Tuesday, June 30, 2009

Medicare Open to All (3)

President Obama's lobbying efforts with governors may be smart politics, but they show the sad state of ethical discourse with regard to health care reform. Here's what I read in this morning's New York Times:
In a meeting last week with five governors — including Republicans who may be more sympathetic to health legislation than those on Capitol Hill — Mr. Obama privately urged them to serve as his emissaries to Congress. He even coached them on the language they should use with lawmakers, two of the governors said, advising them to avoid terms like “rationing” and “managed care,” which evoke bitter memories of the Clintons’ ill-fated health initiative....Instead, he spoke of “evidence-based care,” the practice of using research to guide medical decisions.
Unfortunately, thoughtful rationing and wisely managed care are exactly what our health system needs!

As I've written about before, the public option proposed by the administration has a crucial advantage with regard to the all important goal of cost containment (see here and here for previous posts). At least 30% of the care we currently pay for is useless at best, and potentially harmful through side effects and errors. We can't have an affordable health system without managing our utilization. This won't happen by publishing studies. We have to manage care!

Good insurance companies like Harvard Pilgrim Health Care, the not-for-profit health plan at which I direct the ethics program, know how to do this and can do it in a clinically guided, ethically justifiable manner. But the public rebelled against the idea of insurance company driven managed care, largely because of distrust of for profit insurers, who were seen as withholding necessary care to maximize profit and provide huge executive bonuses. Insurers have largely backed off from managing care, which contributes to the runaway cost trend.

A public program would have a significant advantage for managing care - it is ultimately governed by the public! If it chose not to cover marginally useful care it could be criticized for its decisions, but could not be accused of serving private profit or executive salaries. That potential legitimacy matters a lot for setting limits.

As I've said before, a public program could act as a "down field blocker," taking the lead over time in helping the public understand what it means to set limits fairly. If a public program made managed care more understandable and acceptable, private insurers could follow its lead.

But if a public program simply acted like today's Medicare it would have a significant disadvantage. Medicare is currently not allowed to use cost-effectiveness calculations of the kind every human being uses every day. As a result, its main weapon for cost control is the fees it pays. This is a blunt weapon, and has had the effect of discouraging the service we need most - time spent with patients planning rational treatment and explaining why some things patients may want are not needed.

It's fine for political leaders to avoid using the terms "managed care" and "rationing" as long as they are not deluded by their own rhetoric. "Evidence-based care" and "using research to guide medical decisions" may be more acceptable wording. But evidence doesn't make decisions - doctors do. We know from the Dartmouth Atlas studies that doctors vary enormously in how they respond to evidence. We will have to "guide medical decisions" actively to make health care more affordable!

Sunday, June 28, 2009

David Rothman on Medical Professionalism

This summer I'm doing some writing on the ethics of medical professionalism. I reread an article by David Rothman, published in the New England Journal of Medicine in 2000. It stands up well nine years later and deserves attention today.

At a time of massive medical whining about managed care Rothman had the gumption to take medicine to the woodshed. Not only was managed care not the cause of the widespread concern about pallid professionalism - in large measure it was a response to failures of professionalism, especially failures in self regulation, advocacy for appropriate use of medical resources, and addressing multiple financial conflicts of interest.

Rothman made a series of recommendations for promoting more robust professionalism. They stand up well nine years later. And, happily, there's been some progress. What follows is Rothman's recommendations, followed by my comments in bold italics:

1. "Professional and board-certifying societies could require rather than recommend standards of behavior, including service. One could imagine that, like continuing medical education, service to vulnerable groups of people would be required to maintain certification."

To the best of my knowledge this hasn't been done at the post graduate level. But in interviewing residency applicants, the degree of community involvements of this kind on the part of medical students from all over the country appears to increase each year. Many high schools require specified levels of community service as a condition of graduation. (My oldest grandchild set off today to do a week of trail work for the Appalachian Mountain Club. He might have done it anyway, but the high school requirement was a useful prod!) Our specialty societies should do the same.

2. "Professional associations could form alliances with consumer groups to accomplish goals that neither can realize separately."

This is happening in good ways, but also in ways that have been corrupted. As a positive example, the American Psychiatric Association has formed a strong affiliation with the National Alliance on Mental Illness. The two groups work closely to promote services for people with serious mental disorders, lobby for legislation, combat stigma, and more.

Unfortunately, but not surprisingly, alliances with consumers have been co opted to advance commercial interests, most notably by vendors of drugs, devices, and specialized treatments, who provide financial support to "AstroTurf groups" (pseudo grass roots movements) who then express "consumer demand" for their sponsor's services.

3. "The medical school and residency curriculum should be altered, not only by including lectures on professionalism, but also by inculcating the skills necessary to promote it."

There have been some truly remarkable steps forward in medical education, organized around recognition that the "informal curriculum" (the messages delivered in unspoken ways by the organization's culture) is at least as powerful as what is said in class. As one example, Indiana University School of Medicine has conducted a carefully thought out, broad-based approach to changing its culture in ways that promote ethical professionalism in faculty behavior and student learning. If you're interested in the details you can read a full description here.

4. "Medicine in its organized capacity must encourage and protect whistle-blowers, so that the profession is not so dependent on outsiders to identify and publicize problems."

There has been more progress in this sphere than Rothman probably anticipated, but it's in large part due to the burgeoning of the blogosphere, not to any steps taken by organized medicine. As examples, blogs like Health Care Renewal, Hooked: Ethics, Medicine and Pharma, and The Carlat Psychiatry Blog (accessible by links from this blog), are written by physicians who regularly use their whistles to call attention to failures of professionalism.

5. "Professional societies, medical schools, and teaching hospitals should adopt policies to minimize the influence of pharmaceutical companies and their representatives."

The pace of change here has been dizzying. Several states have passed laws sharply curtailing physician-drug company interactions. Medical schools all over the country have prohibited students and residents from taking drug company gifts and eating Pharma provided pizza.

The concept of medical professionalism came under extensive attack in the last three decades of the 20th century as a rationalization for the promotion of guild self-interest. Leaders in the profession - in the U.S. and Europe - responded by convening expert groups to articulate professional ideals in new ways, as in "Medical Professionalism in the New Millennium: A Physician Charter." Rothman challenged the health professions to put their noble words more fully into action. There's been some real progress since he threw down the gauntlet!

Wednesday, June 24, 2009

The Ethical Culture of Medicine

I'm in the Green Mountains of Vermont now, where my wife teaches for 7 weeks at Middlebury College's Bread Loaf School of English. (The campus is at the foot of a mountain that looks like a loaf of bread - thus the weird name!) The opening ceremony last night got me thinking about the culture of medicine in the U.S.

The ceremony welcomed the 250 students - mostly high, middle and elementary school teachers themselves - who can get an M.A. in literature in the course of 4-5 summers. The faculty (from colleges & universities in the U.S. and U.K.) has lots of veterans who've taught here for 20 years or more. In the course of the ceremony 7 faculty plus the president of Middlebury College all spoke. Warmth and enthusiasm are expected in a welcome, but what stood out for me was the depth and consistency of the values that shaped each of the talks. They spoke lovingly of the students and the important work the students do. They spoke lovingly about the enterprise of teaching and learning. And the sense of camaraderie among faculty, students and staff was palpable.

For most physicians, nurses and other clinicians there are very few gatherings in which we explore and reaffirm the ideals of our profession. Our meetings focus on administrative problems. Grand rounds can be engaging, but passively listening to a lecture while a powerpoint flashes by doesn't often engage us with the wellsprings of our values.

One of the major delivery system changes being discussed in the reform dialogue is forming "accountable medical groups" - groups of physicians that can take responsibility for the quality and cost of care for a population. Atul Gawande's New Yorker article and a followup interview with Ezra Klein take the concept beyond administrative accountability. Our health care organizations need to reinvigorate the soul of the health professions.

Doctors cherish the deep satisfaction in helping a patient achieve greater health, and, when we can't do that, helping individuals and families make the most of the life they have. But too many doctors lack collegial settings in which they feel allied with others around their most important values. Except for the rare person who is 100% inner directed, the sense of mission and purpose degrade in the absence of group support.

I interrupted writing this post to play tennis with a friend who has taught here for 25 years. When I told him my reaction to the welcoming ceremony he said - "this institution commands my loyalty more than any other I've been part of." We clinicians need more of that experience in our professional lives!

(See this post about the Swami Vivekananda hospital in Saragur, India, for a discussion of how that institution supports its sense of calling.)

Sunday, June 21, 2009

Drs. Elton and Sanchez Get it Right

I've taken the liberty of copying two letters from today's New York Times. The AMA's ongoing resistance to progressive reforms has given physicians a bad name, so it's a pleasure to see the wisdom of these letters coming from the heartland:
To the Editor:

As a physician, I see every day the type of overuse of medical care described in “Something’s Got to Give in Medicare Spending” (Economic View, June 14).

But the column took too narrow a view in asserting that “the financial incentives for doctors and medical institutions to recommend more procedures” are the chief driving force behind the high cost of care; non financial incentives are at least as strong.

Much has been written about defensive medicine, wherein physicians order additional, and often unnecessary, tests to avoid being sued. Even without the threat of lawsuits, I suspect that this practice would continue. Physicians don’t want to miss things, lawsuits or not. There are also times, perhaps due to the harried nature of medical decision-making, when ordering tests takes the place of careful consideration of a test’s usefulness or the likelihood of an important finding.

Patients are also often insistent on having tests, just as they are insistent on getting prescriptions for the latest, greatest drugs they saw advertised on TV.

Reining in this overuse of care thus goes against the perceived interests of both physicians and patients. Necessary as it may be, changing these attitudes will be difficult.

Eric Elton, M.D.

Evanston, Ill., June 15

To the Editor:

Universal coverage, cost control and quality medical care are essential but insufficient to achieve good health in our nation. As the column stated, factors including where and how we live, as well as social standing, are the significant determinants of health.

Until we begin to seriously address those factors, worsening health status and a growing burden of preventable chronic disease will exceed the health system’s ability to adequately deliver necessary care — health care reform notwithstanding.

Eduardo J. Sanchez, M.D., M.P.H.

Dallas, June 17

The writer is vice president and chief medical officer of Blue Cross and Blue Shield of Texas.
Dr. Elton correctly identifies how poorly we physicians deal with uncertainty as a major driver of runaway costs. And he's right linking our penchant for throwing the kitchen sink at patients to "rule out XYZ" to the "harried nature" of medical practice.

In the 1990s I spent a full day with each of three outstanding GPs in London. Since the average consultation time in the NHS was less than 10 minutes I wondered how they handled their practices. The answer was - they leveraged time and the relationship better than we Yanks do.

With symptoms that could, conceivably, represent what doctors-in-training call a "zebra" (an obscure and frightening but exceedingly rare cause of the symptom), they said - "Here's what I think is going on and here's what I think will happen if we do ABC...Let's try it for two weeks. If things don't work as I expect, please come back to see me..."

Dr. Elton is also right that patients often "insist" on having tests and drugs that aren't necessary. That's where time comes in. A key part of good medical practice is education. Doing a scan or prescribing a branded drug that isn't necessary is harmful, not neutral. Apart from the radiation exposure scans can show "incidentalomas" - findings that look funny but don't mean anything and lead to further unnecessary tests. And unless the patient is paying full freight for the unnecessary branded drug, we're using money that could be put to better use in other ways.

Dr. Sanchez correctly points out that focusing on medical care is a relatively small part of what our nation needs to do to improve health and contain health care costs. Happily, we're beginning to see ideas like keeping high sugar drinks and foods out of school cafeterias and even imposing taxes on foods that are driving the epidemic of obesity and diabetes.

A lot of the success in the effort to improve quality and reduce costs will be driven by what our federal and state governments do. But if we physicians comported ourselves in accord with the common sense wisdom that Drs. Elton and Sanchez propose that would accomplish even more!

Saturday, June 20, 2009

The Ethics of an Individual Mandate

It's looking more and more as if the health reform legislation that the President wants to see emerging from Congress this summer will include a requirement that individuals obtain health insurance, just as the states currently require car owners to obtain insurance for their vehicles.

If health care were a consumer good a requirement for insurance could not be justified. Having a car is desirable, but it's optional. If poor people can't afford a car we regard that as unfortunate, but not unjust. But if a poor person is dying from a curable cancer we believe, correctly, that a society as wealthy as the U.S. is obligated to ensure access to treatment. The Declaration of Independence declares a right to "life, liberty, and the pursuit of happiness." We require ourselves, correctly, to provide public education, because lack of literacy and numeracy impedes liberty and the pursuit of our goals. Basic health care is at least as necessary for us to exercise our freedom in a meaningful way.

One reason our health insurance system works so badly is that so many Americans are not in it. This creates a vicious circle. Rational economic behavior suggests that we should not buy insurance when we are and expect to remain healthy, but should rush to get it when we're sick. Insurers must protect themselves against this form of "adverse" selection by establishing underwriting rules, such as not covering preexisting conditions, and charging more for people who are ill. This results in more people being uninsured, including many for whom access to insurance is most important.

The simplest way to bring everyone into the health system is to fund insurance through taxes. We currently have two major tax supported insurance systems - Medicare and Medicaid. Taxes could be used to support a single public insurance program ("single payer") or a market of private plans, as envisioned in Zeke Emanuel's 2008 book "Healthcare Guaranteed."

It's telling that even though Zeke Emanuel's plan retains the private insurance market, his brother Rahm, President Obama's Chief of Staff, has called it "wacko." I believe Rahm the politician called his ethicist brother "wacko" because Zeke correctly suggests that health insurance must have a capped budget and that the budget should come from a new dedicated Value Added Tax. Even apart from the current recession taxes are the black hole of American politics - any leader who proposes a tax disappears into a void.

If (a) the insured population must include everyone to be actuarially and ethically sound but (b) tax funding is off the table (at least for now), then (c) the individual mandate is the only other route to universality. That's what an article - "The Individual Mandate — An Affordable and Fair Approach to Achieving Universal Coverage" in this week's New England Journal of Medicine argues. A mandate is klunky to administer and will require subsidies for low income folk. But if U.S. political culture forbids an openly tax financed system, the individual mandate is the politically viable and ethically acceptable way to go.

John Donne's communitarian moral outlook sounds too much like "socialized medicine" to play a major role in the U.S. health reform debate, but it should:
No man is an island entire of itself; every man
is a piece of the continent, a part of the main;
if a clod be washed away by the sea, Europe
is the less, as well as if a promontory were, as
well as any manner of thy friends or of thine
own were; any man's death diminishes me,
because I am involved in mankind.
And therefore never send to know for whom
the bell tolls; it tolls for thee.
I would rather hear social solidarity arguments for why our health system should be inclusive. But the individual mandate, which takes the route of telling each of us that we can't be slackers and must take responsibility for paying our own way in the health system (unless we're poor enough to warrant a subsidy), gets us to the same place on the back of individual responsibility. This appears to fit our political culture better than a more communitarian ethic.

Friday, June 19, 2009

Patient Access to the Doctor's Notes

With funding from the Robert Wood Johnson Foundation, the Beth Israel Deaconess Hospital in Boston is starting an "open notes" study, in which the patients of 100 physicians will be able to read their doctor's notes on line. I read about the study in an excellent article in today's Boston Globe. Here's the essence of the article:
Researchers hope to learn whether the notes prove more useful than objectionable. They hypothesize that access to doctors’ notes will improve care partly because patients will become more knowledgeable about their treatment and about their doctors’ instructions.

Studies show that “patients remember precious little about what happens in the doctor’s office,’’ said Dr. Tom Delbanco, a Beth Israel Deaconess internist and a co-investigator.

The Robert Wood Johnson Foundation gave Delbanco and his colleagues $1.5 million for the project because doctors have “strong differences of opinion about this. But there is almost a religious character to the debate. It’s uninformed by evidence,’’ said Stephen Downs, an assistant vice president at the foundation. It will be the largest study yet on the issue, he said.
I think it's a great idea!

For the last 10 years of my psychiatric practice at Harvard Vanguard Medical Associates I wrote my own notes directly into an electronic medical record. Although I'd been taught as a resident not to make notes while with the patient, I'd found that waiting until after the appointment or the end of the day resulted in more meager notes. Luckily I'd learned to touch type in middle school, and was able to keep the keyboard on my lap and maintain eye contact while I typed.

But from residency itself I always wrote my notes with the assumption that the patient would read them. The discipline this imposed was useful. As an example, it helped me in relating to people with paranoia. I didn't write "Mr. Jones is paranoid and delusional," but rather "Mr. Jones believes extra-terrestrials have implanted a chip in his brain. He understands that I do not share this view. We discussed why I believe taking anti-psychotic medication would help him in his life..."

I found that people with paranoia appreciated that I recognized the possibility that (in this example) extra-terrestrials might be causing mischief, but that I found this extremely unlikely. We could frame using medication as a hypothesis - "whether or not there is a chip in your brain, I believe that you will sleep better and be less afraid after a few weeks..." rather than as the equivalent of "you're crazy and I'm sane so you should do what I say..."

Writing notes with the patient in the office allowed for discussion of what should be said. With someone I'll call Mr. Jones, it had taken quite a bit of time to elicit a clear picture of how much alcohol he used and how alcohol might be affecting his mood and his physical health. I explained why I thought it was important for his primary care physician to know about his alcohol use. We sat together in front of the terminal to compose my note. Mr. Jones baulked at the word "alcoholism," but accepted "alcohol problem." This wasn't just a piece of collaborative writing and editing - it was an integral part of the treatment process.

Open notes create a different set of problems for primary care physicians than for psychiatrists. PCPs do much more recording of findings and documentation of potential differential diagnoses. PCPs are appropriately concerned with how best to write about the numerous "rule outs" that must be thought about for symptoms that are almost certainly benign. But the challenge of how to write about uncertainties and improbable possibilities may ultimately help the medical profession deal better with uncertainty. In my own care I'd much prefer to read "I believe this headache comes from tension and does not reflect any other underlying cause - I asked him to call me next week if the symptoms persist - we could consider further testing then," rather than "to rule out a brain tumor I have referred him for a CT scan..." In this way open notes might help reduce the defensive medicine and overuse of resources that are so rampant in medical practice today.

This is a research project very worth following. Hats off to the Robert Wood Johnson Foundation for recognizing the potential value in a disciplined study of the domain!

Wednesday, June 17, 2009

David Leonhardt on Rationing

In the business section of today's New York Times, economics columnist David Leonhardt has the best short discussion of rationing I've ever seen.

I won't summarize Leonhardt's succinct article. Anyone who's read my postings under the heading of "rationing" has seen all the same views, but Leonhardt has compressed lucid thinking and well-selected facts into 1200 words.

Leonhardt gives a link to a 2006 study by Baiker and Chandra in the Journal of Labor Economics. The findings will be useful for President Obama and his team in making the case that not rationing is an ethically irresponsible approach to health care. As I said in yesterday's post, runaway healthcare costs are not just an economic problem, they undermine health itself via the connection between income, employment and health status.

Here's the abstract from the Baiker/Chandra article:
We estimate the effect of rising health insurance premiums on wages, employment, and the distribution of part-time and full-time work using variation in medical malpractice payments driven by the recent “medical malpractice crisis.” We estimate that a 10% increase in health insurance premiums reduces the aggregate probability of being employed by 1.2 percentage points, reduces hours worked by 2.4%, and increases the likelihood that a worker is employed only part time by 1.9 percentage points. For workers covered by employer provided health insurance, this increase in premiums results in an offsetting decrease in wages of 2.3%.
Let's hope that enough business and labor leaders read Leonhardt's piece. The anti-rationing demagogues are sharpening their sound bite spears. The reform debate needs strong voices from business and labor to tell it like it is!

Tuesday, June 16, 2009

Turning the Republican Attack on Health Care Reform on its Head

We're entering the sound bite period of health care reform.

Frank Luntz, the guru of Republican phraseology and the ventriloquist behind the Republican lock step warnings against a "government takeover of health care," has given the Republicans a powerful sound bite. The Republicans are marching to the drum of a 28 page memo Luntz wrote for the Republican leadership. It's a brilliant text book of clever wordsmithing.

I've taken three of Luntz's list of "10 rules for stopping the 'Washington takeover' of health care" and tried to imagine how the president could parry the attacks that are now underway. First I quote from Luntz's memo. Then I've put the words I imagine the president using into bold italics:
Luntz: "Humanize your approach. Abandon and exile ALL references to the “healthcare system.” From now on, healthcare is about people. Before you speak, think of the three components of tone that matter most: Individualize. Personalize. Humanize."

The president has made a good start humanizing and personalizing the issue of health care costs. We (the American public) need to understand that less spending (done right) means better health, not worse. Here's how the president could follow Luntz's advice: "Out of control health care costs are a cancer. They've pushed our economy to the brink of collapse and they're ruining the health of the country. Losing a job hurts our health. Losing a home hurts our health. Getting a grip on runaway spending will be good for our health and our economy!"

Luntz: "Healthcare quality = 'getting the treatment you need, when you need it." That is how Americans define quality, and so should you. Once again, focus on the importance of timeliness, but then add to it the specter of 'denial.' Nothing will anger Americans more than the chance that they will be denied the healthcare they need for whatever reason. This is also important because it is an attribute of a government healthcare system that the Democrats CANNOT offer. So say it. 'The plan put forward by the Democrats will deny people treatments they need and make them wait to get the treatments they are allowed to receive.'"

The president has a tough challenge here. The public believes that more care is better care and less care means worse health. Wise physicians know that "getting the treatment you need, when you need it" means care that would be significantly different in nature (more primary care, less specialty care) and quantity (more time with the doctor, fewer procedures) than what we have now. Here's how the president could follow this piece of Luntz's advice: "Wise doctors - the kind of doctor we all want to have for ourselves and our families - know that the best medicine involves more listening and more healing attention then they can give now. We must stop forcing them to do tests and procedures that aren't needed. Tests and procedures that are done because doctors are afraid of being sued or because they can't take the time that's needed don't just drive up costs - they cause harm by all the complications that can occur.

Luntz: " 'One-size-does-NOT-fit-all.' The idea that a “committee of Washington bureaucrats” will establish the standard of care for all Americans and decide who gets what treatment based on how much it costs is anathema to Americans. Your approach? Call for the “protection of the personalized doctor-patient relationship.” It allows you to fight to protect and improve something good rather than only fighting to prevent something bad."

The president has to undermine the argument that whatever the individual physician wants to do is the right thing. We know that close to half of the care delivered deviates from what the best physicians would do. And we know that when Michigan routinized what was done in its intensive care units potentially fatal infections were almost completely eliminated. Here's how the president could use the tactic Luntz proposed to the Republicans: "We want our doctors to have the best information about what works. That's what let's them cure our cancers and relieve our pain. Our plan invests in research to tell them which treatments work, which don't, and which actually cause harm. Our doctors want this kind of knowledge so they can do what they went into medicine to do!"
I'm a doctor who's interested in ethics, not a sound bite machine. I'm no Luntz. But I think the president can perform jiu jitsu on Luntz's tactics and turn the force of Luntz's practical advice in the direction the health care system really needs!

Saturday, June 13, 2009

Seeing the Hippocratic Oath in a New Light

I've always had trouble with the second paragraph of the Hippocratic Oath:
To hold him who has taught me this art as equal to my parents and to live my life in partnership with him, and if he is in need of money to give him a share of mine, and to regard his offspring as equal to my brothers in male lineage and to teach them this art—if they desire to learn it—without fee and covenant; to give a share of precepts and oral instruction and all the other learning to my sons and to the sons of him who has instructed me and to pupils who have signed the covenant and have taken an oath according to the medical law, but no one else.
It's not the exclusively male focus of the oath that bothers me - there's been an opportunity for change in the 2500 years since the oath was written! What turned me off was interpreting the paragraph as a promise to protect our guild. Guild protectionism is the worst aspect of the AMA and medical specialty societies.

But last night I came to a different view. I attended the graduation of the residency in Primary Care and Population Health, sponsored by the Brigham & Women's Hospital and Harvard Vanguard Medical Associates, a program I teach in. If you're interested you can read about the program here. (If you go to the website, I'm in the blue shirt, third from the left.)

The graduation was a love-in. The four graduating residents received their diplomas from the outpatient preceptors they had worked with for three years. The preceptor described the resident. The resident described the preceptor. They hugged. Then the graduating residents said something about each of the juniors and interns, and the juniors spoke about the graduates. Most of the comments included funny stories, but the essence was talk about the qualities of the individual being discussed as a caring, committed physician.

I've thought a lot about the concept of "medical calling" and where - in secular settings - the calling comes from. (See here for a previous post on the topic.) What the graduation brought home for me is how much the calling that physicians profess is based in mutual affirmation within a group. The ceremony, with its repeated emphasis on clinical excellence, rapport, empathy and care was like a prayer service, in which fundamental values were affirmed again and again.

Those who come to health care from a religious faith perspective can explain their sense of calling in terms of their religious beliefs. But the experience of calling can be just as strong in an atheist. Some of the force comes from each person's psychology - whatever in their development and their genetics sparks devotion and caring. The graduation ceremony brought home to me just how much group solidarity around these shared values contributes to the sense of calling. It's not each person alone - it's "us."

I see Hippocrates' second paragraph differently now. It's about cultivating a family of caretakers, not about guild protectionism.

Thursday, June 11, 2009

The Upside of Health Care Competition

Last fall I wrote about how the Hannaford supermarket chain was offering incentives to employees to have procedures like hip and knee replacement done in Singapore, where the company believed treatment of comparable quality but significantly lower cost was available. I quoted the director of health benefits:
"Hannaford's new coverage policy was prompted by stinging criticism from its European owners. For them, medical costs and outcomes in the United States just don't add up. [They said] look at what they're spending in the United States. It's two or three times what they're spending in any other industrialized country. But if you look at quality, [the U.S.] is ranked dead last. So the Europeans said, 'why is health care going up at this extraordinary rate in the United States?'"
I speculated that self-insured employers might prod our society to be more thoughtful about value in health care by taking a more businesslike approach to the provision of health benefits.

In yesterday's New York Times a distinguished trio - Arnold Milstein (Medical Director, Pacific Business Group on Health and "National Health Care Thought Leader" at the William M. Mercer consulting company), Mark Smith (CEO, California HealthCare Foundation), and Jerome Kassirer (former editor, New England Journal of Medicine) - discussed the pros and cons of programs like Hannaford's and then asked:
So should offshore surgery be welcomed as a modest way to make American health care more affordable? We can’t know until we can directly compare the outcomes with those of American surgery. To begin, we must adopt a uniform way for American hospitals and surgeons to report on the frequency of short-term surgical complications.
They suggest that U.S. hospitals use the National Surgical Quality Improvement Program tools, available from the American College of Surgeons, and adapt the Swedish system for monitoring hip replacement to assess outcomes.

This is clearly a good idea and should be done. But it was clearly a good idea 5 and 10 years ago and with the exception of programs like Kaiser Permanente we've just sat on our rear ends without doing it.

Overseas hospitals are hungry for U.S. business. If the best ones aren't yet tracking their outcomes the way Milstein, Smith and Kassirer suggest, they'll probably start tomorrow. I'm sure that many will have results to be proud of. They won't be bashful about advertising their favorable balance of quality and cost, and they'll siphon progressively more "business" away from the U.S.

Price competition driven by evidence-based assessment of outcomes is exactly what the invisible hand of the market does best. I hope that leading hospitals in India, Singapore, Thailand and elsewhere put our feet to the fire over delivering better value for our health care dollars! That will be an admirable blending of global capitalism and good ethics!

(For previous posts about medical tourism and health system ethics see here, here, and here.)

Wednesday, June 10, 2009

A Palestinian Physician Teaches about Professionalism

Driving to my office this morning I was brought to tears by an NPR story about Dr. Izzeldin Abuelaish.

Dr. Abuelaish is an OB-GYN physician who lives in Gaza. He has cared for patients in both Gaza and Israel. He has also done an MPH at Harvard School of Public Health.

Dr. Abuelaish is well known in Gaza and Israel as a spokesman for tolerance and rapprochement. Here's the story:
During the Gaza offensive that dragged into January, he stayed home with his family, providing updates to journalists by phone about what was happening in the territory. Fluent in English, Arabic and Hebrew, he appeared on Israeli radio and television to give updates during the siege.

"All of Israel, they knew that I am at my house. … Just two days before the tragedy, the tank approached the house, 10 meters from the main gate. I felt secure," he recalls.

But instead of protecting him, the tank's crew fired at his home on Jan. 16. A shell crashed into a bedroom, killing his daughters, 14-year-old Aya, 15-year-old Mayar and 21-year-old Bissan, along with his niece Noor, 17...

Abuelaish says his faith helped him through the next terrible few weeks.

"As a believer, as a Muslim, with deep and strong faith, everything which comes from God is good. Why I was selected? Why my daughters were selected? For a purpose, for something good," he says.

"Because what happened in Gaza, it was craziness, practiced against Gazan civilians. And no one knows. I was selected to disclose the secret, to open the eyes about the size of the tragedy the Gazans were facing. And something good will come from this tragedy," he says.

Shortly after his daughters died, a cease-fire was put in place and Israeli forces withdrew from Gaza. But Abuelaish felt that he needed to do more.

"It's not only terrible, it's unbelievable what happened. I lost three precious, beautiful daughters, but I can't return them back. I have five more, and I have the future. I have many good things that I can do for others," he says.

"They were special — how modest and helpful and lovely, willing to help others, thinking of others. And they were killed full of dreams, of hopes. That's why immediately after, I started to think to establish a foundation in memory of my three lost daughters for only girls and women in education and health," Abuelaish says.

He says the initial funds will come from an unlikely source — the Israeli government, which he says has accepted responsibility for his children's deaths.

"The blood of my daughters will be the seeds of that money. Any compensation that comes from the Israeli government, the majority of it will go for this foundation," he says.

Despite his loss, Abuelaish preaches tolerance and understanding. He says he could be consumed with bitterness and anger at what happened, but he sees those emotions as harmful.

"I am a physician who treats patients, and I don't want to feel diseased. I want to help others. So I should be healthy, physically and mentally," he says...

"Military ways are futile, for both [sides]. Words are stronger than bullets. We have to understand each other. We have to respect each other as a human, as equal, and that the dignity of both is equal," he says.

These days, he says, his philosophy is simple: "Love each other, help each other, respect each other."
One of my writing projects this summer is a chapter about the ethical underpinnings of medical professionalism. I've collected a number of articles to read. Several make arcane philosophical arguments.

But Dr. Abuelaish has said it all in nine words: "Love each other, help each other, respect each other."

(See here for a brief profile of Dr. Abuelaish by a medical student from Be'er-sheva, Israel and here for a previous post on professionalism.)

Tuesday, June 9, 2009

The Medicare Food Fight is Underway

In yesterday's post I argued that we should create - and hold to - a budget for our heath system. Today's news shows how difficult that will be.

Members of Congress are mulling over what to do about the enormous disparities in spending that have been documented so well by the Dartmouth group. Medicare spends 45% more per person in New York than in Hawaii, and twice as much in Miami compared to San Francisco! The question for legislators is - what do the findings mean, and what should we do?

The low road of interpretation is already crowded. Legislators from states that spend less are complaining that Medicare has "shortchanged" them. Legislators from high spending states predictably challenge the data and claim that we don't know what it means.

But we've known for more than a decade what the data mean. More capacity means more utilization. More utilization engenders the view - in doctors and the public - that more is better. The flow of money to high spending areas creates an economic interest in continuing the pattern.

I hope we see more truth in the debate. The country would be better off if legislators from New York, Florida and Massachusetts said "these expenditures create jobs and we don't want to yank them out of the economy when we're trying to pull ourselves out of a recession" or "part of the higher expenditure supports medical education, which is a public good." These are real issues and deserve attention.

Unfortunately it's more effective politically to attack the messenger from Dartmouth, to claim that the higher expenditures are "medically necessary," and to invoke the spectre of "rationing by government bureaucrats."

By good luck, Max Baucus, chair of the Senate Finance Committee, and Charles Grassley, the ranking Republican on the Committee, are from lower spending states (Montana and Iowa). Let's hope that they hold firm to the idea that lower spending is compatible with equal or better care, and that President Obama continues in the role of educator-in-chief.

Monday, June 8, 2009

More Money for Health Care = More Unhappy Doctors

The national debate about health care is heating up rapidly. We're already hearing a lot about whether we'll have the political will to pay for universal coverage (see, for example, this editorial in yesterday's New York Times). But what we really need to do - for the sake of patients, doctors, and the soul of medicine, is to contain costs, not to figure out how to get more money so we can spend even more. Putting more money into the health care system will simply continue the trend towards unhappy and demoralized doctors.

Here's a back of the envelope thought experiment:

(1) Approximately 17% of the U.S. population is uninsured.

(2) But our per capita spending on health care is 40% higher than the next most costly OECD country, while our health status statistics are mediocre.

(3) Experts estimate (and most practicing physicians agree) that at least 30% of the care we deliver (and the costs we incur) are unnecessary.

(4) If we dropped our OECD disparity from the highest OECD expenditure by 1/4 we would save 10% of our per capita spending.

(5) If we eliminated 1/4 of the unnecessary care we would save 7.5% of our per capita spending.

(6) Saving 10% + 7.5% would cover the uninsured.

In my view, what our health system needs is a budget, somewhere in the zone of our current level of expenditure, with increases capped midway between the Consumer Price Index and the projected health inflation trend. Were this to happen (alas, it almost certainly won't) I would predict that in five years we would see an improvement in physician morale and patient satisfaction, both of which are low in the U.S. compared to other countries.

Without a budget we can confidently predict that the cost trend will climb into the economic stratosphere. And faced with continuing health care inflation we'll try to put on the brakes with new forms of external control. That's what we tried in the 1990s with insurance company driven managed care.

Almost 20 years ago Kevin Grumbach and Tom Bodenheimer wrote a brilliant article - "Reins or Fences: A Physician's View of Cost Containment." We can try to tame costs by jerking providers by the reins. But we clinicians won't like that, and when we're unhappy our patients are unhappy. Or we can build budgetary fences and say to doctors, nurses, hospitals et al - "you're smart folks and you care about patients - here's an overall budget...please make it work...for patients and the public."

Faced with a realistic budget we health professionals, over time, would get our act together. We'll organize ourselves into systems like the Mayo Clinic, Geisinger, Kaiser Permanente, and Harvard Vanguard, the group I practiced with for 33 years. Physicians in these accountable group practices are happier with their careers, their patients do better overall, and the per capita costs are lower.

That's the direction we need to go in. But it won't happen without a budget for our health system. That shouldn't be impossible to achieve - we budget for everything else we pay for!

Friday, June 5, 2009

MBA Code of Ethics

Before yesterday's graduation, half of the Harvard MBA class signed an oath, promising "to create value responsibly and ethically." I've copied the short version of the pledge the students made. I'm especially interested in the effort to balance Milton Friedman's teaching that the manager's role is to (a) maximize profits while (b) obeying the law with (c) social justice/communitarian values, and I put comments of my own into the oath in bold capitals:
As a manager, my purpose is to serve the greater good by bringing people and resources together to create value that no single individual can build alone. Therefore I will seek a course that enhances the value my enterprise can create for society over the long term. [FRIEDMANITES BELIEVE THAT A SYSTEM OF PROFIT-MAXIMIZING ENTERPRISES WILL PRODUCE MAXIMUM BENEFIT FOR SOCIETY. THE OATH REFLECTS A GROWING LOSS OF FAITH THAT THE INVISIBLE HAND OF THE MARKET CAN BE COUNTED ON TO DO GOD'S WORK!] I recognize my decisions can have far-reaching consequences that affect the well-being of individuals inside and outside my enterprise, today and in the future. As I reconcile the interests of different constituencies, I will face difficult choices.

Therefore, I promise:



• I will manage my enterprise in good faith, guarding against decisions and behavior that advance my own narrow ambitions but harm the enterprise and the societies it serves.

• I will understand and uphold, both in letter and in spirit, the laws and contracts governing my own conduct and that of my enterprise. [UPHOLDING THE LETTER OF THE LAW IS COMPLIANCE. UPHOLDING ITS SPIRIT AS WELL IS ETHICS. COMPLIANCE WITHOUT ETHICS MEANS WE (a) WON'T GO TO JAIL BUT (b) WON'T GO TO HEAVEN EITHER.]

• I will take responsibility for my actions, and I will represent the performance and risks of my enterprise accurately and honestly.

• I will develop both myself and other managers under my supervision so that the profession continues to grow and contribute to the well-being of society.

• I will strive to create sustainable economic, social, and environmental prosperity worldwide.

• I will be accountable to my peers and they will be accountable to me for living by this oath.

This oath I make freely, and upon my honor.
The Preamble to the AMA Principles of Medical Ethics also grapples with the challenge of helping a profession recognize more than one value. It is clear that a physician's primary commitment is to the patient. But in medicine failure to give adequate weight to population health - as through universal insurance, wide access to primary care, and restraint in overall spending - has led to societal harms in the same way that Friedman's faith in profit maximization has. The Preamble tries to give at least some encouragement to considering a wider range of values:
The medical profession has long subscribed to a body of ethical statements developed primarily for the benefit of the patient. As a member of this profession, a physician must recognize responsibility to patients first and foremost, as well as to society, to other health professionals, and to self.
Cynics have scoffed at the MBA code, but I think they're wrong. Clearly the code has no teeth. Medical societies have ethics committees that can sanction erring physicians, and state medical boards respond to complaints about moral lapses. The management profession has no analogue.

But a movement in which a large number of young entrants into the profession look at their elders and conclude that the emperor has no clothes makes a difference. It's high time that we in the U.S. challenge our faith that the market's invisible hand allows each individual and each enterprise to pursue its own narrow interests without considering other societal values except for the letter of the laws we've passed.

(See today's Economist for an interesting article about the oath.)

Wednesday, June 3, 2009

The Murder of Dr. George Tiller (2)

By good luck I was in my car shortly after noon yesterday and heard the NPR program Here and Now. Host Robin Young interviewed Miriam Kleiman, who nine years ago had a late term abortion at Dr. Tiller's clinic. The interview is very worth listening to, and could be used as a trigger for discussion in a mature high school class, a college or health professional class, or a discussion group.

The baby Ms. Kleiman was carrying was found to have a rare brain anomaly that would lead to death. She and her husband decided to seek abortion. When she spoke with the head of her obstetrical practice he looked her in the eye and said "we call that murder!" This was a serious lapse of medical ethics. It would have been acceptable for the physician to have spoken about his personal values, but not to use "we" for a personal perspective or to use the word "murder" for a legal procedure.

By contrast, Dr. Tiller and his clinic were professional, kind and considerate. I've read more about him. He appears to have been a true moral hero. Here's part of what I learned from an article in USA Today:
As a late-term abortion doctor, George Tiller knew he had chosen a dangerous career, one that made him a lightning rod. His Kansas clinic was a fortress, his days marred by threats, but he refused to give up what he saw as his life's mission.

"He never wavered," says Susie Gilligan, who knew Tiller as part of her work in the Feminist Majority Foundation. "He never backed away. He had incredible strength. When you spoke to him, he was a soft-spoken man, a very gentle man. He said, 'This is what I have to do. Women need me. I know they need me.'"

When thousands of protesters gathered at the Women's Health Care Services clinic in 1991 for the 45-day "Summer of Mercy" demonstration staged by Operation Rescue, he was again unbowed.

"I am a willing participant in this conflict," he said at the time. "I choose to be here because I feel that it is the moral, it is the ethical thing to do."

He told The Wichita Eagle newspaper in 1991 that prayer and meditation helped him through hard times. "If I'm OK on the inside," he said, "what people say on the outside does not make much difference."
Reading about Dr. Tiller's deeply grounded moral strength reminded me of an experience I had during my first year at college. A roommate from Dr. Tiller's part of the country (Kansas/Oklahoma) and I, wanting to earn some extra money, participated in what I later learned was a classical social psychological experiment - the Asch Conformity Experiment.

The ostensible task was making visual judgments about the length of a line. All of the other "subjects" were confederates in the experiment, and after a few correct judgments made a consistent systematic error. The research question was - what was the impact on the one true subject?

I remember a feeling of dis-ease and gradually beginning to question my judgments. The confederates were making a consistent erroneous choice, and sometimes that choice actually looked correct to me.

But my roommate, who I now associate with Dr. Tiller in his inner confidence, never noticed what the confederates were doing. We had 80 judgments to make. He disagreed 80 times. For me, the contrast between his reaction and mine was a learning opportunity I've never forgotten.

I hope at least some opponents of abortion will be able to recognize and respect Dr. Tiller's moral seriousness.

Monday, June 1, 2009

The Murder of Dr. George Tiller

In order to assert the sanctity of life, an abortion opponent murdered Dr. George Tiller, one of only three physician providers of late term abortion in the U.S., as he served as an usher of his church yesterday.

Sadly, as shown in a New York Times article this morning, at least one anti-abortion spokesman, while intending to condemn the murder, showed how deeply entrenched hate-laden rhetoric is:
Opponents of abortion, including those here who have been most vociferous in their protests of Dr. Tiller and his work, also expressed outrage at the shooting and said they feared that their groups might be wrongly judged by the act.

Troy Newman, the president of Operation Rescue, an anti-abortion group based in Wichita, said he had always sought out “nonviolent” measures to challenge Dr. Tiller, including efforts in recent years to have him prosecuted for crimes or investigated by state health authorities.

“Operation Rescue has worked tirelessly on peaceful, nonviolent measures to bring him to justice through the legal system, the legislative system,” Mr. Newman said, adding, “We are pro-life, and this act was antithetical to what we believe.”
Of course a group that is "pro-life" must oppose murder. Sadly, Mr. Newman's statement about "bring[ing] him to justice" pours gasoline onto the fire of hatred. "Bring[ing] him to justice" states as a fact that Dr. Tiller was a criminal. Operation Rescue is entitled to believe that. But Newman should have said something like "Operation Rescue has worked tirelessly on peaceful, nonviolent measures to make a practice we abhor illegal..." The murderer, who may already be in custody, will probably claim that he was "bringing Dr. Tiller to justice."

When I use the terms "pro-life" and "pro-choice" I always put them into quotation marks. For almost 400 years the King James translation of Deuteronomy 30:19 has told us that choice and life go together:
I call heaven and earth to record this day against you, that I have set before you life and death, blessing and cursing: therefore choose life, that both thou and thy seed may live
I don't know the Qur'an well enough to identify a similar teaching, but I'm sure it's there.

Abortion deserves to be controversial. I believe that abortion should be legal, safe and available. But I have friends and colleagues who I respect who believe abortion is evil and should be banned. In my view, "therefore choose life" says it all. In three words it unites the pro and anti abortion believers in the tent of humanity.

This effort to find an overarching principle of unity is what President Obama did with such eloquence in his graduation speech at Notre Dame. Here's part of what he said:
In this world of competing claims about what is right and what is true, have confidence in the values with which you've been raised and educated. Be unafraid to speak your mind when those values are at stake. Hold firm to your faith and allow it to guide you on your journey. Stand as a lighthouse.

But remember too that the ultimate irony of faith is that it necessarily admits doubt. It is the belief in things not seen. It is beyond our capacity as human beings to know with certainty what God has planned for us or what He asks of us, and those of us who believe must trust that His wisdom is greater than our own.

This doubt should not push us away from our faith. But it should humble us. It should temper our passions, and cause us to be wary of self-righteousness. It should compel us to remain open, and curious, and eager to continue the moral and spiritual debate that began for so many of you within the walls of Notre Dame. And within our vast democracy, this doubt should remind us to persuade through reason, through an appeal whenever we can to universal rather than parochial principles, and most of all through an abiding example of good works, charity, kindness, and service that moves hearts and minds.

For if there is one law that we can be most certain of, it is the law that binds people of all faiths and no faith together. It is no coincidence that it exists in Christianity and Judaism; in Islam and Hinduism; in Buddhism and humanism. It is, of course, the Golden Rule - the call to treat one another as we wish to be treated. The call to love. To serve. To do what we can to make a difference in the lives of those with whom we share the same brief moment on this Earth.
(See here and here for recent posts about President Obama's leadership on the abortion controversy.)