Thursday, January 26, 2017

Retirement from Clinical Practice

Next week I have the privilege of facilitating a meeting on retirement sponsored by the Massachusetts Psychiatric Society. On two counts I was happy to be invited to do this.

First, from the perspective of this blog, medical societies are significant organizational players in the world of health care ethics. A well-functioning medical society helps newly minted physicians find their way into practice, provides guidance throughout the active phases of clinical careers, and supports colleagues in concluding their practices in ways that work as well as possible for our patients and for our own well-being. If a medical society isn't strengthening the ethics of its members it's not doing its job!

Second, the invitation prodded me to review my own experience of retirement from clinical practice, with the aim of distilling some comments to launch a group discussion. These are my major thoughts so far:

DREAD: Even though I was only practicing 1/3 time, I was frightened at the prospect of clinical retirement. My fear showed up in two visual images. I identified with King Antaeus, the figure in Greek mythology who derived his strength from the earth. He challenged Hercules to a wrestling match. Each time Hercules threw Antaeus to the ground, Antaeus's strength was renewed. Hercules caught on, held Antaeus in the air and crushed him to death. In one version of the story he hurled Antaeus into space, where he became a constellation. In the other image I saw myself as a sailboat utterly becalmed and helpless. Both images conveyed a feeling that my vitality and worth as a human being came from my role as a practicing physician.

MENTORING: I asked to meet with a colleague who was 10-15 years older, who to my eye was negotiating his life in an admirable manner. I told him about my fear of ending clinical practice. He told me he'd had similar concerns, but was surprised to find an element of relief when he stopped practicing, even though he'd never thought of practice as a strain to be relieved. He gave me some other practical tips, but I still remember with gratitude his reassurance about my fears.
MONEY: The meetings my wife and I had with our financial advisor were crucial. Confidence that we wouldn't go down the tubes financially was necessary for proceeding with the retirement plan, but not sufficient in itself to assuage my fears.
ENERGY: When on Friday August 31, 2007, I acknowledged to myself that I was really going to end my practice at the turn of the year, a surprising thing happened. In a desultory way I'd imagined starting a blog about ethics at an undetermined time in the future. But when I pinned down the date by which I would end my practice, without any forethought I went to Google and put in "start a blog." The inner experience was as if a stream that had been flowing in one direction (clinical practice/identity as a clinician) shifted into a new direction (the blog and the beginning of a new identity). I started this blog that day.
DISORIENTATION: When I was working full time my days were organized - especially on days when I saw patients. For clinicians, our schedule of patients tells us why we should get up in the morning. Trying to help people who are suffering assuages doubts about our purpose in life. 
LONELINESS: Retiring from clinical practice didn't mean retiring from professional activities. I continued my cherished academic position and leadership of the Harvard Pilgrim Health Care ethics program. These activities provided important and valued human connections. But I missed the richness of clinical life - connections with my long term patients and colleagues.

I'm proud of the Massachusetts Psychiatric Society for its attention to the penultimate phase of clinical career and grateful for the opportunity to participate. The health professions are devoted to the well-being of patients and the public health. If clinical retirement is handled well, these values can be pursued in new ways after physicians hand up their clinical hats.

Sunday, January 22, 2017

Affordable Care in Rural India

I just returned from India, where I visited Flame University (the name is derived from "Foundation for Liberal  and Management Education") in Pune.

At a meeting with Professor D.S. Rao, Provost and Dean of the Flame School of Business, I learned about Yeshasvini, a cooperative health insurance venture for farmers in the state of Karnataka. At the depressing moment where the new U.S. administration  is preparing to tear down President Obama's extension of health insurance to a wider population, it was heartening to learn about a program working to advance Obama's ideals by insuring the poorest of the Indian poor.

India does not have a tradition of paying for health care through insurance. The majority of health care is still paid for on an out-of-pocket basis. Even though costs are much lower than in the U.S., for the large population of rural poor, modern health care is unaffordable.

Yeshavini, started in 2003, offers a limited insurance package to members of rural farm cooperatives on a prepaid basis for less than $5 per year per insured person! The state of Karnataka matches some or all of the farmers' payments. Karnataka, approximately the size of Nebraska, has a population of 64 million. As of 2014-2015, 3.8 million were enrolledin Yeshasvini.

Yeshavini's mission is noble:
"To bring health care of International Standards within the reach of every cooperative farmer of Karnataka. We are committed to the achievement & maintenance of excellence in health care for the benefit of farmer cooperator."
Even in India, $10/ year cannot provide "health care of International Standards." The package is largely for surgical services at 550 participating hospitals. Non-surgical treatment for cancer and diabetes is  not covered. But hazards faced by farmers like snake bites. goring by bulls, and accidents involving agricultural machinery are.

From a U.S. perspective, Yeshasvini is best thought about as a "proof of concept." In 1969 when I first encountered the concept of prepaid health care delivered by the not-for-profit Harvard Community Health Plan to a defined population on a prepaid basis, I thought this was the right way to provide modern health care. I still do. I joined the group in 1975, and while I ended my practice in 2008, I still get my own  care from the group and I work with it on establishing its new ethics program.

Somewhere between the pared-down Yeshasvini program in Karnataka that is affordable to poor farmers but covers too little and the super-comprehensive U.S. programs that cover too much and are a stretch for all but the wealthiest, is the golden mean of health care. But Yeshasvini supports the view that health care should be (a) population oriented, (b) prepaid, and (c) not-for-profit.

That's a perspective likely to come under attack from the newly installed Republican administration!

Friday, September 2, 2016

Drug-Resistant TB and a Physician Hero in India

Today's New York Times described Dr. Zarir Udwadia's campaign against drug-resistant TB. He is earning well-deserved international respect.

Dr. Udwadia is a pulmonologist in Mumbai. He did his medical training in Mumbai and Scotland. When he returned to Mumbai in 1991 he followed his pulmonologist father in starting a private practice. But he wasn't busy enough, and to use his knowledge he started a free clinic for patients with TB. It's now the busiest clinic at his hospital.

In 2011 Dr. Udwadia published a letter describing four patients whose TB infection was resistant to all antibiotics currently available in India. The Indian government's initial response was to attack the messenger, not to respond to the message. But Dr. Udwadia refused to be silenced, and brought the government to recognizing and responding to the medical crisis. The government now pays for drugs that were not subsidized in 2011.

I'm currently teaching medical students who are going into their first clinical rotations, and we've been talking about the patient-physician relationship. From that perspective I was especially moved by this passage:
The tall, lean doctor with a halo of black hair refuses to wear a mask to protect himself, even though his wife says he does worry about contracting TB. “How can you connect to a patient that way?” he asks. Instead, he leaves open his window so there is good air circulation, which reduces the chances of infection.
In the jargon of ethics, his actions are "supererogatory" - morally admirable but above and beyond what is reasonable to expect. If I were advising Dr. Udwadia, I would encourage him to protect himself to ensure that he continues to be available for his ministry to the poor. But his commitment to making a real human connection with his patients is in the best tradition of medicine and the spirit of Mahatma Gandhi.

Here are the closing paragraphs from the article:

When Mrs. Sheikh, a tiny woman wearing a salwar kameez, showed up for her recent checkup, Dr. Udwadia grinned and reached across the table to shake her hand, unable to contain his excitement as he reviewed her tests. They were negative for TB for the third successive year.
Her lungs are so scarred from the disease that she becomes breathless after walking several steps, but she says she is grateful to be alive. She takes a two-day train ride from her hometown in northern India to Mumbai every six months for a checkup.
“I know it sounds like a cliché, but these times are what I live for,” he says. “In India, all patients tell the doctor, ‘You saved my life,’ but with Rahima Sheikh, I know it’s really true.”
 When I see the brilliant, idealistic young medical students next week, I'll hope to convey some of the values that Dr. Udwadiah evinces so powerfully!

Wednesday, August 3, 2016

Does Freedom of Speech allow Rejection of a Court's Findings?

In June I wrote about David and Collet Stephan being sentenced to jail for the death of their two year old son Ezekiel. David and Collet treated him with naturopathic remedies and did not respond to clear indications that Ezekiel was developing dangerous meningitis until it was too late. The judge acknowledged that they loved Ezekiel and were trying in their way to help him, but concluded that they did not have a right to choose their own beliefs over mainstream health care. He sentenced David to four months in jail, but allowed Collet to serve a three month sentence under house arrest.

The aftermath so far is fascinating. Both sides are appealing The "Crown" (Canada's term for the "state") is appealing the sentence as too lenient, on the following grounds:
 - The sentence is not proportionate to the gravity of the offence or to the degree of responsibility of the offender, and is unfit.
 - The Sentencing Judge gave insufficient weight to denunciation and deterrence.
- The Sentencing Judge underemphasized, or failed to give weight to, relevant aggravating factors.
- The Sentencing Judge overemphasized mitigating factors, or gave mitigative weight to factors that are not mitigating. 
- The Sentencing Judge misinterpreted the legal doctrine of wilful blindness.
"Wilful blindness"is a legal term referring to motivated ignorance. The Crown is alleging that the Stephans chose to ignore the obvious fact that Ezekiel needed urgent medical attention because of their cult belief in "natural" remedies.

The Stephans have appealed their conviction. A friend from Canada told m that the appeal is based, at least in part, on free speech grounds. According to my friend they argue that the judge's requirement that they post an unedited copy of his ruling on their website infringes on their right to freedom of speech. (I haven't been able to find the details of their appeal.)

David Stephan's two "letters from jail" (here and here) show him to be a principled believer in a false doctrine. He is convinced that he is taking a stand for justice, to protect other parents from intrusions of the state.

I believe, however, that the judge threaded his way between punishment and mercy in an admirable manner. The judge and jury concluded that David and Collet were guilty of failing to protect their son from preventable harm. From my reading of the media reports this was a correct finding. But the judge recognized that the Stephans were loving parents, acting on their longstanding beliefs. They meant well for their son, but they did him the ultimate harm.

The judge gave David, who he saw as the leader of the belief system, a short jail sentence, but allowed Collet to serve on home detention so that she could care for the children. I supported and continue to support his requirement that his findings be posted on the Stephan website. While the Stephans totally disagree with the findings, they have been convicted under the law. Their website promulgates the cult beliefs that led to their son's death, and could do the same in another family. Posting the judge's findings does not abridge their speech rights. They can, and will, continue to disagree the the judge and jury and to speak up for their false naturopathic doctrines. This is their right in a democratic society.

But if they persist in refusing to post the  judge's findings I would favor requiring Collet to serve her sentence in jail once David is out and could care for their children. I do not know the Canadian precedents for contempt of court, but it would seem that a substantial fine and an extended period of probation would be warranted.

I believe the Stephans deserve respect for the principled way in which they assert their beliefs. In their view they are standing up for truth and justice. David is careful to say that he discourages his supporters from anger or hatred. This is admirable. But in the democratic society of Canada, the Crown is the legitimate authority for ruling on the situation. If David can persuade the public to change the law, the situation will be different. But under the law, the judge has ruled correctly.

Saturday, July 30, 2016

Close Reading, Improved Writing, and Service Learning: A Virtuous Circle!

I'm in Vermont at the Bread Loaf School of English, a Middlebury College program in which the students, primarily high school and middle school English teachers, can get a Master's degree in the course of five summers. My wife has been teaching here every summer since 1992 and I enjoy the potential for (a) telecommuting and (b) swimming and hiking in Vermont.

In the past four years I've been doing an annual workshop on "Making Ethics part of High School and Middle School English Class." Working with the students here is a great pleasure and privilege. There's very little that's more important than educating the next generation.The teachers are doing God's work!

There were 18 participants in the workshop I did a week ago, plus three members of the Bread Loaf faculty. The participants taught in settings ranging from the Navajo Nation to public schools in urban and rural settings to elite independent schools.

We focused the workshop around a question that came from a 10th grade teacher, whose class does a service learning module that combines class discussion, a service project chosen by the student, and a research paper. She felt that the unit was well-intentioned, but many students experienced it as a burden, and it didn’t feel integrated with the rest of the semester’s work. She asked the group – did other teachers have ideas about how to make service learning more engaging for students? 

I’ve distilled 4 points from the wonderfully rich discussion:

1. English class is often asked to be the vehicle for humanistic goals in the school curriculum. Ideally, moral development and heightened humanism would be a goal for every component of the school  – inside and outside of class. But this kind of full court press rarely happens, and English teachers are asked to take the lead. Being looked to for leadership in moral development is a challenge and an opportunity! I mentioned to the group that my medical specialty – psychiatry – is in a similar situation. We’re often asked to be responsible for the “understanding the patient’s point of view” component of the medical school curriculum. ..”

2. Several participants suggested that preparatory exercises can help students become more open to and engaged with reflection about values. A participant reported that hypothetical questions like “A lifeboat has 10 people but will sink from too much weight. Everyone will drown unless someone is thrown off. What should be done?” triggers lively discussion. Another participant described how she gives the class statements dealing with issues that come up in a book they are reading. Then she has them do “speed dating” – i.e., talking for 30 seconds with another student about their reactions to the statement. Another participant described how she did a similar exercise before reading Hamlet. She poses questions like “do you believe in ghosts?” or “if someone kills your father, should you kill that person for revenge” and asked students to stand up if they agreed. These teachers reported that like warming up before physical exercise, activities of this kind can help students “warm up” into a more reflective state of mind in which they are prepared to see ethics as something important to their lives.

3. When schools require service learning, unless students are prepared well they can cause harm when they enter into the space of those they are “serving.” And the very idea of doing “service for those in need” can create a noblesse oblige attitude (“the poor can’t help themselves – they need me to do this service for them…”) or cynicism (“this is just resumé padding…”). Some argued that requiring service learning and giving academic credit for it is corrupting. But others who agreed that these risks are real nevertheless felt that some students who would never get involved on their own might be turned on and transformed by the service learning experience.

4. Independent schools and public schools in wealthy communities are increasingly sponsoring “voluntourism” – programs in which students go for a short time to a poorer country to do “service.” With rigorous preparation, a strong relationship with local community partners, and opportunity to reflect on the experience, these programs can be excellent learning opportunities for the students and even if not helpful at the “service” site, at least not harmful. A participant contrasted “asset based community development” to “voluntourism charity work”.” ABCD involves identifying the strengths in a community and helping the strengths to be extended. Another participant questioned why “voluntourism” programs travel to other countries when there are valuable opportunities to contribute in their own or nearby communities.  With regard to the stance of noblesse oblige” I mentioned a favorite quote from Thoreau: “If I knew for a certainty that a man was coming to my house with the conscious design of doing me good, I should run for my life!”

The core idea that has emerged from the workshops is an understanding of a virtuous circle involving literature, writing, and social action, which I've represented in a diagram:

Close reading strengthens empathy and humanism by entering into the worlds that literature creates, and improved writing does the same by asking students to think about the audience they are speaking to and how they can best reach that audience. Understanding our values and biases and empathizing with perspectives of others even if we disagree with them increases “ethical sensitivity.” And when students identify values important to themselves and for their communities, they are primed for ethical activism on behalf of these commitments. Activism can create a virtuous circle by stimulating further learning opportunities that strengthen engagement with literature and writing. 

I hope the high school and middle school teachers learned as much as I did from the workshop!

Wednesday, July 6, 2016

Is this doctor hitting on his patient?

I recently received a very thoughtful email from a reader. I'm posting it here (slightly edited) with permission from the writer:
I recently stumbled across your very helpful and insightful blog. I had a question that I thought you might be able to help me with. I was wondering if you could possibly cover something on appropriate boundaries in the doctor/patient relationship.I have seen a few pieces on obvious violations of this (romantic and/or sexual relationships where the doctor clearly took advantage of a patient), but I was more curious about the grayer areas, where doctors may be a bit too familiar with their patients.
I ask because I saw a male OB throughout a recent pregnancy. He was quite attentive, very competent, and overall a wonderful doctor. However, sometimes he made comments that took me off guard and I was never quite sure how they were relevant to my medical care. For example, he asked if my husband still got erections and later asked me to describe how I felt when I had an orgasm. On one hand, I could see how questions regarding sexual activity during pregnancy are pertinent, but never before has an OB asked me these questions during a pregnancy. The questions seemed a little odd to me, but I also wonder if perhaps this OB is just much more thorough in his care than my previous one.
I'd appreciate any light you could shed on the matter of grayer areas in the doctor/patient relationship.
What a terrific - and important - question! Here's my reply:

As you say, the questions your obstetrician asked could be relevant to your obstetrical care, but they could also be part of an effort to see if you might be sexually/romantically available. As a general rule of thumb, when the medical relevance of questions physicians ask isn't obvious, we should explain why we are asking the questions. Not having done that, your obstetrician created a situation in which a reasonable patient might wonder "are these questions part of good medical care, or is the doctor 'coming on' to me?" 

I think the most we can say is that the obstetrician might have been committing what in medical ethics language would be called a "boundary violation." If that was his intent, it was clearly a breach of professional ethics. But if it was not his intent, he failed to make clear why the questions were relevant. For example, he might have said "In my experience, it's not uncommon for couples to encounter difficulties with sexual intimacy during pregnancy...." But it's still unclear what the relevance of your experience of orgasm would be to medical care, unless you had brought up a concern of your own, or if he had said something like "I'm trying to learn about sexual relationships during pregnancy, so if it's OK with you I'd like to ask you..."

Ideally, patients will ask for clarification when they're uncertain about what we are asking about or doing. But in my practice there were times when I thought I was being clear but learned that I had inadvertently confused my patient. The power imbalance in the medical relationship means that physicians can't rely on patients to ensure clarity. Your email shows you to be a very clear thinker, but apparently you didn't feel comfortable saying something like "Could you explain how that question relates to my obstetrical care?"

If a resident or colleague asked me if it was OK to inquire about a partner's erections or the experience of orgasm in the course of obstetrical care, I would (1) ask about the relevance of the questions to the patient's care and, if there was clear relevance (2) recommend that the physician explain why he was asking the questions, to avoid generating the kind of concerns you experienced.

So, in  answer to the question of whether your physician was committing a boundary violation, my response is that it's possible that he was. We know from patient reports that sexual exploitation is often preceded by suggestive/ambiguous comments that in retrospect appear to be "testing the waters" or "dropping hints." But it's also possible that the questions were entirely relevant to his objectives for your care. If that's the case, he was "guilty" of poor clinical communication.

Thank you again for your very valuable question! 


Tuesday, June 28, 2016

Jail Time for Parents for letting Toddler Die from Meningitis

Last week a Canadian court sentenced David Stephan to four months in jail and his wife Collet to three months of house arrest for their role in the death of their 19 month old son Ezekiel in 2012.

When Ezekiel became ill, his parents thought he had some form of "flu," and treated him with herbs and a mixture of apple cider, vinegar, horse radish root, hot peppers, mashed onion, garlic and ginger root. A friend who was a nurse told them he might have meningitis, but they persevered in their efforts to treat him by the "natural" modalities they believed in. A witness testified that when they drove Ezekiel to a naturopathic clinic, he was too stiff to sit in his car seat. As his condition worsened, his parents had to feed him with an eye dropper. They only summoned medical help when Ezekiel stopped breathing. The child suffered severe brain damage from anoxia and died a few days later.

David and Collet are part of a community built around vaccine refusal and faith in "natural" remedies. David's father Anthony founded TrueHope, after his wife, who suffered from bipolar illness, committed suicide. The company markets EMPowerplus, a "natural" product that they claim as a cure for bipolar disorder, depression, and even autism. Ezekiel's father David is Vice-President of the company.

David and Collet were convicted under a Canadian law that requires parents "to provide necessaries of life for a child under the age of sixteen years." The prosecution asked the judge to sentence them to 3.5 - 4 years in prison, close to the maximum the law allows (5 years). The judge called that "too harsh." He required prison for David because David refused to take responsibility for his actions. He asserted that a government conspiracy to squelch vaccine refusal was at work, and blamed Ezekiel's death on faulty ambulance care. In the judge's view, Collet was less responsible for Ezekiel's death. In addition to house arrest, he required her to publish his findings on her website. After their jail and house arrest terms, David and Collet will be on probation for two years, and will be required to obtain regular medical attention for their children.

Adults capable of making decisions are and should be free to choose no treatment or quack interventions. But they should not be free to refuse potentially life saving interventions - like antibiotics for bacterial pneumonia - for their children. Seen through the lens of both law and ethics, the judge ruled correctly. David and Collet loved Ezekiel, but they - especially David - made decisions a "reasonable" parent would know to be wrong. Ezekiel paid for their commitment to their "naturopathic" doctrines with his life.

(For a compendium of articles on the situation, see here.)