Conclusion

--Overlooking some of the Island from the Sand Ridge--

--Dr Bingham and Dr Lovell arguing and posing--

Well I'm back home safely now. I was up something like 30 hours on 4 hours of sleep before I finally passed out. I'm set to enjoy the last few weeks before 2nd year and the ensuing grade competition that arrives mid-August. This summer has given me great insight into how another system of health care operates. The benefits and disadvantages may be different relative to those facing the US but the underlying trends and stressors are the same. I've also enjoyed the chance to understand the focus of public health and how it can work productively w/ the medical community to accomplish common goals. I spent much of my time addressing various sources/consequences of inequalities most notably deprivation and CVD risk, and prisoner and cancer risk. I've worked with every possible level of health care from hospital housekeeping to executive directors and seen the unique problems but common dependency they all share with each other. Finally, I learned a lot about the history, culture, and people of one Island and of England, in general. The people I've met this summer--especially in the public health office--are some of the warmest, most grounded and enjoyable individuals I've ever met. I felt like an emotionless robotic blob on the way home b/c I was so tired but the first feeling that came back to me this morning was regret for not thanking them all in full and that I already miss them.

I've been told my blog posts are too long and this won't be an exception. I'll try to just summarize some of my main concluding thoughts that compare the US and UK systems. My work on cancer and CVD prevention I think would best be left to the papers and not this forum.

1. More so than anything, the professionals, system, and patients in the UK and US are more similar than different. Health professionals have the same ideals, personalities, life goals, and aspirations while patients have the same diseases, fears, trust, and growing autonomy in care. Mental health access is an issue in both countries as physicians are not "formally" trained to treat such patients or do not have the time to do so properly. Physicians spend roughly the same short 7 minutes with patients, their practices struggle financially despite being overloaded, and all professionals work long hours.

2. Deprivation and inequality are important issues that contribute to significantly different health outcomes in both the UK and US. Though race is a bigger factor (partly b/c we have a bigger minority population) it also plays a role in the UK. Just like in the US doctors often are resistant to addressing this "public health" issue b/c they're overworked and are used to just treating whoever walks in the door.

3. Despite my previous assumptions, access to care is a huge issue in the UK like it is here in the States. Though it doesn't come in the form of inability to pay, it does in that patients must often wait some length of time to see a physician. "Elective" procedures of course also have a waiting time.

Part of it I think is patient education. Though I can't say this with any certainty, patients in the US seem more proactive and informed of their options when they enter the office. The UK is also shaking off the paternalistic medicine tradition but b/c our market is more about consumerism we may be a bit ahead of them in this regard. Contrary to what we're told in the States I would say that the physician profession has more autonomy and more political power than in our system. We're simply owned by HMO's and GP's in the UK are still very much independent businessmen/women.

4. The NHS (UK) is a tax based system focused on improving the health of the population overall and not necessarily on an individual level (no politician would ever tell you this). Therefore a lot of concentration is given to improving early life mortality (under 75) and not extending life beyond all possible means until we're little vegetables running around entirely supported by machines. Therefore, strict guidelines exist for which patients qualify for which procedures. This happens in the States, courtesy of HMO's, but we seem to be more lenient on drawing the line. I think anyone would agree that the NHS's way of doing things is better in that it saves money and ensures that everyone has roughly an equal shot at living a healthy, average lengthened, life---until they get sick. At that point you want to push for every possible chance of surviving even if it costs 1 million dollars and has only a 3% chance of working.

5. The interface of public health and the medical field is maintained better in the UK. Public health doctors have all (until recently) been trained as physicians first. Therefore they have the background and experience which validates (in the eyes of medical doctors) their viewpoints. I think the UK does a better job of at least talking about prevention and trying to incorporate it into the central focus of every NHS administration. I'm not sure if they actually deliver on prevention (they're 5 to 10 years behind us in screening--cervical, colorectal cancer, etc.) but the unity between public health and physicians is important.

It seems we're actually moving to the unification of the two fields. Curiously, the UK may be moving in the opposite direction. Medical training has been taken out as a requirement for public health and meetings between physicians and public health teams are beginning to be phased out with administrators now acting as the mediator.

6. The problems affecting both systems now and those that will arise in the future are identical. The aging population is causing worries in both the UK and US. For the NHS and our Medicare/Medicaid, the balance between young payers and old recipients is shifting in the scary direction.

The rising costs of new technology, cancer treatments, and life sustaining techniques is also stressing both systems. There is a push in both countries by the public for better, faster diagnostic tools that may increase outcomes but at what cost?

The advancing field of genetics and its potential to read your "health fortune" at an early age to predict your susceptibility and drug reactions is both amazing and scary. I've seen 4 stories just this week on the growing ability to quantify risk based on genetics. Both societies will have to struggle with the ethical issues that come up. Financially, though it will reduce the need for screening the entire population, I think overall it will lead to higher costs as people preemptively undergo unnecessary procedures to prevent fulfilling their genetic fortune.

The "grass is always greener" phrase really applies to health care systems. The UK public is crying out for more competition, choice, and consumer ideals while we desire all of our citizens to be insured and for medical costs to stop rising. The future of both systems is certainly not guaranteed. Though the NHS has far exceeded my expectations and reassured many of my doubts, I don't think a nationalized system is necessarily the answer to all of our problems. It would obviously insure everyone but the problems it carries may be as unacceptable to the capitalism-minded US public as the ones we face now.

It seems the answer, as it does in everything else, is in compromise. A mixture of the benefits of a private market as well as the support of public programs I think could solve our problems. Obviously, we have something like that in place now but the extreme costs of health care prohibit people from joining the private market and the public programs cannot afford to be inclusive enough. So, the market aspect isn't working and people are left in the middle. As for how to fix this...I have no idea. Maybe I'll learn that next summer but I think I should probably do something more clinical since all of my classmates have been out saving the world this summer.

Thanks for reading my attempt at a blog this summer. Take care!

Wrapping Up

Last Fun British Word of the Day: Cheerio-goodbye, fitting for one of my last posts

The last few days have been a whirlwind. I leave Friday morning and have only one day left here on the Island. There were a few loose ends and experiences that I had to jam in this week so things have been pretty hectic. I could write pages and pages but I'll try to keep it short. Stay tuned for some sort of conclusive wrap-up that I hope to put up tomorrow, but more likely after my return.

On Monday I went with the Outreach Bus and nurses to screen people in deprived wards and offer health counseling. The bus is the spearhead of the health inequalities project that I incorporated into my comparison of US and UK cardiovascular disease prevention that I also completed on Monday (still can't figure out how to post documents). The nurses let me do the screens and counseling since the testing was very basic and I thoroughly enjoyed talking to people about their lives. I'm not sure if I persuaded anyone to change their lifestyle but at least I got them thinking about the consequences of not doing so.

On Tuesday I presented my paper on cancer deaths to the Prison Operations and Modernis(should be a z)ation board. They were really receptive and my presentation went surprisingly well. I found a lot of interesting trends in the treatment of the 20 gentlemen I reviewed and I think the board was very interested in my suggestions. I'm returning tomorrow in the morning to tour the facilities, meet a few prisoners, and speak one-on-one with the director of prison health care to talk more on my work.

After work on Tuesday the entire public health office and some of the commissioners came out to send me off. We went to a rooftop bar in Newport and had a few drinks. Again, another great time with the Brits who definitely know how to party. After talking about the problem of obesity on the Island for nearly 30 minutes we ran down to Hong Kong Express and gorged ourselves on greasy Chinese food. I met the son of one of the executive directors who brews his own beer and offered to take me to a few pubs to sample the Island's locally made beer. Thus how my intended 8pm return to my room ended up getting pushed back a few hours. The beer, however, was absolutely amazing and well worth the missed sleep.

The guy--who I wish I would have met earlier in my stay here--looked up at me after his 4th pint and said..."Kris, do you want to drive a tank tomorrow?" Apparently his friend owns the military history museum and some 50 odd WWI and II tanks that they like to drive around and fire off blanks. I must admit I didn't believe him until he showed up today and took me, in my shirt and tie, to the "battlefield" north of the hospital. I'm not sure I can put justice in words to what seeing someone drive a tank is like. Very cramped, hot, dusty, and excessive...but absolutely thrilling. They pulled some hairpin turns, climbed 20 ft dirt piles, and other likely unsafe movements and had a great time this afternoon. Tonight he (Ed) and his mother Theresa are taking me to "find" some hops to take back to the States and, if I can get them through customs, I'll try and brew some proper British beer for all of us. I'm not sure what "find" means and, like Dr Bingham's flint hunting, he refuses to explain it to me in advance. Finding amusement at my ignorance seems to be a common theme here.

Also, and I'll stop after this, I shadowed Dr Thomson, a general practitioner this morning. The NHS is more bottom heavy in terms of the distribution and responsibilities given to primary physicians so I'm glad I had the chance to see the vital role they play in gate-keeping for the system. My hands are hurting so I'll try and sum up the differences between what I saw today and our community weeks in my final post. I met a man who had a CABG (bypass-DAD) 30 years ago which makes him certainly one of the longer survivors and amazing. Shannon let me know that Michale Debakey passed away a few days ago (http://www.charlotte.com/local/story/710829.html ). He was the father of modern heart surgery and actually trained Shannon's grandfather who was also a surgeon. The article says that he performed surgery until he was 90 years old which is crazy. Anyways, a good read.

Hope everyone is doing well. Wish me luck on my return flight.

Last Weekend

---Debbie (left) and Mary who accompanied me to the workshop in London---

--Randip (one of the STI specialists) and I out with the public health office for my birthday celebration--

--Down House, where Darwin lived and wrote "On the Origin of Species"--

--Dr Bingham and I outside another random palace/castle--

View of London from Greenwich Observatory--

I started Friday off with another trip to the mainland on the car ferry and a long, but exciting meeting at the regional headquarters for a priorities meeting committee. The purpose of the committee is to decide which treatment options are permitted for which patients and to advise physicians accordingly. They essentially undertake the same sorts of conversations as our HMO's. Usually they deal with new cancer treatments but Friday's agenda was In Vitro Fertilization and Bone Marrow Stem Cell Transplants which are both extremely complicated, and, especially w/ IVF, ethically charged. I won't bore you with the details but seeing the physicians and administrators (commissioners) interact and reach compromises on very difficult issues was amazing. Determining the ages at which the NHS will pay for IVF was exceptionally complicated and heated (only 36-39 if you were wondering).

After the meeting Dr Bingham and I drove to his parent's house in London where I would stay the weekend. They are both in their late 70's but very much in tune with the world and energetic. We stayed up late one evening talking about what it was like to grow up in London during the nightly bombings by Germany which was really interesting and a discussion I'm afraid won't be possible in another 10 or 15 years. Dr Bingham's mother was a great cook and I got to sample typical English dishes like shepherd's pie, cabbage, a full english breakfast, etc.

We went to Greenwich, Downe (Darwin's house), a roman castle, and walked around the hills overlooking London where Elizabeth I grew up in an amazing palace. Overall, a great weekend and fantastic ending to my time here (I have 4 work days left). I've learned a lot about the NHS but also about England in general b/c Paul and others in the NHS have been so willing to teach me the history, culture, politics, and general views of the places and people I've visited. I've been very fortunate to experience another country and health care system in such a thorough manner and though I'm incredibly excited to return, I'm sure I'll miss England as soon as I'm back.

By the way...we really should work on our isolationist attitude. Hearing the BBC Radio News on the way back to the Island today, 14 of 19 news items mentioned the US in some way. What or who in the world is Fannie Mae?...I need to catch up...

I just realized I forgot to put up pictures of people at work so definitely check them out...hopefully more to come tomorrow.

Health Inequalities Workshop

--Parliament and Big Ben early in the morning--

I woke up on Monday at the wonderful hour of 5am to grab a ferry and train to London for a Health Inequalities Workshop specifically focused on cardiovascular disease. I went with Debbie and Mary, the trust's representatives for the morning, and it was quite an experience. Public transportation is so convenient here that people are able to commute by train from as far away as Southampton (2 hours!) every day to London. The train was packed with business types messing on their laptops and chatting away on their blackberry's-a reminder of why I postponed the real world to enter medical school.

The workshop was in the Holiday Inn somewhere near the London Eye b/c I could see it out the windows of the conference hall. Speaking of which, who designs a conference hall with windows and expects people to pay attention? The workshop itself was interesting and gave me a few directions to pursue for my paper. It was great to see all the PCTs come together to swap inequalities projects and the diversity in which the programs were designed. Because I woke up before the sun did (which is 4:30 here) I let my guard down and accepted every offer for coffee that I received which ended up being 5 or so. I apparently forgot one of the first lessons I learned when coming here which is how to say no to drink offers. I actually had to leave for half an hour to settle down b/c I was starting to feel like I'd been drugged...and I guess I actually had been. Good times....

Since Monday I've been at the Medical Commissioners office seeing how the CEOs, directors, and corporate big rollers interact. I must say I'm glad I ended up on this side of medicine b/c the meetings are dreadfully long and technical and the administrators all seem a big detached from the humanistic side of their jobs. I suppose you have to be but that doesn't mean I have to envy their positions.

The girls from the office (Philippa, Randip, Joanne, Gayle) took me out for dinner and drinks last night to celebrate my birthday. It was actually in June but it took us a while to find a time that was compatible w/ everyone's schedule: not that it made a difference to me, my nights are universally open. The people from work were awesome and we had a great time.

Time is running out as I fly out next Friday. My remaining time will be spent with a GP in rural Freshwater, with the cardiovascular prevention outreach bus, and with the public health team. I'm also heading to London this weekend with Paul's family to see the spots I missed when Shannon and I visited in May and maybe check out Kent.

Nobody wants to celebrate Independence Day over here

--Stonehenge--

--Somewhere in Bath--

--Hot Spring that Supplied the Roman Baths--

Fun British Phrase of the Day: Bibs and Bobs-synonymous with "odds and ends", used when going out to buy random things or when saying that you have a little bit of this or a little bit of that to complete at work.

This weekend I made the epic journey up to Bath which is really only a few hours away but not exactly the easiest place to access from the island. The train ride, however, was well worth the inconvenience as the countryside turned more and more Welsh as I traveled north. The rolling, light green hills of southern England gave way to the rugged, darker mountains, with streams snaking through them. Every few miles or so there was a random, massive medieval castle perched up on a mountain with a town almost hidden in the valley below it. The city of Bath was beautiful as you'd expect and I especially enjoyed the roman bath museum with the bubbling hot spring and 2000 year old temple built to support it.

I saw a Boston Tea Party-titled cafe and went in to have some tea and make jokes about taxation. Unfortunately, they didn't get them and when I explained they weren't very amused. Everyone else who remembered the holiday wanted to celebrate it with me and were really open to playful jabs about our breaking from their empire. From what I've seen, the Brits seem really relaxed about their past atrocities to mankind and make jokes all the time about how they screwed up their colonies or gave us a "freedom complex." Not to say that it is necessarily a good way to handle it, but much better than our style of avoiding it or denying those topics altogether.

Bath was an infant compared to Stonehenge, which I saw along with Salisbury on the way back. I think I'd become desensitized after a lifetime of seeing photographs of the rocks but it was amazing up close. I didn't realize how large (45 tons) the stones actually were and the history and myths behind the 5000 year old monument were really interesting. Whatever the meaning of the arrangement, the location itself felt special. You could see burial mounds and additional monuments for miles around.

After checking out the cathedral in Salisbury w/ the Magna Carta and oldest clock in Britain, I headed back to the Island. All together, I used 11 forms of public transportation today without a hitch. I'm becoming more and more European by the day. Still, I can't wait to get back home and resume driving down the driveway to get the mail.

On the way up to Bath I was catching up on the British Medical Journals I've been given and was startled at the number of references to the US system. The 60th anniversary of the NHS has stirred discussion as to whether or not the founding principles still apply today. Some it seems, value the economic ideals of efficiency and competition that (arguably) frame our system. They also argue that a tax-driven system is no longer compatible with consumerism b/c patients will demand more and more expensive or experimental treatments. Correctly, I believe, they also demonstrated that as the population balance shifts towards the elderly you'll have less working, tax payers to support the retired persons who are using more of the system. At some point people will stop wanting to raise taxes to support others which is an argument that comes into play with our own Medicaid and Social Security systems.

However, one author noted that when genetics advances to the point where we're able to predetermine risk of cancer or other diseases, that an insurance-based system where patients pay according to their risk will inevitably collapse. Only a taxed, universal system that can share the risks and avoid slamming people who happen to end up w/ certain genes would survive. This is something we've talked about in school but I hadn't seen it applied to this level yet.

Hopefully, at the end of this summer, no one will ask me my definitive answer for which system works better b/c at this point I still have no idea.

2 Weeks Left!!!!

Not that I'm happy or anything.

There really isn't much to report since my last post. I've finished Darwin's ties to the island which should be published in the natural history society's journal as well as the prison paper which I'll present to the board before I leave. It doesn't look like I can attach documents so luckily you don't have to read them. The Cardiovascular Comparison btw Virginia (b/c they have better data than NC and an Isle of Wight County) and the Island here is underway and I hope to complete it sometime next week.

The plan for the rest of my 2 weeks here is to attend a conference in London, shadow the city council and medical administrators for several days, follow a GP, present my suggestions to the prison, and finish my heart disease stuff. I might also get to hang out w/ the smoking cessation ladies at some point.

My little, adopted brother has started a new treatment called Intrathecal Baclofen Therapy for Cerebral Palsy or, in his case, upper motor damage from shaken baby syndrome (courtesy of his natural parents). The "trial run" was yesterday and they gave him a lumbar puncture to administer the drug that will loosen the rigidity of his muscles and allow him to strengthen and hopefully regain motor function over time. Anyways, the tap didn't go so well and he has a tear in his dura mater and is in the hospital under observation until Monday. So if you can, think of him sometime this weekend.

Off to Bath, Stonehenge, and Salisbury this weekend which should be awesome. Watch out for pictures on Sunday.