I ran 6.3 miles yesterday and 6.5 miles today. Yesterday my pace was 8:05, today my pace was around 8:55, my quads a bit tired but other then that felt pretty darn good.
I think I'm at the point where my base is strong enough that I actually enjoy running more than 3 miles at one time. The onset of spring in San Francisco has really helped with my enthusiasm and motivation, the GG park is so fun to run through, so many people, so many flowers, birds, and other spring-like features!
Since Jan 1st I've now run 212.1 miles over the course of 2 days and 16 hours.
Monday, April 7, 2008
Friday, April 4, 2008
Insurance coverage for medical procedures
I have some questions about insurance coverage that I thought I'd throw into the blogosphere.
Who determines whether a certain medical procedure that reduces risk will be covered financially by the insurance company?
My question comes from issues surrounding prophylactic mastectomies (removing a breast even though it does not have cancer). Given the improvements in cosmetic outcomes of breast reconstrcution, many more women who have breast cancer in one breast are interested in having the opposite breast removed as well. In general, there is about a 10% chance of developing breast cancer in the opposite breast when you are diagnosed with breast cancer. Is this procedure paid for under this particular situation?
Another example: a 30 year old woman with a family history of breast cancer, her mother had it, her older sister had it, has recently tested positive for the BRCA1 gene, meaning that she has about an 85% chance of developing breast cancer in her life time. This woman wants bilateral prophylactic mastectomies. Will this be covered by insurance?
The core of my uncertainty with these two situations is that in neither case does the medical procedure "treat" a disease, it only reduces risk. My question is, at what risk reduction is this procedure considered appropriate? What if the risk of developing breast cancer is 5%? 15? 50? 90? And who has the authority to deem the "medical appropriateness" of this procedure? Let's say that one doctor deems that a particular woman has a 20% risk of breast cancer and this risk warrants a prophylactic mastectomy. What about financial coverage of this procedure? Will insurance companies listen to this physician's logic? Do insurance companies have their own formulas for what risks they are willing to take on (ie deny coverage) compared to what is "too risky" (ie they will pay to reduce the risk)?
In terms of what I think, I think that if a doctor has evidence in the medical literature to reduce risk by doing the procedure, and if the patient is highly risk averse, then the procedure should be covered--assuming that the risks of the procedure are minor compared to the risk potentially reduced.
This is also a situation where the grayness between evidence-based medicine and consumer-based medicine come into play. Let's say the doctor does not feel that the procedure would be a good decision, but the patient really wants the surgery. She doesn't care if the medical literature states that the mastectomy would minimally reduce her risk. Psychologically, she "wants the breast off", "doesn't want to lay awake in bed every night worry about it" etc. What's the role of the physician in this situation? To be consumer-based, to do the surgery because of the patient's desire. Or to be evidence-based and not perform the procedure? How does costs play into this decision? What would most doctors do in this situation? What ought doctors do? What would insurance companies do in this situation What ought insurance companies do?
Who determines whether a certain medical procedure that reduces risk will be covered financially by the insurance company?
My question comes from issues surrounding prophylactic mastectomies (removing a breast even though it does not have cancer). Given the improvements in cosmetic outcomes of breast reconstrcution, many more women who have breast cancer in one breast are interested in having the opposite breast removed as well. In general, there is about a 10% chance of developing breast cancer in the opposite breast when you are diagnosed with breast cancer. Is this procedure paid for under this particular situation?
Another example: a 30 year old woman with a family history of breast cancer, her mother had it, her older sister had it, has recently tested positive for the BRCA1 gene, meaning that she has about an 85% chance of developing breast cancer in her life time. This woman wants bilateral prophylactic mastectomies. Will this be covered by insurance?
The core of my uncertainty with these two situations is that in neither case does the medical procedure "treat" a disease, it only reduces risk. My question is, at what risk reduction is this procedure considered appropriate? What if the risk of developing breast cancer is 5%? 15? 50? 90? And who has the authority to deem the "medical appropriateness" of this procedure? Let's say that one doctor deems that a particular woman has a 20% risk of breast cancer and this risk warrants a prophylactic mastectomy. What about financial coverage of this procedure? Will insurance companies listen to this physician's logic? Do insurance companies have their own formulas for what risks they are willing to take on (ie deny coverage) compared to what is "too risky" (ie they will pay to reduce the risk)?
In terms of what I think, I think that if a doctor has evidence in the medical literature to reduce risk by doing the procedure, and if the patient is highly risk averse, then the procedure should be covered--assuming that the risks of the procedure are minor compared to the risk potentially reduced.
This is also a situation where the grayness between evidence-based medicine and consumer-based medicine come into play. Let's say the doctor does not feel that the procedure would be a good decision, but the patient really wants the surgery. She doesn't care if the medical literature states that the mastectomy would minimally reduce her risk. Psychologically, she "wants the breast off", "doesn't want to lay awake in bed every night worry about it" etc. What's the role of the physician in this situation? To be consumer-based, to do the surgery because of the patient's desire. Or to be evidence-based and not perform the procedure? How does costs play into this decision? What would most doctors do in this situation? What ought doctors do? What would insurance companies do in this situation What ought insurance companies do?
Thursday, April 3, 2008
A life worth living
This may be my most revealing post yet...
I've been trying to write my personal statement for medical school (going nowhere by the way), and I've been thinking deeply about what draws me to the medical profession. Here are some of my thoughts.
To me, the essence of medicine is to help a person live a life worth living. In a perfect world, we would not need physicians. We would not have sickness or disease. Each of us would be able to pursue our dreams and passions with full vigor. This is not the case. There is disease, there is cancer, there are eating disorders, diabetes, alzheimers. To me, the role of a physician is to do the best she can to help a person through a vulnerable time, help them navigate our health care system to obtain the highest and most comprehensive care possible. To help that person get back to their lives, contribute to their family, community, and society. The work of a physician is at the level of individual person, and a physician is morally bound to be fair, to be honest, to be thorough in her treatment of each individual she sees. I am drawn to this duty of a physician, to help each person I care for live a life most worthwhile for them, to treat all of the people I see with dignity and respect. This ground-level work of a physician is appealing to me at my most basic level, as a person of compassion, as a member of society myself, to help those around me when they are often left vulnerable.
A second aspect of medicine that appeals to my character is the need for strong leadership in the profession. The issues of medicine that interest me, continuity of care, disparities in care, costs of care, patient-centric care; are difficult problems facing the medical community, and it is my goal to pursue these problems as a physician. To me, leadership involves an ability to listen, a vision, and most importantly a strong inner moral compass. I think one of my most unique qualities is that I am willing to take on the responsibility of being a leader, and with that responsibility I have a very big respect for the power that comes with it. The idea of being in charge of a clinic, helping to improve all aspects of its systems, helping empower other health care providers, and most importantly, helping to empower and enable those who need our care, is exciting and invigorating to me...
to be continued.
I've been trying to write my personal statement for medical school (going nowhere by the way), and I've been thinking deeply about what draws me to the medical profession. Here are some of my thoughts.
To me, the essence of medicine is to help a person live a life worth living. In a perfect world, we would not need physicians. We would not have sickness or disease. Each of us would be able to pursue our dreams and passions with full vigor. This is not the case. There is disease, there is cancer, there are eating disorders, diabetes, alzheimers. To me, the role of a physician is to do the best she can to help a person through a vulnerable time, help them navigate our health care system to obtain the highest and most comprehensive care possible. To help that person get back to their lives, contribute to their family, community, and society. The work of a physician is at the level of individual person, and a physician is morally bound to be fair, to be honest, to be thorough in her treatment of each individual she sees. I am drawn to this duty of a physician, to help each person I care for live a life most worthwhile for them, to treat all of the people I see with dignity and respect. This ground-level work of a physician is appealing to me at my most basic level, as a person of compassion, as a member of society myself, to help those around me when they are often left vulnerable.
A second aspect of medicine that appeals to my character is the need for strong leadership in the profession. The issues of medicine that interest me, continuity of care, disparities in care, costs of care, patient-centric care; are difficult problems facing the medical community, and it is my goal to pursue these problems as a physician. To me, leadership involves an ability to listen, a vision, and most importantly a strong inner moral compass. I think one of my most unique qualities is that I am willing to take on the responsibility of being a leader, and with that responsibility I have a very big respect for the power that comes with it. The idea of being in charge of a clinic, helping to improve all aspects of its systems, helping empower other health care providers, and most importantly, helping to empower and enable those who need our care, is exciting and invigorating to me...
to be continued.
Risks
Every day we take risks, we drive, we invest in the stock market, we apply for jobs, risky business life is eh?
The vernacular of medical oncology is risk. Local radiation is a treatment to reduce the risk of recurrence of the cancer in the breast Chemotherapy helps to reduce the risk of recurrence of cancer in other parts of the body, it also helps to improve 10 year survival rates. Hormonal therapy reduces risks in similar fashion if the tumor feeds off female hormones.
We know about the benefits of these therapies thanks to clinical trials that have randomized, quantified, stratified up the yinyang.
I think one of the hardest tasks of an oncologist is communicating the risk reduction of treatment to a patient. It's essential that the woman with breast cancer understands her options and understands the benefits of such options, but when the data is so complex, when the benefits are blurred, effectively communicating the concept of risk is crucial to ensure shared decision-making.
So far I've only discussed the risks reduced by treatments for breast cancer. To make things more tangled for treating breast cancer, there are also risks associated with the very same treatments that help fight the tumor. Radiating vital organs, Heart failure caused by adriamycin, uterine cancer from tamoxifen, you have the potential of getting ANOTHER cancer from an anti-cancer treatment. How dumbfounding! So here comes the second layer of risks and benefits for treating cancer. The oncologist and the patient have to weigh the benefits of treatment with the additional risks taken on due to such treatment. Here's a question, if someone told you that you could take a drug for 6 months, lose your hair, feel sick all the time, lose feeling in your fingers, have no energy, and this drug would improve reduce your risk of recurrence of cancer by 10%. But, this same drug comes with a risk of heart failure, say 4%. Getting complicated yet?
The tertiary level of complication is the basis of all of these numbers, where did all these numbers come from anyways? We know the answer: clinical trials. But the deeper questions are, what types of patients were on the trials? Were they your age? Were they your ethnicity? Were their tumors similiar to your tumors? Where they node-positive patients? Node-negative patients? How far along did they start the treatment? Did they take anything to prevent breast cancer in the first place? How successful was the local resection? What other treatments did they have? Talk about opening Pandora's Box...
Given this uncertainty, how are oncologists (or patients my gosh) supposed to make sense of all of this? That's my question, I still haven't figured out the answer. For oncologists, I know that years of training, of questioning and contributing to the medical literature, of immersing themselves in the controversies and successes of medical oncology, and treating a lot of patients can help. For patients, I think it comes down to the realization that at a certain point, you have to trust your physician's judgment, you have to believe in the efficacy of your treatment, and you have to have a lot of hope.
The vernacular of medical oncology is risk. Local radiation is a treatment to reduce the risk of recurrence of the cancer in the breast Chemotherapy helps to reduce the risk of recurrence of cancer in other parts of the body, it also helps to improve 10 year survival rates. Hormonal therapy reduces risks in similar fashion if the tumor feeds off female hormones.
We know about the benefits of these therapies thanks to clinical trials that have randomized, quantified, stratified up the yinyang.
I think one of the hardest tasks of an oncologist is communicating the risk reduction of treatment to a patient. It's essential that the woman with breast cancer understands her options and understands the benefits of such options, but when the data is so complex, when the benefits are blurred, effectively communicating the concept of risk is crucial to ensure shared decision-making.
So far I've only discussed the risks reduced by treatments for breast cancer. To make things more tangled for treating breast cancer, there are also risks associated with the very same treatments that help fight the tumor. Radiating vital organs, Heart failure caused by adriamycin, uterine cancer from tamoxifen, you have the potential of getting ANOTHER cancer from an anti-cancer treatment. How dumbfounding! So here comes the second layer of risks and benefits for treating cancer. The oncologist and the patient have to weigh the benefits of treatment with the additional risks taken on due to such treatment. Here's a question, if someone told you that you could take a drug for 6 months, lose your hair, feel sick all the time, lose feeling in your fingers, have no energy, and this drug would improve reduce your risk of recurrence of cancer by 10%. But, this same drug comes with a risk of heart failure, say 4%. Getting complicated yet?
The tertiary level of complication is the basis of all of these numbers, where did all these numbers come from anyways? We know the answer: clinical trials. But the deeper questions are, what types of patients were on the trials? Were they your age? Were they your ethnicity? Were their tumors similiar to your tumors? Where they node-positive patients? Node-negative patients? How far along did they start the treatment? Did they take anything to prevent breast cancer in the first place? How successful was the local resection? What other treatments did they have? Talk about opening Pandora's Box...
Given this uncertainty, how are oncologists (or patients my gosh) supposed to make sense of all of this? That's my question, I still haven't figured out the answer. For oncologists, I know that years of training, of questioning and contributing to the medical literature, of immersing themselves in the controversies and successes of medical oncology, and treating a lot of patients can help. For patients, I think it comes down to the realization that at a certain point, you have to trust your physician's judgment, you have to believe in the efficacy of your treatment, and you have to have a lot of hope.
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