It's Ten PM - Do You Know Where Your Doctor Is?

Genomics.  Robotic surgery.  Implantable cardiac assist devices.  The list of innovations that have extended life and health in the last generation reads like a sci fi novel.

And yet, patients nowadays find themselves missing out on a critical element of excellent healthcare: their doctor.  More and more patients lack a primary care physician.  They have a cardiologist who manages their heart condition.  They have an endocrinologist who manages their diabetes, and maybe a pulmonologist who expertly cares for their chronic emphysema.

But when they run a fever on a Saturday evening, whom do they call?  Of course, many patients still have a real primary doc - an internist or family practitioner.  But it is far less likely in 2012 that the physician is in a solo practice.  According to a report by the NY Times, that chance was 58% forty years ago.  Today it is mere 18%.  And the rest?  They are in larger group practices with teams of physicians.  At a recent medical meeting, a colleague complained that it is a "miracle" if a patient happens to reach his own physician after hours.  Much likelier she will reach another member of her physician's "coverage pool," which may include anywhere from a few to a few dozen physicians.  And what if you reach a physician "on-call" for, say, 20 colleagues?  If the problem involves anything more complicated that the common cold, the answer will be predictable - "head over to the Emergency Department and the doc there will take care of you."

Nothing the matter with that except for long waits and large copayments.  Well, maybe a few other things.  Like the fact that this doctor doesn't really know you or your history, or whether you will come back for followup.  To make matters worse, hospitals are measuring ED docs on their "throughput time."  And if after sending you home, you need to return within 72 hours a black mark goes next to the doc's name.  So we, the hospital leaders, are sending signals that say to this ED physician, decide fast but decide right.  And if you're not 100% sure, admit the patient.  And while you're at it, do a blood count and a slew of other tests.  If there is pneumonia, don't rely on your stethoscope.  Get a chest x-ray.  And while you're at it, don't rely on the chest film either, send the patient back for a thoracic CT scan.  And now that you have much more data than you know what to do with, get the internist who will admit the patient...and call an ID consult (because pneumonia is an infection), and a pulmonologist, just in case.

Americans are looking on in alarm as our nation is embroiled in a debate about the future of our unsustainably inefficient healthcare delivery system.  Some conclude the efforts to fix it will imperil choice and create long waits for needed services.  Others of us have a different vision.  One that includes much better care coordination and that reestablishes the critical role of the primary care physician.  One that reemphasizes the need to weigh more carefully the benefits of individual tests and treatments, and that acknowledges the principle that simpler care is not only less expensive, but often more timely, less error-prone and more accurate.  And one that will allow patients once again to know how they can get their doc on the phone, even if it is 10 pm.

Treating patients like persons - why we don't always do it and how we can change

Last evening I put aside the urgent matter of getting my taxes done to attend a truly inspiring committee meeting. I know, I know...that sounds like an oxymoron.  But our Health System's new Narrative Medicine committee is truly exceptional. Populated with a diverse group of professionals - social workers, nurse practitioners, art curators, medical school faculty, a "quality" expert, chaplains and physicians from specialties as diverse as opthalmology and pediatrics - this working group shares a passion for putting the "care" in "healthcare."

As I drove home last night, I wondered: "why are we necessary?"  By this I mean, why is it not automatic for health professionals to bring all that they are to the bedside of every patient?  I believe there is no single answer.  What we know is that empathic capacity among physicians and nurses has been measured and tracked, and that it declines during training.  The more time we spend with patients, it seems, the more insulated we become from their experiences of isolation, fear, anxiety and loss of control.  The evidence is clear: without heroic countermeasures, the more expert we become, the more we disconnect from the human experience of illness.

And so we find ourselves in a conference room snacking on nectarines, potato chips and Pelligrino water (true story!) swapping ideas about interventions and research projects that might bring the perspective of "narrative medicine" to bear for the benefit of wounded patients and wounded providers of care.

"Tell me everything you feel I need to know about you" to understand you, to address your fears, to respect your values...in short, to provide you the care you need.  This is one message of Narrative Medicine.  Another, equally important stream is directed at the wounded caregiver: what are you feeling?  What fears, what resentment, what kinds of inadequacy have you locked away in order for you to do your job...to get through your day?  And how can we use words and written expression to unlock those hidden recesses of our psyche, and to purge the toxins from the culture of healthcare?    

I am very hopeful.  The antidote to burnout is not less work.  It is the chance to participate in meaningful work, and to know in our bones that our labors are worthwhile.   Half a century of progress has provided technologies for extending life and health that would have been unimaginable to our forefathers.  We stand at the frontier of a new country...one that values these advances, while also bearing witness to the human act of caring, and honoring in a way that is very new and very old the act of one vulnerable person caring for another.

Would you like to be resuscitated?

I was honored this week to deliver a Grand Rounds lecture to our Department of Medicine on the topic of "advance directives."  This was curious, in a way, since I am expert in neither the law nor bioethics.  But I do see physicians and nurses and patients and families struggling with end-of-life care, and I have participated in many organizational efforts to assist all of them in what are inevitably gut-wrenching decisions.  In all but a few cases the issue is the same - how to do the right thing in the face of radical uncertainty.  When is intervention heroic, and when is it ill-advised?  What do we mean by futile care?  When does prolonging life become prolonging death?

In the last thirty years, a sea change has come over American healthcare that involves the concept of patient autonomy.  "Autonomy"-- the recognition that all persons have a moral right to self-determination including the absolute right to decline any medical intervention -- stands beside two other dicta: to do always what is in the patient's best interest, and finally the Hippocratic proscription against doing harm.  An "autonomy movement" has gathered momentum in recent years for a variety of reasons:  our changing understanding of medical error and potential harm, the commercialization of healthcare, a consumerist movement and growing concern fueled by sub specialization that the doctor doesn't always "know what's best" for me.

Promoting autonomy is the basis for all informed decision making.  It is also the basis for those efforts at end-of-life planning that include recording our wishes (I do not wish to be resuscitated, or intubated, or to undergo tube feedings, etc...if doing these things will prolong my death, but not my life...) or delegating the authority to make those decisions in the event that I cannot make them myself.   Examples of the former include, of course, the Living Will and, more recently, MOLST (standing for Medical Orders regarding Life Sustaining Therapies).  Creating a Health Care Proxy, by contrast, serves to identify a healthcare "agent" who is in possession of knowledge about my values and goals and is formally empowered to act on my behalf.  Many advance directives actually combine these two approaches.

These efforts have not been without their difficulties.  Only a minority of individuals execute such advance directives; many are vague or contradictory.  Appointed healthcare agents, often close family members, are often disinclined to carry out the wishes of their loved one when that means limiting end-of-life interventions.  And too often, such wishes and preferences were never discussed.  In a thoughtful paper entitled "Controlling Death:  the False Promise of Advance Directives" (Annals of Internal Medicine 2007),  Dr. Henry Perkins suggests that these are no mere technical shortcomings.  Rather, he suggests, they are fundamental to the radical unpredictability of life and death.  Perkins writes:


Because advance directives offer only limited benefit, advance care planning should emphasize not the completion of directives but the emo- tional preparation of patients and families for future crises. The existentialist Albert Camus might suggest that physicians should warn patients and families that momentous, unforeseeable decisions lie ahead. Then, when the crisis hits, physicians should provide guidance; should help make decisions despite the inevitable uncertainties; should share responsibility for those decisions; and, above all, should courageously see patients and families through the fear- some experience of dying.


As I conclude this post, I am struck by the coincidence involved.  I had not intended to address this topic during the observances of Easter and Passover - each of which focus on life and death, transition and spiritual transcendence.  But what existentialists see as courage in the face of life's "absurdity,"  others would experience as faith in an ineffable purpose and Reality.  Putting this author's point more broadly, it would seem that the proper role of health professionals is to find patients and families "where they are" and provide attentive presence at the end of life.  Perhaps the timing of this post is not accidental after all.  Happy Easter and Happy Passover.

Is the Affordable Care Act on the Ropes?

The Supreme Court has concluded its deliberations on three issues linked to the 2010 Affordable Care Act.  Optimistically, I am taking the position that the nine justices will be deliberating about the constitutionality of this sweeping legislation, and not about its strengths or weakness - issues for the legislative branch and decidedly not for the court.  As I understand it, they will be answering three key questions.  First, does the commerce clause of the US Constitution empower Congress to mandate every American to buy health insurance whether they want it or not.  Second, if the answer to the first question is "no," does the entire law fail, or is this provision "severable"from other sections that are arguably unrelated.  And finally, is the law's requirement that the states participate in its various provisions in order to receive support for Medicaid coercive in effect.

I am no scholar of the law, and what I know about constitutional law would fit on a three by five card.  However, I am struck by the central irony of this entire discussion.  The Obama administration backed away from the single-payer solution because it was seen as too radical a departure from a system of healthcare delivery in which private insurers were such important players.  Thus, the "mandate" that persons obtain health insurance in the private sector was created to find a solution that would be more palatable to free market advocates.  An expansion of Medicare for the purpose of capturing the uninsured would face no such constitutional hurdle.  Make no mistake: the ACA presented a very complicated solution, but it was a centrist solution.

One more thing.  If we get healthcare coverage taken care of, the job will be only half done.  In fact, less than half done.   Because the skyrocketing costs of US healthcare are NOT just due to an encumbered and expensive insurance industry (which they are) or to fraud and abuse (which represent only a sliver of the pie) but most importantly to patterns of medical practice and over-use that will be very challenging to address.  The psychology and sociology of this phenomenon runs very deep in US medicine and in our culture at large.  More next time.