Saturday, April 30, 2011

More on Concierge Medicine

I recently posted about two physicians in my neighborhood closing their primary care practices in favor of a limited, fee-based concierge practice. An article in today's New York Times describes an even more extreme version - individualized telemedicine that allows wealthy people to be cared for 24/7 on their yachts for a mere $6,000 to $12,000 per month, plus $700,000 for installation of the "ready room" in the yacht, airplane or home.

As I read about this monstrosity of narcissism, an exchange between Joseph Welch, special counsel in the 1954 Army-McCarthy hearings, came into mind. When McCarthy accused a young associate in Welch's firm of being part of a communist organization, Welch responded:
Until this moment, Senator, I think I have never really gauged your cruelty or your recklessness. Fred Fisher is a young man who went to the Harvard Law School and came into my firm and is starting what looks to be a brilliant career with us. Little did I dream you could be so reckless and so cruel as to do an injury to that lad. It is true that he will continue to be with Hale and Dorr. It is, I regret to say, equally true that I fear he shall always bear a scar needlessly inflicted by you. If it were in my power to forgive you for your reckless cruelty I would do so. I like to think that I am a gentle man but your forgiveness will have to come from someone other than me.

When McCarthy tried to renew his attack, Welch interrupted him:

Senator, may we not drop this? We know he belonged to the Lawyers Guild. Let us not assassinate this lad further, Senator. You've done enough. Have you no sense of decency, sir? At long last, have you left no sense of decency?

McCarthy tried to ask Welch another question about Fisher, and Welch cut him off:

Mr. McCarthy, I will not discuss this further with you. You have sat within six feet of me and could ask – could have asked me about Fred Fisher. You have seen fit to bring it out. And if there is a God in Heaven it will do neither you nor your cause any good. I will not discuss it further. I will not ask Mr. Cohn any more questions. You, Mr. Chairman, may, if you will, call the next witness.
I know nothing about the individuals involved in the $700,000 medical folly, so I'm not accusing them as individuals of lack of decency. But it's deeply indecent of our society to launch exclusive islands of concierge practice and yacht-based "ready rooms" alongside of an epidemic of ill-informed rants against "Obamacare."

Friday, April 29, 2011

Atheists in Foxholes

The old saw - "there are no atheists in foxholes" - is a lie.

If you need proof, visit the Military Association of Atheists and Freethinkers and the New York Times article that put me on to the topic.

In U.S. culture the military stands for traditional values - courage, commitment, and, to a large degree, Christian faith. It takes guts to "come out" as a non-believer in the military. According to Defense Department statistics, only 9,400 of the 1.4 million active-duty military personnel identify themselves as atheist or agnostic. The policy of don't ask/don't tell is clearly not limited to sexual orientation!

Jason Torpy, a retired military officer and president of the Military Association of Atheists and Freethinkers, explains that “humanism fills the same role for atheists that Christianity does for Christians and Judaism does for Jews - it answers questions of ultimate concern; it directs our values."

We health professionals don't often answer questions about suffering, death and other matters of "ultimate concern" the way a faith-based cleric would, but we're often deeply involved with people who are struggling with these questions. In that sense we're like the "non-theist chaplains" activists in the military are calling for.

In my psychiatric practice I only occasionally worked with people who were close to death, but many of my patients had chronic psychiatric ailments which were a cross to bear. Suffering, courage, resilience and meaning were common topics for us. I often thought that if an anthropologist from Mars were studying 1:1 human interactions, much of "medical" practice would look similar to "religious" practice - two people talking thoughtfully about life and death in an atmosphere of mutual respect and caring.

In my experience, health professionals often feel timid talking about the "transcendental" components of medical practice. Organized religions provide a vocabulary and a rationale for seeing healthcare as a calling and talking about it that way. I suspect that the same is true for the military. When we use the term "military service" we're rarely thinking of the historical meaning of "service" - to a higher cause, traditionally, a god.

The current wave of hostility to public sector employees - "public servants" - is a deeply destructive form of political demagoguery. Specific public programs may misfire and individual public employees may perform poorly. But serving the public is a noble calling, whether it's as doctor, nurse, teacher or firefighter.

I'm glad to learn that atheists and agnostics in the military are coming out and demanding recognition for their non-theistic orientation. The organized religions do not have a monopoly on service values. I've been privileged to be part of the health profession for my career, but even though society continues to respect us as secular servants, we don't have a monopoly on that role either.

I'm rooting for the emergence of humanist chaplains in the military!

Monday, April 18, 2011

Concierge Medicine

Yesterday the Boston Globe reported that two of the most respected physicians at the Newton Wellesley Hospital, five miles from where I live, are shifting to a mode of practice called "boutique" or "concierge."

In this format physicians limit their practice to 300 - 600, a much smaller number than is typical for primary care, and charge a fee ($1,500 and up) for membership in the practice. Patients are offered prompt appointments, more time for their visits, 24/7 access to their physician, and more. Insurance doesn't pay the membership fee. Patients need insurance to cover tests, office visits, specialty consultations, hospitalization, and other insurance-covered services.

Concierge practice is small in number, but like canaries in coal mines, it's the source of important information. I only know one physician in a concierge practice - Dr. Jordan Busch, co-founder of Personal Physicians HealthCare, a four physician practice near Boston. Jordan is a superb physician with strong caretaker values. He came to feel that he was not able to care for patients in the comprehensive, personalized manner he aspired to while at the same time making a middle class income. Insurance reimbursement (private insurance, Medicare and Medicaid) for primary care pays by the visit, at a relatively low level. Meeting office expenses and earning a middle class income required a large volume practice. For Jordan (and his colleagues), Personal Physicians HealthCare is a way to practice the kind of medicine he believes in.

I've visited the website of MDVIP, a Florida-based entrepreneurial organization that provides support for approximately 225 physicians in the U.S. (16 in my own state - Jordan's practice is not affiliated with it). I wish I could say I was impressed by idealism, but I wasn't. Much of the executive team comes from Proctor & Gamble. The marketing is pitched to affluent patients. I was struck by the absence of any reference to improving the health system. It presents concierge practice as a "solution" to the frustrations of individual patients and physicians by opting out of the larger system. Although the numbers are still small, each primary care physician who moves to a boutique practice makes it harder for patients to find their own physicians and makes practice even busier for those who don't opt out.

When I trained in psychiatry in the late 1960s, many of the best and the brightest chose to become psychoanalysts. I thought of psychoanalytic theory as a source of insight, but the idea of a small panel of affluent patients didn't represent the kind of diverse, population-oriented practice that I aspired to. I can understand the frustration many primary care physicians, perhaps most, feel at present. But if I were a PCP, I'd think of concierge practice the way I thought of psychoanalysis - a failed model from the perspective of societal needs and population health.

Over time, moving to accountable care organizations and other formats that pay physicians for the populations they care for, not for the visits they provide, is a much more promising and socially responsible direction than concierge practice. Concierge practice, like dead canaries in the coal mines, is a symptom of a societal problem, not a solution!

Sunday, April 17, 2011

Pain Control, Hypnosis, and Medical Ethics

Two years ago I wrote about self-directed hypnosis as a effective and ethically admirable clinical intervention. A recent New York times article - "Using Hypnosis to Gain More Control Over Your Illness" - got me back into the literature on hypnosis for pain control. Since I last dipped into it there have been impressive findings about the impact of hypnosis on procedures associated with pain and anxiety. Here are a few examples:

  • A Cochrane review confirmed that women taught self-hypnosis used less pain medication during labor and were more satisfied with their pain management experience than women receiving standard care.

  • A study conducted at Mt. Sinai in New York showed that hypnosis combined with cognitive behavioral therapy reduced the amount of fatigue experienced by women undergoing radiotherapy for breast cancer.

  • 236 women undergoing large core needle breast biopsy were randomized to standard treatment, structured empathy, and self hypnosis. Pain and anxiety were significantly less with hypnosis, resulting in a shortening of procedure time (39 minutes compared to 46 minutes). The savings from a shortened procedure offset the incremental cost of hypnosis.

  • For children undergoing a voiding cystourethrogram, a decidedly unpleasant radiological study that requires insertion of a catheter through the urethra and fluoroscopic visualization of the bladder while the child urinates. (Just thinking about the procedure gives me anxiety.) In a randomized study, children from 4 - 15 who, along with their parents, received a one hour training session in self-hypnosis, reported significantly less pain and anxiety during the procedure and showed fewer outward signs of distress, leading to a 14 minute shortening of procedure time and reduced cost.

If a new drug - I'll call it hypnotyx - was shown to have comparable effects to self-hypnosis, we would see rapid wide dissemination, a likely cost of several hundred dollars a pop, and, ultimately, hundreds of millions of dollars in sales. Parents would demand hypnotyx for their children. Adults undergoing biopsies would insist on receiving it. But self-hypnosis, a low technology, "alternative" treatment, without a glitzy name, vigorous advertising, or significant profit opportunity, has relatively few fans.

This embrace of "pharmacophilia" is a sad reflection on our national medical culture. We physicians can't simply blame the low uptake for an "alternative" treatment like self-hypnosis on our patients. If we expressed comparable enthusiasm and belief in hypnosis that would occur for hypnotyx our patients would move in the same direction. Advertising has a huge impact, but so does our offhand comments, tone of voice, facial expression, and other components of communication.

If I were again involved in managing a group practice - something I've been out of for 25 years - I'd make a systematic effort to bring techniques like self-hypnosis into areas of the practice like those the studies focused on. It's well and good for individual physicians to incorporate "alternative" methods into their standard practice, but that won't go far in changing our medical culture.

The focus of my work is on ethics, but I cringe when I'm introduced as an "ethicist." The term connotes expertise in an arcane domain, when the fact is that articulating and promoting values is a universal responsibility. With regard to promoting self-hypnosis as an effective, low risk/low cost approach to reducing pain and anxiety, the true ethics leaders will be those who succeed in implementing the robust research findings that are readily available in the literature!

(Dear friends - I've been in Hawaii for two excellent weeks of holiday and then in DC for a meeting - that accounts for the two week hiatus in posting.)

Sunday, April 3, 2011

Improving Health By Telling, and Hearing, Stories

The January issue of the Annals of Internal Medicine has a fascinating and important report of a randomized controlled trial of storytelling as an intervention with low income African Americans with high blood pressure. The study unites the best elements of town and gown medical cultures by combining an innovative caretaking intervention with a vulnerable inner city population (town) with rigorous academic research (gown).

Hypertensive patients at Cooper Green Mercy Hospital clinics, an inner-city, safety-net health system in Birmingham, Alabama, were randomized to (a) receiving a DVD with stories about hypertension and its treatment drawn from patients like themselves or (b) receiving a DVD about health habits. Both groups received usual care for hypertension.

The DVD interviews (examples of which can be seen via the link above) involve people from the patients' own community talking about what high blood pressure means to them, what motivates them to want to deal with the problem, and how to relate to the doctor. The findings were impressive. After 3 months, with further follow up at 7-8 months, patients who received the storytelling DVDs had a significantly greater reduction in blood pressure than the control group.

The study did not allow deep probing of how patients reacted to the DVD stories and what the mechanism of the observed effect might be. But the findings correlate with multiple other studies suggesting that peer influence can have a major impact on health behavior and health outcomes.

From the perspective of ethics, what stands out about this study is the way it combined the clinicians' passion to combat health disparities with the rigor of academic study. Typically these strands of medical life track separately. When this happens, promising clinical results which may be reported at conferences or written up from clinical observation don't compel belief because they're merely "anecdotal." And when academic research is done in the laboratory of a medical school clinic, the results may be methodologically rigorous, but they lack relevance because they don't come from real world situations.

The researchers, and the Robert Wood Johnson Foundation Finding Answers: Disparities Research for Change program, which funded the study, deserve congratulations for overcoming the forces that all-too-often keep committed community clinicians and academic researchers in separate silos.