The Doctor Is In

Most people don’t get excited to take a visit to the doctor’s office.  I, however, considered it quite the opportunity.  Since I am a full time student in the UK, I am “entitled to National Health Service treatment” and was curious to see how treatment would vary from what I had previously received back home in the States.  This is by no means an official comparison of the systems, but I thought it would be interesting to share my first impressions.

To register, I took a 10 minute walk to my “local surgery” (the neighborhood clinic) and filled out  10-15 minutes worth of paperwork: name, address, have I previously registered with the NHS, have I received treatment in other countries, etc.   I turned it in and was told that it would take 24 hours for the paperwork to be processed, a requirement for making an appointment.

I phoned ~25 hours after submitting my paperwork and was delighted to hear that I was in their system AND that I could have an appointment the following afternoon.

Receptionist: We have 14:10, 15:40, or 15:50 available.

Me: 15:40, please, that fits in perfectly after class.

Receptionist: Ok, you’re all set.

Me: Oh… ok. Thanks… Um, did you need my chief complaint?

Receptionist: No, you’re all set.

I arrived for my appointment ~15 minutes early and took a seat in the waiting room.  This feels like home. 🙂 Someone from the surgery would open the door to the visiting rooms every 5-7 minutes and call a patient back. Almost exactly at 15:40, a young man (couldn’t have been more than 3-4 years old than me) in a button down shirt, dress trousers, and of course London approved supah-nice dress shoes opened the door and called my name.  Hyperaware of my polka dot wellies, I picked up my purse, walked over to him, and was directed toward the first room on the right.

Let’s pause for a second– a pretty good reenactment of my mild deer in headlights response.  This room to which I was being ushered appeared to be an office: large L-shaped desk with a supah-fancy office chair on the far side of the desk and a no-frills standard chair closer to us.  “Hello I’m Dr X,” he said as he pulled out the standard chair, offering me a seat.  I obliged. He walked around the desk, took a seat in the supah-fancy chair, and asked with a warm smile:

“How can I help you?”

Umm. This felt like an odd encounter with the Customer Service department. When I successfully pushed those associations out of my mind, flashbacks of uncomfortable interviews rushed in:  So, tell us about yourself, Andrea. What do you know already?  Do you want to know where I’m from?  About my family and childhood? The things that shaped me into who I am today?  My hobbies and interests?  My experience that may be beneficial for this position?  The reason I chose to apply?…

As a new patient, I was anticipating that there would be a medical history or basic physical exam incorporated into the visit, but perhaps he had read through my registration paperwork?? Dubious.  A significant portion of that registration medical history focused on which, if any, family members had been diagnosed and treated for high blood pressure, diabetes, or other high profile illnesses.

Umm.

I’m not sure what I had expected to happen in those few seconds of mind-overdrive, but when I finished my internal commentary, I was still uncertain how to answer the question. And he was still looking at me with a smile awaiting my answer.

“My lower back…” I offered cautiously, making sure I had started along the correct route before it was too late to turn back.  He nodded reassuringly, so I continued. After 3 minutes, I was given reassurance that I was taking care of myself in a reasonable manner.  He also provided me with a paper that had pictures of people demonstrating different back exercises (most of which I had already been doing) and gave me an opportunity to request a prescription.

me: For which medication?

GP: A pain medication.

me: Right. Which medication?

GP: A non-steroidal anti-inflammatory prescription drug.

me: I see…  (Unsure if he had intended for his answer to sound condescending, I opted out of describing ibuprofen as a non-steroidal anti-inflammatory over the counter drug.) And do you think I will respond any differently to it than I have been responding to ibuprofen?

GP: No, you’ll probably respond in the same way. You’ll just be able to purchase more than 32 X 200mg pills at a time.*, **

me: Ahh. I see. Well, then no thank you. I think I’ll stick with ibuprofen.

 

6 minutes after I entered the room, he bid me adieu.  Rx: continue self care, but complain more loudly to the facilities management about a better mattress (Student accommodations can be a bit dodgy sometimes.)

 

me: Oh, do I need to check out with reception?

GP: No, no. You’re all set.

me: Ok, well… (I guess that makes sense if there isn’t a chart or copay!) Thank you.

GP: You’re welcome.

 

*This was in reference to an exchange we had shared a minute earlier. Fun fact: in the UK, the max recommended daily dosage for ibuprofen is 1200mg as opposed to 2400mg in the US. You are also limited to buying 2 blister packs (where each pill is stored in it’s own individual foil compartment) with 16 pills X 200mg.  I’m no ibuprofen addict, but I wanted to buy a pack to keep in my purse, backpack, and desk… and was turned down.
**Although a prescription may have been more convenient, it certainly would have been more expensive.  Under the NHS, the flat rate would have been £8 compared with £0.32 per 16-pill OTC blister pack.

***

 Before any fights breakout, let me remind you that this is 1 anecdote.  Two points are required to make a line, and hundreds if not thousands of points are required to draw conclusions.

Rather than attempting to compare US vs UK health systems with very little data, I spent most of my reflection time this week thinking about the way this experience fits into what we have been discussing in my Foundations of Social Science, Health, and Medicine (FSSHM) class.

What is the significance of a the doctor-patient relationship? How is this relationship impacted by the length of the appointment? Or the arrangement of the clinical room? Or by (lack of) physical contact?  How is efficiency defined in medicine? By the number of people seen? Or the number people who receive care? How is care defined?…

I’m planning on shaping some of these questions into my FSSHM essay, so you will be hearing about this again.  In the mean time, I have two videos to recommend:

 

1. Wit

“A renowned professor is forced to reassess her life when she is diagnosed with terminal ovarian cancer” (IMDb).

My thoughts: A very moving story. Some aspects border on becoming a caricature, but as with any caricatures there is as aspect of truth to be seen.   I have experienced this type of “treatment” and I’m sure a number of you have as well.  It pains me to know that situations like this exist, but I find encouragement by interacting with physicians that actively fight this frightening stereotype.

Unique qualities: script features a lot of John Donne, 4th wall is broken (protagonist speaks directly to the viewer)

 

2. A Doctor’s Touch

“Modern medicine is in danger of losing a powerful, old-fashioned tool: human touch. Physician and writer Abraham Verghese describes our strange new world where patients are merely data points, and calls for a return to the traditional one-on-one physical exam” (TED).

My thoughts: An important video for any health care provider or patient.  Yes, that’s you.  If you’re short on time and have to choose one video, watch this (even at 1.5 speed if you have to!)

Many thanks to Dr Behrouzan (one of my FSSHM lecturers) and Zoe Walters (amazing friend and current pharmacy student) for recommending these to me!

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Sex Selection, Organ Allocation, and Other Controversial Topics

As promised, I now return to the continuing story of my curriculum.  I’m going to focus on Foundations of Bioethics and Society (FBS) this time, but you can get an idea of what I’ve been up to in my other course (Foundations of Social Science, Health, and Medicine) by looking at the featured picture above: that was my reading assignment for last week.  Needless to say, I’m getting acquainted with the libraries… 🙂

In Foundations of Bioethics and Society (FBS), we root ourselves in ethics (philosophy) and then apply those ethics to biomedical questions.  Next semester I will be taking an entire course on case studies, but for now we just receive taster themes to stay oriented.

We’ve quickly covered (or for those with a background in philosophy– reviewed) core theories such as Utilitarianism, Consequentialism, Cosmopolitanism, Kantianism, Andreaism… (Ah ah ah!  Testing you… 😉 )  For a new-kid like me, this reading was quite dense.

To help me understand, I picture these theories on a number line where you have the extreme cases (-1, +1) but you also have the indefinite amount of theories that fall somewhere in this spectrum (… -0.0009, -0.0008,… +0.0008, +0.0009…)

Take for example the following set: Moral Realism, Moral Relativism, and Value Pluralism: *

  • Moral Realsim — There are right things, and there are wrong things. This is a fact.  Always.  When we look at history and see that things are wrong that we used to think were right (eg: slavery) we identify this as moral progress; the core morals never changed, we just have a better understanding of them.
  • Moral Relativism  — Defining something as right or wrong depends on a lot of different factors (eg: the time period, location, the group that is being considered, etc.)  Moral progress doesn’t exist.  Just because I define something as right, you could define it as wrong and we could both still be correct.  Situation-based understanding is a must.
  • Value pluralism — Some things will always be right / wrong (like moral realism!), but some things depend on the time period, location, culture, etc. (like moral relativism!)  But how can this be so?!  You identify things as right or wrong by considering different values.  For example, the JUST response is X; the MERCIFUL response is Y.  In some situations justice is more important than mercy… in other situations it is the opposite.

In a classroom with students from around the world, with various educational backgrounds and extra-curricular life experiences, we are able to find people with home-bases set up throughout the entire spectrum.  While thrusting your hands up and shouting Tradition! seems quite enticing at times, it is not altogether beneficial in a classroom.  Instead, we take a lesson from Tevye and practice contemplating what it is like ‘On the other hand’.  This doesn’t mean we always change our minds– in fact, we often do not– but the idea, just as it was in engineering school, is that we will learn to think. 

So what are we thinking about?  The themes presented with lecture (and incorporated into our reading assignments and formal discussion sections) so far have been:

1. Sex selection

Is selecting the sex of your child ever ethically acceptable?  If yes, under what circumstances?

Important notes:

  • When discussing “sex selection” I am referring to pre-implantation embryo selection.  This Wikipedia article gives general info about the most common technique that I’ll discuss– in vitro fertilization / preimplantation genetic diagnosis, or IVF/PGD. Note, to accept embryo selection of any kind as being ethically sound practice, you also have to accept in vitro fertilization as being an ethically sound practice– an admittedly contested practice.
  • “In the UK, sex selection is only allowed to avoid having a child with a serious medical condition; it is illegal to carry out sex selection for social reasons (e.g. for family ‘balancing’)”  (cite: UK’s Human Fertilisation and Embryology Authority)
  • In the US, sex selection is allowed– not only for selecting against serious medical conditions, but also for family balancing.  However, “the Ethics Committee of ASRM ‘recognizes the serious ethical concerns’ that gender selection raises and ‘counsels against its widespread use'” (cite: American Society for Reproductive Medicine via HRC Fertility Clinic’s GenderBaby).
  • What is meant by so-called “family balancing”???  Good question.  “Family Balancing is the term for gender selection done for the purposes of achieving a more balanced representation of both genders in a family. For example, if a couple has a son and desires a daughter, or there is an otherwise unequal representation of both genders among current siblings, the couple would be appropriate candidates for Family Balancing at GIVF” (cite: Genetics and IVF Institute).

2. Shortage of organs donations

Is there an ethical market for human organs?  What are the ethical implications of an opt-out organ donation program?  Should people who have participated in activities that are detrimental for their health (eg: smokers) be removed from organ transplant wait lists?

Important notes:

  • Wales will be adopting an opt-out program beginning in December 2015.  Read more HERE.
  • Since there are a limited number of organs available, for every person A that receives a transplant X, person H (the next person in line that is a proper match for the available organ X) will go without.  In some cases, this means that person H will die waiting for the next good match.
  • The match system is especially a challenge for pediatric patients.  Take lung allocation as an example: as indicated in the figure below, pediatric candidates will only be at the top of the list for pediatric lung donations.  Makes sense right?  (The closer the match, the greater the probability there is for a successful implantation.)  Except when you consider that the number of pediatric lung donations is dwarfed by the adult lung donations.  Thus, being placed into the queue for pediatric lung donations is a lot like receiving a death sentence.   In 2013 (surrounding the case of Sarah Murnaghan) it became possible for pediatric candidates to formally appeal to be placed in the “adolescent” category, thus increasing their chance of receiving a much needed transplant.  You can read a brief background to this change in allocation HERE.

 

Pediatric Organ List

Figure from Organ Procurement and Transplantation Network (part of US Dept of Health & Human Services)

In case it isn’t obvious, I am quite interested in pediatric organ allocation and am considering making this the focus of my final paper for the FBS module.  Are these changes for the better? How receptive should governing bodies (eg: US Dept of Health & Human Services) be to personal pleas to change a patient’s order in the transplant queue?  Considering the influence that we have on governing bodies, what role should we play in participating in these types of personal pleas (eg: social media campaigns)?

Many thanks to all the people involved in organizing and participating in the Notre Dame Medical Ethics Conference (March 2014) where I was first introduced to some of these questions and concerns regarding pediatric organ allocation.

3. Disability and Enhancement

This is actually the name of a module that I will be taking next semester, but we’ve already started conversations on this topic through the Bioethics Film Screening Series that my program jointly hosts with the Department of Film Studies. (Read about this series HERE.)

Last Tuesday we viewed Mandy, a film made in 1952 about the challenges faced by a couple trying to provide the best care for their deaf daughter.  Since my senior design team worked on developing a hearing screening device, I was rather well versed on the topic of hearing loss.  Even still, I learned SO much from the diverse perspectives provided by my Bioethics peers as well as a professor of Film Studies.

Something that felt completely new for me was the question of selecting for deafness.  What?!  you may ask (as seems to be the only response I’ve received when introducing this topic to someone.)  Yes, you read that correctly: specifically selecting an embryo that has hearing loss coded in their genes.  This NY Times article gives a good introduction to this concept of selecting for disability.

From the Oxford English Dictionary

From the Oxford English Dictionary

My questions: In an age that hedges classifying individuals as “disabled”, how do we (and how ought we) understand normal health and the role that medical professionals have in providing healthcare?  If selecting for deafness is ethically sound, can we also support decisions to select for other conditions that are historically viewed as being on the negative end of the “spectrum” (eg: blindness, color-blindness, etc).  What about conditions like Trisomy 21 (Down’s Syndrome)?

This last question stemmed from a discussion I was sharing with a classmate as we discussed the ethics of testing a fetus (via amniocentesis) for Down’s Syndrome.  The rates of “elective pregnancy termination” after prenatal diagnosis with Trisomy 21 range from 50-90% depending on the country, year, etc that the study was conducted. Despite the eugenic-alarm that this type of statistic activates, my colleague defended the stance that access to this prenatal diagnosis should not be limited: information is a prerequisite for making well-informed decisions.  People with Down’s Syndrome are wonderful, loving people with dignity that must be respected AND (even though it is not well publicized in the media) there are families that specifically opt to adopt children with Down’s Syndrome.  (See the website for the National Down Syndrome Adoption Network for more information.)

 

Whew long post! And not many pictures!!

I think that should give everyone enough to chew on for the next few days.  I recognize that these are not easy or comfortable topics, but they are important. If there is something in here that gets you fired up– whether that be in the positive or negative sense– great.  Now do something with that fire!  At the very least, start educating yourself on what is out there by skimming through the links that I’ve included throughout this post.  (I tried my best to find credible sources that were still easy to digest even if Bioethics isn’t your main squeeze.) I know think-time is precious, but just try to ponder some of these ideas as you drive to work, prepare lunch, or brush your teeth before bed.  Though the world of bioethics does not always feature rainbows and kittens, for an engaged citizen to plead apathy toward such topics is at best irresponsible.

ASB

* I had some familiarity with these specific theories before beginning my program but for all intensive purposes, I’m the new kid on the block when it comes to philosophy.  For those of you that are also new to this, I will do my best to distill this down to bite-size chunks. Keep in mind that I am just beginning to study this AND any time you “distill” you eliminate nuances.  If you are interested in learning more, a great online resource is the Stanford Encyclopedia for Philosophy; it’s kind of like the Wikipedia for all things philosophy.

Game time

Classes began this week!   To keep you oriented on what I’ll be doing this year, here are some quick facts.

  • Program: MA Bioethics and Society
  • Department: Social Sciences, Health, and Medicine
  • Students: 20 in total– 10 UK / 10 international, 15 full time / 5 part time. Backgrounds include philosophy, sociology, anthropology, biomedical sciences, medicine, theology… and of course engineering 😉  Bios are slowing being added to our program website. Feel free to check it out!
  • Credits: 180 UK credits– 60 credits in both the fall & winter semesters and 60 credits for writing a dissertation in the summer. Just as £1 ≠ $1, 1 UK credit ≠ 1 US credit. From what I’m told, UK credits indicate the number of direct teaching / contact hours in the semester. Then, multiply it by 10 to indicate the amount of time that is required for that course over the whole semester. So a 30 credit course requires 300 hours of work over the semester. At 60 credits and 11 weeks of teaching (a normal course load for UK students) that’s 55 hours a week.  Seems a bit dubious if they also believe in a 35 hour work week…  I’ll try to keep you posted with a more accurate account.
  • Course titles for this semester: Foundations in Bioethics & Society (FBS), Foundations in Social Science, Health & Medicine (FSSHM)
  • Weekly academic schedule: class 2 times a week for 6 hours (split between lecture & discussion), 1 hour of additional discussion, 1 or 2 seminars / film screenings, lots and lots of reading 🙂
  • Evaluation: Required (but not graded) “formative” midterm essay. Required and graded “summative” essay. “Written final” the first week of January where we will write 3 “mini essays” in 3 hours for each course.  This means that my grades will be 50% summative essay, 50% written final. Certainly different from having engineering problem sets, lab reports, and exams!

 

Foundations of Bioethics & Society  – Week 1: The Origins & Evolution of Bioethics

From the Oxford English Dictionary

From the Oxford English Dictionary

Our readings & discussion for the first week centered around tracing the origin as well as looking to the future of the term bioethics:  Why was this specific term used? What did it mean in the various cases?  What cases have been instrumental in shaping our understanding of bioethics?  What is unique about a program that invites philosophers, sociologists, theologians, and scientists (and an engineer!) into the same discussion?  Why is this diversity so valuable?

Interestingly enough, one of the two main “origin theories” is not published in the Oxford English Dictionary: the establishment of the Joseph and Rose Kennedy Institute for Bioethics at Georgetown University in 1971.

 

Here is a sampling of some of the (publicly accessible) topics from this week:

  • Nuremberg Code — developed after WW2 in response to the Nazi medical experiments.  Somewhat surprisingly, this didn’t have that much effect on the development of the bioethics in the United States. Medical professionals didn’t think that it was very relevant to their work because the crimes committed by the Nazis were clearly barbaric (not in the grey area).
  • Tuskegee Syphilis Experiment — and yet, here’s an example of history being doomed to repeat itself.  If you are unfamiliar with the 1932-72 case (as I was!) here is a brief synopsis. The Belmont Report  was developed in response to this case in 1978 and a formal Apology to Survivors was issued in 1995.
  • Guatemala Syphilis Experiment — repeating history again, and again… Here is another brief synopsis from the 1946-48 research as well as the full government review published in 2011.

I haven’t yet had my FSSHM lecture this week, but I’ll report back when I do.

Cheers,

Andrea