Sunday, December 27, 2015

How to Deal with Controversy over Physician Assisted Death

We in the U.S. are not skilled at resolving controversy. We're vulnerable to demonizing those who hold different views on issues that matter a lot to us. Polarizations like "pro life" vs "pro choice" harden into rigid convictions. Physician assisted death (PAD - sometimes referred to as "physician assisted suicide") could fall into the same intractable trap. The American Association of Hospice and Palliative Medicine (AAHPM) teaches us how to approach the issue in a morally mature manner.

With regard to whether it is ethically acceptable for a physician in a state that allows physician assisted death (currently Oregon, Washington, Montana, Vermont and California) to prescribe a potentially lethal medication for a terminally ill patient that the patient can use if he chooses, the AAHPM believes, as I do, that "sincere, compassionate, morally conscientious individuals stand on either side of [the] debate." That's the opposite of demonization. This crucial recognition leads the Association to take what it calls "a position of 'studied neutrality' on the subject of whether PAD should be legally regulated or prohibited."

Physicians who support PAD will be disappointed that the Association does not endorse it. Physicians who oppose PAD will be disappointed that the Association does not oppose it. What the Association chose to do was to tell its members and society itself how patients can best be cared for if and when PAD is legal. Here's the essence of their view, quoted - with slight modification - from the AAHPM policy statement:
  • The permissibility of PAD is dependent upon access to excellent palliative care. No patient should be indirectly coerced to hasten his death because he lacks the best possible medical and palliative care.
  • Requests for PAD emanate from a patient with full decision-making capacity.
  • All reasonable alternatives to PAD have been considered and implemented if acceptable to the patient.
  • The request is voluntary. Safeguards should focus in particular on protection of vulnerable groups including the elderly, frail, poor, or physically and/or mentally handicapped. Coercive influences from family or financial pressure from payors cannot be allowed to play any role.
  • The practitioner is willing to participate in  PAD, never being pressured to act against his own conscience if asked to assist a patient in dying.
  • The most essential response to the request for PAD...is to attempt to clearly understand the request, to intensify palliative care treatments with the intent to relieve suffering, and to search with the patient for mutually acceptable approaches without violating any party's fundamental values.
The AAHPM has provided admirable ethical and clinical guidance. "Studied neutrality" reflects moral wisdom, not wishy-washy waffling. AAHPM is doing what a professional association does at its best - offering clear guidance to members, the medical profession as a whole, and to wider society.

Sunday, December 20, 2015

Informed Consent for Simultaneous Surgeries

Two months ago (here) and again today the Boston Globe Spotlight team wrote about the practice of having one surgeon doing two operations at the same time, moving between two operating rooms and leaving fellows or residents "in charge." Dr. Dennis Burke, a prominent orthopedic surgeon at the Massachusetts General Hospital, brought his concerns about simultaneous surgery to the Spotlight team. Dr. Burke has been dismissed from the hospital for showing redacted records from his own patients to the Globe team. 

Physician leaders at the Massachusetts General Hospital and elsewhere insist that there is no evidence that simultaneous surgery has led to worse outcomes for patients. And advocates defend the practice - which is common at leading hospitals, as (a) efficient use of skilled surgical time and (b) a way to reduce waiting time for patients. 

If simultaneous surgery were recognized as having even a small effect on patient safety, for reasons of prudence (malpractice liability and terrible publicity) as well as ethics, hospitals would not allow it. But let's assume that definitive studies showed there was no increased risk. What then?

Think about it personally. If you were going under the knife, would you want to know that your surgeon would be going in and out of the operating room to do surgery on another patient at the same time? I would. 

If there's no difference in outcomes, physicians might say - "why do I need to tell patients - there's no difference in outcomes?" The answer is that we have an ethical duty to give patients information that's important to them. I've done an informal survey among friends as to whether they regard the question of whether their surgeon would be doing two operations at once as something they would want to know about as part of their decision-making process. 100% said it is.

Revealing the possibility of another surgeon taking charge in the small print of an informed consent "contract" does not do the job. Good ethics requires open discussion. This may well be uncomfortable for surgeons, just as candor about how often they have done a procedure when they are early in the learning curve is. But it's what we owe our patients, and to the reputation of our profession as trustworthy, not devious and evasive.

Friday, December 11, 2015

The Four "As" of Ethics

Here's a mnemonic I've found useful for thinking about the actions health organizations need to take to walk the talk of their values:

  1. Analysis ("what is the right thing to do?") This is the activity most familiar to ethics committees and classes in ethics. When is it right to pull the plug? At what age should children make their own health care decisions? When the term "ethicist" is used it's generally associated with the analytic activity.
  2. Advocacy ("let's do the right thing!") This is the charismatic leadership function. When  leaders are seen as admirable exemplars of the organization's values, bureaucratic position and natural authority coincide. This is a uniquely powerful configuration. But every group has members who others respect and want to emulate. Wise leaders look to these widely admired member of the group as strong influences on the organization's ethical culture.
  3. Administration ("we need to create structures that make it easier to do the right thing.") Ethical behavior is strongly influenced by internal ego ideals, but it's also shaped by external factors like prompts in an electronic record that help us conduct and record advance care planning and nudge us when it hasn't been done.
  4. Accountability ("how well are we living our ideals? how can we improve?") Many years ago, a primary care colleague had his assistant ask every patient after their appointment - "did Dr. X do what you needed him to do today?" If the answer was "no," the assistant was trained to intervene, either directly or by calling in to the office. Now we have well developed systems like Press Ganey to assist with accountability at the population level, but the basic function is the one Dr. X implemented on his own.
Ethically admirable health organizations need to cultivate all four of the "As". 

Sunday, December 6, 2015

Taking Action on Sexual Abuse by Physicians

"Why Didn't Anyone Stop Dr. Hardy?" is the featured headline on the front page of today's Boston Globe. It's accompanied by the photo of the back of the head of a woman who complained about Dr. Hardy to the Massachusetts medical board in 2004. She has her hand against her cheek with a watch showing prominently, suggesting the passage of time over which numerous complaints were made about Hardy, with no action being taken. What follows is a summary of the article and my analysis of the key issues:

The story went back to his undergraduate days at Princeton. Both male and female classmates believed he had committed sexual assaults. But this was the 1970s, before the kind of focus on sexual misconduct that universities now apply. Hardy was president of the premedical society and even, for a time, a counselor in a sexual education program. A male classmate was concerned enough to send anonymous letters to medical schools warning that Hardy was "a person of poor character." Hardy trained at Cincinnati, Stanford and Harvard, becoming a gynecologist and fertility specialist.
In 1999 a woman reported to the gynecologist who had referred her to Hardy that Hardy has massaged her clitoris, saying he needed to get her "uterus to contract." She asked the gynecologist - was this a normal medical procedure? Her gynecologist said it was not, but apparently did not report Hardy to the medical board. In 2004 the patient featured in the article reported Hardy to the medical board, complaining that her clitoral area was raw and swollen after a surgical procedure. Hardy wrote a three page defense. The board took no action against him, but it did make a record of the complaint.
In 2011 Hardy told  a South Asian patient that women from her country were "clueless about sex," and that being brought to orgasm by his massaging her clitoris would help her get pregnant. When this woman ultimately went to the Massachusetts medical board the board conducted an extensive examination - including interviewing classmates from Princeton -  leading to Dr. Hardy's surrendering his medical license, and promising never to seek to be licensed in any other state. Dr. Hardy now lives in Thailand with his second wife and their young children.
In medical ethics classes we typically work with examples of "good v good" conflicts, as when respecting the patient's choices ("respecting autonomy") conflicts with the patient's health ("practicing beneficence"). I interpret the history of Dr. Hardy's case as the opposite - a "bad v bad" conflict.

If the patients' complaints are true, Dr. Hardy has malpracticed, disgraced his profession, and possibly committed felonious assault. Sadly, we know that some physicians betray their patients' trust and professional responsibilities in the way Hardy apparently did. In the past, however, it was not uncommon for an offending physician's denial to be believed, especially when the physician was a "respectable" Caucasian with top drawer credentials like Hardy. When colleagues and medical boards acted this way they were adding "system level injury" to the "direct injury" done by the abusive physician.

But in addition to bad things being done to patients by individual physicians, unresponsive colleagues and inactive medical boards, there are symmetrical risks of harm being done to "innocent" physicians. 40 years ago a young patient of mine with mild developmental disability was angry when I cancelled an appointment. She complained to the medical board that I had molested her. I had hurt her feelings, but that's not what she said to the board. By the time the board contacted me my patient and I had rescheduled the appointment and we were once again on good terms. I was too naive at the time to recognize how serious a complaint to the board could be. My patient had had a brief adolescent snit, but just as a malicious physician may lie about his offenses, a malicious patient may fabricate an accusation. When a board or the court of public opinion finds an "innocent" physician "guilty," a severe harm is done to the physician.

I don't see any way of ensuring the right answer to these "bad vs bad" conflicts. I know that patients have been harmed by having their reports of abuse disbelieved. But I'm sure that exemplary physicians have, on occasion, been harmed by complaints based on misunderstanding or malicious intent. Years ago, when I was in charge of a medical facility, a female patient complained that her male physician had been masturbating during an appointment. I met with the physician to take up the complaint. He said that perhaps his underwear had twisted around his testicles and that he readjusted his clothing and his anatomy via his pocket. (Male  readers have probably experienced the underwear problem.) I believed him, and explained what I thought had happened to the patient. She seemed to accept my interpretation, and that was the sole complaint ever received about the physician. But stranger things have happened than what the patient initially alleged. While I believe I got the situation right, a crystal ball might tell us that the physician lied and I unwittingly exonerated him and did an injury to the patient.

The excellent reporting done by the Boston Globe gives some guidance about how the health system and medical profession can handle these "bad v bad" conflicts better. Colleagues need to follow up on stories they hear from patients or rumors. At the very least this means talking directly with the physician in question. This isn't easy, but it's clearly the right thing to do. It didn't happen early enough with Dr. Hardy. If the physician is "guilty" it puts him or her on notice that the medical community is vigilant. At best the physician will say "I made a terrible mistake and I need to get help..." But even if the physician lies in a plausible manner, knowing that others are concerned will diminish the likelihood of repeat offenses.And if the accused physician is "innocent" he or she will be embarrassed or appalled, but it's better not to have unchallenged rumors circulating.

It's a privilege to be allowed to become part of patients' lives in the intimate way that medical care involves. But that very intimacy creates risks - primarily for patients but also for physicians. We need our health system to protect patients from exploitation and injury without making physicians so wary about accusations that they overly constrain their human warmth and caring.

Not an easy task!






Sunday, November 29, 2015

How Long Should We Live?

Spending Thanksgiving with my two sons/daughters-in-law and five grandchildren made me more aware than usual about the generations, the passage of time, and mortality. Those musings led me to look at a post I'd written for the (now discontinued) Over 65 blog. I'm republishing that post followed by some further reflections:
Why I Hope Not to Die at 75
By James Sabin
I feel uniquely qualified to comment on Zeke Emanuel’s much-discussed article “Why I Hope to Die at 75.” I’m smack in the middle of the year he hopes will be his last. In addition, many years ago I wrote a book about health care organizational ethics with him (and Steven Pearson). I loved working with Zeke and admire the creative work he’s done on medical ethics and health policy.
Zeke says, correctly, that with limited exceptions, as we pass beyond 75 we typically lose physical and mental capacities, with the result, in his view, that “by 75, creativity, originality, and productivity are pretty much gone for the vast, vast majority of us, resulting in diminished productivity.” Although Zeke recognizes that we “accommodate [to] our physical and mental limitations” by diminishing our expectations and “restrict[ing] activities and projects, to ensure we can fulfill them,” at 57, he is horrified by the vision of diminution.
In Zeke’s view, to be remembered “framed not by our vivacity but by our frailty is the ultimate tragedy.” If a patient said this to me, I’d respond, “We can understand that losing vivacity and becoming frail is sad, but how can we understand why being remembered that way is ‘the ultimate tragedy’ for you?” Over the years, with patients who didn’t want to live beyond a particular age, we virtually always found highly personal fears underlying their picture of what the age meant.
We 75ers know from experience that Zeke has the facts right. I’ve experienced most of the changes he attributes to the age. But as is the case even for people who experience vastly more severe challenges than diminished aerobic capacity and declining productivity, most of us ferret out opportunities to contribute to the world and derive satisfaction. Many posts on Over 65 speak to this effort.
Zeke’s facts may be right, but what about the values he espouses? If Zeke were 17 his article would read as the exuberant outpourings of a brilliant adolescent. But he’s not 17 – he’s one of the leading bioethicists and policy experts in the world. As a result, rather than being understood for what he’s doing – presenting an unflattering view of himself in order to provoke thought in others, the Twitterati see him as telling others what values they should adopt. Even more foolishly, some claim that his highly idiosyncratic perspective, which I believe he will ultimately come to see as misguided, proves the truth of the “death panel” lie.
Many readers of Over 65 will agree with Zeke’s critique of American culture as too focused on the duration of life and too inattentive to the purposes of our lives. He calls this cultural type the “American Immortal.” But very few are likely to emulate his prediction that even if he is in excellent health at 75 he will decline all medical interventions except for relief of pain. No flu shots. No antibiotics for pneumonia.
If that view holds for the next 18 years, which I doubt will happen, I hope that when Zeke declines a flu shot or an antibiotic for a treatable infection his physician will be guided by “Four Models of the physician-patient relationship,” an article Zeke wrote in 1992 with his then-wife Linda. Here’s how they described the “deliberative model”:
“The aim of the physician-patient interaction [under the deliberative model] is to help the patient determine and choose the best health-related values that can be realized in the clinical situation . . . The physician’s objectives include suggesting why certain health-related values are more worthy and should be aspired to . . .” (emphasis added)
The values Zeke anticipates applying are not “the best health-related values” for a healthy 75 year old. It is not “worthy” to invite healthy life to end sooner than need be out of fear that we will be remembered as a frail elder, not as a vigorous youngster. That would be neurosis, not wisdom.
I mentioned above that I had the privilege of working on a project and writing a book with Zeke. I understood him to be a warm-hearted person and a gifted teacher who evinced respect and affection for a wide range of humanity quite independently of whether they were “creative” and “productive.” I believe the article he is being roundly attacked for is actually a gift. Zeke wants us to think seriously about what we value in life. By presenting views that many have found repugnant, and that I see as understandable but wrong, he’s achieving his purpose of provoking thought and discussion.
Zeke gives himself an out in the final paragraph of his long (5,000 words) article: “I retain the right to change my mind and offer a vigorous and reasoned defense of living as long as possible.” (I trust by that he means “as long as possible” in a state in which he can appreciate life and respond to others in a meaningful way.) I’m prepared to bet that when Zeke turns 75 he will no longer regard youthful vigor and stunning productivity as the only values worth living for. If I’m alive, I’ll look forward to his contributions to Over 65 when he hits that birthday in 18 years!

This morning the New York Times carried an article on "Mothering my Dying Friend." The author - Catherine Newman - presents a powerful picture of what it was like to care for her best friend who was dying of ovarian cancer at 47. It's an excellent piece. If you want to read about the experience of (a) caring or (b) dying, follow the link.

I focused on (b). To me, Zeke Emanuel's wish to die at 75 in order to avoid the waning of intellectual and physical energy, seems more like a younger man's phobia about vulnerability than wise thinking about life. But I agree with Zeke that it's important for us to think about how we want to handle aging, illness and death before trouble hits the fan.

I know from many conversations with friends in their 70s and 80s that a majority wish for a more rapid demise than Catherine Newman's friend experienced. Physician assisted suicide is the most talked about approach to hastening death, but VSED, ("voluntary stopping eating and drinking") is a more common practice. When we're close to the end of our lives, we typically experience less hunger and thirst. While some clinicians and facilities are reluctant to honor a patient's decision to stop eating and drinking, there's a strong emerging trend in law and ethics to honor VSED when chosen by competent adults, as evidenced by the strong recommendation made in a recent review of literature on the topic:
...we think that the issue of suicide, euthanasia and hastened death should not be regarded as a last resort option. They have to be discussed early with the affected persons and not in the last days of life. If options of prematurely ending one’s life are known beforehand, VSED is an expression of autonomy and control, and therefore a sign of the patient’s competence. 
Thinking about mortality over this holiday weekend led me to add a codicil to my advance directive. In an aging society, clinicians, health care organizations, and the wider public, need to reflect of values and policies. I'll be writing more about the topic in the future.

Monday, November 23, 2015

Priests and Physicians who betray their trust

If you’re a moviegoer, don’t miss Spotlight, which opened earlier this month. It tells the story of the Boston Globe investigative team that broke the story about sexual abuse of children by priests. For Bostonian’s it’s a must-see. But it’s such a well-acted, well-directed film that even those with no interest in Boston or priestly behavior should find it engaging.

Sexual abuse of children is and should be a crime, whoever perpetrates it. But the story of priests who betray their calling sheds light on the most-read topic on this blog: doctor-patient sex. The further back in time we go, the more overlap we see between medicine and religion. Jesus, Muhammad and Buddha all healed sickness as well as sin. In every religion priesthood is a calling. The priest is literally called by God. I think of health care as a secular calling to which practitioners may be “called” by fidelity to our common humanity.

Spotlight shows how, priests, like physicians (especially psychiatrists), are the object of transference, that can endow them with enormous power in the eyes of their congregants/patients. When that transferential power is combined with recurrent private contact – whether in the church or the consulting room – we have the potential for great benefit or great betrayal. For too-many priests, the combination of sexual temptation in the presence of parishioners who idealized them was a devil’s brew.

For Catholic priests, celibacy adds an additional risk factor. Dylan Thomas nailed the challenge the young priest must contend with:

The force that through the green fuse drives the flower
Drives my green age: that blasts the roots of trees
Is my destroyer.
And I am dumb to tell the crooked rose
My youth is bent by the same wintry fever.

Spotlight dramatizes that while individual priests sinned, the system of the church protected them and neglected their victims by moving the offending priests from parish to parish. It required a diligent and courageous reportorial team to blow past the cover-up. Psychiatrists who betrayed their profession and exploited patients were not protected to the same extent, but it required the brave feminists who outed the offending physicians to stem the psychiatric abuse that was more prevalent in the 1960s and 1970s.


In an especially powerful moment, Spotlight shows a reporter speaking with Father Ronald Paquin. In a strangely dissociated manner, Father Paquin acknowledges that he “played around” with children, but never “raped” them and did not “gratify” himself, as if these claims exonerated him. Self-delusion is a powerful human capacity, and perpetrators frequently find ways to “justify” their actions. Last month Father Paquin, now 72, was released from prison. (For an earlier story, see here.)

It’s comforting to the rest of us to dismiss offending priests and physicians as bad apples. But that excuses us from our own responsibilities for governing the professions of priesthood and medicine. When the bystanders wanted to stone the woman taken in adultery, Jesus rebuked them: “He that is without sin among you, let him cast a stone at her.” Believers and atheists should agree that this was a true teaching.

Monday, November 16, 2015

Walking Meditation and Health Care Ethics

Health care can be frantic. Emergency rooms, intensive care units, and surgical suites are obviously high paced, but so is "ordinary" hospital and outpatient care. In my busy days of practice I sometimes had 18 appointments in 10 hours. It's not surprising that clinicians report high levels of tension.

Tension can sharpen our focus, but when it's sustained over time it can lead to irritability and distraction. These create hazards to patient safety and contribute to burnout. That kind of tension is bad.

Insofar as the conditions of practice can be modified to reduce tension, doing what's needed and possible should obviously be done. But clinical practice inevitably brings tension. For our own sake and for the sake of our patients, we need to develop ways to chill out. As the late Ken Schwartz wrote in "A Patient's Story," "...in a high-volume setting, the high-pressure atmosphere tends to stifle a caregiver’s inherent compassion and humanity." To be truly effective caretakers, we need to cherish our capacity for "compassion and humanity"!

For some, meditation is a tremendously valuable tool!

Unfortunately, meditation is often thought of as a touchy-feely matter of sitting in an uncomfortable lotus position and chanting mantras. That view confuses external practice with the internal objective. If meditation is taken to mean sitting in a quiet space for 20 minutes or more to carry out the practice, not many health professionals will make use of it.

That's where walking meditation comes in. In hospitals, doctors and nurses typically walk a few miles - in short bursts - during a shift. In my outpatient practice I often walked from my office to classrooms where I taught and to meetings at the nearby hospitals. I could even take a few paces in the office between appointments. I tried to use these interludes as opportunities for meditation.

There are excellent on line guides to walking meditation. (See here, here and here for examples.) But no approach fits everyone. I found that the excellent descriptions of how to focus on body sensation and the experience of walking didn't work for me. My mind kept wandering to matters I was fretting about. That got me riled up, not settled down.

I recently found a technique that works well for me. I like to look around as I walk. Here's what I learned to do:
  1. Breathe in, and, at the same time focus my eyes on some aspect of the external world, as by saying "look at the trees," or "look at the clouds," or "look at the people."
  2. As in all forms of meditation, the aim is to experience the trees, clouds, people passing by, or some other focus, not to think about them.
  3. I found that for my obsessional nature, it helped to say numbers sequentially as I breathed out - one number for each cycle. That seems to help me stay with the experience rather than drifting off into ruminations. I also like to keep track of how long I can sustain the process before my mind gets filled with trivia.
I present my experience to make the point that it's kosher to develop an approach that works for us. Gurus can be helpful teachers, but the wise ones don't look for slavish followers. If walking meditation clicks for a person it can fit into the interstices of the day. Parents give children a "time out" for the child to regain some composure. Walking meditation has potential for potentially stressed out health professionals to create mini "time outs" for ourselves. When it works it serves us and our patients well! That's good ethics!



Friday, November 13, 2015

The Invisible Hand Slaps Valeant Pharmaceuticals and the Sequoia Fund

Over the years I've been a staunch critic of seeing the health care "industry" as a commodity that should be governed by market forces. But fairness and honesty compel acknowledgement when the invisible hand acts wisely and supports good ethics.

Today the New York Times reported that two of the five independent directors of the Sequoia Fund resigned in protest over the Fund's decision to increase its already large stake in Valeant Pharmaceuticals, a company whose entirely legal but ethically disgraceful business strategy is to buy drugs and impose huge price increases. When Valeant's business practices hit the front page its stock fell from $260 to $75, and Sequoia's shares fell 22%.

Here's what David Poppe, president of the firm that manages the Sequoia Fund, said about Valeant: "...we thought Valeant was aggressive but stayed within the lines. To say they're immoral is pretty strong."

Sometimes statements that are "pretty strong" are also "pretty true." Let's hope that the lesson the market is sending about exploitative pharmaceutical business practices is widely heard. So far the invisible hand has been dealing out slaps. Next time - the fist!


Tuesday, November 10, 2015

Vietnam, Iraq, and Health Care Organizational Ethics

Vietnam was the shaping experience for my generation. In the later 1960s, all male physicians who were not conscientious objectors did some form of military service. I opposed the war in Vietnam and was active in anti-war demonstrations, but the law did not allow selective conscientious objection. To claim CO status one had to oppose all war, and the memory of World War II - which I regarded as a "just war" - was still fresh.

When I completed psychiatry training in 1968, I had the good luck of being an officer in the Public Health Service for two years at the National Institute of Mental Health. The "real" military who were stationed in the area dismissed us as "yellow berets." But notwithstanding the insult, I was proud of being an Public Health officer.

This past winter, when my wife and I were part of the faculty in the Semester at Sea program, we visited Vietnam for 6 days. That powerful experience led me to read six excellent books about our wars there and in Iraq:
  • The Things They Carried (Tim O'Brien)
  • Matterhorn and What it is Like to Go to War (Karl Marlantes)
  • A Rumor of War (Philip Caputo)
  • The Good Soldiers and Thank You for Your Service (David Finkel)
All six books were terrific. I recommend any and all to readers who want to know more about what the war experience was like for our military. But for this blog, I want to describe three "lessons" I took from the books about the ethics of health care organizations:
  1. The culture of the unit (squad, platoon & company) has enormous influence on the ethics of the unit's behavior. The military has a deeply held commitment to taking care of its wounded and dead. Soldiers risked their lives to act on this value. And, in the opposite direction, Philip Caputo described a massacre-like event carried out by the unit he was leading when he, and his men, were engulfed by hatred for the opposing soldiers. Unit culture could lead ordinary men to become heroes or monsters.

    In health care organizations we should recruit staff who - whatever other skills and talents they have - are caring people. But we need to pay careful attention to building and sustaining a culture of care. Good people can do bad things when the culture they are in points in the wrong direction.
  2. In all of the books it was strikingly clear that the behavior of leaders had a profound influence on the ethical performance of the individuals in the unit. When the leaders were models of admirable conduct, the soldiers were more ethically admirable in their own front-line conduct. When the leaders elicited cynicism, bad things ensued. In Matterhorn there's a scary incident in which a soldier actually tries to kill the commander.
  3. Being in a war shapes soldiers, both for better and worse. Retired General Peter Chiarelli (described in David Finkel's books) was so moved by what he learned about traumatic brain injury, post-traumatic stress, and suicide among veterans, that in his retirement from the military he is devoting himself to suicide prevention. In health care we're not literally in combat, but there are "war-like" experiences in fighting for the health of individual patients. More of us need to emulate General Chiarelli and move from immersive front-line experience to advocacy for social justice and societal benefit. (See here and here for stories about General Chiarelli.)
I've been critical of the ubiquitous use of war metaphors as seen in obituaries that describe the deceased person's "heroic fight with cancer/heart disease...." When physicians feel that death is their mortal enemy they are at risk for overtreating patients. Over the years I've heard students use the term "flogging," as in "the oncologists are flogging the patient again with another treatment that will just make him sicker..." But there are other aspects of war that model what we should strive for in health care: ethical leadership, a culture of caring, and experience-based advocacy.



Wednesday, November 4, 2015

Professional Societies and Stewardship in Health Care

Three imaging specialists from Johns Hopkins published a short but VERY important article - "Medical-Imaging Stewardship in the Accountable Care Era" - in the October 29 issue of the New England Journal of Medicine. (Unfortunately, the article is available free only to subscribers.)

The authors are leaders in imaging at Johns Hopkins. In their eminently practical article, they recommend that hospitals and medical groups designate internal experts to set standards for "appropriate" use of imaging studies. CT, MRI and other technologies are, arguably, the most important diagnostic advances in the last 25 years. When used "appropriately" they are the source of enormous benefit. When used "inappropriately" they are the source of high costs without concomitant benefit, and sometimes cause harm when incidental findings lead to unneeded biopsies or other interventions.

I put the word "appropriate" into quotes because in health management jargon it's used as if it's a statement of fact. In reality, it's a contestable judgment about value. The term, like its cousin "medical necessity," allows the health system and political leaders to pretend that we're just dealing with science, and not making value judgments about interventions and resource allocation.

Many health insurers have turned to radiology benefit management companies to oversee the use of imaging services. When this function is carried out well it applies evidence-based criteria to the ordering process and offers educational services to the clinicians whose orders they are reviewing. However, no matter how well the external review process is conducted, an unavoidable "us versus them" dynamic often emerges. In principle, self-management within a hospital or medical group is a preferable approach. Put simply, if it's good clinical care and "appropriate" resource allocation, we clinicians should be doing it ourselves, and not require external "disciplinarians" to enforce good practice.

What I just said is not a critique of radiology benefit management companies, but, rather, a reflection on a structural dynamic. In growing up, when we start to do the "right thing" on our own rather than depending on our parents to guide us, we're carrying out the same actions but in a more mature manner. That's what we should be doing as clinicians in our medical practices!

In "Medical-Imaging Stewardship in the Accountable Care Era," the authors are illustrating the kind of leadership professional societies and leaders within a profession can provide. Evidence based use of imaging and "appropriate" resource allocation are what we should be doing because it's the right way to provide health care. A true profession doesn't require or want health insurers to take responsibility for these core elements of professionalism.

The medical profession hated managed care when it emerged in the 1980s and 1990s. But if we had been managing ourselves in a clinically and socially responsible manner, external review would not have been needed. We left a vacuum. External entities then filled it.



Monday, November 2, 2015

Two teaching cases about unneeded MRIs

Readers who teach may find these two cases useful. But I think they'll be interesting for most thoughtful adults. 

CASE I.  Many years ago I wrote a hypothetical case for a session on rationing for medical students.
Tension Headache
You are a primary care physician at a not-for-profit health maintenance organization (HMO) that serves 500,000 members, paid for by capitation, a monthly premium paid to the HMO by the members’ employer, Medicaid, or Medicare. The premium revenues create a budget to care for the entire HMO population. 
Susan Jackson, a 28 year old office worker, consults you about headaches. For the past month she has had frequent headaches at the end of the work day. The headaches are much less frequent on the weekends. She describes the headaches as a dull, mild to moderate pain, that feels like tightness or a band around her head. She is otherwise healthy. Her neurological examination is normal. She identifies clear stressors at work.
You explain that this is a classical pattern for tension-type headaches and give practical advice on what to do. You predict that the headaches will improve as Susan learns to master the stressors and to build more relaxation into her day. Susan thanks you, but says that a friend who had headaches received an MRI, which showed a tumor that required surgery. With some urgency she says “unless you can guarantee that there is no possibility whatsoever that I have a tumor, I want an MRI. What harm can an MRI do?”
You know that the likelihood of a tumor is vanishingly low, and that established standards of care do not recommend imaging studies in a situation like Susan’s. There is no medical contraindication to getting an MRI, but you know that it would cost between $1500 - $2000, which would come out of the budget for the HMO population. You reflect on what to do, and how to explain your thinking about the MRI to Susan.
CASE II. Today I read the following case on the excellent "Costs of Care" blog:
Doc, I need an MRI
By Patricia Czapp, MD
“Doc, I need an MRI for my back.”
I recognized the voice immediately and turned to greet one of my favorite patients, Mr. P. There he was, smiling, leaning on his walker.
Mr. P visits me several times a day in my primary care office that is essentially in his living room.  The practice itself, sized fewer than 1,000 square feet, is on the first floor of a high-rise apartment building that houses disabled and low-income adults.
My team and I provide primary care to the residents of the building  (a public housing unit) and the surrounding community, a diverse population that has in common these characteristics:  social isolation, low health literacy and low general literacy, a high prevalence of behavioral health problems, and limited transportation.
We came to practice in the building because our health system, Anne Arundel Medical Center, several years ago noted a high number of ED visits from individuals of one address. We visited the address to meet the residents of the building and their landlord, the local housing authority.
We found a population of individuals who were aged beyond their years, suffering from preventable complications of chronic disease and for whom a visit to the hospital met medical as well as nonmedical needs…individuals like Mr. P.
Mr. P is a man living a marginalized existence. He thrives when people take the time to listen to him, touch him, and show him that they care. For many decades , he found this comfort in the ED. When his landlord agreed to try an experiment with us, we came to practice in his building.  Mr. P was one of our earliest patients.
We provide a low-cost alternative to meet his needs and do so with kindness, tolerance and generosity.
“What happened to your back, Mr. P?” I asked.  “Did you fall or hurt yourself”?
“No Doctor, I Just woke up, got out of bed and it hurt real bad for a while.  I could hardly stand up. ”
Rather than lecture him about the lack of medical necessity for an MRI, I accompany him to his modest apartment where we review the condition of his bed and mattress and suggest alternative ways to use pillows to support his back.   Mr. P beams, “Thank you so much.”  And then shuffles toward the Community Room.
If we had not been there to intercept Mr. P, he would have dialed 911. It shocks many to learn that individuals use the ED for nonmedical needs. But for some, this is the only way they feel human.
Our practice has been open for two years. In that time, we have experienced a significant decrease in medical 911 calls, ED visits, admissions and readmissions of residents of the apartment building. They have an alternative now to the ED, and we meet their social needs in their living room – one visit at a time, sometimes multiple times a day…
“Doc, I need a CT scan for my head.”
___________________________________________________________________
Patricia Czapp, MD was contestant of  “The Best Care, The lowest cost: one idea at a time” – a collaboration between Costs of Care, Healthcare Financial Management Association, Strata Decision Technologies, and Yale-New Haven Health.

"Tension headache" works well with medical students and residents. It ends with a resource allocation dilemma. Ms. Jackson wants a guarantee of absolute certainty, which is virtually never possible. The MRI is not required for good clinical care, but if  it cost $15-$20, not $1,500-$2,000, should it be covered because of her understandable anxiety? And, however one thinks through the dilemma, what should the primary care physician actually say to Ms. Jackson?

The second case is a beautiful example of ministering to one's patient - clinical practice as a calling. It's invites learning about "hotspotting" - meeting the real needs of people who are "overutilizing" expensive medical care. Mr. P was suffering, but ED visits were not the best pathway to relief. Dr. Czapp's remarkable practice has the potential to reduce costs even as it provides vastly better care for the population she serves.

Political candidates continue to bash their opponents by accusing them of health care rationing. Cases like these allow us to understand how cost reduction and frank rationing can be conducted in an ethically admirable, clinically sound manner.

Friday, October 30, 2015

Learning about end-of-life care

The "death panel" frenzy propounded by Sarah Palin and an army of uninformed and ill-intentioned allies when the administration proposed paying physicians for conversations with their patients about end-of-life care has come to a quiet conclusion.

Medicare  has finally authorized payment for advanced care planning "at the discretion of the beneficiary" in both the outpatient and hospital setting. These discussions require sensitivity, thoughtfulness, and time. Medicare will pay $86 for the first 30 minutes and up to $75 more for 30 additional minutes. The fee is far from lucrative when overhead costs for maintaining an office are taken into consideration, but it recognizes and compensates physicians for a core medical responsibility - collaborating with patients at every phase of life.

The moral of this happy story is that although it took six years, it shows that we are capable of moving beyond disinformation and hysteria and understanding what caring medical practice requires!

(For previous posts about "death panels" see herehere, here and here.)

Monday, October 26, 2015

Anna Stubblefield: Victim and Perpetrator

An article in  yesterday's New York Times told a remarkable story about Anna Stubblefield, former chair of the philosophy department at Rutgers University, who was convicted on two counts of aggravated sexual assault for having sex with a 31 year old man who the jury concluded was so severely disabled he could not consent to a sexual relationship.

The story hinges on "facilitated communication," a scientifically discredited practice that claims to achieve access to the hidden thoughts of persons with autism and other conditions that have hitherto precluded communication. In the technique, the "facilitator" claims to reach the "communication partner" by assisting the partner to type responses to questions.


I'd somehow never heard the fascinating history of facilitated communication until I read the NYT article. Imagine how moving it is to parents when they are told that their supposedly disabled offspring tells them that he is now overjoyed to be able to communicate and that he loves them very much. And imagine how horrified families are when the facilitated message accuses them of incest and other forms of violence.

Thursday, October 22, 2015

More About Unethical Drug Prices

As if the example of Turing Pharmaceuticals and the 5,000% price increase for Daraprim weren't enough, two days ago the New York Times described another example of blatantly unethical - but entirely legal - drug  pricing.

Horizon Pharma has combined the generic equivalents of Motrin and Pepcid into a single pill, Duexis. Taking one of each would cost no more than $40 per month. For the single pill that combines the two ingredients, Horizon asks for $1,500! To circumvent the stunned look a pharmacist would give to a patient who brings the Duexis prescription into the pharmacy, Horizon encourages physicians to send the gold-plated prescription directly to a mail order pharmacy that will send the medication to the patient and deal directly with insurers.

Several decades ago I saw a patient for whom I wanted to prescribe a low dose (25 milligrams) of the antidepressant Zoloft. At the time the two available dosages - 50 and 100 milligrams - were priced the same. The patient was a thoughtful person and I was interested in the relevant ethical issues, so I asked if he thought it was fair for me to prescribe the 100 milligram pill and ask him to divide it into four pieces. He initially said "no," and I prescribed the 50 milligram pill to be broken in half.

Some minutes later he returned to my office. "I've been thinking," he said. "I survived the Nazis during World War II because other people took risks to protect me. I want to do this little bit for the public good. Why should the people who help pay for my insurance spend more than is necessary for me to get my medication?"

Unfortunately, Horizon does not share my patient's moral vision. Although its actions are legal, if Hippocrates were reincarnated, here's the dialogue that might ensue:
Hippocrates: "Didn't I make 'first, do no harm' clear in my teaching?"
Horizon: "What harm are we doing? Duexis is a good medication. And the patient isn't paying - it's the insurance company!"
Hippocrates: "We didn't have insurance companies in my day. But even an old timer like me can understand that the insurer's money comes from all the working people who pay into the insurance pool. For every patient who uses Duexis instead of the two generic ingredients separately, you are taking $1,460 per month out of the pocket of working people. That's harm! You should be ashamed of yourself!"
When I Googled Horizon a few minutes ago I was happy to see that the revelation of its legal but unethical practice has sent its stock tumbling. The invisible hand is giving the company a well-deserved slap!





How Three Competing Ethics Frameworks Let Drug Prices Run Wild

A few weeks ago I gave a talk about the ethics of high cost pharmaceuticals at a Connecticut Health Council event. After I accepted the invitation I was initially at a loss about what to say. Simply excoriating Turing Pharmaceuticals for raising the price of Daraprim by 5,000% would be too easy. But when I asked myself what allowed Turing's actions to be grossly unethical but completely legal, I saw that three competing ethical frameworks - "good vs good" conflicts - help explain why we've been so impotent in relation to drug prices.
  1. Free market theology vs ethics of care. A teaching from Milton Friedman's Capitalism and Freedom has achieved the status of unquestionable religious truth for many: "There is one and only one social responsibility of business - to use its resources and engage in activities designed to increase its profits so long as it...engages in open and free competition, without deception or fraud." But many of those who are deeply involved in health care, including many in the pharmaceutical industry, see their work as a calling, in the spirit of Hippocrates, who articulated the ethics of care 2500 years ago. Both frameworks embody ethically admirable values. But in many sectors of the US health system, with the current pharmaceutical industry as a prime example, the theological commitment to free markets is overly dominant.
  2. Life is priceless vs opportunity costs matter. More than 30 years ago, in  his deservedly admired evocation of the ethics of care, Norman Levinsky invited physicians to believe that the sacredness of their calling meant that the opportunity costs of our interventions should not be considered: "physicians are required to do everything  that they believe may benefit each patient without regard to costs or other societal considerations. In caring for an individual patient, the doctor must act solely as that patient's advocate, against the apparent interests of society as a whole, if necessary...When practicing medicine, doctors cannot serve two masters...The doctor's master must be the patient."

    These are stirring words, and in my teaching I've found that most physicians embrace them with pride. But looked at closely, it's clear that Levinsky's passionate embrace of the ethics of care led him into the error of ignoring opportunity costs. When physicians indicated solidarity with Levinsky's position I sometimes responded as follows: "Doctor - congratulations on your altruism. If your patient needs a heart transplant and you are the only match, you're prepared to donate your own heart!"

    Until recently, the "life is priceless" ethic led us physicians to ignore the impact our interventions imposed on individuals and wider society. Nurses, social workers, and other health professionals have been more attuned to the way the over-costly health system harms population health by undermining income and other social determinants of health. Only now, with drug prices going through the roof, are we physicians beginning to see the limitations in Levinsky's noble and inspiring rhetoric.
  3. Government is the problem vs government is [part of] the solution. My generation (I was born in 1939) was conceived in the New Deal era, came into adulthood during Lyndon Johnson's Great Society movement, and have watched the pendulum swing from inflated confidence in government action to the nihilism of the Tea Party and the Freedom Caucus.
The crucial point is that the three conflicting frameworks represent "good vs good" conflicts, not "good vs evil." As such they call for a political culture that is prepared to follow Winston Churchill's advice:



Nationally, we lack the courage to listen. This has led to a failure to balance the three competing ethical frameworks. Runaway pharmaceutical prices reflect our theological commitment to free markets, the reluctance of the medical community to consider the opportunity costs imposed by health care expenditures, and the national distrust of government action. Mature organizations speak and listen. At present, our political culture cannot do both. We see one result of the national skill deficit in our inability to rein in pharmaceutical pricing.

Monday, October 19, 2015

From Clinical Care to System Improvement

A reward I derive from working half time is the flexibility to take on labors of love, one of which is being a member of the ethics committee at the Commonwealth Care Alliance.

Commonwealth Care Alliance (CCA) is a not-for-profit, consumer governed care system for Medicare and Medicaid beneficiaries with complex medical problems. It embodies the values that have guided my whole career, so when I was invited to join the CCA ethics committee I jumped at the chance.

Here's a story (slightly edited) from the every-other-week email circulated by Bob Master, CEO of the organization:
RA is a 61-year-old man with poorly controlled diabetes and severely compromised circulation in his legs who is living alone with a very limited ability to care for his complex medical issues. RA has also been battling a long-standing heroin addiction without success until he was prescribed Suboxone, which for many like RA, is a newer, more effective and safer treatment approach than Methadone. With Suboxone treatment, RA has experienced a full recovery from his addiction with dramatic improvement in his ability to live independently. 
 During his recovery, RA fell and sustained an ankle fracture that required surgery. Because of his diabetes, very compromised leg circulation, and requirements to avoid “weight bearing” on his surgically repaired foot, post hospital skilled nursing facility care was deemed essential. 
 However, existing regulations today prohibit individuals requiring Suboxone to be admitted to Skilled Nursing Facilities. RA’s primary care physician, and CCA Medical Director, Stefan Topolski, explains it this way: “To find that something so simple, so easy and so safe to prescribe as Suboxone – somehow becomes an impediment to needed skilled nursing facility care even when physicians providing care in that facility are certified to prescribe it, makes no sense.”
 Nurse practitioner Cary Hardwick explained that RA had been very well maintained on Suboxone. “It dramatically changed his life and his ability to live independently.” RA agreed, saying “It kept me from doing a lot of bad choices.” 
So without other options but suboptimal care in a compromised home situation, a home care plan with a high likelihood of failure was instituted. Sadly, despite best efforts, significant infection occurred at the surgical site. Ultimately, RA needed to have an amputation below his knee.
[A short video featuring RA, Cathy Hardwick, and Stefan Topolski, can be seen here.]

This is a powerful and painful clinical story. The reason I'm publishing it in a blog on organizational ethics is what Bob Master said next:
RA’s story did not need to happen, and likely would not have happened if policies were in place that promoted rather than restricted the use of effective ongoing addiction medications such as Suboxone in skilled nursing facilities. Clearly, this policy and probably many others need to change. It should come as no surprise that we are the first entity to uncover this problem and the first entity engaged in promoting such needed changes.
Accordingly, I’m proud to report that our skilled nursing facility team is now actively working with the Massachusetts Department of Public Health to change this counterproductive regulation so that individuals like RA in need of SNF care can be admitted to SNFs while being prescribed these important medications. It is admittedly a small step but I am proud to say a very important one. 

It's all too easy for us clinicians to throw up our hands in despair when we encounter a problem like the one that arose in RA's care. And it's easy for the wider public to fall into cynicism about "dumb bureaucracy." The story from CCA illustrates the kind of quality improvement from the ground up that our health system needs. I know the Massachusetts Department of Public Health. It's not a nest of "uncaring bean-counting bureaucrats." But we're all capable of making mistakes. The key skill our system needs is the kind of activism the story illustrates - moving from impediments to giving the right kind of clinical care to improvement of the system.

Hats off to the Commonwealth Care Alliance, and to RA, who wanted his experience to be used to help others!

[For a 2011 post about the Commonwealth Care Alliance, see here.]

Thursday, October 15, 2015

Nuka & Organizational Ethics

Yesterday morning an email with the subject heading: "Strong Patient-Provider Relationships Drive Healthier Outcomes" appeared in my in-basket.  I might have thought - "ho hum, been there/know that" and deleted the message, except that it came from the Harvard Business Review. I was curious. What made business folks interested in a topic that every seasoned primary care clinician has known about for years?

It turned out that the authors have been doing  what business schools do so well - studying exemplary primary care systems as a basis for developing teaching cases. What struck me in the Business School findings was that the outstanding organizations they were reporting on had not simply preached about the importance of strong clinician-patient relationships: they had engineered the organizations themselves to encourage and facilitate excellent relationships.

In our teaching of medical students and other health professionals we emphasize the values and behavior patterns of individuals. This is an important starting point for health care ethics. But as the discussion of the Southcentral Foundation in Alaska demonstrated, a properly designed and managed organization can point clinicians in the right direction and make it easier for us to get there.

In the 1990s, Southcentral Foundation, well-described in an excellent article by Katherine Gottlieb, president and CEO, looked into its heart and reconceptualized its mission as being about relationships:
Alaska Native leadership recognized that the core product is something bigger than just tests, diagnoses, pills and procedures. It is about human beings and relationships – messy, human, longitudinal, personal, trusting, informing, respecting and accountable relationships...If a practice or organization really believes that the core product is relationship – that is, partnering to make a difference over time – a fundamental change is required. Where money and time are spent, what work staff members do, who is hired and how staff are trained – every action is intentionally designed to optimize relationships.
Southcentral calls its approach the "Nuka System of Care." "Nuka" is a native Alaskan word meaning "big living things." Gottlieb describes four key ideas driving the "big living" Nuka system:
  1. "The customer drives everything." Southcentral thinks of those it serves as "customer/owners." The SCF approach goes well-beyond the current buzzword - "patient centered care" - which often connotes an empathic attitude but not redesign of services to meet patient preferences.
  2. "All customers deserve to have a health care team they know and trust." It's easy to endorse this principle. What distinguishes SCF is the actions they take to facilitate trusting relationships, not simply their words. Words are cheap. Making the sentiment a reality takes sustained work over time.
  3. "Customers should face no barriers when seeking care." 75-80% of the appointments are for same-day care. That says it all!
  4. "Staff members and supporting infrastructure are vital to success." Again, what counts is well planned, consistent devotion to this aim at all levels of the organization.
The crucial insight arising from the Harvard Business School project, which is being conducted in collaboration with Center for Primary Care at Harvard Medical School, is that organizations are moral actors, just as individuals are. Strong clinical relationships promote trust and health. In a health system in which organizations play an ever increasing role, we need to focus on and strengthen the moral behavior or organizations as well as individuals.

[For readers who want to delve further into the concept of organizations as moral actors, see this article by my friend David Ozar, an early leader in thinking about the ethics of organizations.]


Wednesday, October 7, 2015

I'm Back

It's been two years since my last substantive post on this blog ("The Right Kind of Love Between Doctors and Patients"). I'd shifted my blogging energy to Over 65, a blog about aging issues published by the Hastings Center. My co-editors and I put that blog to rest in the spring, and I'm just now getting back to Health Care Organizational Ethics, which I started eight years ago.

If I'd been smarter I would have chosen a less wonky title, especially since over the years I've written about much more than the ethics of organizations. (Not surprisingly, the posts that got the most attention are those filed under the "Doctor-Patient Sex" tab!) But organizational ethics continues to be my central focus in ethics, so I'm sticking with the original title. My aim is to post at least weekly.

As always, I'm eager to hear thoughts and comments from readers.