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Moral courage - Health Care Rx Panelists

Moral courage

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When I was in ninth grade, I returned home after a particularly inspiring world history class and announced to my mother that I wanted to be Secretary of State when I grew up. Far from being excited, she was worried. Politics, in her mind, was a corrupting profession that was more about self interest than service.

It's no secret that many people in the United States share her view. They have watched in frustration as the promises of politicians have faded into the status quo. They've watched with resignation as moneyed interests have rendered their opinions inconsequential.

For most of the year, the health-care debate did not inspire many to feel differently about politicians or the political process. But in the closing days, a different strain of passion emerged in the debate, most clearly from the President himself. It was the moral argument for health reform.

The moral argument for health reform is not new; people have been voicing it for decades. But in the back and forth of the last year, it has been buried under stories about sparring politicians, raucous town halls, and clashing protesters. Stories of people who suffered in silence with preventable illness are difficult to hear, and they don't sell many papers. But these stories are important to tell because they inform our motivations for taking action.

The health-care bill that has now made it through Congress is far from perfect. Personally, I would have liked to have seen a public option included and a national exchange to provide more choice and competition in the insurance market. But the legislation that was passed takes powerful steps forward. It increases coverage to 31 million more Americans, it regulates insurance companies and prohibits discrimination based on pre-existing conditions, it lays the ground work for doctors to deliver higher quality care to patients, and it takes major steps control cost. In these four areas, it does more than any piece of legislation in over half a century.

In a nation where over 40,000 Americans die each year because they have no health insurance, how could we have justified waiting to pass legislation that we know can save lives? In a country that values hard work and self reliance, how could we not have acted when Americans who have done everything right still have their insurance revoked when they get sick?

What we do when faced with such questions says something about who we are as a people. When we responded to the Pearl Harbor attacks and rose to Europe's defense in World War II, we didn't base our decision on the price tag. Our national conscience told us what was right, and we found a way to make it work. When disaster struck Haiti, we didn't base our decision to help on political risks and benefits. Gathering food, clothing, money, and rescue workers, we rose to meet the needs of our brothers and sisters overseas because we knew it was the right thing to do. It was a moment that should have made all Americans proud.

Choosing to pass a comprehensive health reform bill this week, contentious and complex as it was, was another defining moment for our country. We defined ourselves as a nation with rich ideas and a great deal of passion. We reminded ourselves that we are not just a collection of individuals but also a community that looks out for each other.

Most importantly, we defined ourselves as a people with moral courage who are able and willing to make extraordinarily tough decisions for the greater good of the nation. In the process, we also helped restore a sense of faith in everyday Americans like my mother that our flawed political system can still effect positive change.

"It is not the critic who counts, not the man who points out how the strong man stumbled, or where the doer of deeds could have done better. The credit belongs to the man who is actually in the arena, whose face is marred by dust and sweat and blood, who strives valiantly, who errs and comes short again and again, who knows the great enthusiasms, the great devotions, and spends himself in a worthy cause, who at best knows achievement and who at the worst if he fails at least fails while daring greatly so that his place shall never be with those cold and timid souls who know neither victory nor defeat."
- Theodore Roosevelt from a speech given at the Sorbonne in 1910

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A good point, well made, Dr. Murthy! Some commitments we make as a society are driven by factors that supersede price and politics.

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Freedom of choice, except for women - Health Care Rx Panelists

Freedom of choice, except for women

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Opponents of the various Democratic health-reform proposals spend a lot of time talking about how people should be free to purchase whatever kind of insurance they want. Except, it turns out, if those people are women.

Going into Saturday's debate on the House health-care bill, the measure included provisions designed to maintain the status quo against federal funding for most abortions. It took steps to ensure that federal subsidies to purchase insurance wouldn't be used to pay for abortion coverage. It required that every exchange include one plan that did not cover abortions, so that no one would be forced to subscribe to a plan that violated anti-abortion beliefs. That wasn't enough for the anti-abortion crowd, including the Catholic bishops. So House Speaker Nancy Pelosi (D-Calif.) was backed into a corner, facing the loss of anti-abortion Democrats unless she acceded to an amendment offered by Rep. Bart Stupak (D-Mich.) that effectively prevents insurance companies participating in the new insurance exchanges from covering abortions. It passed, 240 to 197, with 64 Democrats voting in favor.

Under the Stupak amendment, no plan that accepts people eligible for federal subsidies is permitted to cover abortions. It's hard to imagine a plan participating in the exchange that refuses to accept people with subsidies, since the vast majority of people in the exchanges will receive subsidies. Therefore, no abortion coverage in the exchange -- except to save the life of the mother or in cases of rape or incest. If you are a woman whose health is endangered by a pregnancy, you'll have to pay for an abortion out of pocket. Same if you are carrying a fetus with severe birth defects.

Stupak supporters argue that women will still be able to obtain abortion coverage by purchasing a separate rider to the policies. As if people plan ahead to have abortions. As if insurance companies will go to the trouble -- and risk the controversy -- of providing such riders.

It wasn't worth torpedoing health reform over this issue, so I understand Pelosi's choice. It's outrageous, though, that she had to make it.

Originally published on the opinion blog Post Partisan, updated daily at washingtonpost.com/postpartisan.

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Gee whiz, ya think mothers and fathers will have to take care of their children if they are not born perfect now ? I have an autistic grandson who is also mildly retarded. But he is so wonderful. Had he been aborted because of his disabilities, the world would have been a darker place. When did we earn the right to determine who gets to live or die, simply because they are not perfect.
I am so against this health bill for all sorts of reasons . However this is the one thing that actually makes me glad about it. I hold all life as precious. retarded, disabled, severe birth defects, whatever. They all deserve the right to a life that was given them by our Creator.

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Tax Insurers, Not Consumers - Health Care Rx Panelists

Tax Insurers, Not Consumers

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If the 35 percent tax is going to be passed on to consumers, I am definitely against that. However, it is clear that there are efficiencies built into other versions of health-care reform legislation with electronic medical records and meaningful use of health information technology. And it is clear that the ultimate benefit of electronic records will go mostly to the insurance companies; therefore, I think the tax on them is appropriate.

As a matter of fact, since the insurance companies will benefit the most with the added resources of health information technology, they should be paying largely for the set up, education and maintenance of electronic health records in physicians offices. That way, physicians can more efficiently provide services to the increased numbers of patients in the most need of medical help.

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@Frankn1:
You can only pass a tax on to consumers if the good is not price elastic. It isn't always true that companies pass their taxes on to consumers.

Since a large part of the reform effort entails increasing the healthcare price responsiveness of consumers, we have a strong reason to believe that reform, taken as a package, will not pass the costs onto consumers.

Doctor, Doctor, Doctor......With all your years of education I would have "ASSUMED" you had some decent intelligence. Yet, your comments seem to indicate that during all your years in school, economics was the one area of education you avoided.

Have you ever heard the concept that CORPORATION DO NOT PAY TAXES, PEOPLE DO!
You can tax any insurance company (corporation) the full amount of revenue they bring through the door before they even pay out one dime in expenses or claims. It would do no good whatsoever, since they would just raise the amounts they collect in premiums. You need to understand that any tax they pay just becomes an expense. Once you understand that you will become a little better informed when you sit with your accountant who does your taxes and maintains your financial books for you.

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A Growing Circle in the Pond of Medicine - Health Care Rx Panelists

A Growing Circle in the Pond of Medicine

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As a chronically ill patient and a former nurse of many years, I see malpractice as an ever-growing circle in the pond of medical care. The threat of lawsuit eats at the judgment of good, well-trained physicians.

Our wildly litigious society is ever ready to "collect." I've seen friends collect from stores when they trip over their own feet. The person or institution should pay the costs of injuries if they are truly at fault. Doctors are not the only ones who are liable -- we all are. We have to worry about cracks in the sidewalk in front of our house, don't we?

We have to educate the public to realize it is not their God-given right to collect for every incident in their lives. Why does blame always have to be placed? Many of our fellow citizens see all insurance companies, both medical and others, as banks to be visited when the opportunities arise: make a withdrawal.

Doctors are a much-needed part of our society but they are, after all, only well-trained, well-paid, very well educated technicians. They are also human beings who often work long hours, have bad days. Sometimes, they screw up. There's a big difference between a doctor who makes a medical mistake and one who is irresponsible and careless. All doctors, even the best ones, make mistakes. One of the best OB men I ever knew cut a baby's ear during a C-section. Errors occur. That's a far cry from the doctor who is poorly educated, drinks too much or callously schedules too many surgeries so he can take his vacation a day early.

Since most hospitals already have physicians and lawyers who watch and evaluate these problems, perhaps we could also use a special court that could make fair judgments. They could consist of doctors and attorneys. Their main purpose would be to find and uncover the truth. Insurance companies and attorneys have to stop encouraging the "give me" behavior of individuals who know the insurance company will settle rather than go to court.

The confidence and trust that should exist between a doctor and his or her patient is being eroded by this threat that hangs over the head of all physicians. Are caps the answer? Perhaps. An independent court could decide based on full medical knowledge. Certainly, there are cases in which the individual patient has been maimed or harmed and will need life-long care. There are others cases in which someone is being paid off for punitive damages alone. This is a much larger subject than simply embracing the medical community. It requires re-education of society to knock it off. What are the chances of that?

3 Comments

There is a big difference between an honest mistake and gross neglegence. Doctors who are negligent would like to tell you that everything is a simple mistake but sometimes they don't act professionally and in their patient's interest. The quality of care varies quite significantly. The job is not paid well only because it requires skill but also because it requires responcibility.

I agree there are many abuses of medical malpractice, but when malpractices are made legally difficult to persue, gross negligence will be easier to justify. There will be nothing to punish hospitals who cut essential services. As corporations they want to reduce costs, and their main costs are quality doctors and nurses. While most hospital doctors and nurses are still good many of them are overworked and exhausted. What do you think that does to their quality of care?

TonieB, So true. Life has changed in our country and we've embraced the open hand with the "give me" attitude instead of the helping hand and the "I can take care of myself" attitude. Many of us have had hard times, worked our way through school and known what it is to be in charge of our own lives. Taking money from someone else because they're insured or have more than we do is not the secret to success. Of course, when great injury is done and someone needs lifetime care that's a different matter entirely. Thanks again for sharing, Sue

I remember where I grew up in rural Va, there was an older couple who always had the best of everything. It was well known they had sued several people for car accidents and the first malpractice suit I ever heard of. You knew to stay clear of them and their property. "they'll sue you" No one wanted to be friends with them for fear of a fall or accident taking place at your home.

Now it has become a ritual of "get rich quick". I agree with you that where there is neglect or harm done, that is a different set of circumstances. We do need to reeducate the public to get away from the mentality that someone "owes" you something and that there is an easy way out of lifes' daily routine. Being responsible for ones own actions has become a thing of the past. The fault always lies at the other man's door.

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The Good Daughter Syndrome - Health Care Rx Panelists

The Good Daughter Syndrome

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This week's topic, how the proposed overhaul will impact senior citizens, is very dear to my heart. I am a family physician with substantial experience in geriatric medical practice; I have always tried to be an advocate for my elderly patients. I wish to focus my comments on the issue that seems to have hijacked the reform debate from the senior perspective: advanced directives and end-of-life care.

What I refer to as "Good Daughter Syndrome" is a scenario that I have seen play out innumerable times in my career, and it breaks my heart every time I see it. Too many elderly have little or no family support. But oftentimes, there is one attentive family member, most often the good daughter (or son, or niece -- you catch my drift) who has stayed close to Mom and has heard many times from her, "I don't want to die in pain / un-dignified / a burden." There may or may not be an advanced directive. Regardless, as the terminal stage clearly develops, the less-attentive family members seem to come out of the woodwork, their guilt at having ignored their loved one kicking in and now everybody adds their voice to the cacophonous din. The good daughter's voice is drowned out by a chorus of, "But you gotta keep Mom alive at all costs." Then, despite Mom's well-known prior wishes to the contrary, all the stops come out and two weeks of painful, expensive and ultimately futile hospital care ensues.

Let me be clear: I am no proponent of euthanasia, which I find to be morally repugnant. And that is not what the advanced directive provision in HR 3200 proposes. There is a huge difference between euthanasia and compassionate palliative care. At some point in every chronic, terminal condition, it becomes clear that effecting a cure is not possible. However, attempting to relieve pain and anxiety at the end of life is always possible. You have to know when to say when. Regardless of whether this activity is mandated by legislation, it is critical that we embrace the spirit of advanced directives and keep faith with our loved ones by supporting all the good daughters out there: enforcing Mom's wishes when the time comes. It is not merely an economic imperative, it is a moral imperative.

As I view the heated debate over health-care reform legislation taking place at various town hall meetings across the country, it feels to me that the frustration spilling over is a lot like the angst I see family members grappling with at the time of the impending demise of their loved one. Emotions strained. Statements curt. Manners often in short supply. And then the end comes... And the family dynamic re-casts itself. Some folks reconcile; others retreat to their respective corners.

I suspect that health-care reform legislation is ultimately going to play out in much the same fashion. As the heat of August burns away, we'll all become resigned to the fact that a dramatic transition is coming. Hopefully, cooler, more moderate voices will hold sway in September. And we'll pass meaningful, fiscally responsible, morally upright health-care reform legislation.

It's what Mom would've wanted us to do.

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Making Medicare More Secure, Not Less - Health Care Rx Panelists

Making Medicare More Secure, Not Less

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It astonishes me that current and future Medicare beneficiaries are raising concerns about future legislation: in the absence of reform, these programs will fail!

The Medicare Part A program (the hospital insurance program) runs out of money in just a few years. There is no statutory authority to fund this program without new legislation: it is entirely unclear how the program functions once the trust fund is exhausted.

The Medicare Part B program (outpatient and physician services, primarily) is not going to run out of money (it is funded via beneficiary premiums and federal tax revenues). But, written into statute are draconian cuts to physician reimbursements. If allowed to occur, many physicians will opt out of the program, leading to dramatically reduced access. Thus, the program will begin failing our Medicare beneficiaries unless there is legislative change.

Only the Medicare Part D program (the prescription drug benefit) faces no immediate challenge.

Medicare is at great risk in the absence of reform. It is beyond the scope of this posting to offer real solutions, but clearly we need to communicate with the public about how the reform effort will make Medicare more secure, not less.

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Medicare is socialized medicine. Those opposed to socialized medicine should oppose this socialism.

If they do not, and are against health care reform, they are hypocrites

I know I said I would sit this one out, but statements like this by an MD have to be refuted. The question is not whether Medicare is now fully funded, but whether we can afford to keep Medicare as it is. As a matter of fact we can. I reproduce below a calculation by Uwe Reinhardt that shows that under very conservative assumptions, we will have 70% more money (in real dollars) after paying for Medicare in 2050 than we have now after paying for Medicare. The problem lies in the enormous waste of private insurance. There is so much waste there in high overhead and compliance costs, that we could give an improved Medicare to everyone and it would not cost us anymore than we are now paying, probably less.

Here is Uwe's calculation:

"If "economic sustainability," then exactly what do people have in mind with that phrase? During the past 4 decades or so, the long-run, smoothed average annual growth rate in real (inflation-adjusted) GDP per capita has been about 2%. Suppose that fell to only 1.5% for the next four decades. The current average real GDP per capita of about $40,000 would then grow to about $72,500 by 2050 in constant-dollar terms. Medicare now absorbs about 3% of GDP, leaving a non-Medicare real per capita GDP of $38,800. It was estimated by the CBO about a year ago that Medicare will absorb about 9% of GDP by 2050. Let’s make that 10%. At these numbers, the non-Medicare real GDP per capita available to today’s little critters who will run America in 2050 will still be close to 70% larger than is our current non-Medicare GDP per capita."

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End-Of-Life Preferences Are Key - Health Care Rx Panelists

End-Of-Life Preferences Are Key

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The old saying that "the devil is in the details" certainly applies to this question. For the elderly, what matters most in health care reform is what lawmakers do about how doctors and hospitals are paid. The Medicare system pays them for activity, not quality of care, so the elderly get a great deal of care, but, like the rest of the population, they get the right care only about half the time, according to a RAND Corporation study. If health care reform drives better quality care, the elderly, as the highest-volume health care consumers, will benefit most.

A courageous part of the legislation attempts to get everyone to document end-of-life preferences. We spend a lot on keeping people alive while they are in extreme pain and discomfort with no hope of recovery, or while they are in comas, without knowing what they would have wanted. My dad lapsed into a coma in July 2001 on a Friday and died two days later. On the day before he died, a nurse attempted to administer a $2,300 injection for prostate cancer therapy. Since he had a living will and my sister and I had powers of attorney, we were able to refuse the treatment. In too many cases, unnecessary care is provided simply because the patient has not taken the steps my dad did.

We should not fall into the trap of denying care to the elderly based on some formulaic approach to the value of an additional year of a person's life. At the same time, we cannot provide any care anyone wants, whether or not it is effective. I do not believe in micromanaging individual patient-doctor decisions, but overall regional incentive payments given to an integrated health-care system will drive doctors to discuss difficult issues in advance with their patients.

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This is a simplistic comment. No one could disagree with the prostate cancer example, but it doesn't take a 1000 page document and 500 members of congress to come up with this plan. How about a real analysis of what's in the bills...

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Deliberations and Deliberateness - Health Care Rx Panelists

Deliberations and Deliberateness

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This week's question is outside of my own expertise, so I am only weighing in as an optimist. While I respect the need to maintain momentum and prevent ourselves from being distracted from this important domestic agenda item, I can not help but wonder whether a brief delay could be a good thing. Our elected officials have made health care reform (in its full meaning) a major priority; and there is little doubt that thousands of hours of real work has been incorporated, thus far; But getting the details right and building a true bipartisan base of support should be equally important.

If this bill cannot be bipartisan as it stands now, then the extra time will still have been useful in demonstrating that the opposition is obstructive rather than merely looking out for our nation's best long-term interests. There is such strong consensus that health care delivery and insurance-coverage is broken and headed in the wrong direction: it just seems impossible that we can not generate full support for positive change, once we get the details right.

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Medicare and Tax Reform Are the Answers - Health Care Rx Panelists

Medicare and Tax Reform Are the Answers

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The current, seemingly permanent, extraordinary growth in domestic health-care spending is a predictable result of our tax policies and the many federal rules forced upon Medicare. If we are going to be serious about making health care more responsible and effective, we need to address these issues first.

Our tax system provides ever larger federal subsidies for ever-more-generous insurance policies. Thus, it is not surprising that we buy the most insurance we can afford -- or get our employers to pay for. As predictable, we then allow insurance design and coverage to dictate what health care we need. In the absence of evidence about the effectiveness of new technologies, we find ourselves willing to "buy" the latest and greatest tools, irrespective of known value, confident that someone else will pay.

As important, our federal Medicare program, though less than 20 percent of national health expenditures, affects a disproportionately large amount of health-care delivery. Hospitals, physicians and numerous other providers receive reimbursement that is variably influenced by Medicare policy. Health plans mostly follow Medicare coverage decisions even when there is little evidence that it will be a true improvement in health for their members. Physicians, in an almost vicious circle, chase the latest technology, as long as it is covered by Medicare; then proceed to apply it to ever broader populations, even when evidence for positive effect is lacking.

However difficult it may be to transition to outcome- and health-based reimbursement, we must make that effort. However challenging it may seem to revise our tax code, in order to reduce the distorting effects, we must make that stride. Through these and other reforms, we can curtail cost growth and bend the curve back!


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The cost of Medicare is rising at a slower rate than that of provate insurance. Your concerns are misplaced.

As my daughter says we are rearranging the band aids on the TB patient while the rest of the world is using antibiotics.

You omit one of what should be the easiest and most effective ways to get quality health care to all. A well run for profit corporation has one and only one goal--to make money for share holders. In the case of health insurers this conflicts with the goal of quality effective health care. They waste $400 Billion each and every year on high overhead and compliance costs designed to raise their stock price by lowering their medical cost ratios.

The reason we have so many different and complicated proposals is because the first principle of all of these proposals is to preserve the riches going to insurance company executive and shareholders. These proposals run 1,000 pages. HR676, Medicare for All, is 70 pages long. It gives quality health care to everyone. It solves problems like pre-existing condition and like lose job=>lose insurance and since it picks up the $400 Billion mentioned above, it will cost no more than we are now spending, probably less.

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Our Greatest Strength Lies Within - Health Care Rx Panelists

Our Greatest Strength Lies Within

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Our health-care workforce includes a dynamic group of individuals willing to go above and beyond the call of duty for the sake of another, a testament to the notion that health care ought to be a right, not a privilege.

I know. You have read the reports on workforce overspending that underestimates the human and financial cost of questionable practices. True. But, what often goes unnoticed is the tireless devotion and innovation that health-care providers employ to fill the system's gaps.

Imagine the 7-year-old cancer patient whose last round of chemotherapy failed. Recognizing that an experimental treatment is his last hope, a benevolent group of oncologists, nurses and social workers spend long hours convincing an insurance company to cover the cost of therapy. He is treated and shows improvement. Or the diverse group of physicians who collectively understand that youth violence is not the mantra of delinquent hoodlums, but rather a public health problem that is modifiable and preventable. Against tradition, they collaborate with local youth to address the issue. Community members start talking to each other and take steps to address youth violence.

Examples like this occur across the U.S and with them, the emergence of a new generation of health-care leaders who possess an incredible array of talents and gifts that will facilitate the path toward a healthier society. Medical students are being educated to look beyond diseases to understand how social influences affect well-being. Promising health-care leaders are being trained to not only ask the tough health-care questions in our country but to answer them with clarity and forethought. Providers across the country are volunteering their skills and time in the service of others, sometimes without compensation; and, that is cause for hope.

A system is only as good as what is put into it. By extension, an unsupported workforce compromises the system. To ensure that the workforce is not weakened, we must create new paradigms in medical education that cultivate the manifold gifts our future workforce currently possesses, generate incentives that keep talented health-care providers in the system and support innovative approaches that ensure the health of society. In short, we must dare to think outside the box.

6 Comments

Dr. Asomugha,
You are truly a leader in your field. You have been called for such a time as this. I am excited about your suggestions and look forward to the impact you will have on the medical industry.

Kari

Dr. Asomugha,

Great blog post! We need more discussion and education around how caring communities create change in health care outside of the "fee-for-procedure" system that tends to dominate the debate. Thanks for the work, looking forward to more!

RG

Dr. Asomugha,

Great blog post, looking forward to more great posts! We need more discussion around how communities work together to create change outside of the traditional "fee-for-procedure" approach that health care debates typically focus on.

Rishi

Dr. Asomugha,

You are an inspiration. Thank you for illustrating a way out of the box. I don't hear of these cases on my favorite cable news shows, and that is a shame. This type of innovation in your stories of hope is essential in changing the way this country looks at health care.

I am grateful for your dedication.

KAH


I say YES! YES! YES! To you for bringing it to the forefront, to the individuals involved in getting involved and to the hospital that has already implemented a mentoring program, that pairs students from inner city public high schools with resident physicians in an emergency department. This act exposes the students to careers in medicine that may have seemed intangible to them before, those that dared, did so.Outside of the box.

Dr. Asomugha,

Thank you for a very informative look on the inside of a very much overlooked group of individuals. In a society that places so much emphasis on things that don't matter, thank you for pointed us in the right direction.

Will Moreland

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