August 17th, 2009 by DrRob in Better Health Network, Health Policy, Opinion
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Death panels. They are all the trend these days.
I went to Home Depot to look for some, but couldn’t find any. There was some drywall of doom, tiles of the abyss, and sheet rock of destruction, but no panels. I guess the Obama administration has bought them all.
Honestly, I am not sure what the “death panel” fuss is about. Everyone dies. There are times it is a surprise, but many times it is expected. When it is expected, shouldn’t people plan for it? Shouldn’t we encourage people to plan for it?
The focus of a physician is twofold: to prolong life and to minimize suffering. We practice preventive medicine to keep the person from avoidable pain and/or death. The younger the patient is, the more we call their death things like tragic, pointless, and distressing. We go to great lengths to save the life of someone who has many potential years ahead.
But there is a point when things change. There is a point when the focus shifts from quantity of life to quality of life. There is a time after which a death is no longer tragic, but instead the end of a story. My focus as a physician shifts from trying to find and prevent disease, to maximizing function and minimizing pain. When does this happen? It depends on the health of the patient. But eventually, ignoring one’s inevitable end becomes more tragic than the end itself.
I had a man in my practice who had advanced Alzheimer’s disease. I cared for him before he started his decline, and so had a good chance to know both him and his family. They were people of strong faith, accepting the hard things in life as being from the hand of God. The children took their father’s condition not as a horrible burden, but an opportunity to pay back the man who had given them so much. There was no fear of illness or death.
His wife died fairly soon after I started caring for them. He grieved greatly when she died, but was so surrounded with the love of their children that his grief was short. He spoke often of her in subsequent visits, talking about her as if she was not far away.
As he became increasingly short in his memory, my relationship with their children grew. You can tell a lot about people from their children, and these children were a dazzling crown of honor to these two lovely people.They always came asking good questions, patiently dealing with their father’s confusion, anxiety, and occasional outbursts. Together we worked to maximize his quality of life. When I suggested we stop cholesterol medication and cancer screening tests, they understood. Our focus would not be on the length of life, but the quality of time they could spend with their father.
I was shocked, therefore, when the report of his admission to the hospital came across my desktop. He had chest pains and some difficulty breathing. In the emergency room, a plethora of lab tests, x-rays, and other studies were done. The hospitalist physician on call felt there was a good possibility of heart attack or pulmonary embolism (blood clot to the lung). My patient was sent to the ICU, where he underwent CT angiography, serial lab tests, and even a stress test to rule out heart problems.
I was mystified as I read these reports; the family clearly understood that prolonging his life wasn’t the goal. The patient was ready to die and join his wife, and the children were very comfortable talking about his eventual death. These reports made absolutely no sense with what I knew of this man and his family.
He looked his normal self when he came in to my office for a hospital follow-up. I questioned the daughter about the details of the admission, which she recounted carefully. Then I paused and asked her, “Can I ask you one more thing?”
She smiled at me, “Of course, Dr. Rob” she said gently.
“I was honestly a little surprised when I read about your father’s admission to the hospital. It seems like they pulled out all the stops, even putting him in the ICU. Did they ask you if this is what you wanted? I thought that you wouldn’t want to be that aggressive.”
She thought about what I said and a puzzled expression slowly appeared on her face.
“Did you ask to have everything done, or did you just follow what the doctors at the hospital told you?” I asked.
“They didn’t ask us. We just did what they told us we needed to do.” she said, now scowling slightly.
I explained to her that they need to make their wishes known in advance. If they don’t say anything, the doctors will assume that you agree with what they are doing. As I told her this, she nodded and looked down sadly.
“It’s OK what you did” I reassured her. I patted her father on the shoulder and added, “he looks great now. I am glad I get to see him again. I just want you to know what to do if it happens in the future. You never know what will happen, and I’d hate for him to suffer needlessly.”
This one short hospital stay undoubtedly amassed a bill many times that of all my bills over the 12 years I saw him in my office. My years of care, long conversations, and real personal connection built with this man and his family are worth only a fraction of a few days of unnecessary care. This care was not demanded by the family. It was not done because of denial or ignorance; it was because the family wasn’t prepared for the mechanics of the hospital stay. I never had that conversation with the family until after this event.
Politicians have labeled this merciful conversation as an act of rationing. That is not only ignorant, it is shameful. Talking to people about end-of-life issues will certainly save money. But it’s a contemptible step to imply that this money is saved by killing the elderly. It’s more wrong to make money off of keeping them alive unnecessarily than it is to save money by letting them die when they choose.
This is politics at its ugliest – taking a provision that will reduce suffering and help people and pervert it to be used as a tool to scare the people it will help. The discussion about healthcare has been subverted by those who want poll numbers.
Shame on you.
*This blog post was originally published at Musings of a Distractible Mind*
August 10th, 2009 by DrRob in Better Health Network, Opinion
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Let me kick the hornets’ nest again. I still have misgivings about sending information like this to my patients:
How does one not trained in what to overlook interpret the above? To me, this lab result is entirely expected for this patient – given the other medical history that is there. My concern is that this will either cause unneeded worry, or it would prompt a phone call to ask about labs that I would be quick to accept. Yes, there are times when this may help the doctor who overlooked abnormal tests in error, but the majority of abnormal lab values are not significant. The vast majority are insignificant. I’d put the rate at nearly 10:1.
When we e-mail patients their lab results, we have two options: to send the actual report, or send an abbreviated form of it. Here is what I sent this patient (for these actual labs):
I had a woman complain to me when I didn’t send her this “sanitized” version of her thyroid labs. She didn’t understand the lab report and just wanted my explanation. Which would you rather have? Do patients really need to know their MCHC, RDW, RBC count, and absolute eosinophil count? Do they want to? I don’t care about those numbers 99.9% of the time I look at them.
Here’s another example:
“Doctor! I am really worried about my Bun Level and Carbon dioxide levels. I read that these can all mean I am dehydrated! They also can mean I am going into kidney failure. I don’t want to go on dialysis! And what about the monocytes and MPV levels? One website I saw said this could mean leukemia.”
Sound outlandish? Sound like something that won’t happen much? Wrong. We spend a very large amount of time explaining these basically normal (MPV?? Absolute Monocytes??). All lab tests need to be put in the perspective of the patient’s age, disease state, race, and medications they are taking. They also need to be seen as a single point on the graph and so must be looked at in comparison with previous lab tests. How would I interpret this? Normal.
Do you, my readers, REALLY want to see the absolute monocyte counts and MPV?
Here’s another:
Look at all the extra information put at the bottom of the lab report. What does it mean?
Most of this is fluff meant to keep the lawyers happy. The average patient will not quite know where to look here and will either just be confused by it or become anxious and want to question this as being abnormal. ”I thought you said my diabetes control was good, but the diabetes test was high according to this!” or “A hemoglobin of 6.5 is dangerous, isn’t it?” I have had both of these comments from patients.
Here’s a typical echocardiogram report:
What percent of patients want all of this? I don’t! I really could care less about everything above the “Impression” section from the cardiologist. I was not even aware that pressure had a halftime. None of these findings are significant.
The cardiologist has to include all of these in his note for herself because of documentation requirements and because the fine details mean something to her. But they mean nothing to me, and I would prefer just getting the “Impression” sent to me. Why should patients be different from me?
Wouldn’t you rather get from me something that says: “Your echocardiogram looked good”?
I really think that giving full access to all information opens a hornet’s nest of its own. We will spend a lot of time educating our patients to the nature of medical information and medical terminology. Again, I am fine with having folks who feel they need this information; but I am a little skeptical that they really do need it.
I don’t need most of this stuff, and would be much happier if I got only what I asked for.
*This blog post was originally published at Musings of a Distractible Mind*
August 4th, 2009 by DrRob in Better Health Network, Opinion
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They gathered around the figure who was lying with face toward the ground. Holding stones, they demanded justice – that the sin of this person be exposed for what it is: inferiority. Her sin had been exposed for all to see and the righteous rage of those who were pointing fingers and holding stones was pounding at her on the inside, just as the stones would soon pound her on the outside.
“Her BMI is over 30! It may even be over 40!” one of them cried out. The others responded to this with a howl.
“How can she be fit for leading the country’s health if she can’t even fit into her pants?!” another asked, causing raucous laughter to echo from the crowd.
Nearby, a news reporter spoke into a camera: “People are questioning her fitness for surgeon general, as she obviously is overweight. The president had initially hoped the popular TV doctor would take the job, but fell back on Dr. Benjamin as a substitute. Clearly a president, who himself is a closet cigarette smoker, doesn’t see the fact that she is overweight as a disqualifying factor. These people, and many others around the country, disagree with that assessment.”
———————–
Forty years ago, people would also have cried out about this nomination. They would have said that a woman shouldn’t be in charge of the nation’s health, or that a black person doesn’t have the wherewithal to manage such a big task. Times have changed, as her nomination shows – nobody is talking about these facts that have nothing to do with her ability to do this job. We have truly progressed.
Sort of.
This objection, of course, is that her weight shows that either she doesn’t understand what is causing her obesity, or that she doesn’t have the moral fortitude to successfully fight it. Either way, she’s disqualified for the job. Right? It’s a sign of weakness to be overweight, and we certainly don’t need someone with a personal weakness to be in a leadership position!
It is clear that some view the overweight (which, by the way, constitute 2/3 of our adult population) as being emotionally weak and somehow inferior to everyone else. After all, study after study has shown that the way to beat obesity is simple: eat less and exercise more. It’s simple; and those who don’t do it are weak, lazy, dumb, or just plain pathetic.
It angers me to hear these suggestions. Racist and sexist people put down others because of the fact that they are different than themselves. But the moral judgment against the overweight and obese is not meant to be a judgment against something inherent in the other person; it is a judgment against their character, their choices, and their weaknesses. The implication is that they are somehow either smarter, stronger, or just plain better than the overweight. The implication is that the other is weak and they are not.
There is a word for this attitude: hypocrisy. A bigot is a person who hates those who are different; a hypocrite is one that hates others for something they themself have, but choose to ignore. Both mistakenly act as if they have the moral high-ground. Both disqualify themself from any argument based on morality.
Healthcare exists because of human weakness. We all are weak in various ways, and we all will eventually die when one of our weaknesses overcomes us. Obesity exists because of human weakness – either the genetic or biological miscalibration of the person’s metabolism, or the inability of that person to act in ways that are in their own best interest.
I have to say that I probably fall in the latter category, as my lack of desire to exercise and my exuberant desire to eat rich foods make it so I have struggled with my weight for years. Somehow the prescription: eat less and exercise more, is not very helpful for me. Yes, it is simple; but it is not easy. Having others explain it to me at this point is not only unhelpful, it is insulting. Of course I know that my weight is a problem! Of course I know I should exercise more and avoid that cookie dough in the refrigerator!
To successfully fight the battle against obesity in our country, we have to stop the condescending finger-pointing and instead ask the question: why is it that we humans don’t always act in our self-interest? Why do smokers smoke? Why do alcoholics drink? Why don’t people take their medications, eat enough vegetables, or go for walks instead of watching The Biggest Loser on TV? This seeming self-destruct switch is, to some degree or another, present (in my opinion) in everyone. It is the same drama with different actors and props. We all sell our birthright for some soup at times. We all go the route of easy self-indulgence rather than personal discipline.
Does that mean we are all weak? Yes, in fact, it does. My admission of my weakness has actually made it easier to have frank discussions with patients about their own personal struggles – be they weight, smoking, or other self-destructive behaviors. They listen to me because I don’t insult them with statements of the obvious. If it was easy to lose weight, don’t you think we’d have a little less than 2/3 of the population being obese? Does 2/3 of the people remain overweight because they want to be that way? No, the problem is not that simple; and suggesting otherwise won’t do much to deal with our national problem.
Dr. Benjamin has impressive credentials. She is a practicing primary care physician who cares for the poor. She’s not some subspecialist TV personality; she’s a doctor who has spent a lot of time face to face with the neediest people in our system. She doesn’t just know about the poor and needy, she knows them. She’s one of us; and her weight does nothing to lessen that – for me it actually makes her more relevant, not less.
So put down your stones, people. We are all weak. Having someone who understands the real struggle of the overweight may actually give us a better chance to successfully fight it. And if some of you still hold stones, let me rephrase a famous statement: The person without personal weakness can throw the first stone.
*This blog post was originally published at Musings of a Distractible Mind*
July 29th, 2009 by DrRob in Better Health Network, True Stories
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A recent oft-cited study showed that doctors who who apologized for mistakes were less likely to be sued. My initial reaction to that is to file it under “duh.”
But then I was greeted with a note lying on my desk.
Dr. Rob:
First, I want to tell you that for the majority of the many years my family has been patients of your practice, I believe we received excellent care and you always had our best interests in mind. Further, we appreciate all that you and your staff have done for us.
However, it is with great regret that I find myself in the position of writing to you with a problem I see as pervasive in your practice…
Ugh. This is not the way to start my day.
The letter went on to describe a problem with communication of a concern the patient had about a medical problem that was very worrisome to her. It didn’t point the finger of blame at my nurse, nor any one else in the office. It wasn’t at all angry in its tone to me. It simply expressed the disappointment of a patient who felt let-down by her physician.
The letter ended with:
I look forward to speaking with you about this issue early in the week of July 20.
Thank you in advance for your attention to this matter.
I put off calling her until the end of the day. I knew she would be reasonable overall, but beyond the fact that I hate calling people on the phone at all, I hate calling when I know I have to apologize. The problem in this case was not with my staff or with confusion in the office. The problem was with a physician who simply dropped the ball and did not follow-up as promised.
I finally called:
Hi.
First let me say thank you for the letter you sent. I mean that sincerely. I would much rather hear about problems in our office than to simply having people get angry and leave. This is something I needed to hear.
Second, let me say that the blame is 100% mine. I really wasn’t worried about the problem and so I honestly just let it slip my mind. I did tell you I’d contact you and would send you to a specialist if things weren’t clear after the tests I ordered. I’m sorry about that.
I went on to discuss the situation and that I didn’t think anything was serious at all. She still wanted to go ahead with the consultant because of some stuff she had heard about the condition. I told her that I have no problem with that, as I see my job as one of giving my advice and perspective; but not as making the final decisions. The most important thing is that her worries are addressed and that she feels comfortable that everything is OK. If it takes a consultant to do that, then I have absolutely no problem with that.
I also explained that communication in a medical office is very difficult – and has gotten much harder as we have gotten busier. It is our plan to eventually have communication by e-mail, but that is not ready for prime-time. This is not an excuse, I told her, but an explanation and a promise that I do see the problem and we are doing something about it.
As expected, she was gracious about the situation and was thankful for the apology. I didn’t do it to avoid lawsuit or to protect myself. I like this family and didn’t want to lose them as patients. Beyond that, though, I owed her an apology. I had let her down. I hadn’t done what I promised I would do. She had been kind enough to send me the letter and deserved a quick resolution to the situation.
I still hated picking up the phone, though. It isn’t easy to admit fault, no matter how accepting you know the other person will be.
As obvious as it seems that apologizing will prevent lawsuit, it is a hard thing to do.
But I am glad I did.
*This blog post was originally published at Musings of a Distractible Mind*
July 16th, 2009 by DrRob in Better Health Network, Health Policy, Opinion
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It seemed like a reasonable plan.
I was having trouble keeping track of my chickens – they kept somehow escaping from their coop. So I figured that I would set guards to make sure none of them got out any more. I got some rabid wolves and put them outside of the coop, figuring that they would scare the chickens enough to stay in their place.
But here’s the problem: these rabid wolves are eating my chickens! Can you believe it?? You would think they’d have the moral decency to respect the fact that I hired them to guard my chickens, but now they try to bite me whenever I go out there! It’s amazing to me that these wolves would act in such a way. What’s the world coming to when you can’t trust rabid wolves to guard your chickens??
—-
What? You think I’m crazy? Take a look at our healthcare system! This is exactly what we are doing with our healthcare dollars.
In a recent article, Ezra Klein (coincidentally mentioned in two consecutive posts) discussed Wendell Potter, a disillusioned insurance executive who shared why he left the industry. Potter explained that the for-profit insurance industry (Cigna in this case) uses the following tactics to maximize profits:
The industry, Potter says, is driven by “two key figures: earnings per share and the medical-loss ratio, or medical-benefit ratio, as the industry now terms it. That is the ratio between what the company actually pays out in claims and what it has left over to cover sales, marketing, underwriting and other administrative expenses and, of course, profits.”
So it seems that a for-profit company is in it for the profit. Disgusting. Klein goes on:
The best way to drive down “medical-loss,” explains Potter, is to stop insuring unhealthy people. You won’t, after all, have to spend very much of a healthy person’s dollar on medical care because he or she won’t need much medical care. And the insurance industry accomplishes this through two main policies. “One is policy rescission,” says Potter. “They look carefully to see if a sick policyholder may have omitted a minor illness, a pre-existing condition, when applying for coverage, and then they use that as justification to cancel the policy, even if the enrollee has never missed a premium payment.”
So the insurance industry is “cherry-picking” healthy people to insure – people they won’t have to pay much on – and dumping unhealthy people. How can this happen? How can the insurance industry be taking money from the system and using it for their own profits?
But who is actually the problem here? Are the Wolves evil for eating my chickens? No, they are just acting like wolves. I am the fool for trusting them to watch my chickens without getting taking advantage of their position. Putting for-profit insurance companies in charge of huge sums of money is just as foolish. As Klein states:
The issue isn’t that insurance companies are evil. It’s that they need to be profitable. They have a fiduciary responsibility to maximize profit for shareholders. And as Potter explains, he’s watched an insurer’s stock price fall by more than 20 percent in a single day because the first-quarter medical-loss ratio had increased from 77.9 percent to 79.4 percent.
Actually, I think Mr. Klein understates it a touch. It isn’t that the insurance companies need to be profitable; they are under huge pressures from shareholders to maximize their profits. They are being pressured to milk as much money from the system as possible. Maggie Mahar underlines this fact:
Potter is right. Disappointed shareholders can be brutal. And it doesn’t take much to disappoint them. In this case investors sent the share price plummeting because the insurer had the poor judgment to increase the amount that it paid out to doctors, hospitals and patients by 1.5 percent.
Even if an intelligent CEO wanted to do the right thing, take the long-term view, and provide labor intensive chronic disease management so that, over the long term, customers would be healthier—the CEO of a large publicly-traded insurance company probably wouldn’t keep his job long enough to find out whether or not his ideas worked. This helps explain why for-profit insurers have not followed the example of non-profit insurers and created “accountable care organizations” like Geisinger or InterMountain.
Those who have followed this blog have heard me say it before: the system won’t change until we stop trusting for-profit insurance companies to guard the money. Those who are morally indignant over the fact that these companies would milk the system as they do are blustering in the wrong direction. You don’t blame wolves for acting like wolves, and you don’t blame for-profit publicly-held companies for trying to maximize profit. They are just being themselves. We are the idiots – assuming they could be trusted in this position.
Obviously, the best solution is to put the politicians and lobbyists in charge. Surely they are trustworthy.
Image Credit
*This blog post was originally published at Musings of a Distractible Mind*
