repeal could impact vulnerable communities, as outlined in this article.

The article notes that African-Americans are more likely to live under the poverty line (26%) and are uninsured a higher rate than the overall U.S population (21%, as opposed to 14-15% overall).  Those calling for repealing the PPACA have not put forward any measures that would address this lack of access to health insurance, they have not proposed any process to address the lack of primary care physicians working in medically-underserved communities, and have no plan to promote preventive care--all of which are addressed in the PPACA.  In essence, the call for repealing the PPACA would entrench the status quo that already results in significant health care disparities in minority and poor communities.

As an aside, I think it is interesting that the call for repeal embodied in the Republican "Pledge to America" states it will ensure that insurance companies cannot refuse care to those with pre-existing conditions.  This is interesting because the Republicans oppose the main mechanism for reaching this goal (the individual mandate that everyone would need to purchase health insurance) and because this requirement would involved significant government regulation (something the Republicans claim to oppose).

As it stands, then, the Republicans aim to repeal the PPACA's reforms that actually protect patients and that could improve access to care for marginalized communities while having no mechanism in place to fix the problems that already exist--even as evidence increases that the public does not support the call for repeal. 

I think the Republican's insistence in pushing for this unpopular proposal for repeal will end up changing nothing and serving as nothing more than an opportunity for political grandstanding.  As a result, the House will waste time engaging in showmanship when they could be working to effect fixes in the bill that would strengthen it and that could address areas of concern.  In that case, we all lose.

AMA Guidelines on Physicians and Social Media

Just posted about the newly-released AMA guidelines addressing physician use of social media.  I'm not sure that these guidelines will help very much right now, but I hope they might lead to further discussion heading forward.

How Popular Is Repealing Health Care Reform?

Now that the fallout from this week's elections are evident, we are already hearing calls from the new Republican majority in the House that they will start actively pushing for repeal of the Patient Protection and Affordable Care Act (PPACA).  This made me wonder: how popular is the notion of repeal among the American public?

The Kaiser Family Foundation published a poll recently that seeks to answer that question.  My reading of the situation is that the polling is fairly hard to interpret, with somewhere between 26% and 51% reporting they would like to see the law repealed.  However, the highest %s that are in favor of repeal were reported when the only choice was repeal/don't repeal.  If the poll offered additional questions, including making small changes, or giving the law a chance to work and adjusting as things move forward, the % supporting straight-out repeal was much lower.

Finally, one poll asked respondents which of the reforms enacted by the PPACA they would like to see repealed.  When analyzed at this level of detail, more than 50% supported keeping 6 of the 8 reforms discussed.  Only 2/8 reforms had 50% in favor of repealing them: the individual mandate that everyone must purchase health insurance (51% favored repeal), and the new taxes and fees on "cadillac" (high cost) health insurance plans.  The reforms that more than 50% wanted to keep included allowing children stay on parents' plans up to age 26, eliminating lifetime benefit caps, making insurance available to people with major preexisting conditions, improving the Medicare part D drug benefit for seniors, and setting up health insurance exchanges to make health insurance available for those who cannot afford it now.

Sounds as though most Americans who disapprove of the PPACA overall still like many of its key reforms, and prefer that the law be adapted/modified, not repealed.  I hope the new Republican House majority is paying attention.

Busy Saving The World

(tongue firmly in cheek)

I realize that it has been some time since I posted to the blog.  Lots of reasons, lots of excuses (including my contributions at smhcop.wordpress.com), but a big reason has been my participation with Una Vida Sana! (UVS).  This project enrolls medical, pharmacy and nursing students to provide outreach screening services to the Hispanic community in Richmond.  The screening also involves medical interpreter students (to help interpret for the students and providers) and lay health workers (promotoras) from the CrossOver Ministry (who help with peer-to-peer health education for the community).  The UVS outreach includes measuring height and weight to calculate a body mass index (BMI; helps assess overweight/obesity), waist circumference, smoking status, blood pressure, blood sugar and cholesterol measurements.  This allows the team to assess patients' current health status and risk of future health concerns related to cardio-metabolic disease: high blood pressure, high cholesterol, diabetes, etc.  The most recent screening event for UVS was as part of the City of Richmond's Imagine Festival, and took place last weekend (October 16, 2010).

In the last 10 years, Richmond's Hispanic community has nearly doubled, and my perception is that much of the increase is made up of young families that are establishing themselves in the community.  In many cases, the adults are young (20s and 30s) and currently in good health, but run a significant risk of health problems in the future and may not realize the importance and value of screening for asymptomatic medical conditions.  My fear is that these conditions could progress, and the incidence of asymptomatic disease could increase in the community until patients develop symptoms and start presenting to emergency departments and other safety net providers with symptoms or complications related to their illnesses. 

Our early events last Fall and Spring suggested that we were working with a community at risk of future illness but without true illness at this point.  The most recent UVS event supports this: a number had elevated blood pressures or elevated blood sugar, and a smaller number had a significant risk of heart disease in the near future.  Past events showed similar results: a lot of "soft" outcomes (elevated blood pressures or sugars, but no official diagnosis) but not a lot of established cardio-metabolic disease yet.

We plan to hold more events during this academic year: December is planned as the next screening this semester, and we expect to hold three or four other events during the Spring semester in order to more clearly determine the community's current health status.  My hope is that we might find that the community is at risk of serious illness but has not yet developed the illnesses themselves.  If that is the case, there might be an opportunity to work with the community's members to emphasize and effect lifestyle changes. 

At the same time, while providing these screening services to the community, our health professions students learn to provide team-based care while working across disciplines and with patients of different cultures.  We think this experience will allow to learn from each other, and might encourage them to consider careers working with under-served and multicultural communities in the future.

I doubt I'll be saving the world on my watch, though that's no reason not to try.  But maybe some of these students might...and our patients and our communities will benefit for their efforts.