As many of you know, I am taking two classes during my study abroad here in Cyprus. I just completed my anatomy and clinical skills class, but just a week and a half ago now I was taking Management of Care as well! I had my final exam in that class, which was an essay comparing the health care systems in the U.S. and EU and solutions to various problems in these systems, as well as my final presentation, which was on the same topic as the essay, though I did focus on different aspects. Here is a link to the presentation I made:
https://docs.google.com/a/umich.edu/file/d/0B2lA9nnV8BhRbWF4T1VxSlBhdUU/edit
I hope that even without me presenting to the talk to you guys that the powerpoint makes sense. If you have any questions about it or want to know more/want to read my references, please let me know and I would be happy to explain things and provide resources for you! I will talk some about what I have learned throughout my semester in this class now. Part of the experiential component in this class was to visit hospitals in Cyprus. I posted about Makarios Children's Hospital and Nicosia General Hospital in previous posts so I will not talk much about them here, except for funding sources perhaps.
As I have mentioned in some other posts, my professor for Management of Care was amazing! She is very kind and has a deep Greek Orthodox Christian faith. She also donated some clothes to the NGO associated with the Kykkos Monastery that I worked with! I went back a second time and delivered the unused baby clothes she so generously donated:
The people at the NGO were very thankful for her generosity! She also told me the names of some stores in Nicosia where the NGO could call for donations for pregnancy bras and underwear. I too was very grateful for her help! She really is an amazing woman. Her presentation of ethics and professional conduct in medicine is always supported with anecdotal evidence and discussions of medical circumstances. The class was really a mix of a medical ethics and study of health care systems course.
For our first class, our instructor, Savoula Ghobrial, did not shy away from any intensity. The lecture was titled "Critical Challenges for HR (Human Resources) in the Health Sector in Europe." I have never studied the European healthcare system in depth at all, so this class was instantly interesting to me. I learned that one of the biggest issues in Europe is that of health worker migration. In other words, doctors and other health professionals tend to leave the poorer EU countries for the more wealthy, where they can maintain a higher salary. It is unfortunate, as the poorer countries already have limited resources and facilities for provision of healthcare for the population. I don't even know how the EU would go about trying to correct such a problem. Everyone, including doctors and nurses, need to make a decent salary so they can support families and basic needs, so it makes sense in some ways that they would move to more wealthy countries. It is a vicious cycle though, as places such as Romania and Bulgaria are subject to healthcare poverty, and the export of healthcare workers contributes to a further decline in population health. This also leaves a huge gap in quality of care between the richest EU countries and the poorest EU countries. Another problem with EU healthcare that is exemplified in Cyprus, that is also a problem in America, is that rural areas have a lack of access to care. All 5 major hospitals in Cyprus are in the cities. There are some small health clinics in the mountain regions, the Troodos mountains and the Kyrenia mountains, but many of them are facing shut down due to the financial crisis. The mountain villages also hold an older population, meaning that the small clinics may not be equipped to meet the long-term facility needs of the elderly as they approach the end of life phase. Yet another problem is that different countries in the EU have different standards regarding patient safety. This results in harm done to patients in the countries with less stringent guidelines.
The second lecture was called "Ethical, Legal, and Professional Issues in Health Care." She opened the lecture with a wonderful statement along these lines: "Every patient is a human being with feelings and is wanting information about their health." In other words, patients are not medical objectives to be completed, they are people who are suffering and looking for answers, and healthcare providers need to remember this in their practice. One of the main problems with European healthcare is that patient rights are not written into the law. This is not true in America, where everyone knows their rights and the law enforces the rights of the patients. A concept from this lecture that I found interesting was that of accountability. She explained that this entails a responsibility for actions AND omissions in a healthcare setting. In other words, people who provide healthcare are just as responsible for what they do as what they don't do. Along these lines is the principle of competency. It is humanly impossible for even the best doctors to know absolutely everything and every skill. Competency involves knowing one's limits and learning to back away when a lack of knowledge, experience, or skill in a case presents itself.
One of the most interesting lectures we had was called "Health Care Systems" and was about just that. There are four main health care system models used throughout various world countries. The Beveridge model is the model that has the most government involvement in the provision of care. In this system, taxes fund the health care system and a yearly budget is given to the health sector. Under this system, hospitals and clinics belong to the government and doctors are considered government employees. Even though the government dominates the health care system, there are still some private doctors. The Bismarck model involves contribution to the health care system by every employee and employer based on salary. Health insurance is provided through the private sector, but the funding comes from a government insurance program that the population pays into. The third model is the National Insurance Health System. This model incorporates various features of both the Bismarck and Beveridge systems. This is the type of model used by Canada. Finally, the cost model of health care is a system where patients pay when they need the health care services. This model only affords access to care for the rich, while the poor are left unable to afford care. This model is found in Africa, China, and India and is the most unjust of the four models. It is also used in the poorer EU countries, such as Romania. In my presentation, I use Romania a lot to talk about the health care disparities in Europe. Our professor also told us that a child in Slovenia, a country with a similar healthcare situation to Romania and Bulgaria, will live less than a child in Sweden, just 5 miles away, due to the huge socioeconomic disparity! This boggles my mind and the injustice actually makes me pretty angry. This reminds me a little bit of the disparities that exist in the US, often within the same community, and just as close in proximity as that statistic I just shared about Slovenia and Sweden.
In this lecture, we also studied different countries in Europe who use these various systems. England uses the Beveridge model and as such, the government is entirely responsible for provision and payment of health care. Unfortunately, in England, many procedures are not covered by the health system. For instance, dentistry and eye care are not covered except for children and for very specific surgeries like wisdom teeth removal. Every other dental procedure is not covered by the insurance. This is unfair for the elderly, as they tend to experience vision and dental problems as their age increases. Germany uses the social insurance health system. It is very accessible for its population as only 0.2% of the population is uninsured! Unfortunately, the aging population in Germany has strained the system by leaving less health care workers and increasing health needs.
We also learned about health care here in Cyprus! The health care system in Cyprus is actually somewhat broken, unfortunately. There is no official system that tackles the issue of public health. This lack of public health leads to deaths that were probably preventable. Furthermore, the financial crisis here in Cyprus that was in the news a few months ago has prevented the government from overhauling the health care system this year like it wanted to. Cyprus will have to wait until 2020 at the earliest for any changes to be made because the country is out of money. One of the main results of this is that there are no electronic medical records in Cyprus. Every medical record is done by hand! When we visited Makarios Children's Hospital, we indeed saw piles of un-filed medical records in envelopes that had been written instead of recorded in a computerized system. The Cypriots have trouble accessing emergency care as well because they must pay ten euros for ER treatment, which in this financial crisis is too much for many people. There are also serious problems with safety measures in the health care in Cyprus. For instance, patients do not wear ID bracelets, which is extremely important in preventing administration of medicines that patients are allergic to. As a result of lack of safety codes in the Cypriot law, medical providers must buy medical malpractice insurance, which there are not even enough insurance companies in Cyprus to do this. Another serious problem in Cyprus is lack of knowledge of patient rights amongst health care professionals and patients themselves. Patient rights are codified into Cypriot law, but many have no idea these rights exist and therefore do not know what to advocate for on behalf of themselves while receiving health services. This is information all applies to the Republic of Cyprus (the South). The situation in Northern Cyprus is less well known, but probably much more dire, because of the lack of government recognition there and the lack of international regulations. Many people from the North do come to the South part of Cyprus to get treatment in the ER.
In addition to learning about health care systems and challenges in the EU and US health care systems, we also learned about the ethical issue of euthanasia in health care. I did not know this prior to the class but there are actually several different types of euthanasia. There is active euthanasia, which comprises both agressive and non-aggressive euthanasia. Aggressive euthanasia involves use of a lethal dose of medication or the use of force to kill a patient. Non-aggressive euthanasia is simply discontinuation of life support. Passive euthanasia involves giving a palliative medication to relieve pain while also causing the death of the patient. There is also euthanasia by consent. Voluntary euthanasia occurs when a patient directly consents to termination of life. Non-voluntary euthanasia occurs when the person is not legally competent to make a decision about termination of life so a person with medical power of attorney makes the decision. Then there is involuntary euthanasia, a highly unethical practice where the patient is killed against their will. Involuntary euthanasia is practiced under the table in Europe in order to free up beds or to save money, a truly evil motive and action. Involuntary euthanasia is practiced in Cyprus for this reason, despite the extremely powerful conservative voice of the church in the government. The WMA has this declaration about euthanasia according to our lecture notes: "Euthanasia, that is the act of deliberately ending the life of a patient, even at the patient's own request or at the request of close relatives, is unethical. This does not prevent the physician from respecting the desire of a patient to allow the natural process of death to follow its course in the terminal phase of sickness." The discussions in our class about euthanasia centered around quality of life for the patient. It was a general consensus that fighting death at some point becomes futile (futile treatment) and more painful for the patient than exercising palliative care. It was a very interesting topic to think about, as well as very complex. I tend to agree with the WMA policy about euthanasia, but it is very complex and situational as well in my opinion.
Another ethical issue we discussed involved dignity in health care. Dignity in care was defined in lecture as "the kind of care, in any setting, which supports and promotes, and does not undermine, a person's self respect regardless of any difference." It might seem like common sense for this to be practiced in health care, but many times health care professionals are not sensitive to a patient's particular preferences for treatment. Our professor mentioned that as health care professionals, we should take time and care to treat patients, instead of rushing through our visits with them, even with busy schedules. I really liked that she emphasized this, because in health care these days with increasing crowding, doctors and nurses tend to rush instead of focusing on each individual, which detracts from a patient's sense of feeling cared for. Our professor told us that many patients often don't complain when they have a right to because they are afraid the health care professionals watching over them will mistreat them as a result. This really made me sad that health care systems around the world have often failed to put the patient first to the point where the patient feels they cannot express their needs. Another thing we talked about in class was maintaining a person's dignity, even if they are not aware. For instance, an advanced-stage dementia patient will not be aware of their hygiene status, but part of respecting them and caring for them is making sure they are clean, if not for respect of the patient but to prevent skin infections and other issues that come with lack of hygiene, even though the patient cannot contribute fully. I wrote in the margins of my lecture notes that this could be summed up with the Golden Rule and using the model of the way Jesus treated people applied in health care settings. This lecture also really made me think about how to be approachable to my patients when I am a doctor. I really want them to feel like they can be honest about what they need when they are under my care and I want them to feel that they can express dissatisfaction without fear of retribution in my future clinics. These principles actually apply to life in general anyways.
To summarize my experience in this class, Management of Care, I have to say that I learned a ton of useful information about health care systems and ethical issues in health care in addition to little tidbits of medicine that our professor would use to illustrate many of these principles. I learned much about global health as well as my own health care system. I learned alot from my wise professor, who was also very encouraging and whose life experience was very evident. The class was not only about the topics covered, but also about life and being a better person. I truly enjoyed it and I wish it were longer than a three week class! The patients I visited in the hospital visits and the principles I learned will stay with me for the rest of my life and are highly applicable to my career.
I hope those who have read this post found it interesting and informative!
"Care is essential to curing and healing, for there can be no curing without caring."
"Sometimes you cannot cure someone but you can care for them."
The above quotes are what I want to end this post with. Think about them! They are very true for me and I found them very insightful when our professor used them in lecture.
-Julia
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