Below, a guest post by Pat S. . I would add only that I share his faith that the system will change because the current paradigm is  both untenable and unaffordable. Some older doctors will resist change, but I believe that many, who have been increasingly frustrated for the past twenty to twenty-five years, will welcome it.  One paper distributed at the Mayo Clinic conference reminded everyone that when a doctor takes an oath to practice medicine, he is implicitly committing himself to “continuous improvement.”   MM

The World Turns

“What you have outlined is the usual situation when orthodoxy is replaced. Many old ideas have been difficult to discredit over the course of medical history.” – HealthBeat reader Christopher George

Back in the 60’s, Thomas Kuhn published his famous work, The Structure of Scientific Revolutions.  One of his basic models is that existing paradigms for scientific systems persist until it becomes impossible for them to continue to function because of their failure to account satisfactorily for real world data and until their explanations of that data become too complicated and cumbersome to be acceptable.  At that point the environment is conducive to replacing the old system with a new model.

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Below, a guest post from HealthBeat reader and blogger, Dr. Chris Johnson. Formerly the head of the pediatric intensive care unit at the Mayo Clinic, Johnson is the author of Your Critically Ill Child and blogs at www.chrisjohnsonmd.com.

When you read his post, it is worth remembering that a larger share of U.S. children live in poverty than in any other nation in the developed world.

We have known for a long time that  poverty is associated with illness. Tiny Tim did not die at the end of Dickens’ Christmas Carol. The reason he lived was because, just in time, Scrooge had an epiphany and raised the Cratchit family’s standard of living. That Christmas goose brought more than good cheer to the Cratchits — it brought good health, too. Some historical studies, such as those of Thomas McKeown,   have linked the long population rise of the past century to improved nutrition. Experts still debate if this is true or not, but either way it is old news.

It may be old news, but for today’s Tiny Tims it is still very much current news. The furious debates over what to do about health care reform are often about choice — what choices Americans should have selecting their health care, what choices doctors should have in providing it, and what choices society has in paying for it. I take care of children, so that is the lens through which I see the issue. And children have no choice at all in this matter, because the family they are randomly born into determines everything, even if they will live or die. Across America we have constructed what are, in effect, a series of laboratories to test the results of what happens when different sorts of children get severely ill. These laboratories are pediatric intensive care units.

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While in medical school, students are supposed to know the answers. They spend hours cramming, memorizing arcane language and hard-to-remember numbers so that if the question appears on a test—or worse still,  if a resident decides to quiz them during rounds—they can answer it.

“I don’t know, but I know where to look it up,” is not an acceptable response.

“Looking up the answer is considered cheating,”  Dr. Denis Cortese, president and CEO of the Mayo Clinic pointed out on the opening day of Mayo’ s National Symposium on Medical and Health Care Education Reform.

Yet, Cortese observed, once the student becomes a doctor, he is supposed to “cheat”—i.e.  look things up. He is not supposed to “take a stab” at the right dosage the way he might take a stab at the right answer on an exam. His patient’s well-being depends upon him knowing where and how to look up the information he needs, or whom to consult.  A doctor who is reluctant to admit “I don’t know” is a dangerous doctor.

Today, we recognize that medicine is a team sport. No one doctor can know everything that he needs to know, even in his own specialty.

Yet, we continue to train would-be doctors as if they were going to be practicing medicine circa 1950, when “The Doctor” was supposed to have all of the answers. 

The Symposium acknowledged that today, we are educating medical students the way we always have—preparing them to work in the old, broken system that we are trying to reform.  Just as the system requires change, so does medical education.                

For instance, the symposiums’ participants recommended that “Exams should test information use and information gathering rather than memorized knowledge.”  Moreover, rather than spending all of their time in classrooms and hospital wards, students should spend more time learning to practice medicine in real-life settings.  Voting on the best solutions to improve medical care, the majority of the audience agreed that “to understand patients, students should interface with the patients in their communities, experiencing medical care through their patients’ eyes and experiences.”  

Finally, we need to change the way we choose students for admission to medical school. One speaker made a persuasive argument that today, we rely too heavily on grade point averages (GPAs) and medical college admission tests (MCATs). We need to draw medical students from a larger pool.    

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Below, a guest post by Jim Jaffe, health editor at Centered Politics.com

Obama’s health care plan, in particular, is focused on figuring out which services and products are effective for particular patients. Insofar as it “rations” care, it strives to limit the amount of ineffective care that patients receive, knowing that, by definition, ineffective care exposes patients to risk without benefit . 

Feared Health Rationing Is Already Here

We’ve barely started to discuss the specifics of health insurance reform and already confront a debate among the deaf.  Consider the concerns of the Washington Times, which opines:

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Rahm Emanuel has warned that when gauging President Obama “Republicans and others have made a mistake: He has an open hand, but it's a very firm handshake."

I don’t usually think of Rahm Emanuel as a phrase-maker , but in this case, he has hit upon a superb metaphor for the president’s willingness to reach out to his opponents, and invite them into an honest  bipartisan dialogue– while making it clear that he is not willing to compromise his bedrock values.

The president displayed his inner steel last Thursday when he told Republicans that he will not let them use a filibuster to veto his health care proposal. The threat of a filibuster had hung over the administration’s health care initiative until last week, when President Obama persuaded Senate Democrats to follow the House and include “reconciliation protection” for health care in the budget bill.  This means that Republicans cannot  block reform by reading the phone book—and Democrats need only a simple majority (50 votes ) to pass health care reform in the Senate.

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Earlier this month the House passed a landmark bill allowing the Food and Drug Administration to regulate tobacco products, granting the agency broad authority in controlling the manufacture, marketing and sale of cigarettes and other tobacco-based goods. This legislation, called the Family Smoking Prevention and Tobacco Control Act (H.R. 1256) , is now awaiting a vote in the Senate where it is expected to be approved “expeditiously” according to Senator Edward Kennedy, one of the bill’s sponsors.  Senator Harry Reid, the majority leader, recently told Congressional Quarterly that he thought the bill will be taken up before the current session ends at the end of May.

A year ago, with the Bush Administration opposing similar legislation, sponsors of the Senate bill worried that they would not be able to muster the 60 votes needed to override the expected Presidential veto and never voted on the measure. This year, with a strengthened Senate Democratic majority and implicit support from President Obama and Kathleen Sebelius, his Health and Human Services secretary-designate, there appears to be much more optimism that the bill will pass with the two-thirds majority needed to overcome a possible filibuster from Senator Richard M. Burr, Republican of North Carolina, the nation’s leading tobacco producing state, and home to R.J. Reynolds.

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Below, a post from Media Matters

Reporting that “President Obama went golfing and the Department of Health and Human Services is short a secretary, so other U.S. officials took the controls” dealing with the swine flu, FoxNews.com omitted Senate Republicans’ role in delaying Kathleen Sebelius’ nomination as HHS secretary.

In an April 26 article on the government response to the swine flu, FoxNews.com omitted the fact that Senate Republicans have delayed a vote on the nomination of Kansas Gov. Kathleen Sebelius as secretary of Health and Human Services and misrepresented an exchange during an April 26 White House press briefing to suggest the administration may have held the briefing to distract from President Obama’s golfing that day.

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Tuesday, the Senate Finance Committee hosted the first of three roundtable discussions on health care reform. This session honed in on reimbursement and delivery reform; future roundtables will focus on expanding health coverage  to all Americans  (May 5) and financing health care reform. (May 14).  (Many thanks to reader Brad F. for calling my attention to a report on the roundtable.)

“Medicare is the big driver here,” declared Finance Chair Max Baucus (D-MT), and “How to scale it up” will be one of the key questions, he said, but “Medicare will be a big part of that solution.”

As I have suggested in the past, Medicare is likely to become the place where policymakers can experiment with wringing some of the waste out of our health care system, so that we can provide affordable, sustainable, highly effective care for everyone. In fact, Medicare already has embarked on pilot projects that provide incentives for health care providers to collaborate and become more efficient. The projects that work are likely to be expanded and become part of national health care; those that don’t work can be quickly discarded. During the roundtable discussion, many suggested that Medicare needs more freedom to innovate, additional funds, and a mandate to launch  more pilot projects.  Ultimately, a new, improved Medicare could become a model for a public insurance option. National health care reform does not have to wait on Medicare reform; I suspect that policy-makers will be working on both, simultaneously, over the course of President Obama’s first term.

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Below, a post by Naomi Freundlich, who has joined The Century Foundation.  Welcome Naomi! — MM

I still remember the sound of her voice on the phone: scared, frustrated and looking for answers. That summer I was working as a patient representative at a New York City hospital when I got a call from a middle-aged woman who had undergone a routine mammogram two weeks earlier. She still hadn’t received the results. When the woman called the imaging center, she was told that the radiologist had not yet provided his report because he wanted to see films from her last mammogram in order to make a comparison. This simple request created great anxiety for my client:

Why was it taking so long to get results? Had the radiologist seen something suspicious? Was this a sign that something was really wrong? The woman then told me that several years before, a doctor had seen an anomaly on her mammogram and that had led to more invasive testing, including further imaging and a surgical biopsy. The lesion ultimately turned out to be benign, but the experience had been extremely stressful and made her yearly mammograms a dreaded procedure.

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