January 28th, 2009 by Dr. Val Jones in Opinion, Primary Care Wednesdays
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By Steve Simmons, M.D.
When I graduated from the University of Tennessee’s Medical School sixteen years ago, my last act as a student was to take the Oath of Hippocrates with my classmates and 98% of the other medical students graduating in the United States that year. This oath still resonates within me today and connects me to all physicians reaching back over 2,500 years to the time of Hippocrates.
Implicit in an oath is the understanding that the profession chosen will require more sacrifice than the average vocation, that the occupation’s rewards should be more than a paycheck, and that a paycheck would impart less value than the enrichment gained from nobly serving others. The high standard which society holds physicians to is still accurately described by the Hippocratic Oath. Regardless of what changes seep into our profession from outside influences, doctors will always be held to the ideals written in the Hippocratic Oath.
When I was a young medical student, the hope that becoming a physician would bring value and meaning to my life was more rewarding than thoughts of job security or financial stability. This helped propel me and my classmates through many long nights of study. One sentiment oft-heard in my medical school, and I suspect many medical schools today, was that no one would put up with ‘this’ just for money–usually stated prior to a re-doubling of the effort to get past a particularly challenging task. Painful physical effort often was required, such as waking at 3AM to make hospital rounds, or spending 24-hour long shifts stealing naps and bathroom breaks, sometimes even working over 100 hours a week during demanding rotations. Steven Miles, a physician bioethicist, wrote, “At some level, physicians recognize that a personal revelation of moral commitments is necessary to the practice of medicine.”
I would proffer that few students would endure the sacrifices necessary to graduate without understanding this point.
In Paul Starr’s 1982 book, The Social Transformation of American Medicine, he stated that in the future the goal of the health industry would not be better health, but rather the rate of return on investments. This unfortunately has come to pass. Arguably, medicine now is controlled by CEOs and other executives in the health industry — individuals who are not expected to take an oath. Physicians, remaining loyal to the Oath, are an unwitting weak and junior partner in today’s health care industry. Worse, doctors are now employees, often seen as interchangeable parts with one doctor considered no different than another. Third party providers in the health care industry fail to place any value on the personal interactions between doctor and patient. It may be better that the CEOs of health insurance companies are not required to take an oath, since many are on record, admitting loyalty to the share-holder alone with profits their first consideration.
Before the Great Depression, only 24% of the U.S. medical school graduates were given the Oath at graduation. Does this suggest they were less ethical? I don’t think so. I believe the increased use of the Oath demonstrates a growing awareness on the part of our educators that business has taken a controlling interest in the practice of medicine and that their graduates should be reminded that society still expects them to deliver on the noble promises of the past. Hippocrates’ Oath helped pry medicine away from superstition and the controlling interests of Greece’s priesthood in the fifth century B.C. Hippocrates plotted a course towards science using inductive reasoning while his Oath anchored his fledgling art on moral truths unassailable even today. I suspect he would see little difference between those profiting within the priesthood of his day and those monopolizing healthcare today. He would find familiarity in those putting forth their difficult-to-decode rules of reimbursement, recognizing these rules as intentionally confusing, pejorative, and detrimental to patients and physicians alike while profiting those few in control.
How would Hippocrates advise today’s students and physicians when shown how monetary realities have finally subsumed us all? He might remind us that money was not our motivation in pursuing this career and show us how a return to the reverence for our art, embodied by the Oath, could become a modern conveyance to the ideals of the past. By regaining our reverence for what motivated and guided us through medical school and residency we should find ample courage to do whatever is necessary. Much is needed to wrest control of today’s broken healthcare system from those making huge profits…. and an oath can remind us why it is important.
Until next time, I remain yours in primary care,
Steve Simmons, MD
January 27th, 2009 by Dr. Val Jones in Announcements, Audio, Expert Interviews
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Better Health’s policy writer, Gwen Mayes, caught wind of an interesting new conference being held tomorrow in Miami. She interviewed Ken Thorpe, Ph.D., one of the conference organizers, to get the scoop. You may listen to a podcast of their discussion or read the highlights below. I may get the chance to interview Billy Tauzin and Donna Shalala later on this week to get their take on healthcare reform initiatives likely to advance in 2009. Stay tuned…
[Audio:http://blog.getbetterhealth.com/wp-content/uploads/2009/01/gwenken2127.mp3]
Mayes: Tell us about the upcoming conference in Miami on January 28th called “America’s Agenda: Health Care Policy Summit Conversation.”
Thorpe: The conference will start a conversation on the different elements of health care reform such as making health care more affordable and less expensive, finding ways to improve the quality of care and ways to expand coverage to the uninsured. The conference is unique in that we’ve brought together a wide range of participants including government, labor, and industry for the discussion, many of whom have been combatants over this issue in the past.
Mayes: Will there be other meetings?
Thorpe: This is the first of several. There will others in other parts of country over next several months. President Obama and HHS Secretary Designee Tom Daschle have talked about engaging the public in the discussion this time around. So part of this is an educational mission and part of it is to reach consensus among different groups that have not always agreed in the past.
Mayes: What encourages you that these groups will be more likely to reach consensus now when they haven’t in the past?
Thorpe: The main difference is that the cost of health care has gotten to the point that many businesses and most workers are finding it unaffordable. In the past, most businesses felt that, left to their own devices, they could do a better job of controlling health costs by focusing on innovated approaches internally. What we’ve found, despite our best efforts, working individually we haven’t done anything to control the growth of health care spending. The problems go beyond the reach of any individual business or payer and we need to work collectively.
Mayes: How will health care reform remain a priority in this economy?
Thorpe: The two go hand in hand. As part of our ability to improve the economy we’re going we have to find a way to get health care costs down. Spiraling costs are a major impediment to doing business and hiring workers. To the extent we can find new ways to afford health care it will be good for business and workers.
Mayes: Health information technology is also an important aspect. What are the common stumbling blocks to moving forward?
Thorpe: There are three issues we have to deal with. First, we have to have a common set of standards for how the information flows between physicians and physicians, and with payers and hospitals. What we call interoperability standards. Second, we have to safeguard the information. Finally, cost is the biggest challenge because most small physician practices of 3 or 4 physicians don’t have electronic record systems in place. To put in a state-of-the-art system can cost $40,000 per physician and most cannot afford this expense. I think the stimulus bill will provide funds to help with these costs.
Mayes: There’s always growing interest in the patient’s role. How will this be addressed?
Thorpe: We have to find a better way to engage patients in doing better job of reducing weight, improving diet and those with chronic disease to follow their care plan they worked out with their physician. We also want to make it more cost effective for patients to comply with the plan. Patients who comply with health plans will have better outcomes at lower costs.
Mayes: Who’s on the agenda in Miami?
Thorpe: It’s at the University of Miami so it will be hosted by President Donna Shalala who was Secretary of HHS under the Clinton administration so she is well versed on health policy. Also attending is the head of PhRMA, Billy Tauzin, a former Congressman and former majority leader of the House, Dick Gephart. There will be some lay people as well for a nice cross section of consumers, labor, providers, business and others.
Mayes: How can people learn more about American’s Agenda and the conference?
Thorpe: The executive director of American’s Agenda is Mark Blum. He can be reached at 202-262-0700 or at America’s Agenda.org.
January 27th, 2009 by Dr. Val Jones in Uncategorized
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My favorite blog posts of the past week or so, organized loosely by topic/theme. Enjoy!
Kids Dying From Vaccine-Preventable Illnesses:
Dr. Rob: These parents probably thought “what’s the harm? Why can’t we just wait to do the immunizations until the risk is less?” A 7-month-old infant died from this logic.
Dr. Whitecoat: Should parents who fail to take steps to prevent a largely preventable illness be held accountable if their children suffer a bad outcome?
Rules Meant To Be Broken
Dr. Scalpel: Protocol-driven medical decision-making is always going to be inferior to expert clinical judgment. This is also one of the reasons you should be suspicious of the current fad of the various “accreditation” merit badges hospitals proudly display. They are equally worthless.
Increased Costs Without Increased Value
Paul Levy: Now, let’s acknowledge that MGH and the Brigham are powerful brands. To the extent patients are influenced by that reputation or other factors to migrate to the PHS facility from Norwood Hospital, the overall health care bill for the state will rise for no documented additional value to those patients or society.
Dr. Wes: According to the Illinois Fair Patient Billing Act, hospitals can charge 35% above cost for services provided to the uninsured. The natural question we should ask, then, is why the insured should have to pay “full price” if a profit margin is already built into the price offered to the uninsured.
The reason, of course, is simple: someone has to pay for the insurer’s offices and staff salaries, don’t they?
10 out of 10: The cost of confirming the obvious: The scan came back showing “likely early appendicitis.” I examined her yet again and she now had clear localization to the right lower quadrant. Lucky for me it was positive I thought, at least now I won’t get dinged for overtesting.
Rural Doctoring: Noo’s chart missing most of the pathology reports from her recent procedures, despite the 25 phone calls made to various providers offices to release this information. However, I am an excellent historian and fill in the blanks.
The Best Sarcastic Blog Post Of The Week
Edwin Leap: The Leap non-severity score.
Anti-Quackery Efforts
Dr. Dinosaur: If the next Surgeon General were to adopt the elimination of Quackery — whether known as “alternative,” “natural,” “complementary” or “integrative” medicine — as his or her major issue, that bully pulpit might help generate enough of a popular political groundswell to overcome the few credulous members of Congress who pushed the whole thing onto us in the first place.
Somehow, I don’t think Sanjay Gupta is up for that, so I hope President Obama picks someone else.
Science Based Medicine: NCCAM not only funds studies of dubious “alternative” therapies, such as reiki and homeopathy, that estimates of prior probability alone would argue to be so close to impossible as to be not worth spending millions, much less thousands, of dollars upon, but it also promotes quackery by funding “fellowships” at various institutions to teach “complementary and alterantive medicine” (CAM) sometimes also called “integrative medicine” (IM). Given that it spends over $120 million a year on mostly dubious studies and CAM promotion, we all have called for NCCAM to be defunded and disbanded.
Weird Factoid
ACP Internist: Brown recluse spiders only bite when you press against them.
Scary Death
KevinMD: Although most infectious disease specialists acknowledge that contracting a Pseudomonas infection outside the hospital is not common, this is a sobering reminder that drug-resistant infections are not only possible, and may be on the rise.
January 26th, 2009 by Dr. Val Jones in Uncategorized
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When I was invited to join a blog conference at the Consumers Union headquarters in Yonkers, I had no idea what to expect. It hadn’t dawned on me that the company is as large as it is – employing 630 people (most of whom work out of the warehouse-sized building in NY) with a 60 million dollar/year budget. The facility itself is a beehive of product testing labs – with rooms devoted to the analysis of product performance for everything from washing machines to baby strollers.
And what were health bloggers doing in the midst of this? Apparently Consumer Reports is dipping their toe into the health ratings game, and they wisely decided to ask providers what they made of that. I explained my experience with the lack of consumer incentives to rate doctors – and offered a cautionary tale of a failed rating database at my previous company. Others suggested that quality ratings are impossible to quantify without consistent data reporting, and that care is provided to most patients by teams of providers, not one single physician, so ratings might not mesh well with outcomes anyway.
We had a productive discussion with familiar faces and old friends (Jan Gurley, Micheal Breus, Edwin Leap, Dr. Rob, Amy Tenderich, Scott Hensley, Julie Deardorff, Alvaro Fernandez, Jennifer Huget, Wendy Lawson, Craig Newmark, Gary Schwitzer, and others) but my favorite part of the program involved cookie taste- testing.
We bloggers all filed in to the sensory testing lab and were asked to sample some commercial chocolate chip cookies. Each of us had our own little plastic container with two cookies inside, and we were instructed to taste and describe them in as detailed a manner as possible. I offered “chalky” as my adjective of choice, and Scott Hensley (of the Wall Street Journal Health Blog) seconded my notion as another blogger added “chemically.”
There was general consensus that we didn’t like the cookies – and we began inquiring as to their brand name. The Consumer Reports lab director dutifully declined to disclose the manufacturer’s name, at which point Scott Hensley reached into a nearby garbage can and produced an empty cookie package. He held the wrapper aloft and asked with gleeful sarcasm: “Might it be this brand here?”
We all burst into laughter as a triumphant Hensley proved his investigative reporting skills in the midst of us. It was one of those surreal moments that you never forget.
But on a more serious note, I was struck by the scientific approach that Consumers Union takes in its product testing. It struck a chord with me since I worry about the evidence (or lack thereof) behind certain medical practices and treatments. The Internet seems to be teaming with subjectivity rather than tested and true information. How are consumers to know what’s real anymore?
I certainly hope that companies like Consumers Union can weather the financial storms and continue to empower people with carefully tested, controlled, and unbiased information. Without them we’re left with a bunch of anecodotes in a sea of opinion. Perhaps physicians and health scientists have more in common with Consumers Union than we know? I for one am convinced that our common interests go even deeper than chocolate chip cookies.
January 24th, 2009 by Dr. Val Jones in Book Reviews
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Laurie Edwards has an extremely rare disorder called primary ciliary dyskinesia (PCD). The condition causes similar signs and symptoms to cystic fibrosis (CF), including chronic lung infections and difficulty breathing. In her recent book, Life Disrupted: Getting Real About Chronic Illness In Your Twenties And Thirties, Laurie invites readers to experience her life as a chronically ill young woman. She spares no gory details:
I had to wear the probe for forty-eight hours to see if irregularities in my GI tract were contributing to my breathing problems. It was an awkward contraption, and just as I finished speaking, I sneezed. Because of the tubes, I couldn’t control it well and a bloody mess spewed out of my nose and onto my shirt. I looked down at the mess and up at John.
‘Sexy, huh?’ I asked, completely mortified.
But beyond the raw realities of her illness (including the regular disruption in her education, her unfulfilled longings to “fit in,” and her lack of control of her circumstances), is the amazing story of the people who love her. Life Disrupted‘s ironic subtext is the unshakable support of her family and friends.
From her earliest first moments at home, Laurie’s brother “spent hours standing guard at her bassinet, as if to reassure her mother nothing would happen to her.” As she grew older, her brother continued his protective commitment, promising to always be ready to help her in any time of need. Laurie’s parents had a strong and loving marriage, and their patience and kindness were a constant source of security and comfort.
Laurie’s husband shows incredible stoicism and endurance – undeterred by her diagnosis (which she revealed to him unwittingly on their first date), he learns how to give her chest physical therapy by week three of their relationship, and remains calm during a dangerous near-suffocation episode.
He was perfect. He did not get flustered, did not panic, just got me home as quickly as possible, unlocked my door, and ran to set up the nebulizer. He clapped me while I positioned myself with the nebulizer mask and tubing, trying to manually break up the thick mucus that cut off my air supply.
My favorite part of Life Disrupted is its humor. Laurie does an admirable job of capturing the amusing banter that she and her friends used to lighten the mood:
My friends and I refer to my nebulizer and oxygen face mask in the hospital as the “Super Bong.”
And my favorite sentence of the book is this one:
It was a container of honey mustard salad dressing that turned out to be my Waterloo, the moment of my crushing, flabbergasting defeat.
Laurie’s life – disrupted by chronic illness – is charming, vibrant, and rich in affection. The disruption itself is perhaps diminished by the connectedness of her family and friends – a healthy emotional backdrop to the physical illness at center stage. In the end, Life Disrupted offers compelling evidence that love really can conquer all.
By Steve Simmons, M.D.
