Health Care Organizational Ethics quoted in the New York Times

I'm a regular reader ot "The Ethicist" column in the Sunday New York Times. This morning's column started with a rather sordid situation:

My ex-wife is a physician. We divorced when I found out she was having an affair with one of her H.I.V.-positive patients. I feel compelled to tell the state medical licensing board and the professional societies to which she belongs about her affair. My reasons for doing so are that I feel an intense urge to retaliate her breach of trust and that she potentially exposed me to H.I.V. (fortunately, I tested negative). I also know that, as a physician myself, I should report her to protect other patients, so that she may get increased supervision at her workplace and treatment if needed. Should I report her even though my main motivation is revenge? NAME WITHHELD

After dispensing with revenge as a motive ("There’s no moral argument for ruining someone’s life just because she ruined yours"), Chuck Klosterman, the columnist, goes on to discuss doctor-patient sex. I was surprised to find a quote from "Doctor-Patient Sex: Why is it Unethical?", a 2009 post on this blog:

There is, however, a problem here. The fact that your ex-wife had an affair with someone who is H.I.V. positive is not a professional issue (and a physician would be well positioned to conduct such a relationship, as she would fully understand the risks). But the fact that the man was her patient is reason for concern. Personally, I can easily imagine situations in which a doctor could have romantic interactions with a patient and everything would be fine — but those hypothetical possibilities don’t make the practice acceptable. R.M. Cullen, a doctor in Auckland, New Zealand, has written at length about the import of a “zero-tolerance” policy when it comes to doctor-patient sexual relations. Here is the core argument, as interpreted by Jim Sabin, director of the Pilgrim Health Care Ethics Program at Harvard University: “Cullen argues — in my view correctly — that it is not necessary to prove that every instance of doctor-patient sex will be harmful . . . to establish that doctor-patient sexual relationships are unethical. The medical profession can, and should, adopt a zero-tolerance ethical stance based on a) the potential for harm to the patient with b) no offsetting potential benefits for the patient, combined with c) the inevitable harm to trust in the medical profession itself.” In other words, the potential downside is massive, the potential upside has nothing to do with medicine and the social take-away makes every other doctor look sketchy.


So does this mean you should report your ex-wife? If you agree with Cullen’s argument, you should. If you simply want to hurt her, your position is weak and immoral, but the action of reporting her itself remains defensible.

In the past five years I've written 20 posts on doctor-patient sex. These posts have had more than 25,000 page views - not much by internet standards but a lot for a blog with a wonky title and a somewhat esoteric focus. The 20 posts have received 128 comments. I have the impression that folks get to the posts via Google searches when they're concerned with the topic. I assume that was the case with Chuck Klosterman.

Public Learning about ACOs

"Culture beats strategy every time" is a truism in management consultation. The Accountable Care Organization concept is excellent strategy, but it won't get anywhere if our health system culture doesn't support it.

This morning I was happy to see a front page article in the New York Times about how Advocate Health Care is developing its ACO. The article is clear and informative. But the amateur medical anthropologist in me was struck by what the language reveals about the cultural context within which ACOs will thrive or crash and burn. In what follows, snippets from the article are in italics, followed by my editorial comments. I've highlighted key phrases - all of the emphases are mine:

On a stormy evening this spring, nurses at Dr. Gary Stuck’s family practice were on the phone with patients with heart ailments, asking them not to shovel snow. The idea was to keep them out of the hospital, and that effort — combined with dozens more like it — is starting to make a difference: across the city, doctors are providing less, but not worse, health care.

In recent years I've been careful to shovel snow slowly and not to overload the shovel. If I was one of Dr. Stuck's patients I would have appreciated a call from the nurse. But note the assumption that less care is likely to be worse. As a physician who practiced for 43 years my default view is that less is better/more is worse. Many of my colleagues think the same way. ACOs won't succeed unless we can nudge the wider public into understanding that "more" does not equal "better" and "less" is often an improvement!

For most health care providers, that would be cause for alarm. But not for Advocate Health Care, based in Oak Brook, Ill., a pioneer in an approach known as “accountable care” that offers financial incentives for doctors and hospitals to cut costs rather than funnel patients through an ever-greater volume of costly medical services. Under the agreement, hospital admissions are down 6 percent. Days spent in the hospital are down nearly 9 percent. The average length of a stay has declined, and many other measures show doctors providing less care, too.

Insofar as the kind of integrated care ACOs are designed to promote is the right way to deliver care, the changed payment structure is removing a barrier to doing the right thing, not "incentivizing" us like rats in a maze. I don't think I'm alone in finding all the talk about "incentivizing physicians" to collaborate with their patients and colleagues offputting. And if I were a naive patient I'd be suspicious of care that my doctor had to be "incentivized" to provide!

“It’s hard to imagine that you could start from scratch and do this and be successful in three years," said Dr. Lee Sacks, Advocate’s chief medical officer, noting that other systems may find it far harder to flip the traditional fee-for-services system on its head. “We had a running head-start going back to 1995.”

The organizations that joined in 1995 to create Advocate have a 100 year history of faith-based health care. As a non-Christian I found the Advocate mission inspiring. I would be proud to practice with colleagues who shared the values Advocate promulgates. I wish the article had taken the following great quote from Dr. Sacks that I found on the Advocate website:

"There is just a special feeling throughout Advocate Health Care. We regularly recognize those who exemplify our values of compassion, equality, excellence, partnership and stewardship, even though many of them would say that they were just doing their job.”

A piece of cheese at the end of a maze isn't what "incentivizes" health professionals - it's the privilege of being part of a caring profession whose values go back for millennia! The admirable clinicians Dr. Sacks is talking about would be stunned to be told that their comportment reflected economic incentives, not personal mission!

In some ways, accountable care resembles earlier efforts to control medical spending, including the health maintenance organizations that proliferated in the 1980s but fell out of favor, in part because they severely limited patients’ choices. But accountable care differs by giving doctors and hospitals a direct financial stake in saving money and a reason to invest in various programs of preventive care rather than relying exclusively on the fees they would normally earn from providing services.

This snippet tip toes towards getting the culture issue right, but it still misses the crucial point. Capitated payments facilitate investment in programs (and not just for prevention) that are not paid for in our cockeyed fee-for-service/widget-rewarding payment system. But that's not what gives doctors a "reason" to invest. The reason is that it's the right thing to do in light of a mission that even many athiest clinicians regard as "sacred."

So far, Advocate has achieved a small but significant savings of about 2 percent below projected costs, Blue Cross Blue Shield said, but it is not clear whether it can continue to make progress. Already, some Advocate hospital chiefs have expressed fears over losing revenue and warned about the threat to their financial performance. Doctors fret that their incomes may suffer. “We’re doing it because it’s the right thing to do for patients,” said Dr. Stuck, the Advocate family physician. “We’re not making more money.”

Dr. Stuck's point about doing the right thing speaks for itself!

“You’re trying to overlay a payment design onto a benefit model that allows a patient to go anywhere he wants,” said Steve Hamman of Blue Cross Blue Shield, noting that patients can undermine the advantages of the new approach if they ignore the advice or insist on unnecessary tests and procedures. “We can talk all we want about provider accountability and how important that is. But there is a measure of patient accountability that is critical as well.”

For readers who aren't familiar with the ins and outs of the ACO concept, this paragraph is referring to the fact that Medicare beneficiaries who are receiving their care from an ACO aren't "locked in" to the ACO network. If Dr. Stuck's patients want to go to the Mayo Clinic they can do so. This is likely to create clinical, economic and ethical challenges for ACOs. What if the Mayo Clinic does knee replacements better than the ACO? Do we have to refer patients "out"? What are the acceptable ways for ACOs to try to keep patients "in network"? And, most important, how do we engage patients and the public in seeing stewardship of shared resources as a societal imperative they share responsibility for?

We Yanks believe in magic bullets. That's why we have so many drugs in our medicine cabinets and drones in the sky. ACOs, alas, will not magically solve our health "system's" problems of quality and cost. The ACO is a good concept, but it won't thrive without a supportive culture. The otherwise excellent article in the New York Times shows how far we have to go to develop the culture we need!

(See here, here, and here for posts that discuss related aspects of the ACO concept.)

Should You Kill Your Disabled Child?

I've just read a remarkable book about this question: Rescuing Jeffrey, by his father, Richard Galli. I got to the book via "Calling It Quits: When Patients or Proxies Request to Withdraw or Withhold Life-Sustaining Treatment After Spinal Cord Injury," an article assigned to Harvard Medical School students for this week's class on end of life care in the required course on "Medical Ethics and Professionalism."

On July 4, 1998, Jeffrey Galli, 17 at the time, dove into the shallow end of a swimming pool and fractured his neck, injuring his spinal cord in a way that left him quadriplegic and unable to breathe without ventilator support. Richard saved his life by pulling him out of the pool and breathing through his nose. But when Jeffrey got to the Hasbro Children's Hospital in Providence, Rhode Island, and the extent of his injury became clear, Richard and his wife Toby considered whether the right thing to do would be to withdraw treatment and let Jeffrey die.

Galli renders the anguished flow of his thoughts and feelings in admirably spare prose. Not surprisingly for a 17 year old, Jeffrey had given no guidance about he would want to have done in a situation like the calamity he experienced. In his initial state of unconsciousness, and the next few days of impaired awareness, his parents had to make decisions for him. Galli initially felt that Jeffrey - a very physical boy who was not drawn to reading or other forms of "living in his mind" - would not be able to tolerate the helplessness and immobility of quadriplegia. But he recognized that he wasn't a reliable decision-maker. Perhaps he was the one who couldn't tolerate Jeffrey's condition. Galli conveys the way thinking about Jeffrey mixed with projection onto Jeffrey brilliantly. At one point he imagines pulling the plug on Jeffrey and then committing suicide himself!

When Jeffrey started to regain consciousness and began to fathom what had happened, his first reaction was "I want to die." But over the course of the ten days Galli's narrative describes Jeffrey first oscillates between wanting to die and wanting to live, gradually settling on the will to survive.

Galli provides a service to clear thinking by using harsh words to bring out harsh facts. For him the question isn't whether to "withdraw medical treatment from Jeffrey" but whether to "kill Jeffrey." In part, making that choice would have been an act of love - sparing his son from the suffering that he expected would be Jeffrey's fate. But in part the choice would have reflected his own suffering at the loss of a son with mobility. For that reason. "killing" wfelt to him like the right word.

The crucial help Galli received was from a physician whose name he does not give and who was not part of Jeffrey's ongoing treatment. The physician conveyed that the life vs. death decision didn't have to be made now. If Jeffrey decided in the future that life in a wheelchair with no use of arms or legs and no ability to breath on his own was not worth living, he could have the ventilator withdrawn. Galli concluded that letting the treatment proceed was not committing his son to a life of unwanted suffering.

The book is painful to read, but once I picked it up I couldn't put it down.

(Jeffrey completed high school and then college. For an article about him at the University of Rhode Island, see here. For a video of Jeffrey and his younger sister Sarah in 2012, 14 years after the accident, see here. And for a post I wrote about an adult patient with quadriplegia who elected to have his ventilator turned off, see here.)

Keep Sound Minds

In 2008 I blogged about how after Marci Thibault, in a state of psychosis, walked into New Hampshire traffic with her twin sister Danielle's two young children, killing them all, Danielle and her husband Ken formed a not-for-profit devoted to "prevent[ing] similar incidents from occurring by improving society's understanding and management of mental health issues."

Keep Sound Minds, the organization Danielle and Ken founded, is hosting an event in Woburn, Massachusetts, on Saturday evening May 18. I have the privilege of being one of the speakers, along with Ken and Danielle. The event is co-sponsored by the Wellstone-Barlow Mental Health Initiative. David Wellstone is son of the late Senator Paul Wellstone, who crusaded for mental health causes. Ken Barlow is a popular TV meteorologist in Minnesota who recently "came out" about having bipolar illness. (See here for a great interview with him.) Their organization is devoted to de-stigmatizing mental illness. David Wellstone and Ken Barlow will also speak.

I encourage readers to go to the Keep Sound Minds website and to watch the interview with Ken Barlow. And, if you're in the area, come to the event on May 18th and tell folks you know who have a special interest in mental health matters about it.

The Bias Towards Drugs in Psychiatry

Two days ago I posted about the bias towards drugs in treating depressed older patients. The next day the New York Times published a heartbreaking op ed on the same theme by Ted Gup, whose son died of a drug overdose 18 months ago.

Gup reflects with pain on his decision to allow his son to be put on stimulants for what was diagnosed as ADHD. In retrospect, he feels he contributed to his son's ultimate death:

In another age, David might have been called "rambunctious." His battery was a little to large for his body. And so he would leap over the couch, spring to reach the ceiling and show an exuberance for life that came in brilliant microbursts...

No one made him take the heroin and alcohol, and yet I cannot help but hold myself and others to account. I had unknowingly colluded with a system that devalues talking therapy and rushes to medicate, inadvertently sending a message that self-medication, too, is perfectly acceptable.

I had the good luck to have been allowed to outgrow my rambunctiousness. I remember my elementary school report card identifying "self control" as a "special need." I remember as well not understanding why it bothered my parents that when I spoke with them I went through the motions of a baseball pitcher. "Ants in your pants" was the "diagnosis" they gave me. After some years, the ants disappeared. The key interventions came from wise parents, teachers, and sports coaches.

Gup sees how the culture that contributed to the death of his son affects us at every stage of life:

I fear that being human is itself fast becoming a condition. It’s as if we are trying to contain grief, and the absolute pain of a loss like mine. We have become increasingly disassociated and estranged from the patterns of life and death, uncomfortable with the messiness of our own humanity, aging and, ultimately, mortality...Instead of enhancing our coping skills, we undermine them and seek shortcuts where there are none, eroding the resilience upon which each of us, at some point in our lives, must rely.

The young move too fast for our comfort and we give them drugs to slow them down. The elderly move too slowly for our comfort and we give them drugs to speed them up.

The Bias Towards Drugs in Treating Depressed Older Patients

I recently read an article on "How to adapt cognitive-behavioral therapy for older adults" that came to me in Current Psychiatry, a "throw-away" journal (one that comes to professionals free of charge and without subscription, typically containing non-peer-reviewed articles and often replete with advertising). The article itself was excellent, but the opening paragraph was revealing in terms of the problematic way psychiatric treatment is typically framed nowadays:

Some older patients with depression, anxiety, or insomnia may be reluctant to turn to pharmacotherapy and may prefer psychotherapeutic techniques. Evidence has established cognitive-behavioral therapy (CBT) as an effective intervention for several psychiatric disorders and CBT should be considered when treating geriatric patients. (emphasis added by me)

Perhaps as the spouse of a college English teacher I'm overly fussy about language, but to my eye this paragraph gives drugs the position of privilege in treating elderly patients with the common symptoms of depression, anxiety, or insomnia, and relegates psychological interventions like CBT to "be considered" if drugs are rejected. Readers wouldn't guess that the National Institute for Health and Clinical Excellence (NICE) guideline on treating depression in adults recommends various applications of CBT as the first intervention for subthreshold depressive symptoms or mild to moderate depression. Drugs only come in later (except for more severe depression)!

Outcome studies suggest that CBT is at least as effective as medication for mild to moderate depression. Given that medication side effects can be especially problematic in an elderly population, why the bias against psychosocial interventions? I see four main reasons:

1. From non-stop pharmaceutical marketing to physicians and the public, we associate drugs with images of butterflies, sunshine, smiling faces, and other seductive visions. The multi-billion dollar marketing campaign synergizes with our wish for quick and easy fixes to our problems.
2. Ageism, as reflected in aphorisms like "you can't teach an old dog new tricks," promotes the belief that elderly folks are too set in their ways to change by psychological means. Empirical studies show this isn't true.
3. Non-mental health clinicians may worry that they aren't adequately skilled at providing CBT or other psychosocial interventions like my primary care colleague years ago who said, in unintended verse: "I know what to do when they're dying/But not what to do when they're crying."
4. For harried primary care physicians (the likeliest group to see elderly patients with mild depression) writing a prescription takes much less time than initiating a psychosocial intervention.

Lack of skill and the crunch of time are serious impediments. But they're not insoluble. CBT has been adapted to self-guided formats. Non-mental health clinicians and aides have been trained in basic CBT approaches. And CBT has been delivered by telephonic means.

The degree to which we favor drugs over psychosocial treatments ultimately reflects a form of bias. That's why I discuss it in a blog about ethics!

(For an example of how our national tilt towards mechanistic thinking about human process affects another age group, see yesterday's New York Times article reporting that 11% of school aged children have been given a diagnosis of ADHD. Stimulants represent a nine billion blockbuster business.)

Badmouthing Your Doctor

A headline on the front page of this morning's Boston Globe jumped out at me - "Doctors fire back at patient critiques: Lawsuits target harsh web posts." It tells the painful story of the relationship between Gary Cotour and Dr. Sagun Tuli, neurosurgeon for his late wife Lyn.

Dr. Tuli operated on Lyn Votour to remove cancerous vertebrae. During the second surgery Ms. Votour experienced a stroke. After a stay at a rehabilitation hospital she returned home, bedridden and dependent on a feeding tube. Two years later, depressed and in pain, Lyn Votour asked Gary to remove her feeding tube. He did so, and she died.

Mr. Votour's relationship with Dr. Tuli apparently went well during her acute hospitalization, but after discharge it fell apart. After her death Mr. Votour asked to meet with Dr. Tuli. Here's what he later said about the situation:

I was not doing well with grief. I wanted to go back and talk to Dr. Tuli about some questions that were bothering me. I really wanted to ask her why don’t doctors follow up after discharge. I wanted to understand why doctors just wash their hands after discharge.

The meeting Mr. Votour wanted never happened. Dr. Tuli claims that a hospital lawyer told her not to meet with Mr. Votour. The hospital denies this and claims that Dr. Tuli "indicated that she was not comfortable meeting with Mr. Votour."

Mr. Votour posted on his blog that doctors at the rehabilitation facility had encouraged him to file a malpractice suit against Dr. Tuli and that he lost his wife "not to cancer but to indifference and egotism."

In response, Dr. Tuli is suing Mr. Votour for defamation, asking for $100,000 in damages.

Whether it was the hospital lawyer's advice or Dr. Tuli's discomfort that led to not meeting with Mr. Votour after his wife's death, that meeting should have occurred. In addition to all of the work that has been done on the benefitial effects of apology, I draw on a personal experience here. Some decades ago I had brief contact with a college age student suffering from severe depression. The student believed that the depression stemmed from stressors, and that returning to school would alleviate the symptoms, as had occurred in the past. After discussion, I agreed with this prediction, but advised the student (I'm deliberately leaving out gender and other identifiers) to seek immediate help if the symptoms recurred. The symptoms did recur. The student sought help as I had advised, but committed suicide in the course of the care process.

The student's family asked to meet with me. We met for an hour or two. They pressed me to explain why I supported return to college rather than immediate hospitalization. After I did so they asked if I felt I had made a mistake. I said that I had thought carefully about the advice I'd given, but that in retrospect I wished I had followed a different course. I expressed my great sorrow about the student's death. It was one of the most painful meetings of my entire career.

Some years later I was contacted by a malpractice lawyer representing the family. My anxiety soared. The lawyer asked me for information, but told me that the family was bringing suit against the college, and had specifically requested that I not be brought into the case.

Given the terrible outcome it would have been entirely understandable for me to have been sued. I believe the heart to heart meeting we had had after the student's suicide assuaged potential bitterness against me. The family may well have felt that I made an erroneous judgment, but they did not feel as Mr. Votour did that the student's death was caused by "indifference and egotism."

The Boston Globe article quotes David Ardia, codirector of the Center for Media Law and Policy at the University of North Carolina, about the impact of the Internet on physician concern about our reputations: 

the Internet has realigned the power structure that existed between doctors and patients, giving patients far more influence than they have ever had. The Web is just chock-full of people commenting on their experiences. Doctors have reacted with a great deal of hostility toward this.

The article led me to look myself up on the rate-your-physician sites. The single patient response on healthgrades gave me the lowest possible grades on every category. I ended my clinical practice five years ago, but if I were still in practice I'd be concerned that 100% of the reviews I'd received gave me a F grade.

Dr. Tuli's suit against Mr. Votour reflects a classical form of "good vs good" ethical conflict. Freedom of speech is a fundamental good, enshrined in the First Amendment. But our public reputations are precious to us, and even a non-verbal critique like the one an anonymous former patient gave me on healthgrades can undermine a career. As unseemly as it is for a physician to sue a former patient, Dr. Tuli will not be the last physician to follow that unhappy route.

(Two examples of enterprises that offer to protect physician reputations can be seen here and here. And, thanks to an anonymous reader, here is a link to the original post that is no longer on the web.)