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British TV Character Worth Watching: Doc Martin

No, not the shoes. The British TV series.

Martin is surgeon, whose glittering career comes crashing down around him when he develops a phobia which prevents him conducting operations. He makes a life changing decision to retrain as a GP, and applies for a vacant post in the sleepy Cornish hamlet of Portwenn, where he spent childhood holidays.

Doc Martin is as grumpy, short-tempered and brilliant as House, and while he has no cadre of residents to torture, he does have a town full of varied and wonderful characters to annoy him. And of course, there’s a love interest.

We’ve barely started watching, and already there have been these memorable lines -

Patient – Am I your first official patient?
Doc Martin – You are indeed. Collect a thousand loyalty points and you get a free coffin. Read more »

*This blog post was originally published at The Blog That Ate Manhattan*

Dr. Lisa Sanders: Medical Detective

If you follow me regularly, you know I enjoy watching the Fox television drama House M.D. on Monday nights (although I often watch the recording later in the week). Doctor Gregory House (Hugh Laurie) is a sorry character but a terrific diagnostician.  In almost every episode someone is on the brink of death from an elusive illness when House’s “light bulb” goes on and, in a flash, he saves the patient’s life by proving himself to being the world’s best medical detective.

Doc Hollywood

Doc Hollywood???

Dr. Lisa Sanders is watching 3,000 miles away in New Haven, Connecticut where she teaches first and second year med students at Yale how to learn to be House-type medical detectives – but much more respectful ones. She is like that herself. She’s so good at it she writes a medical column for The New York Times Magazine. That column was actually the inspiration for the television show. And it won Dr. Sanders a job as technical adviser on the medical drama. Read more »

*This blog post was originally published at Andrew's Blog*

Niche Science And Targeted Medicines Vs. “Magic Bullets”

Maybe you read the other day in The New York Times that the pharmaceutical industry has a problem. Big blockbuster drugs like Lipitor are going off patent and the industry leaders don’t have new blockbusters showing promise to replace them. So the big companies search for little companies with new discoveries and they consider buying them. Industry observers think the days of $5 billion-a-year drugs to lower cholesterol or control diabetes may be past for awhile, and the companies will have smaller hits with new compounds for autoimmune conditions and cancer.

When I saw my oncologist for a checkup yesterday — the news was good — we chatted about the article and the trend toward “niche science.” We welcomed it. We didn’t think — from our perspective — the world needed yet another drug to lower cholesterol. We need unique products to fight illnesses that remain daunting, some where there are no effective drugs at all. For example, my daughter has suffered for years from what seems to be an autoimmune condition called eosinophilic gastroenteritis (EGID). Her stomach gets inflamed with her own eosinophil cells. They would normally be marshaled to fight a parasite in her GI tract but in this case, there’s nothing to attack. So the cells make trouble on the lining of the stomach and cause pain and scarring. Right now, there’s no “magic bullet” to turn off these cells. My hope is some pharma scientists will come up with something to fill this unmet need.

In the waiting room before I saw my doctor at the cancer center in Seattle I overheard a woman on the phone speaking about her husband’s new diagnosis of pancreatic cancer. I was sitting at a patient education computer station nearby. When she was finished I introduced myself and showed her some webpages to give her education and hope: pancan.org and our Patient Power programs about the disease. She was grateful. I did tell her — and she already knew — that there was no miracle drug for pancreatic cancer and that it was a usually-fatal condition. But that there were exceptions and, hopefully, her husband would be one. Of course, wouldn’t an effective medicine be best? Read more »

*This blog post was originally published at Andrew's Blog*

In The News: Boosting Disease Prevention And Unethical TV Doctors

An article in the New York Times this week looks at a raft of new public health initiatives passed by Congress that are aimed at boosting disease prevention. Examples include requiring restaurants with at least 20 locations to include nutrition information on their menus and mandating employers with at least 50 employees to allow new mothers to express breast milk at work. In addition, Medicaid will now cover smoking cessation counseling for pregnant women and Medicare beneficiaries will be eligible for an annual physical. The initiatives are expected to eventually save money by decreasing the country’s chronic disease burden. (New York Times)

Researchers from Johns Hopkins University recently did a study applying physicians’ ethical codes to the conduct of the fictional doctors on “Grey’s Anatomy” and “House, M.D.” Perhaps to no one’s surprise, TV doctors are behaving very badly. As the abstract of the study states, both shows feature “egregious deviations from the norms of professionalism and contain exemplary depictions of professionalism to a much lesser degree.” (Philadelphia Inquirer, Journal of Medical Ethics)

*This blog post was originally published at ACP Internist*

Ethics Essay: Why Does America Love Dr. House?

DrRich thanks the Cockroach Catcher (his favorite retired child psychologist) for pointing him to an article (by Mark Wicclair, a bioethicist) and an accompanying editorial (by Deborah Kirklin, a primary care physician) in the peer-reviewed medical journal, Medical Humanities, which deconstruct the television show “House MD.”

A TV show may at first glance seem a strange subject for a medical journal, but this is, after all, a journal whose subject is the “softer” side of medical science. (DrRich hopes his friend the Cockroach Catcher will take no offense at this characterization, and directs him, in the way of an apology, to the recent swipes DrRich has taken at his own cardiology colleagues for their recent sorry efforts at “hard” medical science.)  Besides, the Medical Humanities authors use the premise and the popularity of “House MD” to ask important questions about medical ethics, and the consequent expectations of our society.

DrRich does not watch many television shows, and in particular and out of general principles he avoids medical shows. But he has seen commercials for House, and has heard plenty about it from friends, so he has the gist of it. The editorial by Dr. Kirklin summarizes:

“[House] is arrogant, rude and considers all patients lying idiots. He will do anything, illegal or otherwise, to ensure that his patients—passive objects of his expert attentions—get the investigations and treatments he knows they need. As Wicclair argues, House disregards his patients’ autonomy whenever he deems it necessary.”

Given such a premise, the great popularity of “House MD” raises an obvious question.  Dr. Kirklin:

“… why, given the apparently widely-shared patient expectation that their wishes be respected, do audiences around the world seem so enamoured of House?”

Indeed. While it has not always been the case, maintaining the autonomy of the individual patient has become the primary principle of medical ethics. And medical paternalism, whereby the physician knows best and should rightly make the important medical decisions for his or her patient, is a thing of the past.

It has been formally agreed, all over the world, that patients have a nearly absolute right to determine their own medical destiny. In particular, unless the patient is incapacitated, the doctor must (after taking every step necessary to inform the patient of all the available options, and the potential risks and benefits of each one) defer to the final decision of the patient – even if the doctor strongly disagrees with that decision. Hence, the kind of behavior which is the modus operandi of Dr. House should be universally castigated.

So, the question is: Given that House extravagantly violates his patients’ autonomy whenever he finds an opportunity to do so, joyfully proclaiming his great contempt for their individual rights, then why is his story so popular? And what does that popularity say about us?

To DrRich, the answer seems quite apparent.

The notion that the patient’s autonomy is and ought to be the predominant principle of medical ethics, of course, is entirely consistent with the Enlightenment ideal of individual rights. This ideal first developed in Europe nearly 500 years ago, but had trouble taking root there, and really only flowered when Europeans first came to America and had the opportunity to put it to work in an isolated location, where rigid social structures were not already in place. The development of this ideal culminated with America’s Declaration of Independence, in which our founders declared individual autonomy (life, liberty and the pursuit of happiness) to be an “inalienable” right granted by the Creator, and thus predating and taking precedence over any government created by mankind. And since that time the primacy of the individual in American culture has, more or less, remained our chief operating principle. Individual autonomy – or to put it in more familiar terms, individual freedom – is the foundational principle of our culture, and it is one that is perpetually worth fighting and dying to defend.

So the idea that the autonomy of the individual ought rightly to predominate when it comes to making medical decisions is simply a natural extension of the prime American ideal. Of course, most think, this ought to be the governing principle of medical ethics.

But unfortunately, it’s not that easy. There’s another principle of medical ethics that has an even longer history than that of autonomy – the principle of beneficence. Beneficence dictates that the physician must always act to maximize the benefit – and minimize the harm – to the patient. Beneficence recognizes that the physician is the holder of great and special knowledge that is not easily duplicated, and therefore has a special obligation to use that knowledge – always and without exception – to do what he knows is best for the patient. Dr. House is a proponent of the principle of beneficence (though he is caustic and abrasive about expressing it).  DrRich believes House is popular at least partly because the benefits that can accrue to a patient through the principle of beneficence – that is, through medical paternalism – are plain for all to see.

Obviously the principles of beneficence and of individual autonomy will sometimes be in conflict.  When two worthwhile and legitimate ethical principles are found to be in conflict, that is called an ethical dilemma. Ethical dilemmas are often resolved either by consensus or by force. In our case, this dilemma has been resolved (for now) by consensus. The world community has deemed individual autonomy to predominate over beneficence in making medical decisions.

DrRich’s point here is that Dr. House (the champion of beneficence) is not absolutely wrong. Indeed, he espouses a time-honored precept of medical ethics, which until quite recently was THE precept of medical ethics. There is much to be said for beneficence. Making the “right” medical decision often requires having deep and sophisticated knowledge about the options, knowledge which is often beyond the reach of many patients. And even sophisticated patients who are well and truly medically literate will often become lost when they are ill, distraught and afraid, and their capacity to make difficult decisions is diminished. Perhaps, some (like House) would say that their autonomy ought not be their chief concern at such times. Indeed, one could argue that in a perfect world, where the doctor indeed has nearly perfect knowledge and a nearly perfect appreciation of what is best for the patient, beneficence should take precedence over autonomy.

It is instructive to consider how and why autonomy came to be declared, by universal consensus, the predominant principle of medical ethics. It happened after World War II, as a direct result of the Nuremberg Tribunal. During that Tribunal the trials against Nazi doctors revealed heinous behavior – generally involving medical “research” on Jewish prisoners – that exceeded all bounds of civilized activity. It became evident that under some circumstances (circumstances which under the Nazis were extreme but which were by no means unique in human history) individual patients could not rely on the beneficence of society, or the beneficence of the government, or the beneficence of their own doctors to protect them from abuse at the hands of authority. Thusly was the ethical precept which asks patients ultimately to rely on the beneficence of others starkly revealed to be wholly inadequate. The precept of individual autonomy, therefore, won by default.

Subsequently, the Nuremberg Code formally declared individual autonomy to be the predominant precept in medical ethics, and beneficence, while also important, to be of secondary concern. Where a conflict occurs, the patient’s autonomy is to win out. It is important to note that this declaration was not a positive statement about how honoring the autonomy of the individual represents the peak of human ethical behavior, but rather, it was a negative statement. Under duress, the Nuremberg Code admitted, societies (and their agents) often behave very badly, and ultimately only the individual himself can be relied upon to at least attempt to protect his or her own best interests.

DrRich will take this one step further. When our founders made individual autonomy the organizing principle of a new nation, they were also making a negative statement. From their observation of human history (and anyone who doubts that our founders were intimately familiar with the great breadth of human history should re-read the Federalist Papers), they found that individuals could not rely on any earthly authority to protect them, their life and limb, or their individual prerogatives. Mankind had tried every variety of authority – kings, clergy, heroes and philosophers – and individuals were eventually trampled under by them all. For this reason our founders declared individual liberty to be the bedrock of our new culture – because everything else had been tried, and had failed. In the spirit of the enlightenment they agreed to try something new.

There is an inherent problem with relying on individual autonomy as the chief ethical principle of medicine, namely, autonomous patients not infrequently make very bad decisions for themselves, and then have to pay the consequences. The same occurs when we rely on individual autonomy as the chief operating principle of our civil life. The capacity of individuals to fend for themselves – to succeed in a competitive culture – is not equal, and so the outcomes are decidedly unequal. Autonomous individuals often fail – either because of inherent personal limitations, bad decisions, or bad luck.

So whether we’re talking about medicine or society at large, despite our foundational principles we will always have the tendency to return to a posture of dependence – of relying on the beneficence of some authority, in the hope of achieving more overall security or fairness – at the sacrifice of our individual autonomy. In DrRich’s estimation the popularity of “House MD” is entirely consistent with this tendency. (Indeed, the writers almost have to make Dr. House as unattractive a person as he is, just to temper our enthusiasm for an authority figure who always knows what is best for us and acts on that knowledge, come hell or high water.)

Those of us who defend the principle of individual autonomy – and the economic system of capitalism that flows from it – all too often forget where it came from, and DrRich believes this is why it can be so difficult to defend it. We – and our founders – did not adopt it as the peak of all human thought, but for the very practical reason that ceding ultimate authority to any other entity, sooner or later, guarantees tyranny. This was true in 1776, and after observing the numerous experiments in socialism we have seen around the world over the past century, is even more true today.

Individual autonomy will always be a very imperfect organizing principle, both for healthcare and for society at large. Making it an acceptable principle takes perpetual hard work, to find ways of smoothing out the stark inequities, without ceding too much corrupting power to some central authority. This is the great American experiment.

Those of us who have the privilege of being Americans today, of all days, find ourselves greatly challenged. But earlier generations of Americans faced challenges that were every bit as difficult. If we continually remind ourselves what’s at stake, and that while our system is not perfect or even perfectable, it remains far better than any other system that has ever been tried, and that we can continue to improve on it without ceding our destiny – medical or civil – to a corruptible central authority, then perhaps we can keep that great American experiment going, and eventually hand it off intact to yet another generation, to face yet another generation’s challenges.

*This blog post was originally published at the Covert Rationing Blog.*

Latest Interviews

How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

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How To Make Inpatient Medical Practice Fun Again: Try Locum Tenens Work

It s no secret that most physicians are unhappy with the way things are going in healthcare. Surveys report high levels of job dissatisfaction burn out and even suicide. In fact some believe that up to a third of the US physician work force is planning to leave the profession…

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Latest Cartoon

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.

***

Click here for a musical take on over-testing.

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The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

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Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

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Unaccountable: A Book About The Underbelly Of Hospital Care

I met Dr. Marty Makary over lunch at Founding Farmers restaurant in DC about three years ago. We had an animated conversation about hospital safety the potential contribution of checklists to reducing medical errors and his upcoming book about the need for more transparency in the healthcare system. Marty was…

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