The End-Of-Life Movement and Medical Ethics
August 18th, 2008 by DrRich
Last week DrRich offered some friendly advice to health plans that would like to take advantage of the cost-saving potential of assisted suicide. DrRich was moved to help in this way upon witnessing the initial, typically ham-handed forays which health plans are making into this promising new arena of High Quality and Efficient Healthcare.
Among the sage recommendations which DrRich so kindly provided to directors of American health plans was the admonition to tone down their overt enthusiasm for assisted suicide, and to let the robust end-of-life movement do the selling for them.
DrRich finds the end-of-life movement to be an extremely interesting social phenomenon. These folks purport to act solely on the behalf of the autonomy of the individual, that is, to help people to preserve their freedom of choice, sense of control, and personal dignity when faced either with inevitable death, or with a life that is no longer worth living. They see the medical-industrial complex as an insensate machine which, for its own purposes (i.e., profit), will inevitably act to prolong the suffering and indignity of these unfortunate patients for as long as possible, long past the point where the individual sufferer would wish it to stop.
As with most passionate social movements, there is more than a grain of truth to their underlying premise. However, their own actions with regard to the three major issues they have taken up – assisted suicide, advance directives, and medically futile care – should make us suspicious of their true dedication to the precept of individual autonomy.
The stance the end-of-lifers have taken on advance directives and assisted suicide, of course, is entirely consistent with supporting the autonomy of patients who wish to forgo aggressive medical treatments, or even to hurry death along. It’s with the issue of medically futile care that the end-of-life movement reveals that its true motivation lies elsewhere.
For, when patients or families insist on continued medical care that even the insensate healthcare machine agrees is very likely to be unavailing, an end-of-life movement dedicated to preserving the autonomy of the individual would want that care to be offered anyway (since that is the explicit desire expressed by the affected individual). But instead, the end-of-life movement strongly favors withholding such care from these individuals, and indeed, seems anxious to expand the sorts of medical services that are to be considered futile.
One can argue logically about whether the position of the end-of-life movement with regard to medical futility is reasonable or not. But one cannot argue logically that this position is based on preserving individual autonomy. It is not.* Instead, their position is most consistent with wishing to limit spending on healthcare. Cost cutting, and not individual autonomy, accurately predicts the position the end-of-life movement takes on all three of its signature issues.
When reducing cost and preserving individual autonomy work in the same direction (as they do with advance directives and assisted suicide), it is easy for them to claim that they are motivated by their passion for individual autonomy. But when reducing cost and individual autonomy are at odds (as with medical futility), they immediately side with reducing cost, and not with autonomy.
(DrRich chooses to attribute the specific positions taken by the end-of-life movement to a desire to control costs, rather than to the other possibility suggested by their actions. Namely, he is reluctant to consider these fine people to be a death cult, of simply being in favor – due to some pathological or morbid fascination with death – of whichever action hastens it. DrRich is far too charitable to believe that.)
DrRich understands utilitarianism, though he most often does not agree with it. However, he finds it dangerous, and nearly reprehensible, to disguise utilitarianism as an ethical argument. If we as a society want to debate the hastening of death as a method of reducing spending on healthcare, then let’s have that debate.
But what the end-of-life movement seems to be doing is attempting to cut off this debate before it starts by claiming an ethical high ground that is actually inconsistent with its own positions. We should not treat the ethical argument advanced by proponents of the end-of-life movement any more seriously than they do themselves.
And we should avoid embracing assisted suicide (and other end-of-life solutions to the problem of healthcare rationing) until we’ve carefully considered the real ethical implications of doing so.
*Medical ethicists are actually much more subtle than this argument allows, and indeed have come up with an ethical system that permits us a way of preserving individual autonomy by (get ready) ignoring the clearly expressed desires of individuals! DrRich will address the medical ethicists’ support of the end-of-life movement in a later posting.
How to Sell Assisted Suicide
August 10th, 2008 by DrRich
In July, the Oregon Health Plan injudiciously sent a letter to lung-cancer patient Barbara Wagner denying coverage for the expensive chemotherapy her doctor had recommended, and offering instead to cover palliative care “including doctor-assisted suicide.”
The firestorm of outrage this letter triggered (to see the outrage for yourself, simply Google the search terms “Barbara Wagner” and “suicide”) penetrated even the dulled sensibilities of the Oregon insurance executives. One Jim Sellers, a spokesman for the Oregon Health Plan, admitted to ABC News that “the letter to Wagner was a public relations blunder and something the state is ‘working on.’”
DrRich expects that the Oregon Plan executives must feel at least a little blindsided by the general reaction to their ham-fisted denial letter. Denial letters, after all, routinely list (as an aid to the patient) services which the insurance company judges to be reasonable alternatives to the denied care. While in this case the denied service offered some reasonable hope for prolonged survival, and the service being offered as an alternative (to say the least) did not, that’s really not so much different from the content of more “routine” denial letters. The difference is one of degree, and not of substance. So, Oregon Plan executives might be thinking, “What’s the big deal?”
One must try to be understanding of such insensitivity. It is a fundamental task of health plans to deliver unpleasant news to people whose lives are at stake, and it is normal – even necessary – for those who are charged with this task to grow thick skin. It is perfectly predictable that such thick skin might dull one’s ability to discern subtle differences in degree between various denials of services, subtle differences that might call for more artful phraseologies than those employed in this instance by the Oregon Plan. The failure to recognize the need for a more artful denial letter, Mr. Sellers appears to say, is the problem in the case of Ms. Wagner. The solution, consequently, is not a substantive change in any policy, but better public relations.
Those who run the Oregon Health Plan must be particularly disheartened to learn that even vocal proponents of physician-assisted suicide are criticizing their ill-considered denial letter. To so blatantly juxtapose healthcare rationing with the “option” of assisted suicide seriously undermines the chief argument advanced publicly by the end-of-life movement, namely, that assisted suicide is primarily an individual autonomy play*, and not primarily a cost-saving mechanism.
In other words, whether or not you embrace physician-assisted suicide, everyone seems to agree that offering it as a covered medical service immediately after denying potentially life-prolonging therapy is both insensitive and unseemly.
And so – as a public service to insurance executives in both the government and the private sector who are severely challenged by trying to understand simple human emotions, to patients like Ms. Wagner who may suffer true physical harm by exposure to such institutional callousness, and to the rest of us who simply would appreciate not being confronted so blatantly by the dark abyss that underlies our healthcare system – DrRich offers some friendly advice to health plans on the right way to sell physician-assisted suicide.
How Health Plans Should Sell Assisted Suicide
1) Don’t be so anxious.
Sure it’s easy to get excited about physician-assisted suicide. All you need to do is look at your own data. Whatever sort of health plan you are running, it’s likely that a huge proportion of your spending goes to patients who are in the last year of life. Enticing these end-of-lifers to choose assisted suicide (which you can accomplish in a sufficiently tasteful way for about $100) is such an attractive proposition that it’s indeed become very hard to make yourself appear reasonably circumspect about it. At the very least, it’s difficult not to push the idea out there to your subscribers. Otherwise how can you be sure they know all their options for end-of-life care?
But doing even that much is a mistake. If you don’t believe that, simply look at the small firestorm the Oregon Health Plan created with their simple and helpful “reminder” letter to Ms. Wagner. As a result, neighboring states that appeared ready to pass their own assisted-suicide laws are now having second thoughts about it. It is clear that for a health plan to seem overly interested in assisted suicide, or even to mention the option to their subscribers, is a very counterproductive idea.
A much more subtle approach is required.
2) Publicly disown assisted suicide.
Think about Tom Sawyer whitewashing the picket fence. Ole Tom didn’t get all his friends to paint that fence for him by asking for their help, or by overtly trying to sell or cajole them on the idea. Instead, he got them to do the job by pretending he wasn’t the least bit interested in having them do it, by ignoring them altogether, and making himself seem completely absorbed in the delightful task. By the time Tom was done, his friends were begging for a turn, and even giving him wondrous gifts (such as dead cats on a string) to bribe him for a chance to participate.
What you need to do is pretend that encouraging assisted suicide – even if it’s a covered service that patients ought to be made aware of – is the farthest thing from your mind. Instead, you are completely invested in and insistent upon providing full-service end-of-life care, with all the bells and whistles and no holds barred; and – while patients of course have the option to exercise their individual autonomy as they see fit – you take great pride in squeezing every last instant of life out of those elderly, used-up, chronically ill bodies that present themselves in your ICU, no matter what the cost to the patient and family in terms of pain, suffering, humiliation and anguish. It is your mission to stave off death to the bitter end, come what may, and you’re proud of it.
3) Have somebody else push it.
In the meantime, clear the path for agencies and interest groups which are dedicated to the end-of-life movement. There are plenty of them out there. Have them do the selling for you.
Make sure they have access to your patients and patients’ families, especially in the ICU setting. Allow them space for educational displays; provide them some private space where they can talk to interested patients and families; see that hospital social workers are aware of their presence. In the meantime, make it clear you do not endorse or encourage their efforts, and indeed wish they would go away, but are providing such groups with access in the interest of full transparency and your dedication to patient choice. If patients choose to avail themselves of such information, you will do nothing to stop them.
4) Make the advantages to assisted suicide seem real.
There’s no need for you to talk up the advantages of assisted suicide – let the end-of-life proselytizers do the talking for you. All you have to do is to make their arguments seem accurate. The great part is, that’s just a matter of maintaining business as usual.
The end-of-life zealots will tell patients that assisted suicide is a way of asserting some measure of control over the dying process, of holding on to some level of personal dignity at the very end. So simply make sure your end-of-life care continues robbing patients of any semblance of dignity and control.
They’ll tell patients that assisted suicide will end pain and discomfort and suffering when all hope of recovery is gone. So simply continue with inadequate pain control** and half-hearted comfort measures, and keep the ICU as hectic, loud, scary and impersonal as possible.
They’ll tell patients that assisted suicide will finally bring comfort to their long-suffering family and friends. So make sure family and friends suffer long, by keeping those ICU waiting rooms hot, cramped, noisy, uncomfortable and smelly.
You get the idea. Simply make sure the arguments of the end-of-lifers have teeth. You’re good at that.
5) Tell patients to consult with their doctors before making this choice.
That’s right. Refer patients to their doctors, their supposed personal advocates, the selfsame individuals you yourself have long since fatally compromised (by grabbing control of their individual professional viability). Assuming you have placed sufficient cost-cutting pressures on your doctors, then their willingness to encourage (or at least not discourage) assisted suicide will increase substantially. So when patients do consult with their doctors, the doctors will not undermine your subtle efforts, but will be your partners in convincing those approaching end-of-life to just be reasonable.
6) Make physician-assisted suicide legal, but not reimbursable.
You’re going for the Botox model here. You do not want physician-assisted suicide to be merely another hush-hush medical procedure, conducted quietly and almost secretly in a typical doctor’s office, so that people can pretend it doesn’t exist. Rather, you want to establish it as something that’s front and center, something people will want and ask for and go out of their way to seek. You want to encourage doctors to establish inventive business models for assisted suicide, just as dermatologists have done for Botox clinics.
Accomplishing this, of course, will require assisted suicide to be made legal everywhere (and not just in Oregon and a few other progressive states), but at the same time will require you to NOT make it a reimbursable medical service.*** For once it’s made reimbursable it will become subject to typical healthcare price controls, and you will severely limit the possibilities.
Think of those possibilities: One envisions physician-assisted suicide becoming established as a “life cycle event” like a wedding or Bar Mitzvah, where the right atmosphere, the right spirituality, and the right tone come together to create an unforgettable, uplifting experience for everyone. Some assisted suicides will take place in a doctor’s office, of course, but why not in a place of worship, a favorite city, a resort, a mountain top, a rocky coast, a casino? Why not allow the prospective decedent to actually hear the eulogies and experience the tearful tributes before actually engaging (ritually) in the Act? Why not partner with the deathcare industry to wrap the final healthcare service into a comprehensive package with funeral services? Why not engage American media to celebrate the event with a new mode of reality programming (one that is sure to garner a massive share of viewers)? Why not convert what is today an antiseptic, impersonal and frightening process into one that makes everybody present say, “Yes! That’s the way to go!”
The beauty is that this sort of model will convert what is today, at best, merely the option for assisted suicide into something that’s expected – a true destination event, a natural part of life. Indeed, not opting for assisted suicide, at a certain point in one’s life, will come to be seen as being unreasonable, greedy and selfish. And when granny begins to spend more time in a doctor’s office or (worse) in a hospital where frequent visitation is expected (and other family inconveniences are generated), some loving grandchild will pat her precious wrinkled hand, and say, “Granny, you know, it’s getting to be about that time. Wouldn’t a last weekend in Vegas be just the thing?”
So, if you play your cards right - passively encouraging the end-of-life movement in its effort to spread the word, while making the alternative (i.e., not committing suicide) as nasty and foul an option as possible, and also while coercing doctors and encouraging families to view assisted suicide as the most advantageous modus exodus one could ever imagine – well, the “right” to assisted suicide will shortly become the expectation and even the duty for assisted suicide.
And if those who run health plans will just follow DrRich’s program, you will have accomplished all this without seeming crass and self-serving as you most certainly do each time you send somebody a letter like the one you sent the unfortunate Ms. Wagner.
*Preserving the ethical precept of individual autonomy is the basis upon which modern utilitarian ethicists build their defense of physician-assisted suicide, passive euthanasia, active euthanasia, and even involuntary, secret euthanasia. DrRich will elaborate on the ethicists’ defense of doctors killing people in a future posting.
**This will simply require the government to continue severely and very publicly prosecuting the occasional pain-management doctor. Whether the target physician is actually engaging in analgesic excesses is unimportant to the goal of making any American doctor afraid of aggressively controlling their patients’ pain, for fear of becoming a target themselves.
***You may need to fashion the payment model so that assisted suicide is paid for in the case of hospitalized patients, and for patients in Medicaid programs. The point is to make assisted suicide a highly-desired self-pay service for anybody with enough money for a decent car or central air conditioning.
Skin in the Game
July 30th, 2008 by DrRich
The New York Times recently took dermatologists to task for creating a two-tiered system of dermatology - one for patients with skin disorders, and one for “cosmetic dermatology.”
As the Times describes it, patients who wish to see a dermatologist for, say, possible skin cancer are put on a waiting list, and when their appointed time finally arrives (generally months later) they are subjected to modern medical hell. To wit: Upon arriving in a lackluster office, the patient is shelved for a while in an unattractive, poorly lit waiting room equipped with a broken TV, old magazines, unruly children of other patients, and surly office personnel. Eventually her name is called by a not-necessarily-pleasant nurse practitioner who will “triage” her to the appropriate category (e.g., acne, fungus, cancer, warts- you know, dermatology stuff), have her strip in order to fully expose the large surface-area organ (the skin) for which she has sought assistance, give her a scratchy yellow paper gown to cover her nakedness, and have her wait for some time in a chilly exam room to see the actual doctor. At last the dermatologist arrives, mutters a greeting (or some other ritual uttering), glances at a clipboard, and announces, “Show me your [acne, fungus, cancer, warts];” whereupon, having regarded the cause of cutaneous concern and having made a professional determination, he either signs the prescription that has been pre-written for him by the nurse practitioner, or schedules a procedure. Then, shoving into the patient’s arms her bra and other structural and non-structural equipage, the doctor pushes her out into the hall, as the formal interview is over.
Presumably, one hopes, some dermatology practices not visited by the New York Times might not be quite so bad. Still, anyone who’s been seen by an American PCP lately will nod sympathetically at the dermatology patient’s ordeal.
Now observe what the Times observes when the patient, instead of having an actual skin problem, merely is sagging here and there and wishes to be shorn up. That is, the patient has a cosmetic issue. That is, the patient wants Botox.
The same dermatologist will often have an entirely different setup for these patients. This time the patient is seen immediately, possibly the same day, as dermatologists are sensitive to the needs of those who are about to appear in public, say, at an impending dinner party. If this patient is to wait at all, she will wait in a modern, tastefully decorated private room. She will then be seen not by a mere nurse practitioner but by an aesthetician, who will do a formal assessment of the sagging parts, and, aside from suggesting more injection sites than the patient might originally have had in mind, will offer a complete program for long-term cosmetic maintenance, which naturally will include quarterly Botoxification. At just the proper moment the dermatologist comes in, greets the patient warmly and reassuringly; then reviews the recommendations of the aesthetician and discusses those recommendations at length with both the aesthetician and the patient, studying the patient’s face in depth as he does so, pointing, nodding, agreeing, adjusting, all the while smiling confidently. Yes, he indicates, we will all be very happy indeed with the results. Finally the doctor begins to make the now-thoroughly-discussed-and-agreed-upon injections, doing so with the greatest solicitation and sensitivity. The patient is then given as much time as she needs to collect herself, and is invited to “recover” in a room set aside for this purpose with flattering lighting, soft music, a cappuccino machine, and perhaps a glass of wine. She leaves the office a new person. And, just as the dermatologist has promised, all are indeed very happy with the results.
Naturally, the New York Times is scandalized by the dichotomy which its discerning readers will note here. Why should a patient with a mere cosmetic issue be treated so well, when a patient with an actual medical problem, possibly even skin cancer, is treated so shabbily? How can dermatologists openly encourage such a two-tiered system?
DrRich has a word of advice for the commentators and reporters of the New York Times and any other concerned Americans worried that dermatologists, by setting up separate-but-not-equal practices for their two kinds of patients, are moving us one step closer to the dreaded two-tiered healthcare system we all abhor. That word is: Chill.
Allow DrRich to support this friendly recommendation with two observations.
1) We already have a multi-tiered healthcare system, and little or none of it is the fault of dermatologists. It is the fault of human nature. All countries have at least a two-tiered healthcare system, including countries (like Cuba and China) that have specifically embraced egalitarianism (rather than individual autonomy) as the fundamental operating principle. The second tier, like the poor, will always be with us.
2) When a dermatologist spends Tuesday afternoon in her run-down office, treating people who come to her for bona fide skin disorders like they’re widgets on an assembly line, then goes to her other, better office on Wednesday, treating the merely cosmetically-challenged like minor nobility, she is not really engaging in two-tiered healthcare. Not at all. Instead, she is practicing real, true, prescribed-by-society, by-the-book American healthcare on Tuesday, and doing Something Altogether Different on Wednesday.
Injecting Botox is officially and formally not part of American healthcare. How do we know this? Because it is not covered by Medicare or health insurance. If you want Botox you’ve got to pay for it your own self, just as you do if you want a TV or a car. So by all that is sacred, injecting Botox is NOT American healthcare.
Furthermore, when one looks objectively, injecting Botox is not even really practicing medicine, at least not in any true sense. In actual truth, it takes very little training or expertise to inject Botox. There’s no reason one must go to college, graduate from medical school, or do several additional years of training in dermatology (or any other specialty) to do this. Anyone with a needle and syringe, an alcohol wipe, and access to Botox could do as well. Just find the wrinkle and stick it. If they made the materials available over-the-counter, folks would do just fine with it.
Of course, doctors in general (and dermatologists in particular) have legally cornered the market on Botox injections. So it’s not like you could just set up a booth at the Mall and hire high school students to do this (as you can for, say, ear-piercing - which, in contrast to Botox injections, is an actual surgical procedure which results in a permanent structural change in a body part). If you set up a chain of Botox Booths, you would be practicing medicine without a license, which is a serious offense.
And consider this. Dermatologists could just as easily have taken up a somewhat different well-known cosmetic procedure, one that also involves injecting substances through the skin via needles, and that has much more to do with the skin itself than Botox injections (which actually do not affect the skin itself at all, only the muscles under the skin), but they chose not to. DrRich speaks, of course, of the tattoo. But unlike making Botox injections, tattooing requires real skill, knowledge, training, expertise and artistic talent. Most dermatologists simply could not manage a highly-technical skill like that.
The point, of course, is that injecting Botox does not involve intrinsic skill, knowledge, difficulty, risk, or any other objective characteristic that necessarily renders this a medical procedure while ear-piercing and tattooing are not. Viewed from this perspective, one must conclude that declaring the injection of Botox to be a medical procedure, which cannot be performed by anyone not having a medical license and years of specialty training, is an entirely arbitrary determination.
Fundamentally, then, while performing Botox injections may have a certain legal status, in any true sense it is not really practicing medicine. Rather, it is simply an activity some dermatologists may choose to do when they’re not doing real dermatology.
Doctors engage in this sort of thing all the time. That is, they partake in activities other than practicing medicine when they could, in fact, be seeing more patients. Some have taken up golf. Others have started side businesses such as restaurants or software companies. Some go to graduate school (usually for MBAs). Still others have opted to work part time in order to raise their families.
Society generally finds such activities acceptable, and - to this point - does not insist that all doctors forego all other human endeavors in order to see as many patients as humanly possible, during all their waking hours. While society seems to be moving closer to declaring that doctors owe this duty, it has not reached this point quite yet.
Until society sees fit to legislate otherwise (which, DrRich supposes, could happen as early as the next president’s administration), doctors will continue to spend some of their time engaging in hobbies and business or family activities outside of the formal healthcare system. Some may even leave the formal healthcare system altogether in favor of these other activities. DrRich himself has done this. And until society renders it officially illegal for doctors to do so, DrRich respectfully asks that doctors be left alone to celebrate their individual autonomy as granted to them under America’s founding documents, whether it’s by establishing authentic Indian restaurants, setting up Botox clinics, or even becoming retainer practitioners.
One last word of advice for dermatologists: Have fun with your Botox clinics, fellas, but please don’t become too invested in them. Injecting Botox is not exactly cardiac electrophysiology. This is definitely a shallow-moat business, and the only thing that gives you any protection at all is your aura as highly trained specialists, with special and secret knowledge about an organ (i.e., the skin) which visibly droops when the underlying muscles become lax with age and gravity. A single action by forces entirely out of your control - say, Congress or the FDA - could render your monopoly entirely moot overnight, and you will be instantly priced out of business by hordes of PCPs, nurse practitioners, Botox booths in Walmart, and even home Botox injection kits. So please remember to at least keep your hand in genuine dermatology, or get your MBA, or perfect your long iron shots - but do something that will provide you with a Plan C. Because Plan Botox is definitely a high risk endeavor over the long term.
Medical Grand Rounds, Vol 4, No. 41
July 1st, 2008 by DrRich
Welcome to Medical Grand Rounds, Volume 4, Number 41, July 1, 2008. This week, bloggers from across the Internet have submitted articles that will help us celebrate the 232nd birthday of the United States of America. Their patriotic postings, organized according to their relationship to the Founding, follow:
Lists of Grievances
Annie at Home of the Brave sets the tone for this week’s Grand Rounds. She does a brilliant job showing what the Founders might have said about the current state of the American healthcare system, in What They Were Saying: A Riff on the Declaration and Resolves of the First Continental Congress. The First Continental Congress, of course, met in 1774 to petition King George for a redress of grievances stemming from the Intolerable Acts. The King rebuffed their petition and a shooting war broke out the following year, which led to, well, quite a bit. (Faced with their own intolerable Acts, many doctors, in stark contrast to the Founders, simply keep their heads down and continue making those little marks on their Pay For Performance checklists.)
Ian Furst of Wait Time & Delayed Care is Canadian and knows something about healthcare and the bureaucracy (not that doctors in the U.S. have any excuse not to know the same thing). Ian analyzes the results of England’s 4-hour ER wait-time guarantee, and shows once again how bureaucrats tweaking one variable in a complex system always manage to create interesting unintended consequences. But, since these unintended consequences will always require further bureaucratic activities in order to produce corrections, they guarantee perpetual growth of the bureaucracy, and thus are seen, by the people who really matter, as exceedingly good things.
Speaking of the proper limits of government, Doc Gurley considers, in her post, Hope and Death, the implications of the California Assembly’s latest bill, essentially requiring doctors to tell patients when they are terminally ill. This information, no doubt, would substantially lower patients’ expectations, and patients with low expectations can be managed very cheaply. (Which explains the legislative impetus to become involved in such matters.) But as Doc Gurley points out, the definition of “terminally ill” is often in the eye of the beholder, and the definition favored by those running the healthcare budget may be quite different from the definition patients (and doctors, if left to their proper medical functions) would favor. Doctors not wanting to break the law (or expose themselves to yet another, particularly promising, form of healthcare fraud) will predictably begin shading the definition of “terminally ill” toward the cost-saving side, i.e., making the determination somewhat earlier than traditional (or proper). DrRich predicts that our faithful public servants will soon take note of the prolonged anguish that will ensue as a result of the newly prolonged (by legislation) duration of terminal illnesses, and their bureaucratic compassion will move them to legislate a mitigation; namely, a law requiring the easy availability of physician-assisted suicide.
The Happy Hospitalist this week offers one of his patented, in-depth analyses of the utter mess that Medicare has become, in This is What You Voted For. For a system that produces the exact opposite of what it says it wants to produce, you can hardly beat Medicare. Happy says, “Look out America, get ready for even lower access to cheap effective [primary] care and a highly expensive and wasteful proceduralization [by specialists] of your friends and family. . .Well America, this is what you voted for. I hope you’re ready to live with the consequences.” Taking into account the bizarre incentives, Byzantine inefficiencies, and systematized grievances that are provided in such luxurious abundance by Medicare, Happy (and DrRich) can only marvel in dazed wonderment that anyone thinks that turning the whole healthcare system over to these people is a good idea. Imagine our honored forebears clamoring to turn over the entire colonial economic system to the perpetrators of the Stamp Act!
And anyone who still thinks any government knows how (or can know how) to run a healthcare system should become a regular reader of Dr. John Crippen’s NHS Blog Doctor, to get a taste of what healthcare across the pond is really like. His recent posting, The Rise of the Healthcare Professionals, describes just a few examples of the systematized dumbing-down of healthcare that has accompanied England’s NHS, and will accompany any system in which codified policies, procedures, and guidelines, handed down from on-high and strictly enforced, replace genuine medical thought.
Inalienable Rights
DrRich has always been amused by those boutique diseases that doctors occasionally invent in order to justify new avenues for payment. Psychiatrists (in DrRich’s humble opinion) have been particularly adept at this game. Dr. Shock MD PhD gives us his opinion on the latest such neo-diagnosis - Internet Addiction. Dr. Shock, we are happy to note, is not enamored with this new disease, and to his very great credit finds in America’s founding documents an inalienable right to the Internet. All self respecting bloggers must unite against declaring as a disease the robust appreciation of the Internet!
The anonymous blogger who writes How to Cope With Pain wonders in Can I Still Blog? whether blogging is an inalienable right - and concludes that while it may be a right, the fact that something is a right does not necessarily relieve you of the attendant risks or consequences. So that’s why all those other physician-bloggers choose to remain anonymous! Is it too late to inform you that DrRich is actually a 58-year-old housewife from the upper Midwest who learned everything she knows about medicine from Dr. Kildare reruns?
Alvaro at Sharp Brains talks about the inalienable right of men and women to own functioning brains - and what they can do to keep them - in Why We Need Walking Book Clubs.
Theresa Chan at Rural Doctoring tells a painful story, in Another Reason Why Healthcare is Going Down the Toilet, documenting how some patients (and patients’ families) feel they have an inalienable right to all the time and toil they desire of physicians, and for free.
The Spirit of the Individual, That Which Made America Great
Rob, at Musings of a Distractable Mind, shows us that the independent, creative spirit that made America what it is remains alive and well - even in PCPs! DrRich has long maintained that PCPs need to think outside the box in order to salvage their profession, and in What are You Going to Do? Rob demonstrates thinking that is, uh, way outside the box.
Over at Insure Blog they’re talking about another aspect of the right to fend for yourself - this time, using a patient’s own cloned immune cells to treat cancer. This research, which comes from the UK, is not funded by the National Health Service, nor has the NHS expressed the least interest in it. So, one might say, the British government is keen to remain “independent” of potentially expensive cancer cures. Read about it in Interesting Cancer News.
David E. Williams at the Health Business Blog tells us about an idea whose time has surely come - enticing patients to take their medication by rewarding them with chances in a lottery. Now, what can be more American than that? Go read You gotta play to win.
Kim of Emergiblog reminds us in Give Me Empathy, or Give Me . . . Another Nurse, how, when we are sick and frightened, nothing can soothe us like the presence of a confident, knowledgeable and empathetic nurse. The continued empathy of nurses is quite remarkable to DrRich, who notes that nurses are under as much stress from the bureaucracy as are doctors. Add to that the stress from being expected to follow orders from those harried, frustrated, angry, not-always-clear-thinking doctors, while still doing the right thing for the patient - dual responsibilities that are not always 100% in alignment. Continued empathy under such challenging conditions can only be attributed to individual character and dedication.
Kerri of Six Until Me reminds us in My Own Shoes that knowledgeable, intelligent and rational patients will always take doctors’ recommendations under advisement, but may ultimately decide that their own personal situation is best served by some deviation from those recommendations. Such patients are not being “non-compliant;” they are considering the doctor’s advice within the context of the totality of their lives (which will always include data their doctors can never fully understand), and exercising their own individual judgment.
Christian Sinclair at Pallimed reports on the practice of hospice medicine during the ongoing Midwestern floods. His report reminds us of America’s greatest asset - the dedication, ingenuity and spirit of individual Americans - which is always most impressive under the toughest of circumstances.
Christine of You Don’t Look Sick tells us how patients can take a major step toward declaring their own independence from a hostile healthcare system - by taking charge of their own medical records. Great advice for any patient.
Standing Up To Powerful Authorities
Dr. Mintz takes on the all-powerful popular media in telling us the truth about the 8 drugs that doctors wouldn’t take. It is very popular to bash the drug companies these days, and accordingly, any negative news about (expensive) new drugs is invariably hyped far beyond any objectivity. DrRich would likely say that this behavior is just another example of covert rationing. But Dr. Mintz more usefully provides the objective truth about these “never drugs.” Perhaps, as a follow-up, he should write about the 8 sources of medical news that doctors (at least the smart ones) wouldn’t read.
JunkMD over at Progress Notes sounds like he’s just about ready to tell the feds what they can do with their latest pay cut. In They Just Don’t Get It, he is fed up both with his Medicare-age Senators and with fellow citizens who expect him to just sit there and take it. Maybe, he allows, it’s time to consider retainer medicine. “Opponents of this model wonder who will see the patients who can’t afford a retainer physician. Well, if none of us are in business, it won’t matter.” That sounds about right to DrRich.
DrRich his own self offers an alternative (and most uplifting) explanation for the fact that doctors apparently owe the IRS multi-millions of dollars in unpaid taxes. Rather than merely being tax cheats, perhaps these physicians are emulating their forebears who nobly defied oppressive Acts of Parliament by throwing tea into Boston harbor. But then again, perhaps not.
The Freedom From Misinformation Act
Dean Moyer of The Back Pain Blog helps one reader declare her independence from misinformation by answering the question Can Herniated Discs Really Heal?
Dr. Paul Auerbach at Medicine for the Outdoors tells those who are exposed to the smoke from wildfires (now raging in California) how to stay healthy. Being aware of oncoming threats in this case is a bit more complicated than “one if by land, two if by sea,” but is no less important.
When DrRich was a medical student, the only decent doctor show on TV was Marcus Welby, MD - a series that was heavy on personal interaction but weak on medical information. So cracking the books was the only good option for learning a little medicine. Today, medical students have many more options. Monash medical student, for instance, is fighting misinformation (his and ours) by reviewing episodes of House.
David Harlow of HealthBlawg reports on the launch of the Massachusetts eHealth Collaborative’s latest Health Information Exchange (HIE). An HIE is more about interdependence than independence, but then, our Founders also banded together (vowing to hang together so as not to hang separately), in their struggle for autonomy.
And Dr Penna reports on new information on Genetic Risk Factors for Alzheimer’s Disease. If you decide to get the test, don’t tell the government or United HealthGroup.
The Obligations of the Individual in a Free Society
Marshall, the Episcopal Chaplain at the Bedside, reminds us in Returning to those Hard Conversations that doctors caring for the terminally ill should more often just say the plain truth, even when it’s painful (for the doctors) to do so.
Dr. Val and the Voice of Reason informs us that it’s plain to both the Surgeon General and to any beat cop that “most people just don’t know what it means to be a good citizen anymore.” Read her plain-spoken interview with Sgt. Zlotkus here, then go do the right thing.
Tories
Some, when a growing conflict reaches the point of no return, will always side with the more powerful disputant. In the Colorado Health Insurance Insider, Louise writes about why doctors are unhappy, and postulates that as a result many physicians now say they are in favor of universal, single-payer (i.e., government) healthcare. DrRich simply notes that after the American Revolution, thousands of Americans who had favored continued rule by the King moved to Canada and got what they desired; and finds it interesting that today’s Americans who want the sovereign power to take over healthcare could do exactly the same thing (if they were to lose the “healthcare wars,” as unlikely as it now may seem), and with precisely the same result.
Am Ang Zhang of The Cockroach Catcher blog tells us about the systematic abuse of the diagnosis of Post Traumatic Stress Disorder by “an alliance of antiwar psychiatrists, VA hospital administrators, and patients who never saw combat or even Vietnam service but found that reciting the PTSD symptoms would result in the awarding of disability payments.” Read about it in PTSD: Diagnosis du Jour. Even John Adams has an opinion about this one.
Picnic Advice, or Don’t Be Stupid
RLBates of Suture For a Living wants to make sure we have a happy 4th. She posts again this year on fireworks safety - a matter whose importance she, a plastic surgeon, unfortunately knows all about.
The Samurai Radiologist at Not Totally Rad offers advice on keeping kids from ingesting foreign objects in Coming Soon to a Child’s Stomach Near You. SR helpfully reports on a missive he received from a concerned parent who is dismayed by the existence of such a thing as Kellogg’s Lego Fruit-Flavoured Snacks: “I just spent the first three years of my son’s life trying to get him not to eat blocks, and now you’re telling him they taste like [fornicating] strawberries. Thanks a lot assholes.” Picnic advice like this you can’t get just anywhere.
What Doesn’t Kill You Will Make You Stronger
Americans have learned repeatedly that adversity produces strength. So, if the rising prices of food have you down, Walter, at Highlight Health, urges you to be of good cheer! In The Upside of High Food Prices he describes how more people are eating local produce - and eating healthier. He neglects to point out (though DrRich will kindly take up the slack) the other problem caused by cheap food that is now being mitigated. We refer, obviously, to the fact that cheap food is the chief source of what has become the latest scourge-of-society: obesity.
Service and Sacrifice
Fighting for what you believe in is always costly, and the cost is never more apparent than in Healthline’s posting on Suicides in US Troops. If you know a serviceman or servicewoman this holiday, let them know how much we all love them and value their service and sacrifice.
The Most Important Aspect of Any Holiday
Bongi at other things amanzi offers us the sad and most affecting story of little k. On this holiday - or any holiday - the best lessen we can take away from k’s story is to gather around us those we love, give them a hug, then count our blessings and thank God for every one of them.
Next Week’s Grand Rounds
Next week Grand Rounds will be hosted by The Blog that Ate Manhattan.
Another Reason To Let the Doctor-Nurses Take the Whole Thing
June 18th, 2008 by DrRich
According to NewScientist Magazine, David Fishbain, Professor of Psychiatry and Behavioral Sciences at the University of Miami, says that up to 1 in 20 patients would like to kill their primary care physicians.*
He learned this interesting tidbit in a survey he conducted among 800 patients undergoing physical rehabilitation or suffering significant pain. He presented his findings at the American Pain Society meetings in Tampa in May.
DrRich, who knows his readers, suspects that several who are physicians and who are unreasonably upbeat or excessively cynical (either personality trait will do) are at this moment thinking, “Sure they want to kill me. But as they’re disabled, their chances of success seem low.”
So chew on this. In a control group of patients not suffering from pain or disability, Fishbain reported that “only” 1 in 50 admitted to having murderous tendencies toward their doctors.
The math is not pretty: the typical primary care physician with a patient load of 3,000 souls can assume that at least 60 of these individuals (up to 150, if he/she treats a lot of patients with pain or disability) would not only like to see them dead, but would be pleased to be the instrument of their demise. (These statistics assume, of course, that everyone who wants to see their doctor lying lifeless in a pool of blood are comfortable admitting this fact to medical researchers doing written surveys.)
We have expended much space on this blog describing how physicians have been maneuvered into covertly rationing healthcare at the bedside, how they have allowed themselves to be limited to 7.5 minutes per patient encounter, and how they have acceded to spending those 7.5 minutes making little marks on a handed-down-from-on-high Pay For Performance checklist (thus leaving little or no time for whatever pressing issues may be on the patient’s own agenda). We have described how, to assuage guilt and to make such behaviors seem less than reprehensible, revered medical organizations have formally amended the code of medical ethics, thus officially wrecking the classic doctor-patient relationship - and committing professional suicide.
The fallout from these developments has landed disproportionately on the PCP, the gatekeeper for the bulk of expensive medical services, whose actions the healthcare system must control at any cost. The loss of PCPs’ professional integrity and their ability to act as autonomous advocates for their patients has done far more than the steady ratcheting down of their pay to make primary care medicine exquisitely unattractive, both to current practitioners and to potential future PCPs. (As per design, says DrRich.) Consequently, this carefully manufactured “PCP shortage” will soon become the medical crisis du jour.
When this crisis is finally ripe for unveiling, the healthcare system will be ready with a solution. Doctor-nurses (the healthcare system fervently hopes) will be more malleable than today’s PCPs, less encumbered by tradition, attitude, and delusions of autonomy, and more likely to follow whatever guidelines the “experts” choose to hand them.
But what about the risk to doctor-nurses from murderous patients?
If the healthcare system is wise enough to create enough of these doctor-nurses, they will be able to relax the 7.5 minute-limit-per-patient-encounter, thus decompressing some of the frustration patients now feel when they leave the doctor’s office, and preventing doctor-nurses from becoming as much a target for patients’ wrath as PCPs apparently are today. To receive that extra time however, doctor-nurses will need to use it wisely, unlike their physician forebears. They will need to spend it engaging in relationship-building and other feel-good activities, instead of (as physicians all too often are wont to do) uncovering new, potentially expensive medical issues that need to be explored.
Doctor-nurses are in the catbird seat, and as long as they follow the script and stick to the guidelines, they’ll be given enough time to keep their patients from hating them.
As for the soon-to-be-obsolete PCPs, DrRich has previously made them some friendly suggestions for salvaging their professional integrity, and he cannot understand why they are not adopting them. Are they waiting for the bullets to fly?
*Thanks to Laura Dolson, Guide to Lowcarb Diets at About.com, for pointing DrRich to this important study.
The Right Way to Think About Medical Ethics
June 11th, 2008 by DrRich
Wherein long-time readers of this blog (or anyone who has merely read the title of this post) will be reminded that DrRich, not unlike some more well-known figures, does not mind audacity.
Both Dr. Gault and Sandy Szwarc have recently revisited the current state of medical ethics, and once again, both have found modern medical ethics wanting. Dr. Gaulte recounts the recent, sad history in which ethicists steeped in utilitarianism have seen fit to add the ethical precept of Social Justice to the individual physician’s ethical obligations. While this change brings medical ethics more in line with the actual behavior of American doctors in the wild, Ms. Szwarc nicely elaborates for us why this change in ethical precepts poses a grave threat. (She even bravely uses the “other” N-word, that word which today is invariably banned in polite conversations on ethics, but which, for better or worse, is unfortunately quite illustrative of the ultimate fruits of utilitarianism. Utilitarianism has again become fashionable after an all-too-brief time-out, and so we must not insult or embarrass respectable modern ethicists by dwelling too deeply on the lessons of history.)
DrRich himself has pointed out that by making Social Justice a chief ethical mandate of physicians at the bedside, doctors have not only committed professional suicide, but have formally embraced the covert rationing of their patients’ healthcare, and all of the social ills that flow therefrom (social ills whose enumeration is the main subject of this blog).
So several of us in the medical blogosphere have made, and continue to make, the point that the “new” medical ethics is counterproductive to the medical profession, to society, and to patients. But still, it must be acknowledged that the “old” ethics, under which the doctor’s only obligation was to the rights and welfare of the individual patient, no longer seems feasible. Any doctor who doggedly sticks to classic medical ethics today is likely to find him/herself out on the street in short order. And besides, the argument of the utilitarians that Social Justice must be honored within the healthcare system is, in fact, legitimate and essential.
Acknowledging that it does little good to criticize the status quo without offering something better, DrRich feels obligated to propose a different way of looking at medical ethics that a) honors the classic ethical obligations of physicians, and b) honors the needs of society. If he has seen fit to label this proposed solution for medical ethics “the right way,” it is more in the way of challenging his critics to engage in debate than to declare a final victory. Though, if critics fail to engage, DrRich will naturally assume he must indeed have nailed it.
“Classic” medical ethics.
Classically, doctors have been obligated to recognize two ethical precepts: Patient Welfare and Patient Autonomy.
The precept of Patient Welfare (also called the precept of beneficence, or “first, do no harm,”) obligates the doctor to always behave in a way that accrues to the benefit of the individual patient. The doctor’s patient comes first, and must be the doctor’s primary concern, above, for instance, personal and financial considerations.
Under the precept of Patient Autonomy, patients are acknowledged to have the right to self-determination regarding their own healthcare. Fundamentally, this means that patients have the right to know, and the doctor is obligated to inform them, of any and all information that might help them make their decisions regarding their own healthcare.
So classically, doctors were obligated to do whatever they must to assure that their individual patients were fully informed about all their medical options, and to act to assure that their patients got the care they needed (as long as, fully informed, they agreed to it).
Since under classical medical ethics the doctor’s one and only ethical obligation was to the patient, classical ethics did not allow the doctor to recognize any limits. Whatever bit of medical care promised even a small hope of benefitting the patient, doctors were obligated to offer it, no matter how expensive it might be to do so. This ethical system worked well enough until 40-50 years ago, since medical technology up to that time was relatively primitive, limited, and cheap.
The “New” medical ethics.
DrRich will not review here how skyrocketing costs, produced by rapidly advancing technology and an aging population, eventually led to the unavoidable need to ration healthcare, or how, because we’re Americans and Americans don’t ration, the unavoidable rationing was necessarily covert. (See virtually any post ever written on this blog for details.)
But, by the 1990s, medical ethicists became troubled that doctors who were forced to conduct covert rationing at the bedside could not do so under the classic ethical precepts that obligated the doctor to the welfare of their individual patients. But rather than pointing out that their behavior had become unethical, and calling for doctors to insist on being allowed to practice medicine without violating their fundamental ethical and professional obligations, ethicists instead began calling for a “new ethics” that would encompass doctors’ actual behavior.
This feat was accomplished in 2002, when the ABIM Foundation, the ACP-ASIM Foundation, and the European Federation of Internal Medicine published their manifesto, Medical Professionalism in the New Millennium: A Physician Charter. In it, these respected organizations proclaimed a third ethical precept: The principle of Social Justice. Social Justice charges physicians to work for “the fair distribution of healthcare resources.” That is, it specifically and directly justifies bedside rationing. (For a fuller discussion of this point, go here.)
That this third medical precept so directly contradicts the first two is either ignored by ethicists or celebrated as “balance.” DrRich’s only surprise is that ethicists have not (yet) found within this utter contradiction the virtue of diversity (the uber-virtue, from which the seven classic - though subsidiary - virtues must necessarily spring).
The negative implications of this official “new” medical ethic on doctors, patients, and society are truly staggering. For a masterful discussion of those implications, DrRich refers you to again to Ms. Szwarc. Here, DrRich will take only enough space to reiterate for his physician colleagues that once we physicians adopted this new ethic, we surrendered any claim we might have had to the title “professional,” and accordingly, we made ourselves fair game to any treatment, tactic, or travesty that any more powerful interest group (such as trial lawyers, Congress, or doctor-nurses) can get away with foisting on us. Physicians no longer have any ethical standing for turning such attacks aside. Rather, as non-professionals, our ability to withstand attacks can only be proportionate to whatever socioeconomical or political pressure we can muster.
So if “classical” medical ethics has been rendered obsolete by rising costs that mandate limits on spending, and if “new” medical ethics is irredeemably bad, then what are we to do? The answer of course, is “right” medical ethics.
The “Right” medical ethics
Medical ethics would be “right” if it could be made to comport with the classic notion of the doctor’s primary obligation to his/her individual patients, and yet respect society’s need for cost control. That is, the “right” ethics will recognize that society’s needs and the needs of individual patients are often in conflict, and will provide an ethical framework for resolving these conflicts.
We can profitably address this problem if we think of the ethics of healthcare as being organized into two concentric spheres. The outer sphere holds the ethical precepts adopted by society in order to guide the behavior of the healthcare system for the entire population. These outer-sphere precepts help ensure that the needs of society as a whole are served in an ethical manner by the healthcare system.
Contained within (and therefore subject to) that outer sphere of societal precepts is an inner sphere which holds the ethical precepts that govern the behavior of the healthcare system (including the behavior of physicians) toward individual patients. Inner-sphere precepts help ensure that individual needs within the healthcare system are addressed in an ethical manner - yet, in a manner consistent with outer-sphere (societal) precepts.
So, while the physician’s primary ethical obligation must be for the benefit of the individual patient, and thus while the physician must operate according to ethical precepts that honor this duty to individual patients (the inner-sphere precepts), their behavior must also conform with the ethical constraints imposed by society on the entire population (the outer-sphere precepts).
Because doctors and patients operating within the inner sphere must honor outer-sphere ethical precepts, it would be easy to surmise that the needs of society must always take precedence over the needs of the individual. To some degree this is the case. But it is more useful to think of the inner-sphere precepts as an immutable core of ethical beliefs that serve the fundamental American commitment to the autonomy of the individual, and of the outer sphere as a coating, fashioned by society and therefore changeable, that places a limit on individual autonomy, while protecting its essential immutability.
The inner sphere - ethical precepts for individuals
The inner sphere of ethical precepts - the core - obligates physicians to place the interests of their individual patient above all else, within the bounds imposed by society. This inner sphere holds the two ethical precepts of classical medical ethics, described above - patient welfare and patient autonomy.
While individual autonomy is critical, it has its limits. When a patient demands that everything possible be done for them, they are exceeding the bounds of autonomy if doing “everything” means that some other individual would thereby be deprived of what otherwise would be rightfully theirs. These bounds of autonomy are defined by the outer sphere.
The outer sphere - ethical precepts for society.
Under any equitable healthcare system we are going to have to carefully define our outer sphere ethical norms, because those are the standards that bound and govern the inner-sphere behaviors of doctors and patients. The outer sphere also consists of two ethical precepts, societal beneficence and distributive justice.
Societal beneficence (or social welfare) requires the healthcare system to maximize the overall public good realized from whatever resources society expends on healthcare. Social welfare is not the same as patient welfare, because what is optimal for an individual patient may often reduce overall benefit to society, and vice versa.
Distributive justice requires the benefits of the healthcare system to be distributed fairly, that is, in a way that does not discriminate against individuals or groups based on who they are.
The outer-sphere precepts honor society’s right to accrue optimal benefits from whatever resources society provides collectively toward healthcare. That is, the outer-sphere precepts recognize society’s legitimate interest in limiting and equitably distributing society’s collective resources.
Medical ethics and the spheres.
Now it is easy to see why the American healthcare system is presently inequitable and unethical. A hallmark of our system is the lack (thanks to our culture of no limits) of effective outer-sphere societal norms that would bound the appropriate behavior of individual physicians and patients. This lack makes it entirely feasible and very common for some patients to soak up a disproportionate share of publicly funded healthcare resources while others (though they are also paying into the system) are left with next to nothing.
Establishing equity should have nothing to do with adjusting the inner-sphere precepts. Individuals in the United States (to paraphrase the Declaration of Independence) have a self-evident right to their individual autonomy. The inner-sphere precepts are granted to us by the Creator, by natural law, or at the very least, by the Magna Carta and its derivative documents. As Americans we should avoid modifying the inner-sphere precepts at all costs, since, once we do, we are abandoning our foundational principles.
It is the outer-sphere precepts - those that can be negotiated legitimately by society, and which can legitimately limit the scope of inner-sphere behaviors - that we need to get into proper order.
A properly functioning system of medical ethics, therefore, would have society negotiate a set of outer-sphere precepts that would transparently define the rules for how society has chosen to set limits on healthcare spending. Then, within that system of societal rules, doctors and patients would work together, under a fully restored doctor-patient relationship, to assure that every patient receives all the information he needs on all the legitimately available medical options, and that the doctor leaves no stone unturned in obtaining those legitimate medical services for her patient.
In stark contrast is the process which gave birth to the “new” medical ethics now being promulgated by medical ethicists and the medical establishment now under their thrall. The current ethical model was the result of ethicists responding to the lack of functional outer-sphere precepts by simply moving the principles of societal beneficence and distributive justice (lumped together as Social Justice) down into the inner sphere, where individual doctors are expected to deal with them. You can’t actually do that, of course, because these are intrinsically outer-sphere norms. But our present-day ethicists have deemed it so, thus formally placing doctors into the position of having to serve the best interest of their patients (individual beneficence and autonomy) while at the same time, rationing healthcare covertly, at the bedside (societal beneficence and distributive justice). These interests, being often in stark conflict, simply are not possible for a physician to manage at the bedside. Charging doctors with the obligation to act in such an illogical, nonsensical and indeed impossible manner produces no good, and much harm.
Ethicists behaving badly
DrRich has thought long and hard about why medical ethicists have created such a non-solution for us. Are they stupid? DrRich thinks not, having tried unsuccessfully to read some of the arcane literature they produce, which is chock full of logical legerdemain, and by which (it appears to DrRich) they can justify almost any behavior you care to imagine. The stupid could simply not do that.
Rather, DrRich sadly concludes, it is cowardice. For, once ethicists determine that it is the obligation of society to establish the rules for limiting the rising cost of healthcare, the ethicists will be placed squarely in the line of fire; that is, the ethicists themselves will be asked to lead the process. Finding that to be a very scary prospect (many ethicists having chosen their field of endeavor, it seems to DrRich, precisely because it allows them to substitute critical commentary for difficult action), they instead have placed doctors in the position of having to ration healthcare for society at the same time they are supposed to be advocating for their individual patients. If there ever was an example of ethicists behaving badly, this is surely it.
If it’s any consolation to them, DrRich would like to assure modern ethicists that, having observed their recent behavior, he personally would never choose to burden them with the task of determining society’s rules for rationing healthcare. Indeed, if DrRich were in charge ethicists would have nothing to worry about, and might just as well tell us the truth.
Primary Care: Time to Reboot
April 8th, 2008 by DrRich
American primary care medicine has entered into a period of change. “Change” is perhaps too mild a term; many - especially the primary care practitioners (PCPs) themselves - might call it a period of crisis. In any case it is change so profound that one might be forgiven for thinking Senator Obama is already president.
Consider. PCPs have been hogtied to a dysfunctional reimbursement system that (thanks to the government, the insurers, the AMA, and their own specialist colleagues) has drastically and systematically devalued their training, expertise, and time. The very concept of what a PCP is and does (and indeed, what they should be called - whether PCP, family doctor, general practitioner, gatekeeper, or medical homemaker) seems in constant flux.
Whatever it is PCPs do, the government, the insurance industry, and experts on medical policy have spent years making the primary care job seem, well, easy. Their practices have been reduced to a series of discrete, easily cookbookified tasks. Each of these tasks can be directed by “guidelines” (devised, of course, by non-PCP “experts”), compliance to which can be easily tabulated and monitored, thereby to determine the adequacy of the individual PCP’s performance. And, because their job is now so codified, they are expected to perform it accurately and reproducibly in a matter of minutes (some say 7.5 minutes per patient encounter, though others will allow up to 12.5), just like any other rote industrial process.
To make matters worse, PCPs are slowly awakening to the realization that they are being squeezed out from the bottom. Some of what they do (the really easy stuff) is being corporatized into mini-clinics by the large drug store chains, and the rest is being threatened by newly assertive nurse practitioners and doctor-nurses, who are at least tacitly supported by the insurance industry. (Thanks to Dr. Poses for pointing out the relationship between doctor-nurses and big insurance.)
No wonder PCPs have become so terminally frustrated.
It is natural for PCPs to want to fight the changes that are destroying their profession, and causing their numbers to dwindle. Many have offered ideas. Gain the public’s support by alerting them to the impending and dangerous shortage of PCPs. Improve PCP payment schedules. Forgive the student loans of young doctors who choose primary care. Lobby congress for pro-PCP legislation. Offer novenas.
Some of this (DrRich is thinking the novenas) might hold off the inevitable for a time. But PCPs are fighting more here than just the government, the insurers, their specialist colleagues, and nurses filled with thoughts of vengeance (for 150 years of having to give unquestioning obedience to arrogant, clueless and unfeeling doctors, if you care to ask them). The PCPs are fighting history.
What is happening to PCPs is what happens to many experts whose jobs are fundamentally based on knowledge and/or technology. That is, as knowledge and technology advance, some (and perhaps a lot) of what the experts do can be sufficiently simplified and “democratized” that less well-trained individuals become enabled (or believe they are enabled, which amounts to the same thing) to do it themselves.
This is what the market is telling PCPs has happened to them. A substantial part of what they do indeed has been reduced to guidelines and cookbooks (thanks to remarkable advances in clinical studies and medical technology). The typical patient (note: DrRich said “typical”) with hypertension, diabetes, cholesterol abnormalities, and common infections can be relied upon to respond reasonably well to reasonably standardized therapy. And the market is saying to the PCP: “We can find ways of doing this without you.”
The same thing has happened countless times in history. The 1500-year monopoly enjoyed by the clergy in interpreting the Word of God was completely disrupted by the printing press and by the upstarts who translated scripture into the vernacular. The music industry has been fundamentally disrupted by digital recording software, which enables anyone with a PC to do things that had always required multi-million dollar studios. Ditto for book publishing. Ditto for real estate agents, accountants, car dealers, teachers, newspapers. All are wrestling to one degree or another with the “creative destruction” that is produced by advancing knowledge and/or technology.
For the most part, of course, nobody (except, perhaps, the doctor-nurses) will come right out and tell the PCPs to go away altogether. Instead, they’re telling them to dumb down, to just follow the rules, to stick to the guidelines and be paid to perform (one thinks of trained seals), to become like the lesser-trained practitioners who inevitably will be replacing them over the next decade or so. That’s where the profession is going, they’re being told. Get with the program, adapt to reality - or don’t let the door hit you where you keep your wallet.
Looking at the situation from this more historical perspective, one can see why it seems futile for PCPs to respond by railing and complaining, by lobbying for the public and the legislatures to understand that they’re actually quite important, by appealing to their specialist colleagues for more than lip-service support, or by trying to convince more medical students to choose a disintegrating profession such as this.
PCPs are in the path of a tidal wave of disruption, triggered by economic realities and enabled by technology. They are unlikely to prevail by a’wishing, and a’hoping, and a’singing, and a’praying.
From the perspective of history, it becomes apparent that what PCPs need to do is reboot. They need to reinvent themselves in a way that is compatible with the new reality. So far, they seem to be seeing only the disruption part of the creative disruption now tearing their profession apart. They need to find the creative part.
From a simple examination of history, two possibilities will immediately come to mind.
1) Just as advancing medical knowledge and technology has made it possible for lesser-trained individuals to encroach on their turf, so have the same advances made it feasible for PCPs to encroach on the turf of their snugger (and smugger) colleagues - the specialists. Observing how some of the bread-and-butter skills of the PCP have been sufficiently reduced to the point that nurses can do it, one finds it inconceivable that similar basic skills now monopolized by specialists haven’t been similarly reduced. It is undeniably true that for a lot of what specialists do, one doesn’t actually need a specialist anymore to do it. (As a cardiologist, DrRich knows for a fact that this is the case, but unfortunately he is bound by blood-oaths extracted by the high priests of his guild - oaths which mortgaged the immortal souls of his progeny down through 10 generations - not to mention the specifics. Sorry.) But look around. You’ll find examples easily enough.
Fundamentally, advancing technology allows individuals to migrate upwards into areas formerly occupied only by more specialized individuals. This is a law of technologically progressive societies. That nurses are aggressively migrating upwards onto the turf of PCPs is merely a case in point. So, rather than fighting a doomed-by-history rear guard action against the advancing army of nurses, why should PCPs not instead launch a blessed-by-history invasion of their own, against the smugocracy (the people whose jobs end in -ologist)? Heck, they’ll even have the insurers and the feds on their side for once (for the same reason the doctor-nurses now do). Wouldn’t that be novel?
2)Another law of technologically progressive societies is that, whenever specialists are displaced by upwardly mobile, technology-enabled non-specialists, there will always be a portion of the customer base that is likewise displaced. That is, the new, less-sophisticated service providers will be able to provide useful services to a majority of customers - but not to all customers. The customers with high-end needs, who are left out under the new regime, present a new business opportunity.
PCPs operate in a world where the majority of their patients probably have relatively common, relatively easily cookbooked medical problems, and most of these patients will do just fine with their new doctor-nurses. But a substantial minority will have high-end needs, either in terms of complex medical problems that cannot be reduced to simple treatment pathways, or in terms of atypical medical problems that are not easily diagnosed.
DB has discussed at some length this “long tail” in the patient population, as defined by some aspect of material complexity in their medical conditions. The long tail simply cannot be served by guideline-directed care, whether administered by doctor-nurses, or by those more malleable (or complexity-averse) PCPs who will simply allow themselves to be absorbed by the new, dumbed-down primary care regime. Long-tail patients, the outliers, will not be small in number. They will comprise an important new business opportunity, “new” because it is a niche that is not recognized today, as it will be when these patients are being systematically (instead of randomly) culled out.
That business opportunity can be filled by many of today’s PCPs. These will be doctors who enjoy puzzling through complex diagnostic problems, and dealing with complex management issues, and have been trained to do so. To DrRich, this spells “internist.” Doctor-nurses can’t do this job. Specialists can’t do it either. This will be a specific niche for internists.
The best part is that the feds and the insurers, in selling us on the dumbed-down PCP model, are busily assuring us that there is no substantial need for sophisticated PCPs (hence, the appropriateness of doctor-nurses). And in proving the point they’ll be able to rely on carefully constructed, population-based outcome measures (which, since they speak to the average patient, will look very favorable) to marginalize the complaints of the outlying patients. Having refused to acknowledge the existence of complex patients, they’ll hardly be able to make special provisions for their care.
This leaves the door wide open for internists to establish practices to provide healthcare services to patients with difficult diagnostic or management problems, who are being neglected and mishandled by the “official” healthcare system. (These patients know who they are, and are desperately looking even today for somebody to help them.) And since to insurance companies and the feds these patients don’t exist, these practices will have the opportunity to operate outside the system, as private-pay practices, which will eliminate the demeaning checklists, the one-size-fits all guidelines, and the stifling time limits under which PCPs now must operate. And, like plumbers and electricians, they can get paid for what their time and expertise is worth.
(To those of you who immediately object to such a thing because asking patients to pay themselves for medical care is unethical, DrRich asserts it is indeed possible to do this entirely fairly and ethically, while allowing almost anyone who wants this kind of service to have it, and some day he will describe how. But for now, just celebrate the right of people to spend their own money on their own healthcare even when it’s provided by actual physicians, just as [DrRich suspects] you celebrate their right to spend money on chelationists, homeopaths, or reiki practitioners.)
The bottom line, as DrRich sees it, is that the identity crisis now being experienced by American PCPs, while certainly catalyzed by healthcare economics and politics, is a manifestation of the natural and inevitable disruption produced by advancing knowledge and technology. PCPs may be the first, but all physicians will soon face similar challenges as long as medicine continues to advance.
If the PCPs respond logically to this crisis - that is, instead of fighting it, recognizing the opportunities it presents - their specialist colleagues will soon experience their own “encroachment from below,” which is the hallmark of a mobile, technologically progressive society.
Should We Aim For Equality or Autonomy in Healthcare?
March 31st, 2008 by DrRich
In a previous post we considered the first of three questions we must resolve before we can decide on any plan to fix American healthcare, namely, the question of whether the healthcare system should be universal.
In this post we will take up the second question: Should our healthcare system be designed to enforce equality, or should it instead permit Americans to exercise their autonomy as individuals?
Note that this question becomes relevant only because the answer to the first question (should the healthcare system be universal?) is “yes.” If we don’t have a universal healthcare system, then by definition we won’t have the option, much less the means, of trying to enforce equality. But once we decide on a universal system (i.e., a publicly-funded system of providing healthcare to everybody), then equality - equal access to healthcare services for everybody - seems not only the fair and logical next step, but also at first glance a very good thing.
The very fact that equality of access seems so naturally desirable - and thus will be very difficult to turn aside - is what makes the notion of a universal healthcare system so disagreeable to DrRich and many others, and is what makes the necessity of a universal system so fundamentally distressing. As it happens, the mere fact that this issue will have to be debated threatens the very nature of the American compact.
We should note right away that there is nothing inherent about a publicly-funded system of healthcare that demands equal access to all healthcare services. The only equal access demanded by such a system is equal access to whichever healthcare services are publicly-funded. That is, universal healthcare does not necessarily preclude individuals from supplementing publicly-funded services with their own resources. To achieve equal access to all healthcare services (and not just the services that are publicly-funded), we would have to actively restrict individuals from exercising their rights of individual autonomy.
To say this another way, ensuring the overall equality of access to healthcare services turns out to be not a positive good (i.e., granting the populace a boon they otherwise might not have), but instead turns out to be a negative restriction of rights.
The right that will have to be restricted is not a trivial one, like, for instance, the right to board an airplane without undergoing a body search. Let’s be clear on what we would be restricting here: We would be denying individuals the right to spend their own money on their own health.
Health - avoiding illness, disability and death - itself has a high intrinsic value, and restricting an individual’s right to use their available resources to maintain their health will have a high personal cost. But the cost will be much higher than just to individuals.
If We the People cede to our government the power to restrict us in this way, we will be abrogating the very foundation of our culture. We will be saying we no longer hold as self-evident our unalienable rights to life, liberty and the pursuit of happiness.
Our founders, recognizing the human condition, consciously tried to establish a system of government that would guarantee individuals the liberty necessary to pursue for themselves the best achievable outcomes, and that would maintain a reasonably level playing field (i.e., as level as practicable) on which they could pursue it. As imperfectly realized as it may be, this effort has made the United States everything that it has become.
It is beyond disturbing that we seem ready to abandon our foundational principle, especially since it will be for no good reason. We would be empowering our government to abridge our personal liberties, all in a vain attempt to achieve something that our founders recognized could never be achieved and should not be sought - an equality of outcomes
Why an equality in outcomes is not achievable.
Achieving equality in healthcare services is simply not feasible; it can’t be done. At least not in America.
Any healthcare system we devise will simply fail if we try to restrain people of means from exercising their fiscal freedom. Restraining this freedom does not work in Canada (whose efforts to enforce a universal system has created a powerful flow of wealthier Canadian patients to healthcare facilities in American border states), nor in Britain (which has given up altogether its attempts to restrict people from seeking healthcare outside the National Health Service, and has allowed a shadow self-pay healthcare system to develop). It certainly won’t work in America.
If we were to attempt to enforce equal healthcare across the population (and at the same time achieve the necessary limits on public spending), the demand among many Americans for more healthcare than the bureaucracy allows will inevitably stimulate a response from creative entrepreneurs. Some of the offerings one could imagine might include black market healthcare, overseas medical tourism, converting mothballed Soviet aircraft carriers to off-shore healthcare Meccas, or (following the example of the gaming industry) building Mayo Clinic equivalents on Native American reservations. (DrRich assumes here that retainer practices will long since have been declared illegal, fraudulent, and heretical, and will no longer be an option for American patients.)
Why an equality in outcomes should not be sought.
It is axiomatic that whenever a society becomes dedicated to achieving a perfect equality of outcomes (any outcome), the power of the individual is greatly diminished and the power of the central authority is greatly strengthened. This, simply, is because achieving equal outcomes demands that the central authority must have the power to take whatever commodity is being equalized from individuals whom it deems undeserving, and give to other individuals whom it deems more deserving. While actually achieving equal outcomes is never really possible, societies that doggedly pursue this end ultimately become tyrannical. This axiom our founders understood perfectly.
If we insist on perfect equality under our universal healthcare system, and forcibly prevent individuals from pursuing their own medical happiness, we will fundamentally redefine what it means to be an American. We will change the essential character of our culture - and of our government.
We should not take this path without careful reflection on what it actually means, both for us and for the generations that follow us.
What should we seek to do, then?
Since insisting on enforced equality in healthcare will undermine the founding principles of our culture, and won’t work besides, a better solution would be to first acknowledge that fact, and then to devise a system that - while incorporating universal access to publicly-funded healthcare - honors the autonomy of individuals to provide for their own well-being, in a way that maintains an acceptable degree of social equity. Such solutions can be imagined.
They will never even be imagined though, let alone achieved, if we allow our political leaders to lure us down the “obvious” path of enforced equality in healthcare, at the cost of individual autonomy. If this is the kind of change we opt for, we’ll be changing America in much more fundamental ways than by just altering our healthcare system.
In a later post we will take up the third and final question we must answer before figuring out how to fix American healthcare: Where’s the rationing?
Note: This is the fourth in a series of posts that discuss healthcare economics, and the three basic questions we will have to answer before we can devise a way to fix American healthcare. The first post in this series can be found here.
Should the Healthcare System be Universal?
March 26th, 2008 by DrRich
As noted in a previous post, there are three basic principles we are going to have to resolve before we can decide on any plan to fix American healthcare. The first of these is: Should the healthcare system be universal? That is, should our reformed healthcare system apply to every individual legally residing in the United States?
DrRich is truly distressed to report that the answer to this question can only be: Yes.
DrRich is constitutionally predisposed against a universal healthcare system. By “constitutional” he refers not only to his own inherent biases, but also to the document produced by our nation’s founders. In that document our founders took pains to preserve individual liberties against the opposite extremes of anarchy and tyranny, and recognized that an indispensable component of personal liberty is personal responsibility.
The personal responsibility that makes personal liberty feasible includes the responsibility to provide for oneself the necessities of life, as well as those nonessential things one typically consumes during the course of one’s lifetime. A society founded on liberty and economic freedom, for instance, requires that products and services consumed by individuals, such as Caribbean cruises, ice cream, food, clothing and healthcare, should be provided by the individuals who are consuming them.
To be sure, in a compassionate society arrangements can and should be made on occasion to support individuals whose circumstances prevent them from supplying themselves with certain necessities of life, such as food and shelter. Healthcare will also often fall into this “necessities of life” category, and therefore a compassionate society will find it salutary to provide such care to some of its citizens on occasion. (Some of what we now deem “healthcare” has aspects more in common with Caribbean cruises than food and shelter, and we seem to have an increasingly difficult time differentiating the essential from nonessential varieties; we will leave this problem aside for purposes of the present discussion, and instead take it up later.) But the desire to help certain of its citizens who are unable to gather some of life’s necessities - a charitable desire that redounds to the civility and well-being of the whole - is a far cry from the duty, or even the desirability, of providing the necessities of life to all people, or even to certain categories of people defined by some arbitrary characteristic (such as age).
There are, of course, philosophical problems in taking what ought to be the responsibility of individuals and handing that responsibility off to society. You can find discussions of these problems by reading the founders. But DrRich is no philosopher, and besides, it appears to him that roughly half of America believes today that society ought to provide the necessities of life to all its citizens. Not wanting to cause unnecessary turmoil among his readership (DrRich being a lover and not a fighter), he will leave philosophy aside and instead rely on the economic question. For, while bad philosophy often smolders for many generations before bringing down a culture, bad economics will do it much quicker.
We have detailed in a previous post the astoundingly dysfunctional economics of American healthcare, and how the fiscal obligations to which we have already agreed are leading us inexorably to destruction. The idea of a further expansion of those fiscal obligations at this point is beyond absurd. (”Beyond absurd,” that is, in the sense that it’s beyond absurd to shoot yourself in the head while falling to your death after jumping off a cliff. Putting a bullet in your brain might normally be considered absurd, but actually it adds very little net harm once you’ve already leapt off a cliff; that is, it’s beyond absurd.)
So, you may be asking, if making the provision of healthcare a societal obligation is morally, philosophically and economically undesirable, then why would DrRich assert that any reform of the healthcare system should be universal?
It’s not because healthcare is necessary for life (since necessities of life ought to be the responsibility of individuals), nor because healthcare is a right (since there is no such thing as a right that requires forcibly reducing the rights of others; such a thing is properly labeled not a right but a tyranny), nor even because healthcare is very desirable (since, after all, so are Caribbean cruises). No - our reformed healthcare system will have to be universal not because of any positive attribute of healthcare itself (not because healthcare, being good, ought to be provided for everybody), but rather because of the negative character of our current healthcare economics.
Because the healthcare obligations we have already signed up for promise fiscal ruin in the foreseeable future, the one non-negotiable requirement of any meaningful healthcare reform we may undertake will be (must be) to restore some real hope of economic stability. (Anything else we may do, including insuring the uninsured, sending men to Mars, defeating terrorism, or achieving energy independence won’t matter if society collapses under the weight of its accumulated healthcare debt.) And saving our society from economic collapse requires a solution that applies to everybody.
In a previous post we saw that the underlying cause of our impending healthcare fiscal crisis is our systematic failure to establish limits. That failure derives directly from our decision - taken over the past 60 years - to collectivize healthcare expenditures. Whether directly (through Medicare and Medicaid), or indirectly (through tax-deductible “private” insurance premiums), the taxpayer is subsidizing virtually all healthcare spending in the U.S. While this arrangement might be fiscally acceptable if we were on a pay-as-you-go basis, the fact that our present unfunded obligation for Medicare alone reaches $34 trillion demonstrates that we are not. By saddling future taxpayers with an enormous fiscal burden that guarantees societal disruption - slapping away that small hand that reaches up for ours - we reveal ourselves as being something other than compassionate conservatives, or compassionate liberals, or compassionate anything. If we fail to limit our appetite for healthcare expenditures that benefit only ourselves, we will be revealed in a decade or two to our own children and grandchildren (not to mention to future historians) as among the most morally repugnant generations in history.
Any real healthcare reform will have to be universal not in order to spread the benefits of healthcare evenly. It will have to be universal because real healthcare reform, fundamentally, will have to be an assertion of limits on publicly-subsidized healthcare. Anyone whose healthcare is subsidized by present or future taxpayers will have to receive their healthcare benefits under this new system of limits. Since it is difficult to imagine anybody today whose healthcare is not so subsidized, any meaningful healthcare reform will have to apply to everybody; it will have to be universal.
Stated another way, healthcare reform must be universal in order to accomplish the one thing that such reform absolutely must accomplish - setting the limits that will allow rising generations of Americans a fair chance at maintaining societal stability. Universality is not required by a concern over healthcare benefits; it’s required by the need to establish real limits.
In future posts we will look at the Fuchs/Emanuel universal voucher system (DrRich’s original assignment), to see how well it meets the “universality” criterion herein defined.
But first we need to consider the second principle that must be resolved before we can effectively reform American healthcare - should our healthcare system be designed to enforce equality, or should it instead permit Americans to exercise their autonomy as individuals?
Note: This is the third in a series of posts that discuss healthcare economics, and the three basic questions we will have to answer before we can devise a way to fix American healthcare. The fourth post in this series, “Should We Aim For Equality or Autonomy in Healthcare?” can be found here. The first post in this series can be found here.