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Dr. Val’s Take On The Medical Ethics Debate: America’s A Funny Place

god-bless-americaDr. Rich recently posted a 3-part series on the shortcomings of medicine’s new ethics. While I personally find Dr. Rich’s writing style both nuanced and entertaining, there is no doubt that his posts require some focused attention. And so I thought I’d provide a “Cliff’s Notes” version for my regular readers (since Google analytics tells me they are unlikely to spend more than 2 minutes here at a time). ;-)

Advances in science and technology have provided us with valuable new treatment options for many diseases and conditions. Unfortunately, these new drugs, devices, and procedures are so expensive that we cannot (as a country) afford to make them accessible to everyone who could benefit from them. Medical technology has outpaced our ability to pay for it. This leaves us with an ethical dilemma: how do we ration access to modern medicine?

Dr. Rich argues that America must face this dilemma head-on, and agree to overt-rationing of services. Other industrialized nations have done this to greater and lesser extents. However, Americans appear to lack the will to discuss such an approach – preferring to believe that the best care can be offered to everyone, if we only reduced the wastefulness in the current system.

The ACP has expanded the definition of medical ethics from a physician-patient contract (where a physician becomes a fully committed advocate for the best interests of each individual patient) to a physician-patient-society contract (where a physician should also consider allocation of scarce resources, avoiding unnecessary testing, and adopting evidence-based practices when caring for an individual patient).

Dr. Rich argues that a physician can’t honor the best interests of each patient and also ration their access to certain treatments so as to save money for society. The ACP argues that the physician must be judicious in her use of scarce resources so as to preserve access to as many treatments for as many patients as possible.

My opinion, in summary, is this:

1. Dr. Rich is right – medicine has evolved to such a high-tech state that we cannot afford to offer expensive treatments to everyone who might benefit. Therefore, we must ration care. Currently, we are rationing care covertly – which results in the unfair distribution of resources. Access is largely dependent on healthcare navigation-savvy, determination, wealth, and luck.

2. The ACP is right – physicians should try to be less wasteful of scarce resources, and use the best evidence available to target therapy to need. Practice variation (and its associated costs) could be reduced significantly if all physicians adhered to stricter decision-support guidelines.

3. America has not yet accepted the fact that we truly can’t afford to give each patient every drug/treatment/service that might benefit them. The resulting covert rationing undermines the ethical principles of societal beneficence and distributive justice. And, as Dr. Rich rightly points out, physicians are regularly forced to subject their ethical principles to the powers of covert rationing (e.g. sorry that drug is not on formulary or that test is not covered).

4. Judging from our obvious commitment to covert rationing, it is clear that Americans would rather have the potential for access (reserved for those who have the will/savvy/drive/money to navigate this perilous system) available to all, than a nationally agreed-upon access algorithm based on demographic data (e.g. if you’re over 65 you don’t get a kidney).

America’s a funny place – reward for struggle is in our DNA, and our healthcare system is designed to yield its best care to those who fight for it. Maybe that’s not fair, but that’s what we’ve got. And good luck changing it anytime soon.

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3 Responses to “Dr. Val’s Take On The Medical Ethics Debate: America’s A Funny Place”

  1. hgstern says:

    Dr Val:

    Great analysis of DrRich’s piece (BTW, he’s my fav for the MedBlog awards). I think the most important thing you said is:

    “our healthcare system is designed to yield its best care to those who fight for it.”

    It’s an extension of something which we push quite often at IB: personal responsibility.

  2. What is not spam? I cannot seem to make any comment.

  3. Of course, there is rationing, and it’s not just covert. Everyone understands in theory that we cannot afford every medical benefit for every patient, yet the individual patient in need may want or expect it all. While I acknowledge that the medical community should be mindful of preserving health resources for society, I am not certain that this concern should be present in the exam room when we are advising an individual patient. At that moment, we are advocating for an individual human being, rather than for the community at large. To do otherwise, would pose a conflict that would not serve the patient’s interest. Physicians are free to speak out about national health policy – and we should – but not in our exam rooms. This is one reason why many of us blog.

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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.


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