Student & Resident Report; Sept. 20

Involvement, enthusiasm, and hope
By PATRICK M. REIDY, MD
As medical students, residents, and fellows, the only thing more frustrating than the long hours, belligerent hospital staff, and loss of family and personal time, is the constant barrage of pessimism and oftentimes hopelessness regarding the future of medicine in this country. I remember vividly the wild celebrations enjoyed by so many of my friends and colleagues upon their acceptance to medical school and residency. Yet, from the rise of HMOs and the decline of individual practices to skyrocketing malpractice costs and declining reimbursements, the decision to become a physician has weighed heavily on the hearts, minds, and souls of many of those individuals. I, too, often struggled with my decision. I still approached each patient and each day with the same quixotic enthusiasm that put a smile on even the most cynical of my medical school interviewers, but as I saw an ever-increasing number of patients denied necessary prescriptions, tests, and procedures, my passion and zeal dwindled; replaced by disappointment, frustration, and even anger.
Last year, I finally decided to shed my apathy and to involve myself in the solutions to these problems. I realized that sitting idly, lambasting pharmaceutical corporations, HMOs, and lawyers for the troubles in medicine was not the productive path to restoring the health of our nation. The plight facing medicine, regardless of the specific issue, was that we, as physicians, lost our power and authority in medical decision-making; we lost the voice for our patients. I began to see that the only way to conquer our troubles was to strengthen our collective resolve. So, despite a busy schedule as a chief resident in Otolaryngology, I sought out and became active in my local and professional medical societies.

My involvement in the Wayne County Medical Society, Michigan State Medical Society, and my activities in my specialty society, the American Academy of Otolaryngology Head and Neck Surgery, has invigorated my decision to become a physician. I was part of the Medical and Public Health Committee that reviewed the Report of the Detroit Health Care Stabilization Workgroup. I watched as a group of extremely dedicated and motivated physicians spent hours discussing the best way to strengthen the health care safety net, which is responsible for providing equal care to the uninsured and underprivileged in our community. As a member of the Michigan Doctors Political Action Committee (MDPAC), I had the privilege of hearing from the campaigns of a number of physicians, who made the difficult decision of putting their practices on hold while they fought their way to Lansing and Washington.  These individuals, whether Republican or Democrat, had one thing in common: the will and desire to give physicians and our patients another vote in the decisions being made by our government.

As a member of my specialty's board of governors, I was fascinated to learn about the growing public relations campaigns developed to spread information and education on otolaryngic illness. I participated as hundreds of my fellow otolaryngologists convened in Washington, DC, to attend seminars on the legislative process, and to take our greatest concerns, including malpractice reform, directly to the offices of our senators and representatives on Capitol Hill.

Through my involvement in my county, state, and specialty medical societies, I learned that the outlook for the future of medicine is not bleak. While in the past it may have been fair to characterize physicians as apathetic, this is no longer true. The community of physicians at the county, state, and national level will no longer sit idly by while HMOs, lawyers, and businessmen make decisions for our patients. The tide is turning, and the number of physicians organizing to promote the health of our citizens is rising. We are no longer accepting defeat. Poor laws and bad decisions are being challenged at the highest levels, including the Supreme Court. I encourage you to become active in the Wayne County and Michigan State Medical Societies. The time commitment is minimal, and the rewards are huge. You will regain your enthusiasm and hope, as you witness the dedication of fellow physicians who are working hard to promote the health of our patients and our nation.

Dr. Reidy is Rhinology/Allergy Fellow, Division of Otolaryngology, University of Chicago.

Doctors sue Blues over Auto/UAW health care plans
EAST LANSING - The Michigan State Medical Society and the Michigan Osteopathic Association today jointly filed a lawsuit against Blue Cross Blue Shield of Michigan alleging that BCBSM is wrongly fixing the fees physicians charge for office visit services provided to enrollees in the new "preferred provider organization" health care plans for United Auto Workers under the most recent UAW/automaker contracts.

The conduct of BCBSM directly affects more than 10,000 Michigan physicians. The lawsuit is aimed at preventing the potential disruption of health care services to millions of patients with Blue Cross coverage served by these physicians.

Michigan's doctors are concerned because under the new UAW health care plans, BCBSM deemed a physician office visit a "covered benefit" for UAW members even though it requires a 100 percent co-payment from the UAW member, or the payment of a deductible amount intentionally set so high ($5,000 in the case of DaimlerChrysler) that no patient can reasonably be expected to meet it.

"It really boils down to the simple principle of fairness," said Detroit radiologist Michael A. Sandler, MD, Chair of the MSMS Board of Directors. "We are extremely concerned about what else in the future might be called a 'covered benefit' that UAW members or other employee groups will pay 100 percent out of their own pockets and what other physician fees will be unilaterally set by BCBSM. It is not in the best interests of our patients for the automakers and Blue Cross to act in a way that violates generally accepted business practices.

“By calling an office visit a ‘covered benefit’ even though the patient pays 100 percent, BCBSM believed it could require physicians to accept a unilaterally discounted office visit fee based on another physician contract that does not apply to these new ‘PPOs.’"
Especially troubling was the fact that BCBSM had indicated that any physician who does not accept the reduced fee would be eliminated from providing health care services to any patient in seven other BCBSM PPO plans, potentially limiting the choice of physicians for millions of Blue Cross subscribers.

"Thousands of Michigan doctors are being affected and health care may be disrupted to a significant number of our patients," said MOA president-elect Robert J. Stomel, DO, of Farmington Hills. "This 'PPO' label is being used falsely since none of the auto companies or BCBSM have contracted with any physicians, hospitals or others to provide the health care services that these so called 'PPOs' are supposed to provide to their enrollees. Instead, BCBSM and the auto companies believe they can force physicians to discount their fees without input as to how these arbitrary conditions may affect access of UAW members and their families to physicians of their choice."
MSMS and MOA are seeking a declaratory judgment from the Ingham County Circuit Court stating that physicians are not obligated to charge the discounted BCBSM fee screen amount for office visit services physicians provide to UAW employees enrolled in one of the new UAW "PPOs."

Additionally, the complaint seeks a preliminary injunction preventing BCBSM from terminating any of its contracts with a physician based upon that physician's refusal to charge the discounted fee for these services.

The UAW/automaker collective bargaining negotiations last fall resulted in moving all UAW members previously covered under the Traditional BCBSM Plans into so-called "PPOs" created by BCBSM for each of the auto companies. Legal counsels for the two physician associations argue that BCBSM and the automakers did not create PPOs at all since they did not directly contract with physicians and other health care providers that are necessary to provide the covered services. Instead, they are wrongly relying on existing physician contracts and informing UAW members that their new "PPO" requires physicians to provide office visit services at discounted fee screen rates. 

Michigan's doctors further assert that BCBSM wrongly believed that these existing contracts with physicians (TRUST Network Agreements) obligate physicians to charge the discounted fee rather than the amounts historically charged for office visit services.  This interpretation of the TRUST Network Agreements by the auto companies and BCBSM was based on their erroneous conclusion that the benefit plan descriptions for these new plans were issued by BCBSM or under its sponsorship, as required by the TRUST Network Agreements. In addition, BCBSM and the auto companies wrongly believe that an office visit is a "covered service" even though it requires a 100 percent patient co-payment or a deductible that has been set so high that it will never be met. 
Even though the UAW patient has a 100 percent co-pay, BCBSM still requires physicians to submit a bill for the office visit to Blue Cross despite the fact that BCBSM will provide no reimbursement for that office visit.

Originally, BCBSM officials stated that physicians who did not comply with the office visit discounts would be disaffiliated from the TRUST Network.  This would mean that physicians could be disaffiliated from all BCBSM PPO programs in the TRUST Network including Community Blue, Blue Preferred, MI Child, State of Michigan Health Plan PPO, Mental Health Services PPO, MESSA Choices, FEP-PPO, the new DaimlerChrysler Standard Care Network, the new GM Traditional Care Network, and the new Ford National PPO Plan. BCBSM has penalties and other disincentives in place so that patients will be discouraged from seeing an out-of-network provider.
Over the past two weeks during discussions between BCBSM and leaders from MSMS and MOA, Blue Cross proposed changes to address physicians' concerns. As of Sept. 7, physician leaders and legal counsels from both associations concluded that the proposals provide neither complete solutions nor long-term, enforceable resolutions and determined that filing a lawsuit was necessary.

National Business Coalition on Health (NBCH)
In June, GDAHC celebrated its 60th Anniversary during its 48th Annual Meeting at the Dearborn Inn Conference Center.   Part of the program included the Annual Business Meeting Luncheon.  The featured speaker was Andrew Webber, President & CEO of NBCH.  The national network includes 80 employer-based health coalitions representing 7,000 individual employer members with 25 million covered lives.  The speech included comments about health care policy, employers' concerns, and "value based purchasing."

NBCR plans to establish and advance a Value Based Health Care Market in every community of its members.  He noted the political directions of US healthcare range from   consumer directed models to single payer, with employer sponsored health benefits in the middle.  However, employers are changing their corporate philosophy from the worth of employee retention as the most important asset to consider the increasing cost of employer health insurance cost.
Webber then reviewed the Institute of Medicine strategy for reinventing the Health Care System in its report CROSSING THE QUALITY CHASM, especially the OUTCOMES section that included "safety in medical care" and "effective use of information technology."  My personal view was the items are crucial, but the problems for implementation remain the expense and confidentiality of the information.

He discussed the keys to "value based purchasing" as a path to increase quality and decrease costs.  He illustrated how data could be used to identify provider value of health plans, hospitals and physicians in local communities.  He touched on examples "Consumerism" by corporations:  plan selection by General Motors; hospital selection by Boeing; and pharmaceutical benefit design by Pitney Bowes.

He challenged all stakeholders to embrace the IOM's CROSSING THE QUALITY CHASM and urged employers and plans to lead in driving the Value Based Purchasing Agenda (demand side reform).
I trust our physician medical societies leaders will actively assume a "stakeholder" role!
—Gilbert Bluhm, MD

LETTER: Blues ‘promises’ remain dubious
Editor:
As I read the headline of the lead article on page one of the July issue of Detroit Medical News, "Blues Execs promise improvements in service," it brought to mind Yogi Berra's wise comment some years ago, "It’s like deja vue all over again."

Having had the opportunity to practice medicine in Michigan over 43 years, most of those years in Wayne County and in more recent years in rural Northwestern Lower Michigan, I can assure you that Blue Cross executives make such promises on an almost yearly basis, with no intention to fufill them.  It almost reminds one of a recent president who swore to all of us that he never had sex with that woman.

No monopoly or near monoply, BCBSM included, has the ability nor the motivation to be nice to its customers, in this case, patients/subscribers and physicians/providers.  BCBSM doesn't have to develop a "good relationship" with physicians any more than SBC or your local cable company has to.

Dear colleagues, don't hold your breath.  It ain't gonna happen!

Louis R. Zako, MD
Harbor Springs

EDITORIAL: A Satisfied Patient
By GILBERT BLUHM, MD
Associate Editor
Physicians exhibit a keen interest in each patient's welfare and outcome throughout their medical careers. They make judgments for what is best for the patient. There was little doubt after a few years of practice that what is thought "best for a patient" didn't equate necessarily with "a satisfied patient." At least in the last decade, measurements for quality assurance or "outcome assessments" place emphasis on patient satisfaction. A key question is "what makes a satisfied patient?"
A number of questions to determine "satisfaction" by a patient after health care is rendered may be sent by a health care facility or insurance company for a response. Patient expectations differ from one another. From my experiences there can be different concerns for satisfaction.

Whenever ill, an accurate diagnosis is paramount. A disturbed patient is soon incensed whenever it's necessary to report, "There is no explanation for your symptoms or signs." Most of the time a diagnosis is evident and the major concern becomes, "Doctor, is it treatable and how long before I'm well?" Have any of you seen a "satisfied patient" who had to be told a condition wasn't treatable, or that it couldn't be cured?

If it can be treated, cured or controlled, every patient is interested in "How long will it take to feel better, relieved of pain, and able to resume usual activities of daily living? Patients want to be comfortable, free of pain, able to eat, sleep, work and play.

It is also surprising the unpopularity of hospitalization in recent years. Now, most patients plea to be treated in the office or outpatient facility. It wasn't always that way. In the mid 1980s, cost containment efforts managed to change most patients' attitudes and seldom does a patient want to be hospitalized for a test. However, a cross word from a nurse, ward clerk, lab tech, a prolonged wait for a medical diagnostic test, an unusual delay for physical therapy, or a lab report lost, make for a less-than-satisfied patient. Even worse, prescribe  a medicine that causes an adverse reaction before the patient recovers or has relief of symptoms!

It's doubtful that any physician not long in practice has experienced most of these nuisances to produce a dissatisfied patient. Newly trained physicians should take heart, because most polls suggest 91 percent of our citizens say they "like their Doctor."

EDITORIAL: Scope Of Practice — What Makes Sense And What Is Silly
By JOSEPH WEISS, MD
Editor
It is reasonable to believe that a registered nurse with additional training could function as a nurse practitioner. It is beyond the most liberal thinker in the medical community to consider giving chiropractors the privilege of diagnosing and treating hypertension, diabetes, and congestive heart failure.

The State Medical Society represents the physician in the issue of scope of practice. What is appropriate for nurses, optometrists, physical therapists to diagnose and treat?

As you may be aware, bureaus designated by the state legislature regulate our professional licenses. When nurses, optometrists, physical therapists and other groups petition the legislature to extend their privileges, what should be our response? How should physicians react when chiropractors and naturopaths come to the state legislators with bills that would open new areas of privilege for their intervention?

Eternal vigilance is not only the price of liberty. We are required to exercise the same vigilance on scope of practice. Critics say that we do so to protect our income. The closer truth is that we are undertaking surveillance to protect our patients and the public. The physician community is like the Institute of Automotive Engineers and car safety. This group has a far greater understanding of what is reasonable in car safety than the public who drives a car. Therefore this group can, does and should voice its opinion on this matter.

To exercise responsibility in the matter of scope of practice, the Michigan State Medical Society (MSMS) uses its Committee on Legislation and Regulations. This group reviews any state bill pertaining to scope of practice. These sessions are lively, bringing together the experience of 15 or more practitioners to focus on the question of what is equitable and practical.

Residents need not feel that they can't attend. The Legislation and Regulation Committee meets every three months in Lansing. Many committee members use telephone conferencing, which allows full participation without taking the time otherwise needed for a trip to East Lansing and back.
No single response exists on scope of practice issues. Each bill requires an impartial review by physicians; participation in this activity will gain you as much as you give. To become part of this process contact Colin Ford -MSMS Legislative Coordinator at (517) 336 5737.

Editor's note: Keep in mind a number of services MSMS provides residents: Physicians Insurance gives you quotes on personal, home, liability and other insurance needs including disability insurance. The MSMS publication, Resident's Handbook, contains information on practice management, reimbursement, contracting and licensure; MSMS seminars include topics such as  electronic billing and the paperless office,  handling incurred debt, and career options.
For information on these services call Irene Frost at (517) 336 5734.

MSMS recruits residents, offers host of services
The Resident & Fellows Section (RFS) of the Michigan State Medical Society (MSMS) is actively recruiting new members who are interested in organized medicine.  Members of the section may participate in local issues of interest as well as important matters at the state level.  Additionally, residents are given the opportunity to attend both the annual and interim meeting of the American Medical Association, where resolutions are debated and forwarded to the AMA House of Delegates. 

Once again this year, the RFS will be sponsoring a free educational dinner session for residents in conjunction with the MSMS Annual Scientific Meeting. The session will be held on Thursday, Nov. 4, beginning at 6 pm at the Somerset Inn, in Troy. It will include lectures on a number of topics of interest to residents including contracting issues, joining or starting a practice, debt management, how to prepare a CV, interviewing tips and disability insurance. 

The RFS is also proud of the educational opportunities available to residency programs through our network of resources at MSMS. We are able to offer a diverse menu of Core Competency programs to residents at no cost. These free seminars are designed to conveniently provide residents with superior education at their own facility. Topics include: career options after residency, Civics 101, communicating to your patients, contracting issues, debt management, disability insurance, domestic violence, E & M coding, end-of-life issues, ethical issues in medicine, handheld technology, HIPAA regulations, how to run a meeting, how to write a CV, interviewing tips, joining a practice, legislative advocacy, long term care, medical records and the law, professionalism and leadership, starting a practice/business 101 and third party advocacy.
For more information about the RFS and to register for the free dinner session, please contact Rebecca J. Blake, Manager, Physician Education and Leadership at (517) 336-5729 or rblake@msms.org. Residents interested in the RFS should contact me, Jim Fugazzi, MD, RFS chair, at (313) 745-9563 or jfugazzi@dmc.org.

My summer experience in Fortaleza, Brazil
By LIAM PATRICK HOWLEY
My July trip to Brazil was a time of many "firsts": my first trip to South America, my first time living in a foreign country and my first experience as a medical student outside of the United States.  Though I was very nervous about breaking so many boundaries at once I had an amazing experience I will never forget.

I spent time in four different hospitals in Fortaleza and observed many operations and procedures that I never had seen before.  First, in the OB/GYN hospital I saw my first cesarean section, hysterectomy, and hystoscopy.  Then at the university hospital I watched several amazing head and neck surgeries, including the intricate removal of a large benign mass from the maxillary sinus.  My favorite hospital experience was observing a mitral valve replacement because it was amazing to watch the heart transform from an extremely animated organ to a completely static one while keeping the patient alive.  Finally, at the general hospital I saw my first neurosurgery
In addition to the many medical firsts I experienced, I also had many novel cultural experiences.  I learned to dance forro, a Brazilian style of dancing, and samba in a Fortaleza dance hall.  I saw capouela, a Brazilian sport that combines martial arts and gymnastics in a dance-like motion, in the secluded beach town of Jericocoara.  I ate tapioca, a pancake-like bread, in a real Brazilian home. 
By far the most important cultural lesson I learned was that it is difficult to be in a place where the customs and language are not familiar. But the kindness of strangers can help one get through those trying times.  This summer venture to Brazil will help me be a more accepting, understanding doctor and human being to those who are brave enough to come to the United States to make a new lives for themselves.

A woman’s worth: A report on the Ghana Mission Project
Women comprise more than 50 percent of Ghana's population of about 20 million and play an extremely important role in the economy of the country. Women dominate the local market place where they trade in food crops, fish, and manufactured goods. Specifically, they are key players in Ghana's national and international economic scene, while providing for their families and educating their children. So, when asked to visualize a van loaded with 15 female occupants fatally crashing into a building, every month; one can't help but be disturbed. Yet this is the image that a Ghanaian obstetrician asked me to mentally conjure in order to appreciate the severity of maternal mortality in Ghana and the need for the existence and growth of the Women's Health Foundation - Ghana.
I arrived in Accra, Ghana, on July 8, 2004, to present more than 200 units of medical supplies along with monetary support to the Women's Health Foundation - Ghana (WHF-G), a two-year-old Non-Governmental Organization comprised of health professionals at Korle-Bu Teaching Hospital (KBTH), Accra. The donated medical supplies (which included 11 nebulizers, a hemoglobin centrifuge and measurement kit, boxes of gloves, gauzes, etc.) were distributed to various departments at KBTH; including the Obstetrics Clinic, Internal Medicine, Pediatrics, and a children's hospital in Accra, Ghana's capital. In addition, some supplies were designated for the provision of free medical examinations, screenings, and counseling services to women in some of the rural districts surrounding Accra. A portion of the monetary donation was used toward assisting some of the patients in the Obstetrics ward who would have otherwise been unable to pay their discharge fees.

This initiative, named "Ghana Mission Project," was a product of my resolution to make a difference, no matter how small, in the quality of care of the women who patronize the Obstetrics and Gynecology Clinic of the KBTH. Last summer I was privileged to work at the OB/GYN Clinic of KBTH as a participant in the Minority International Research Training Program, with a grant from the National Institutes of Health through the University of Michigan. It was an awesome experience and even served to reinforce my passion for practicing clinical medicine, both of the domestic (United States) and international level. While there, I witnessed the challenges faced by the Ghanaian physicians and health care providers in their attempt to meet patients' needs with limited human and medical resources. I was also touched by the consequent impact of these challenges on the overall well being of the women who received care at the clinic.
As a result of the experience, the Ghana Mission Project (GMP) was established in the summer of 2004. The mission of GMP is three-fold:

-To support the efforts of a Ghanaian health-focused organization (Women's Health Foundation) in order to identify and address key areas of need in women's health.
To facilitate the establishment of partnerships between that Ghanaian health-focused organization and the Michigan health community.

To serve as a means through which all members of the Michigan health community (medical students, residents, physicians, nurses, public health professionals, etc.) could volunteer their services at Ghanaian and/or suburban hospitals and health care facilities/clinics and gain international clinical experience.

While working at KBTH's OB/GYN Clinic last year, I became acquainted with Dr. E.Y. Kwakueme, the OB/GYN department head and executive director of the Women's Health Foundation - Ghana (WHF-G). I gained an appreciation for the work of the foundation and the passionate commitment of its members to the promotion of women's overall health. Confident of an efficient, focused, and productive relationship, GMP and WHF-G agreed to form a partnership.
The motto of WHF-G is, "Empower a man and you empower an individual, empower a woman and you empower a community." WHF-G has made it their mission to reduce the maternal mortality rate within the next five years. The foundation has decided to take control of the wheel of the van and reroute 15 women every month from a fatal course to hopeful and successful destination. Comprised of physicians (mostly OB/GYNs), nurses, and allied-health professionals including psychologists and medical students who volunteer their time and expertise, the foundation adopts a multidisciplinary, culturally relevant, and holistic approach to identifying and addressing areas of need in order to reach its goal.

The foundation has identified poverty and lack of health education as the two main barriers to accessing health care. These are the problems facing the general population, with particular relevance to women, especially those living in rural areas. Ghana has a pay-for-service health care system, where patients pay out-of-pocket for all treatment and services. If one does not have money, one does not receive care. Sometimes benevolent physicians and/or nurses may help to cover the costs for a very sick patient. But, most often, patients do not get the care they need because they are unable to afford it, and providers cannot provide the care they should because their patients cannot afford it. In the obstetrics clinic, if a woman is unable to pay her bill after delivery, she is not allowed to leave the hospital until her spouse, relative, or a benefactor pays the bill. These issues result in women not seeking ante-natal care at the hospital until they are develop a chronic condition (e.g., heavy uterine bleeding) or have been referred from another clinic that was unable to meet their need. The hospitals serve as a last resort after the pharmacies and traditional medicine have failed to meet patients' needs. In the rural districts, there are few health care facilities and those that exist are severely understaffed and have inadequate facilities and resources to meet the health needs of the population in those areas, particularly those of women. The lack of health education has its most apparent impact when women tend to seek ante-natal care late, if at all, due to limited knowledge of how to take care of their pregnancy and inability to recognize danger signs. So, when complications arise, they aren't recognized soon enough and tend to result in fatal consequences for the mother, her child, or both. KBTH's structural barriers limit health care provider's capacity to meet needs due to shortage of essential equipment and supplies, limited theater space, limited sterilization units and limited bed space. Staff shortage is another challenge the foundation faces, as more health professionals leave the country in search of more lucrative opportunities in other parts of the world.

To address the structural problem at KBTH, WHF-G plays an instrumental role in securing equipment and supplies for the hospital and health facilities in the rural districts in order to provide assistance in the provision of quality care at a reduced cost to patients (as patients would not have to pay for those supplies). The foundation also has assisted in the allocation of resources for the renovation of the department of obstetrics and gynecology, and the maintenance of its environs.
To address the issue of poverty, WHF-G supports the very recent government initiative to implement universal health care: National Health Insurance Scheme. This initiative is an attempt to eliminate the pay-for-service health system and increase health care access to all. The foundation also lobbies for financial assistance toward the payment of patient discharge fees. In addition, WHF-G works with various organizations that provide training programs for poor women who come from rural areas to the city of Accra without skills, in order to set them up in a trade that would enable them to be self reliant.

To raise awareness of issues affecting women's health, the foundation conducts clinics in the marketplace and in the rural district where it provides free medical examinations, health screenings, and counseling. Members of the organization also have radio programs in English and indigenous languages to educate the public on health topics, particularly those affecting women. The foundation prints and distributes pamphlets regarding women's health in indigenous languages. Members of the foundation sit on advisory boards of other organizations where they represent women's interests. For instance, one of the WHF-G physicians is an active member of a group of lawyers and doctors who ensure that justice is served in cases of sexual crimes against women. He makes certain that cases of rape seen in the hospital are reported to police and he provides expert testimony during trials so that the perpetrator is brought to justice.

In the future, the foundation hopes to renovate all maternity floors and improve the facilities of the labor ward. They also hope to establish an ambulance service to transport women in need of urgent care to the hospital, reducing delay and in treatment and increasing the patient's chances for survival. It is the hope of the foundation to continue their efforts even more aggressively and expand their endeavors even further in order to ensure a significant decline in the maternal mortality rate in the next five years.

While in Ghana this year, I was privileged to spend two weeks rounding with third-year University of Ghana medical students during their obstetrics and gynecology rotation at KBTH. This experience provided me the opportunity to observe obstetric and gynecology inpatient and outpatient care including gynecological history taking, physical exams, case presentations, and surgery. I was also able to observe a rare case of congenital urogenital malformation and to briefly spend some time in a labor ward.

This experience allowed me a more intimate glimpse of the health care system KBTH and caused me to realize that despite much room for improvement, the health care system in the United States is more available and accessible than in other parts of the world. Even so, this realization is not a good enough reason to wallow in a pool of appreciation of the wonderful opportunities available in this country. Rather, this disparity is a call to action because "to whom much is given, much is expected." With power comes responsibility. Any opportunity to make meaningful and lasting impact must be exploited to the benefit of humanity.

It is in this spirit and in these times when the world is such that when one hemisphere catches a cold, the other hemisphere sneezes, that I encourage the readership to become partners in real change and partner with the WHF-G.

WHF-G is in need of designated drivers to help drive that van of 15 women per month on a road of quality care and empowerment via health education to a destination of excellent perinatal and overall health. The foundation relies upon very limited charitable contributions from private organizations and individuals, which have had to be supplemented with out-of-pocket contributions from its members. The foundation seeks to establish partnerships and seeks the professional, intellectual, and skill development of its members so as to be better qualified to meet its goals. Partners are regular contributors (financial and equipment) and/or actively participate in information exchange for professional development.

The Ghana Mission Project (GMP) will serve as a liaison between WHF-G and her partners in Michigan. GMP will serve as a portal through which WHF-G partners could make regular contributions to the foundation and receive regular updates on the progress and activities of the foundation. GMP will also act to facilitate professional collaborations between WHF-G partners and foundation members. GMP is open to collaborating with individuals and groups in mutually beneficial efforts.

The GMP would not have been possible without contributions from the Wayne County Medical Society, International Society for Hypertension in Blacks, Wayne State University School of Medicine, Davison Medical Society, Physicians for Women, Phoenix Medical Supply, Detroit Medical Society - Obstetrics and Gynecology Division, and various health care affiliated and non-health care affiliated individuals and organizations mostly in the state of Michigan. GMP enthusiastically looks forward to the continued support of these partners in the near future.
To become a partner with the Women's Health Foundation - Ghana, please contact Ijeoma Nnodim at innodim@wayne.med.edu and (734) 730-0662.

Ijeoma Nnodim is a second-year medical student at Wayne State University School of Medicine. She is considering obstetrics and gynecology as a field of specialization.

Japanese health care: Different twist, similar problems
By ANDREW COMPTON
Japan during the month of July was a truly uncomfortable environment in which to spend my last summer vacation ever.  It was between 85 and 105 degrees everyday with humidity so high, it felt like you were in a sauna.  Mot atsui deshite!  Fortunately the people, the culture and all of the sights to see made it an absolutely wonderful experience.  I spent five weeks in Japan, with three-and-a-half weeks of that spent south of Nagoya at Mie University Hospital in Tsu city.  My weekends and a few days at the beginning and end of the trip were spent visiting Nagoya, Hiroshima, Kyoto and Tokyo, all culminating in an all night hike up Mt. Fuji to the summit by sunrise.  As you can imagine these once-in-a-lifetime experiences were amazing and truly gave me a cultural, historical and social perspective on the Japanese people.  Having a university hospital as a host gave us the opportunity to meet many Japanese medical students and faculty who were eager to practice their English.  They spent many meals with us discussing the many political and social issues facing their country.  We discussed the many health care issues and compared their system, where the government pays 75 percent of the bill and you are required to pay the rest, to the American health care system.  Picking up that 25 percent can really mean a lot of money though when you are talking about an expensive operation with a lengthy hospital stay.  Of course if you are truly unable to pay, the government will assist you with the burden.  This system may be heading for some rough roads ahead though with a large population of the same age as the baby-boomers and an insufficient number of children to eventually support them.  This is because many young adults are unwilling to get married and convert to the traditional lifestyle so strongly promoted in the culture.  Many men prefer their current bachelor lifestyle and are unwilling to take on the extra financial burden of a family.  Many women are unwilling to give up their careers to care for the home and children as would be expected of a married woman.  These dilemmas have created a situation in which neither sex wants to get married, which has sent the birthrate through the floor.  The problem of supporting the baby boomers will face us here in the United States also, but it will not be quite as severe as it will be in Japan. 

The health care system has also set up an environment in which there is virtually no family practice medicine.  Mie University has one of the only available family practice rotations in the country.  Most of the health care is delivered through the hospitals and well visits are virtually unheard of.  If a physician decides to open an office apart from the hospital, he must relinquish hospital privileges and is then considered a separate entity.  This means that physicians did not have private offices in which to do initial interviews or follow up care, they used the hospital facilities for everything.  Another interesting fact is that wages are determined by seniority, not by department, so thoracic surgeons are paid the same as their colleagues in pediatrics.  Even though I have spent little time working in the hospitals here, these were some of the most obvious differences that I noticed between the two health care systems, which will hopefully allow me to critique the US health care system more effectively.