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
December 19th, 2008 by Dr. Val Jones in Opinion
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I was reading a good blog post about ethics violations in clinical trials in India, and was reminded of an interesting case in the U.S. Several years ago a 21-year-old woman (Abigail Burroughs) with terminal cancer (who had exhausted all treatment options) was denied the option of purchasing a drug that was in the final process of receiving FDA approval. The FDA ruled that terminally ill patients should not be permitted to purchase drugs until the drugs have completed the approval process, citing safety concerns. Their arguments also included that:
1. Patients cannot make a truly informed decision regarding whether or not to try a medicine that has not yet been fully tested.
2. Allowing access to drugs before they are FDA approved would undermine the clinical trial process.
3. If terminally ill patients could buy treatments, others would soon expect health plans to cover these costs for others.
4. Allowing access to drugs before they were proven effective would add to the public’s general confusion about evidence-based medicine and promote magical thinking.
I don’t know how you feel about this, but it makes me squirm a little bit. Although I appreciate the FDA’s position (and my colleague Dr. Jim Sabin has blogged about his support for the ruling) it just seems a little heavy-handed, especially in light of the details of the Abigail case. Here’s what I wrote to Dr. Sabin:
About the Abigail case… I think they were trying to get access to Erbitux for Abigail, and it was in phase III trials at the time (so there was mounting evidence for its efficacy – their request to purchase it wasn’t scientifically unreasonable.)
I have very mixed feelings about the FDA ruling. I understand that we don’t want to 1) set a precedent that would lead to insurers having to pay for expensive experimental therapies 2) discourage people from entering clinical trials 3) allow drug makers to profit from “false hopes” in terminal cases. However, couldn’t we add enough caveats to make it reasonable to allow patients who have exhausted all other options to purchase (with their own money) drugs that have shown promise but are not yet FDA approved?
What if we said that the drugs had to be in phase III trials, with enough evidence to suggest a plausible benefit for the patient? Terminal patients are rarely good candidates for clinical trials (I don’t think we’d be poaching from the CT pool), few can afford to buy monoclonal antibodies (and the like) on their own so if there were trials for terminal patients, they’d still have great incentive to join, and I’m not sure that just because a patient can buy a treatment that insurance will HAVE TO follow suit.
Something about limiting personal choices (for those who have the means to make them) seems un-American to me. There are very low risks of harm in monoclonal antibody treatments (so the argument that the FDA must err on the side of patient safety doesn’t really fit the Abigail case). Yes, it’s sad for those who can’t afford to buy every possible therapy – but why should we deny access for those who can? With the right caveats, I think we could allow people like Abigail to try every remaining option. But of course I agree that phase I drugs are just not far enough along the research pipeline to make educated choices about them.
Maybe Abigail was a casualty of the one-size-fits-all, population-based rules that are appropriate most of the time, but fail in exceptional cases. I predict that this sort of thinking (where evidence-based protocols are applied in a cook book manner to all patients with a given disease) will dominate the healthcare landscape in the coming years as we seek to reign in costs and do the best thing for most. I just wish there were a way to bend rules on the edges a bit. What do you think?
December 5th, 2008 by Dr. Val Jones in Opinion
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Thanks to KevinMD for pointing out a recent NYT article about “etiquette-based medicine.” The author, a psychiatrist, suggests that physicians should use a check list to ensure courteous behavior and that this sort of thing should be taught in medical school. His suggestions were also published in the New England Journal of Medicine:
• Ask permission to enter the room; wait for an answer.
• Introduce yourself; show your ID badge.
• Shake hands.
• Sit down. Smile if appropriate.
• Explain your role on the health care team.
• Ask how the patient feels about being in the hospital.
If this sort of thing isn’t intuitively obvious to a physician then I’d say the blame should rest with his parents not his medical school. I mean, do we really need to teach doctors to knock on doors and smile on cue? Aren’t those sorts of things taught in pre-school?
It grieves me that some of my peers do not display what some might call “normal behavior” when interacting with patients. But I don’t think that’s related to their medical school curriculae – it’s the sad result of a broken healthcare system that wears thin our common human decency. Doctors are exhausted by clinical volume, henpecked by bureaucracy, delirious from lack of sleep, and stressed out by the daily grind of bad news, disease progression, and death. When well-groomed adults of sound mind require a checklist in order to smile appropriately, you know something’s terribly wrong.
Now, I don’t excuse disrespectful behavior – we docs must rise above our natural urge to be irritable at times, and remember that our patients are vulnerable and need our help. But for heaven’s sake… let’s drop the smug check lists and finger pointing. We’re all in this together, and it ain’t pretty.
October 7th, 2008 by Dr. Val Jones in Medblogger Shout Outs
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Many thanks to Dr. Bongi at All Things Amanzi for hosting me at his blog in South Africa. Here’s an excerpt from my post:
When I was a medical student rotating at a hospital that shall remain unnamed, I witnessed a medical error that has haunted me ever since. I was partnered with a team of residents in the inpatient pediatric unit, and late one night a two month old baby was accidentally infused with an entire bottle of Foscarnet instead of normal saline. The nurse who gave the infusion was working as a locum tenens – a traveling nurse who spent a few months here and there filling in for others at various hospitals…
To read the rest of the story, please click here.
August 12th, 2008 by Dr. Val Jones in True Stories
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Always do right. This will gratify some people and astonish the rest.
–Mark Twain
I am out of town for the week and will be blogging sporadically. I hope you enjoy this true story/repost:
***
I remember a case where a young internal medicine intern was taking care of a 42 year old mother of 3. The mother had HIV/AIDS and had come to the hospital to have her PEG tube repositioned. Somewhere along the way, she required a central line placement, and as a result ended up with a pretty severe line infection. The woman’s condition was rapidly deteriorating on the medicine inpatient service, and the intern taking care of her called the ICU fellow to evaluate her for admission to the intensive care unit.
The fellow examined the patient and explained to the intern that the woman had “end stage AIDS” and that excessive intensive care management would be a futile endeavor, and that the ICU beds must be reserved for other patients.
“But she was fine when she came to us, the line we put in caused her downward spiral – she’s not necessarily ‘end stage,’” protested the intern.
The fellow wouldn’t budge, and so the intern was left to manage the patient – now with a resting heart rate of 170 and dropping blood pressure. The intern stayed up all night, aggressively hydrating the woman and administering IV antibiotics with the nursing staff.
The next day the intern called the ICU fellow again, explaining that the patient was getting worse. The ICU fellow responded that he’d already seen the patient and that his decision still stands. The intern called her senior resident, who told her that there was nothing he could do if the ICU fellow didn’t want to admit the patient.
The intern went back to the patient’s room and held her cold, cachectic hand. “How are you feeling?” she asked nervously.
The frail woman turned her head to the intern and whispered simply, “I am so scared.”
The intern decided to call the hospital’s ethics committee to explain the case and ask if it really was appropriate to prevent a young mother from being admitted to the ICU if she had been in reasonable health until her recent admission. The president of the ethics committee reviewed the case immediately, and called the ICU fellow’s attending and required him to admit the patient. Soon thereafter, the patient was wheeled into the ICU, where she was treated aggressively for sepsis and heart failure.
The next day during ICU rounds the attending physician asked for the name of the intern who had insisted on the admission. After hearing the name, he simply replied with a wry smile, “remind me never to f [mess] with her.”
The patient survived the infection and spent Mother’s Day with her children several weeks later.
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
By Steve Simmons, M.D.
