December 15th, 2007 by Dr. Val Jones in Health Policy, Opinion
Tags: Finance, Geriatrics, Hospitals, Medicare, Palliative Care, Technology
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More healthcare dollars are spent on end-of-life measures than perhaps any other single expense. About 25% of Medicare’s 2.8 trillion dollar budget is spent on care for people in the final year of life. That works out to be about $2500/person/year that we spend on government funded end-of-life care. Medicare spending overall is closer to $10k/person/year in this country… and given that the average household pays $6K in taxes/year… you can see that we’re in a real pickle when it comes to healthcare spending (and that’s just for Medicare).
In a recent blog post, PandaBearMD suggests that it’s time to “put granny down.” This gallows humor speaks to what the medical community has been been discussing in more academic terms. Here are some interesting sound bites (click on links for full references):
Terminally ill patients should be treated outside of acute care facilities. …Acute care hospitals are, by definition, set up for handling acute conditions – trauma, childbirth, orthopedics, heart attacks, etc. Terminal illnesses are not acute conditions, and therefore should be treated in a facility or setting that is chronic-care oriented.
The technological advances that medicine has witnessed in the last few decades are no more apparent than in the ICU. Yet when used inappropriately, this technology may not save lives nor improve the quality of a life, but rather transform death into a prolonged, miserable, and undignified process.
Hospice care can reduce the cost of end-of-life care by 30% or more (though this is debated).
“We don’t operate in a closed health care system, where there is a fixed number of dollars for health care, and thus the need to choose how to allocate those dollars,” said Dr. Weissman. “Our health care system is open-ended, which is why the cost of health care goes up every year. So we’re not making a tradeoff of spending more on the elderly and thus not using those resources on children’s care.
While it is fairly obvious that we deliver a lot of unnecessary, costly, and heroic medical care at the end of life, determining how to ration this care is fraught with moral and ethical dilemmas.
What sort of population-based rules should we institute to govern access to acute care services at the highest level? Would limiting care to people based on age or comorbidities sit well with Americans? Imagine that you’re 65 – just entering retirement and expecting to enjoy another 20 years of life – and you’re disqualified from top tier medical treatments because of your age. Who has the right to judge your worthiness of top medical technology?
I know of an elderly woman who accidentally took too many diuretics over the period of two weeks. She became delirious and was admitted to a hospital where the doctors assumed she had end stage Alzheimer’s disease and sent her home with hospice care. Another doctor later discovered the error, rehydrated her and she returned to her usual state of health. It was a close call for that “granny.”
My parents are in their late 70’s and in excellent health, enjoying book writing and traveling. I asked them to read PandaBear’s analysis of end-of-life care in the United States – and how billions of dollars are spent on heroic measures for the frail elderly.
My mother said tersely, “I hope I die in Europe.”
My father replied, “Whether you’re old or young, it’s nice to be alive.”
But I can’t help but think of that patient who was sent home with hospice care for delirium caused by severe dehydration. Will we turn our backs on the elderly and not carefully consider their differential diagnoses simply because of their age? As long time tax payers, are they not the most deserving of access to top technologies if so desired?
This is one tough dilemma – and the best I can advise is that we each create living wills, and save our own money for that rainy day when we need critical care, but are ineligible based on some future population-based rule to save money on futile care. In that case, the wealthy would always maintain access to the best care available.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
December 4th, 2007 by Dr. Val Jones in Medblogger Shout Outs, Opinion
Tags: Hospitals, Pediatrics, Quality, Relationships, Research
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I have witnessed various disappointing doctor-patient interactions over the years. Sometimes the doctor is insensitive, other times he or she doesn’t listen to the patient – and errors can result. Young physicians are more prone to inappropriate patient and family interactions when they are feeling inadequate and insecure. A fellow blogger describes just this kind of problem with a young pediatrics resident:
A meek lady with a white lab coat
walks in and just starts asking medical questions. So
my answer to her first question was “Who are you?” She apologized and
said she was the pediatrics resident and asked a bunch of questions
that didn’t seem to us to have much bearing on the situation at hand.
We asked about why my son was making unusual gasping breaths ever since
he woke up and she said it was because he was crying. We said that he
was making these breaths before he started crying. She then said it was
probably hiccups. My wife, who is a registered nurse, said there was no
way it was hiccups because she felt him pressed against her body and
could tell. The resident then said that it was probably due to the
anesthesia. I could tell she was just giving that answer to say
something but really had no clue what was going on. So I challenged her
on it and said “Have you ever seen this after anesthesia before?” She
paused and said, “Maybe once.”
Although this is not the wost example of an unsatisfying doctor-patient interaction (read the rest of the post to get the full story), it is pretty typical for inexperienced physicians to “make up” explanations for symptoms or problems that they don’t understand. This can be dangerous or even life threatening if certain symptoms are ignored.So how do we protect ourselves against this kind of potential error? Sadly, the current quality assurance programs are rather ineffective. In his recent blog post about ensuring physician quality, Dr. Scalpel published a letter he recently received from his hospital. The letter was prepared as part of the Joint Commission quality assurance program. They actually require doctors to get a letter of recommendation from someone (who doesn’t work with them) to ensure that they’re practicing good medicine… It’s like asking a stranger to grade your work competence.
Dear Dr. Scalpel:
In
accordance with Joint Commission regulations, we are required to
request an evaluation of your clinical performance. The Credentialing
Committee now requires the completion of an evaluation form by a peer in your specialty who is not a member of your group practice.
Attached,
you will find a letter and accompanying evaluation form which you
should forward to a peer of your choice for completion. In order to
proceed with the processing of your reappointment application, it is
necessary that you ensure that the required evaluation form is
forwarded to a peer and returned to us in a timely manner. A return
envelope is provided for this purpose. Please note that the evaluation
form must be returned to us by the person completing the form. If we do
not receive the evaluation form before ________, your clinical
privileges may be interrupted.
Sincerely,
An Unnamed Bureaucrat
So, how do you ensure that you’re getting good medical care? It’s not easy, and you can’t necessarily depend on oversight committees to come up with sensible safeguards. Being an informed patient is part of being an empowered patient – you should do what you can to research your doctor’s and hospital’s credentials and reputation (you can do that right here with Revolution Health’s ratings tool), you should read about your diagnosis or condition on reputable websites like Revolution Health, and you should advocate for yourself or loved one at the hospital when necessary. You have the right to reasonable explanations for care decisions – and if you’re concerned about a symptom, you should ask about it.
Unfortunately, there’s no way to guarantee quality medical care. However, perhaps the most important thing you can do (besides advocate for yourself and become educated about your condition) is to develop a close relationship with a primary care physician. Establishing a medical home with a good primary care physician can go a long way towards helping you to navigate the system. They can be your best advocate in this broken system.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
December 2nd, 2007 by Dr. Val Jones in Opinion
Tags: Beauty, News, Surgery, Women's Health
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I recently had the chance to observe a breast augmentation procedure performed by a surgeon friend of mine. The patient was a tall, attractive woman in her late thirties. Her husband was in the room, quietly listening to my friend’s explanation of the procedure and what should be expected. The patient was friendly and enthusiastic – the breast augmentation procedure was her birthday gift to herself. This was her second procedure, as she had already increased her cup size from an A to a C a few years prior. This time she wanted D or larger.
I felt mixed emotions as I observed the surgery. On the one hand the patient’s breasts looked fine the way they were (in my humble opinion) and it seemed wrong to further distort her natural body type. Yet on the other hand, I think that patients have the right to look the way they want to, and my personal beauty ideal shouldn’t be projected on to them. I asked my friend how she dealt with this sort of conflict.
“Well,” she said, looking at me with her surgical mask and blue hair net, “if a woman wants a green dress, it’s not the store clerk’s business to try to pressure her into buying a red one. I just try to give the patients what they want, and not impose my opinions on them.”
And so I watched as my friend carefully sutured the wounds around the new implants. She checked the movement of the saline-filled sacs inside the chest. She pushed the breasts together to check the cleavage.
“But the breasts don’t touch each other when you push them to the center,” I said, head tilted sideways.
“Her sternum is too wide for that. This is one of the limitations of implants of this size on her body. She just doesn’t have enough tissue to make that kind of cleavage.”
“Is that ok with her?” I asked, glancing down my own scrub top.
“It’s a give and take – she knows that going larger will not give her a natural look, but she’s ok with that. This is what she wants.”
And so the anesthesiologist woke the patient up, extubated her, and the nursing staff slid her over to the stretcher that would carry her to the recovery area. My friend escaped her sterile gown and gloves and prepared her post-op note at the nursing station desk. I smiled at the nurses who assisted in the surgery, and we shrugged at each other and went on our separate ways. I hope the patient is pleased with the outcome, though most of all I hope she feels content with how she looks, no matter what the bra cup size.
What do you think about breast augmentation?This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
November 18th, 2007 by Dr. Val Jones in Health Policy, Opinion
Tags: Cancer, Complementary And Alternative Medicine, Finance, Medicare, Nuclear Medicine
5 Comments »
A recent blog post at Terra Sigillata really disturbed me. The author describes how, in the face of increasing healthcare costs, Medicare now declines coverage of life saving medicines for lymphoma patients. This is one example of rationing healthcare that will become ever more common (as it is in other leading industrialized nations) as we move towards further cuts in government programs and funding. In Canada, expensive chemotherapies are not commonly covered by the national health plan, and in Britain, age is a determinant for transplant eligibility.
But what troubles me about the apparent capriciousness of denying coverage to certain types of cancer patients over others, is that government programs are – at the same time – allocating millions of dollars to researching implausible alternative medicine treatments while denying coverage of proven therapies to patients who will likely die without them.
Take homeopathy, for example. The National Center for Complementary and Alternative Medicine lists homeopathy as an eligible area of research, and boasts several ongoing studies in the area of stroke, dementia, fibromyalgia, and prostate cancer. And yet, there is no plausible mechanism of action to support its potential use as anything more than a placebo. Homeopathy operates on the assumption that water has memory, and that once it has been exposed to certain substances, such as arsenic, it obtains curative properties for illnesses that bear resemblance to poisoning from those very substances (though the water itself may no longer contain a single molecule of the substance).
Research into scientifically implausible theories should not be funded by our tax dollars at the expense of offering life saving treatments to cancer patients. It is time for scientists to stand up and point out that the Emperor has no clothes when it comes to homeopathy and other similarly flawed alternative medical treatments.
As we move towards rationing limited healthcare resources, we have a moral obligation to prioritize the money correctly. “Open-mindedness” is no excuse for poor stewardship.
Dr. Wallace Sampson sums this up in a provocative recent editorial. Here is an excerpt:
We now see accumulation of useless information in journals and information data bases — hundreds of clinical trials (RCTs) on implausible methods, such as homeopathy, unrefined plant products, prayer, and acupuncture. Initial plausibility retreats before two 20th-century development ideologies of relativism — a principle that all facts and opinions have equal or similar value, and postmodernism — that regards facts as social constructions.
Once thought to be too esoteric for relevance to medicine, these twin ideologies now mold the thinking of policy makers and granting agency officials. Ancient and traditional cultural practices are not diminished for lack of plausibility, but are investigated by RCTs because they are there.
Plausibility depends on prior reliable observations, physical and chemical laws, pharmacological principles, and advocates’ economic and legal misadventures. The National Center for Complementary and Alternative Medicine spends $100 million/year on implausible research and training grants. In performing RCTs on implausible proposals, clinical research has taken a wrong turn and departed from rationality.
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
November 14th, 2007 by Dr. Val Jones in News, Opinion
Tags: Alzheimer's, Geriatrics, News, Relationships
2 Comments »
“Grow old along with me! The best is yet to be, the last of life, for which the first was made.”
— Robert Browning
As a rehabilitation medicine specialist I do a lot of work with cognitively impaired men and women. The brain is a fragile and fascinating organ, and perhaps the most perplexing one to treat. Alzheimer’s disease, of course, has no known cure – and those who contract it meander through a frustrating cognitive web towards a final common pathway of dementia, dependence and eventually death.
Former Chief Justice Sandra Day O’Connor has been in the news lately because her husband, an Alzheimer’s patient who requires nursing home assistance for activities of daily living, has forgotten who she is. But even more emotionally difficult is the fact that he has fallen in love with a fellow nursing home resident, and has been behaving like a love-sick teen – holding hands, staring into her eyes and kissing her tenderly.
The New York Times reports that Ms. O’Connor is “happy for her husband” that he has found joy in the midst of his cognitive decline. I wonder if there truly isn’t part of her that mourns the loss of those kisses that were once for her.
My fondest hope is that I can grow old with my husband, and that we will enjoy our final years together, in possession of all our faculties. I hope that Robert Browning’s poem will ring true at the end, and that I never have to watch my husband forget who I am. Sadly, since my grandmother passed away from Alzheimer’s – I wonder if it will be my husband, and not me, who watches the other decline?This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
