Who Should be Seen as a "Healthcare Executive" and Why Does it Matter?

The American College of Healthcare Executives (ACHE) has as its vision "To be the premier professional society for healthcare executives dedicated to improving healthcare delivery." ACHE's excellent 2015 statement - Creating an Ethical Culture Within the Healthcare Organization - rests on an assertion I wholeheartedly support: namely, that "all healthcare executives have a professional obligation to create an ethical culture." (I added the emphasis)

If you agree with the ACHE assertion, and I'm prepared to go to the mat for it, the first question is: what counts as a "healthcare executive"? How wide is the scope of the term?

Clearly, executives at hospitals, medical groups, and other organizations that deal directly with patients carry major moral responsibilities. After all, health care is crucial for realizing all three of the "unalienable rights" put forward in the Declaration of Independence: life (sometimes health care saves our lives), liberty (we can't exercise our freedom without health), and pursuit of happiness (we can be happy without health, but it's more difficult, and severe enough pain makes it impossible).

ACHE deliberately leaves the scope of the term vague. It defines itself an an organization for "healthcare executives who lead hospitals, healthcare systems and other healthcare organizations." From my experience as a physician, administrator, and patient, I'd cast a wide net for defining "other healthcare organizations" and setting ethical expectations for them.

In the complex U.S. health system direct care organizations aren't the only important moral agents. Health plans and pharmaceutical companies are perhaps the two most important examples of indirect moral agents.

Over the years I've tried to encourage health plans to create ethics programs the way Harvard Pilgrim Health Care, where I have directed the ethics program for sixteen years, has done. I've had zero success. This doesn't mean that other health plans are unethical, but it does suggest that ethical performance is not seen as something that requires the kind of concerted leadership the ACHE statement on responsibility for creating an ethical culture calls for. (For a previous post about my quixotic efforts, see here.)

Executives in the pharmaceutical industry face especially difficult challenges in relation to the kinds of expectations the ACHE standards articulate. They're clearly crucial participants in  the sacred calling of health care. At the same time, they're embedded in a highly competitive industry with strong profit demands. Pharmaceutical executives work in the jaws of a severe dual agency challenge: sacred calling vs the invisible hand of the market.

More than forty years ago, Arnold Relman warned of the potentially disruptive moral impact of what he called "The New Medical-Industrial Complex." Since his prescient warning there have been efforts to establish a shared moral code for all participants in the world of health care. A distinguished U.S. and U.K. group articulated the "Tavistock Principles," but these, alas, seem to have been dead on arrival, and have not been heard from for fifteen years. And for a number of years the American Medical Association sponsored an "Ethical Force" program that sought to establish measurable ethical standards for the major players in the health sector. I had the privilege of being on the advisory panel on health benefits determination. The project produced some excellent materials and a book, but as with the Tavistock principles, the effort was relatively short-lived.

When I mulled over how to end this post I realized that I don't have a tidy upbeat ending. The image that came to mind was of Sisyphus, eternally pushing a rock up the hill. It seems to me that Arnold Relman's call to action points to an ongoing task captured in this cartoon:

I'll do more rock pushing in future posts!

Cooperation vs Competition in Health Care

I've long admired the Cleveland Clinic, so I hope this paragraph from a New York Times article on how drug shortages force rationing decisions, turns out to be incorrect:

The Cleveland Clinic has an advanced compounding room where workers swaddled in disposable gowns, bouffant caps and blue gloves mix up remedies from raw ingredients. During a shortage of papaverine, a drug used for surgery on blood vessels, the clinic produced its own version. When other hospitals began asking about it, Dr. Snyder said he had to tell them, “It’s a franchised recipe we can’t give out.”

 If "franchised recipe" means the Clinic wants to keep its way of producing papaverine secret, it's hard to see how that policy could be ethically justifiable.When a clinician or institution has figured out how to help patients in a better way, the new approach should be shared with others. The overarching goal of the health system is improved health for the entire population. We encourage competition to stimulate local improvements, but once achieved, those improvements must be shared. Competition in health care is justified when it serves population health.

The Cleveland Clinic already has a reputation for clinical excellence. Sharing its "franchised recipe" will enhance the respect the Clinic receives. As such, sharing the recipe would be both good ethics and good strategy. Truly a win/win outcome.

Goldman Sachs, Corporate Culture, and Medical Ethics

When Greg Smith, an executive director at Goldman Sachs, and head of the firm's US equity derivatives business in Europe, the Middle East, and Africa, explained why he resigned from the company in a remarkable New York Times op ed piece two days ago, the story went viral. Here's the essence of what he had to say:

After almost 12 years at the firm...I believe I have worked here long enough to understand the trajectory of its culture, its people, and its identity. And I can honestly say the environment now is as toxic and destructive as I have ever seen it....I have always taken a lot of pride in advising my clients to do what I believe is right for them, even if it means less money for the firm. This view is becoming increasingly unpopular at Goldman Sachs...I attend derivatives sales meeting where not one single minute is spent asking questions about how we can help clients. It's purely about how we can make the most possible money off of them. If you were an alien from Mars and sat in on one of these meetings, you would believe that a client's success or progress was not part of the thought process at all.

Years ago, my friend Marc Bard, a brilliant consultant, taught me the aphorism - "culture beats strategy every time." This is perhaps especially true in health care, which is so strongly mission-driven. If the shared culture of a health organization is truly patient centered every action will express the organization's values.

I experienced how culture works especially clearly 19 years ago, when my father, near the end of his life, was a patient at the Lahey Clinic. In my distracted and distressed state, I locked my keys in my car. I went to the building services office to get help. A staff member (a) picked the car's lock with expertise, but also (b) conducted excellent common sense psychotherapy with me around how we get forgetful when we're upset, and (c) said he would pray for my father. Remembering the incident and writing about it here brought tears back to my eyes. I'm happy that I wrote to the CEO to report on the excellent care I received from his non-clinical staff and to congratulate him on the culture of the organization.

I'm lucky that the four health organizations I've been part of during my career - the Massachusetts Mental Health Center, Harvard Community Health Plan/Harvard Vanguard Medical Associates (HCHP morphed into HVMA), the Harvard Pilgrim Health Care insurance company, and the Harvard Pilgrim Health Care Institute,  have all had cultures and evinced values I've been proud to be associated with. I doubt, however, that the people at those organizations were intrinsically more ethical than the colleagues Greg Smith is writing about.

When one's colleagues and the leaders of an organization share core values they reinforce each other. Newcomers are selected for fit with the culture, and the culture (what educators call the "hidden curriculum") brings out the best in us. It's easier for a health organization than for Goldman Sachs to cultivate a positive culture because the mission of caring for people who are suffering encourages empathy. I'd like to believe that I'd leave as Greg Smith did if I found myself part of an organization with a environment that is "toxic and destructive" and was unable to influence it, but knowing the human capacity for self-delusion, I can't be smug and certain that I wouldn't follow the same playbook Greg Smith discerned at Goldman Sachs.

Aristotle conceptualized "character" as an inner state or way of being that shows itself in the patterns of our actions. "Culture" is the organizational equivalent of "character." Culture is partly formed by the characters of those who constitute it, but the influence goes both ways. In trying to understand our human natures, we need to consider "culture" and "character" along with "nature" and "nurture."

Hand Washing,Teamwork, and Professional Ideals

Hand washing protects hospital patients from healthcare-associated infections. But on average, adherence to hand hygeine standards is under 40%.

In June, 2008, Northshore Hospital on Long Island started an experiment. It installed motion detectors in the doorways of ICU rooms to monitor entrance of staff, and installed cameras focused on the sink and hand sanitizer dispenser. Video auditors (in India) scored each event. The intervention tested the impact of (a) installing cameras and (b) feedback of results. No individuals were identified. Results were only reported in aggregate form.

In the 16 week prefeedback period, hand hygiene rates were under 10%! At that point, electronic boards were installed in the ICU hallway. Results were given on each shift. To my eye, the board looks cheerful. It shows the date, the target rate (>95%) and gives an electronic pep talk ("Sanitize Hands Upon Entry/Exit of Rooms!"). On May 17, 2010, the day displayed in the photo, it tells the staff: "GREAT SHIFT!!" and gives results for physicians and other health professionals.

Once electronic reporting of aggregate performance was given, adherence jumped from under 10% to the mid 80s. The results were sustained for two years.

The report in Clinical Infectious Disease doesn't speculate on what drove the change. There were no financial incentives and no monitoring of individual performance.

So what happened?

Here's my guess. Very few hospital workers doubt the importance of hand hygiene. But resolving to do better is like our New Year resolutions to lose weight or improve ourselves in other ways - easy to vocalize but hard to carry out.

The cameras without feedback accomplished nothing. But daily feedback reminded staff of where it stood relative to its ideals. And the aggregate reporting told staff that everyone was on board. In other words - an experience of unity in relation to professional ideals.

That's like the congregation singing a hymn together and praising the God they adhere to! The electronic board wasn't a voice from heaven, but it spoke to the flock every day on every shift. On a bad day it must have been like the chorus from Messiah - "All we like sheep have gone astray."

I hope a journalist or a qualitative researcher delves into the human side of the statistical story the article tells. We might learn important lessons about what helps us put our healthcare ideals into action.

Hospital Ethics Committees

Hospital Ethics Committees, the most important organizational structure in health care ethics, are a decidedly mixed bag, as measured by skill, reputation, and utilization of the consultation process. Kevin O’Reilly’s excellent article in the current American Medical Association News provides a very full update.

Almost all hospitals with more than 200 beds offer ethics consultation. But the median use is approximately 3 consults per 100 beds per year. Anyone who has worked in a hospital and seen the conundrums that emerge so regularly knows that 3 per year is very low.

O’Reilly cites multiple articles and interviews for concluding that (a) consultants are often under prepared for their role, (b) physician attitudes towards the consultation process are often negative, and (c) evidence for the effectiveness of the consultation process is weak. Howard Brody, director of the University of Texas Medical Branch Institute for Medical Humanities, commented that "if ethics committees were a drug, they would not be approved."

For two reasons, however, I expect that in the next 5 – 10 years we will see an upturn for ethics committees and the consultation process.

First, systematic research on the consultation process, combined with quality improvement interventions, will lead to enhanced consultation techniques and outcome monitoring. The Veterans Affairs IntegratedEthics program, initiated in 2007, is an example of the kind of systematic development that is needed.

Second, the change of language in the 2004 Federal Sentencing Guidelines for Organizations from “compliance” to “compliance and ethics” combined with the statement that organizations should “promote an organizational culture that encourages ethical conduct and a commitment to compliance with the law” creates a strong push for strengthening ethics activities.

Hospital ethics committees are at the end of their entrepreneurial phase. They are up and running and widely disseminated. The phase we are entering now is managerial. The primary challenge is getting more mileage from the time, energy, and (limited) dollars that have been invested in launching them.

The Looming Epidemic of Safety Net Hospital Dialysis Program Closures

I've done three recent posts on the crisis at Grady Hospital in Atlanta that has led to closure of its dialysis program. (See here, here and here.)

As I predicted, the problem is spreading. Now Jackson Health System in Miami-Dade county is closing a dialysis program that has been serving 175 South Florida patients.

Jackson is a prototypical safety net program, as evidenced by these statements from a video about the system: “we proudly step forward when others step back,” “people turn to Jackson when they have nowhere else to go,” and “when there is nowhere else to turn we reach for the impossible every day.”

The details about Jackson are different from Grady, but the underlying theme is the same. Like Grady, Jackson serves large numbers of uninsured patients. In 2008 it spent more than $500 million on charity care. But it ran a deficit of $200 million, which is clearly unsustainable. The dialysis program was losing $4 million per year. I haven't been able to ascertain how many of the 175 dialysis recipients are undocumented immigrants.

For the moment, none of the dialysis patients are in a crisis situation. Some have been able to get onto public insurance programs. Some are having their treatment continued for now at the dialysis centers Jackson contracts with. And some are coming to the emergency department for emergency treatment, which is paid for by emergency Medicaid funds.

The next steps in the scenario are predictable. Jackson will be blamed for (a) not caring and (b) poor management. Undocumented immigrants will be blamed for coming to the U.S. and "milking the system." Government - county, state and federal - will be blamed for underfunding. Citizens will be blamed for refusing tax increases.

There's probably a bit of truth in each blame statement. But the result of all the finger pointing will be more impasse. The dialysis recipients will suffer, and some may die prematurely.

This isn't just a Miami problem, any more than the Grady situation is just an Atlanta problem. Insofar as the dialysis patients are uninsured citizens it's a national problem. And insofar as some are legal or undocumented immigrants, it's an international problem.

I'm not wise enough to know what the best solution for this safety net problem is, but I do know the best way to find it.

We need to convene a working group to scope out the dimensions of the problem and identify options for action. The ideal convener would be the Secretary of Health and Human Services (or her designate - perhaps the Assistant Secretary for Health). The Medicare End Stage Renal Disease Center would be a key participant, as would the National Association of State Medicaid Directors and safety net providers, perhaps via the National Association of Public Hospitals & Health Systems. Because a substantial portion of the patients who are put at risk by program closure are immigrants, the Office of Citizenship and Immigration Services should be represented. And, because programs sometimes try to send immigrants back to their countries of origin, largely in Mexico and Central America, the Bureau of Western Hemisphere Affairs in the State Department should have a voice.

This may seem like overkill for a problem that involves a relatively small number of people. But the values at stake are central to who we are as a country and to the way others see us. Abu Ghraib involved very few people, but for millions, at home and abroad, it is, and should be, a source of shame. It won't take many stories, photos and videos of dying people "dumped" back to their villages, to do the same.

The problem isn't an easy one. But we should not be leaving it to individual safety net programs to struggle on their own, either by swallowing what will ultimately be unsustainable debt or by taking emergency action based on an inevitably narrow perspective.

Unfortunately, we are more likely to leave the problem to our frayed safety net than to kick it upstairs, where it belongs. That means that in 2010 and 2011 we'll be seeing more Gradys and Jackson Health Systems

(I learned about the Jackson Health System situation from a recent article by Kevin Sack of the New York Times, who has done brilliant reporting on Grady.)

Tragic Choices at Grady Hospital (3) - Brinksmanship with Human Lives

Grady Hospital has done the right thing, as I predicted it would in a post last week (here):

Clearly, a safety net provider is accountable for using the funds it receives in the most efficient manner possible. But we the public can't be allowed to turf our moral accountability to the Gradys of the world. We the public created safety net providers to care for the underserved, not to take on the burden of our sins in the manner of Jesus. I believe Grady is right to provoke a crisis over dialysis services. If some of its patients are still in limbo on January 3, Grady can't simply set them loose. It will have to continue to provide for them. But it should keep pointing the finger at its funding sources, with the message that Winston Churchill gave in World War II - "Give us the tools, and we will [do] the job," along with this corollary message - "If you choose not to give us the tools, acknowledge that you are the killers, and take responsibility for your decisions!

In his ongoing series detailing the human meaning of the Grady saga, Kevin Sack of the New York Times tells us that Grady has extended dialysis coverage for another month for 50 uninsured patients, mostly undocumented immigrants, for another month "to help give patients more time to make long-term arrangements," according to Matt Gove, who has the thankless job of speaking for Grady.

Grady is still hoping that the patients will take an active role in figuring out what to do. According to Gove “it should be clear to the patients that there’s a responsibility on their side to continue trying to find a long-term plan because at some point this care won’t be available.”

Many of the patients from Latin American countries refuse to return, since they believe - correctly - that access to dialysis of comparable quality will not be there for them. For some, the explicit plan is to go to an emergency room - quite possibly at Grady - whenever funding for dialysis at Fresenius, the private vendor Grady has contracted with, ends.

No one is suggesting that Fresenius will have any obligation when Grady stops paying. That's the difference between being a safety net provider and a private enterprise.

There are three main ways to approach the problem:

1. Send the undocumented patients back to their country of origin, let them fend for themselves with whatever help the country provides, and hope for the best. (Given the national anti-undocumented attitudes, there will be a lot of support for this option. The ethical rationale for this position is that each country is a fully separate entity responsible for its citizens. Radically different standards of health care are unfortunate, but that's the way it is. Who said life on the planet is fair?)
   
   
2. Leave Grady with the problem, which is what's happening right now. (Mother Theresa and her Missionaries of Charity could care for the dying in Calcutta as long as they had nuns who volunteered to do the work and a space in which to do it. Grady's situation is different. Dialysis was costing it $50,000 per patient per year. In its finite budget Grady has to choose which needs to serve. It can't meet them all.
   
   From an ethical perspective, this is the least justifiable alternative. Grady is a public institution, funded by a combination of county, state, and federal funds. We can't make Grady responsible for the choices we force onto it by our budgetary decisions.)
   
   
3. Address the situation internationally as part of global public health. (This won't be easy, but it's the right way to go. If our national policy is to send the undocumented patients back to their country of origin, we should work with those countries to solve the immediate needs of the individuals, but more importantly, to improve health and economic standards overall. If we continue to pretend that nation-states are self-contained islands, we'll just have more and more Grady-like crises. Sadly, this is what we're likely to do for the forseeable future.)

The U.S. created its end-stage-renal-disease program under Medicare when patients on dialysis were brought to Congress to be seen as individuals. That's what Kevin Sack is doing through his series of stories. (He's my candidate for the next round of Pulitzers!) There's no sign yet that we the public, through the higher levels of government, are paying attention. Perhaps that will happen when the one-month extension Grady has created, or the one after that, comes due.

Tragic Choices at Grady Hospital

On October 3, Grady Hospital in Atlanta closed its dialysis clinic. Grady committed itself to cover the cost of dialysis for three months for any of the 96 patients under its care who did not have an alternative source of dialysis. The three month extension is up on January 3. An undetermined number of patients - possibly as many as 50 - do not yet have a settled plan for continued treatment.

Grady has been serving the poor in Atlanta since 1892. A quarter of Georgia’s physicians have had at least part of their training at Grady. The hospital has 953 beds. The Grady Health System, which includes nine neighborhood health centers, does 921,000 outpatient visits per year, but has been in dire financial straits for many years.

In 2007, in the context of massive financial losses, the board voted to turn Grady over to an independent 501(c)(3) corporation, hoping that a more business-like board could bring managerial discipline to the hospital and make tough decisions the more political board was not willing to make.

This past summer the board showed it could make tough decisions when it voted to close the dialysis clinic, which was losing $2.5 million each year.

The dialysis clinic is a prototypic safety net program. 35% of the patients are undocumented and uninsured. Another 30% are documented but uninsured. 8% are prisoners. The facility itself is old, with outmoded equipment.

In a September ruling as to whether Grady should be allowed to close the clinic, Judge Ural Glanville of the Fulton County Superior Court recognized the severity of the trade off between Grady's stability and the importance of the clinic to the patients it served:

"Indeed, no value can be placed on human life. Nevertheless, when contemplating the use of injunctive authority, the court is required to balance relative equities, even in cases involving issues of life and death. If the court were to require [Grady] to maintain...the services forming the basis of the complaint, it would likely result in an adverse effect on the services offered to other individuals and the public at-large."

A group of plaintiff's brought a class action suit to block the January 3 funding cutoff, but on December 15 the suit was dismissed.

Predictably, Grady is being vilified as an uncaring killer. When confronted by a City Council member the chair of the Grady board responded by accusing the Council of grandstanding - demanding that the clinic be continued without providing funds to do it. I think this was a useful confrontation.

Uninsured patients, most notably immigrants, and especially undocumented immigrants, are caught in the middle of a life-and-death form of the game of "hot potato." Grady Hospital, as a safety net provider, inevitably loses, since its mission is to care for those who have nowhere else to go. When the public, through its government, stints on funding, safety net programs like Grady are left holding human lives in their care. What is a safety net provider to do if the funds allocated to it by the public don't allow it to meet the needs of its patients?

Clearly, a safety net provider is accountable for using the funds it receives in the most efficient manner possible. But we the public can't be allowed to turf our moral accountability to the Gradys of the world. We the public created safety net providers to care for the underserved, not to take on the burden of our sins in the manner of Jesus. I believe Grady is right to provoke a crisis over dialysis services. If some of its patients are still in limbo on January 3, Grady can't simply set them loose. It will have to continue to provide for them. But it should keep pointing the finger at its funding sources, with the message that Winston Churchill gave in World War II - "Give us the tools, and we will [do] the job," along with this corollary message - "If you choose not to give us the tools, acknowledge that you are the killers, and take responsibility for your decisions!"

(For a previous post on Grady Hospital, see here.)

Medical Culture and Costs at UCLA

An article about the cost of end-of-life care in this morning's New York Times focuses on the Ronald Reagan UCLA Medical Center. UCLA has a national reputation for high quality/high tech care, but also for high costs. According to the Dartmouth studies, Medicare pays UCLA $50,000 during the last 6 months of a patient's life compared to $25,000 at the Mayo Clinic.

The article quoted CEO David Feinberg as saying “If you come into this hospital, we’re not going to let you die”!

I have memories that shed light on the story.

From July 1964 to June 1965 I was a medical intern at UCLA, before returning to Boston to train in psychiatry. I don't remember any limits being set on the tests we ordered until the chief resident came to us in the spring to say "folks, we're running out of money for tests, so cut back where you can." He was apologetic for having to cramp our style. The question of when tests were medically important to do, when they were wasteful, and when the risk of false positive results or otherwise misleading findings was so great that doing the test would be, in medical jargon, "contraindicated," was never discussed. UCLA was probably not unusual in that era, but in retrospect it seems that a cost-unconscious ethos was already part of the culture.

The article in the Times also discussed UCLA's ethic of doing everything possible for patients - sometimes with extraordinarily beneficial results. I experienced this in a very positive way as an intern. During one of my ward rotations a young professor was admitted for a heart attack. He was stable, but the physician in charge had me sleep in the same room with him as an additional element of safety. My skills at cardiology were, to put it politely, "developing" at best. But the message of concern and caution embodied in my assignment made a strong impression on me. (I was also aware of the absence of equity - we didn't have interns sleeping in the rooms of our other heart attack patients.)

Dr. Feinberg, the CEO, is a child psychiatrist. Prior to becoming CEO of the UCLA hospitals he was medical director for the Neuropsychiatric Hospital there. Psychiatry has always been subject to limits in ways the rest of medicine hasn't. In addition to his medical training, Dr. Feinberg has an MBA. I trust that his comment about how UCLA is "not going to let you die" is a wry way of tweaking a culture that has been overly technology-driven and underattentive to the ethics of medical costs.

(See here for a profile of Dr. Feinberg, here for the New York Times story, and here for "Caring about patients and caring about money: the American Psychiatric Association code of ethics meets managed care," a paper I wrote in 1994.)

Patient Safety, Ethics, and Psychiatry

This fall I was asked to discuss a case for the Agency for Healthcare Research and Quality Mortality and Morbidity Rounds - a web-based patient safety education site.

At first I thought they were writing to the wrong Dr. Sabin. Patient safety isn't an area of my expertise. But the case they asked me to discuss had major issues of ethics and psychiatry that arose in the care of a homeless man with a history of IV drug use, admitted to a hospital with a methicillin-resistant Staphylococcus aureus (MRSA) abscess near the spine. The patient left the hospital against medical advice (AMA) with bad aftereffects.

I won't recapitulate the case and my discussion here. The moral of the story in the case I discussed was that homeless IV drug users are more "foreign" to most hospital staff than patients from "foreign" countries. Caring for people who we may see as "other" calls for distinctive cultural competence skills. When an institution lacks those skills safety is jeopardized. Ethics and psychiatric consultation can often be helpful.

(I read a number of cases on the website and found them uniformly engaging and informative. The AHRQ site is well worth visiting.)

Problems for Medicine as a Self-Regulating Profession

Professions are occupations that society believes (a) serve vital human needs, (b) require a high level of knowledge, judgment and skill, (c) place societal benefit ahead of personal interests, (d) adhere to a strong ethical code and (e) can be trusted with substantial autonomy because of their commitment self-regulation.

I've recently had several occasions to talk with residents about their experience giving and receiving critical feedback during residency training. Their reports suggest that we are not educating for professional self-regulation as well as we should. If this is true, the professional autonomy we physicians cherish so much is on shaky footing.

The big picture I got is that critical feedback oscillates between extremes. Sometimes it is given with a sledgehammer - as if residents will learn only if cudgeled into submission. Other times it is whispered (or not given at all) - as if residents are too fragile to hear anything negative about their performance.

The eruptive form of critical feedback can lead to the equivalent of putting in earplugs - residents begin to interpret critical feedback as a symptom of ill-will or flawed character and discount it. The unduly timid approach to giving critical feedback can lead to a "no news is good news" outcome - residents interpret the absence of criticism as a message that their performance is fine, even if it isn't.

The residents were concerned that they had not yet developed a repertoire of skills for giving constructive critical feedback to colleagues and were not being coached in how to do it. When I told a group about a resident who, while shadowing me in practice, (a) felt I'd made a significant mistake, (b) brought her concern to a seminar to see what others thought about the situation, then (c) told me her views in what I experienced as a very constructive spirit, they were (d) amazed at her courage.

It's not surprising that we physicians do a poor job of giving constructive critical feedback to each other. Two reasons stand out for me. First, since the 19th century, cannons of medical etiquette have taught that physicians should treat each other with courtesy. Criticism was seen as a symptom of professional rivalry, not a manifestation of collaboration for improvement. Second, medical mistakes can cause harm, even death. Giving critical feedback can feel like an accusation of incompetence, and receiving it can elicit shame and guilt.

When I did an initial literature search about giving and receiving critical feedback among physicians I came up blank. We do write about personal accountability, as in this article about "System Failure versus Personal Accountability - the Case for Clean Hands." And we've made lots of progress in understanding the value of acknowledging mistakes with our patients and more skill in how best to do it. But we've not done at all as well with the topic of how to give and receive constructive critical feedback in our relationships with each other. This is a serious flaw in self-regulation.

(For a previous post about etiquette in medicine see here.)

A Practical Approach to Organizational Ethics

I've been meeting with a number of organizations to help them develop new ways to deal with the ethical dimensions of their activities. They've asked for practical pointers on how to get started. I've presented this list of six:

1. Understand two meanings of "should." Even the most collegially managed organizations have an underlying heirarchy. "Higher levels" can tell "subordinates" what they should do. Ethics is about values - what we should do. One reason organization are uneasy about formal ethics activities is fear that ethics folks would feel empowered to tell the organization what it should do in the managerial sense of "should," supplanting the CEO and Board. This isn't a question about the organization's commitment to values, but rather a question of who is in charge. We need to understand the distinction between the "managerial 'should'" and the "ethical 'should'."
   
   


2. Ensure managerial authority. If the CEO isn't "Chief Ethics Officer," organizational ethics activities will be a waste of time. Explicit endorsement and support from senior leadership is a requiremnt. An organizational ethics committee wouldn't have influenced Enron!
   
   


3. Ensure moral authority. Managerial authority comes via delegation. Moral authority comes from the respect pertinent others have for those who take the lead in organizational ethics activities. To be effective, organizational ethics activities require both managerial sanction and moral authority.
   
   


4. Ensure appropriate leadership skills. Organizational ethics consultation isn't an academic activity. Analytic and conceptual skills are required, but they have to play out with a wide range of people inside and often outside of the organization. Facilitation, relationship management, and solid understanding of the full range of organizational function are also crucial leadership skills for organizational ethics. To conduct effective organizational ethics activities in hospitals, group practices, and health plans, it's necessary to be comfortable dealing with both clinical and administrative matters and personnel.
   
   


5. Apply stakeholder theory. Here's how the excellent AMA Institute of Ethics publication "Organizational Ethics in Healthcare" defines stakeholder theory:
   
   
   "The core thesis of stakeholder theory is the normative
   claim that the interests of all the parties involved in any
   transaction ought to be considered in determining how
   to act ethically. In order to determine how an organization
   ought to act in a particular situation, it is necessary first to
   identify each of the parties (individual and collective)
   with whom the organization interacts and what each
   party has at stake. Second, one must ask how the
   organization ought to act in relation to each party, and
   then how the organization’s several obligations to these
   parties ought to be ranked, both in general and in the
   situation at hand."
   
   
   
   Faith-based organizations use guidance from their creed in dealing with complex ethical questions, but secular organizations typically find ethical reasoning that draws on the perspectives of its stakeholders more comprehensible and persuasive. Except in the rare situation in which a secular health organization embraces an ethical credo from outside of the organization, the stakeholder approach is most effective.
   
   
   
6. Monitor and adapt as needed. In an ethics class the analytical conclusion is the end point. But organizational ethics consultation isn't a classroom exercise. Well-managed organizations apply a quality improvement approach to all of their activities, including organizational ethics. It's great to make a timely decision, but greater yet if that decision works on the ground. If it doesn't it needs to be tweaked.

I'll probably modify this list of pointers over time, but for the moment these six have been useful in a range of settings.

Shamans, Placebos and Multicultural Ethics

Over coffee I read in this morning's New York Times about how Mercy Medical Center, an acute care hospital in Merced, California, allows Shamans to participate in the treatment of Hmong patients from Laos.

The Merced area has a large Hmong population (from Northern Laos), beautifully described in Anne Fadiman's superb book "The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and The Collision of Two Cultures." What's especially interesting is that Mercy Medical Center is part of Catholic Healthcare West, a faith-based system "committed to furthering the healing ministry of Jesus," as well as "to providing high-quality, affordable healthcare to the communities we serve."

It's easier for our scientifically-minded U.S. culture to recognize the importance of religion and magic in dealing with "foreign" cultures than with our own. In my own experience as a psychiatrist, and in my relatively limited interaction with other doctors as a patient, I've been aware of how much of what we do is anthropologically similar to what Shamans do.

When patients ask "so I have a chemical imbalance, right?" and I agree, our exchange has much in common with what is happening when a Hmong patient asks "so a spirit is causing my pain, right?" and the Shaman agrees. Whether or not a chemical imbalance or a spirit is responsible for the clinical state, applying a cognitive model the patient trusts in concert with a trusted healer can have a powerful impact.

In 1986 I made my first and thus-far only trip to China. On a train I conversed with a man who spoke English. I asked how he used "western" medicine compared to traditional Chinese medicine. His answer made excellent sense. "If I have a headache or pain in my back I go to a traditional Chinese healer. If I have pneumonia I go to a 'western' medicine doctor and get an antibiotic."

On returning to the U.S. I was referred a man who had recently arrived from Southeast Asia but who was ethnically Chinese. He had classical symptoms of major depression - depressed mood, suicidal thoughts, weight loss and sleep disturbance - for which antidepressant medication was (and is) the standard treatment in the U.S. He was dubious about trying the medication, so I wrote out my thoughts and encouraged him to discuss the treatment with his herbalist. The herbalist approved of my suggestion and in some weeks the depression was gone, presumably (but not necessarily) due to the medication.

A year later my patient returned and described what sounded like symptoms of erectile dysfunction. I began to ask the kinds of questions I would typically ask in that circumstance. My patient looked horrified at the direction the conversation was going, at which point I encouraged him to see his herbalist for the problem. A few years later I met him at the clinic carrying a baby. Presumably the herbs did the job!

Mercy Medical Center and Catholic Healthcare West are practicing admirable small 'c' Catholicism (in my dictionary "broad and comprehensive in interests, sympathies; liberal"). U.S. medicine needs to extend the same cultural sensitivity and anthropological sophistication to our own practices. We tend to use the term "placebo effect" disparagingly - "the Shaman's ritual is just a placebo effect." Each group takes its own beliefs as literally true and, ideally, acts like Mercy Medical Center with regard to the different beliefs held by others.

If we were more attuned to how much "evidence based" medical practice depends on the power of faith, magic, and the lowly placebo effect, we would be less inclined to flog patients with excessive technical interventions and readier to minister to them in a truly healing manner. When religious fundamentalists persist in using prayer as the only treatment for children with curable cancers we take them to court. But when medical fundamentalists persist in using one technical intervention after another rather than acknowledging that cure is not in the cards our insurance pays their fees.

Years ago a dear friend had come to the end of the available treatments for multiple myeloma and the disease was progressing. When she visited with her oncologist - a leader in technical medicine - he said "the best thing I can do for you now is to give you a hug," which he gave. I've used that as an example of ideal care with medical students.

Our health system can learn a useful lesson from my friend's oncologist and from Mercy Medical Center and Catholic Healthcare West!

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!

Creating a Culture of Research

I recently came upon a terrific article - "Creating a Culture of Research" - that lays out a strategy aimed at making it easier to do scientifically (and ethically) sound clinical research. I write about it here because while its focus is on research, the article has significant implications for organizational ethics in health care.

The authors, Andy Avins and Harley Goldberg, are both associated with Northern California Kaiser-Permanente. Here's the core of their vision:

Perhaps the most important aspect of change is the need for clinical research to be seen as the enormous social good that it is. By providing the knowledge base that establishes effective prevention and therapy, research participants (often by assuming some amount of risk) provide a gift that transcends the simple scientific aspects of their contributions. Yet, unlike many other members of our society who contribute to the general good, these individuals are rarely recognized for their commitment. Similarly, knowledge of the research process is probably very low among the lay public...Such circumstances contribute strongly to the difficulty in recruiting participants to important research investigations. It is time to take a public-health approach towards confronting these issues directly.

Creating a culture more conducive to clinical research requires actions in several domains:

• As mentioned in the above quotation, the public must see participation in clinical research as a contribution to societal well-being. Charitable gift-giving is strong in the U.S. Participation in clinical research is like making a gift to the heart fund a hospital.


• Clinicians must see supporting clinical research as part of their professional responsibility. We ask clinicians to provide evidence-based care. Without their help evidence won't be created.


• Health plans and large health care organizations benefit from evidence about clinical effectiveness. This creates "a special responsibility to become partners in this process and contribute to this agenda."


• Researchers must make participation in research more feasible for patients and clinicians. And, to an even greater extent than when the article was published two years ago, "research participants are entitled to the expectation that those designing and carrying out research protocols are free from suspicious conflicts of interest."

Preaching about the importance of scientifically and ethically sound clinical research won't enhance the research process - a concerted campaign will be required. Unfortunately, the flood of revelations about suppression of negative results in commercially sponsored research and corruption of medical judgment makes fostering a culture of research much more difficult.

I agree with Avins and Goldberg about the importance of strengthening the clinical research enterprise. And from the perspective of ethics I like the potential impact of their ideas on (a) the doctor-patient relationship and (b) health care organizations.

In my writing, teaching, and in this blog, I've often sounded off about the degree to which we underattend to population interests in our approach to health care ethics. In teaching and in the media we focus on the numerator (the individual) but largely ignore the denominator (the population the individual is part of). This myopic approach to ethics encourages selfishness (as if only the individual matters) and social irresponsibility (as if collateral damage from our overly individual-centered system - like our high uninsurance rate - doesn't matter).

In encouraging clinicians and patients to see themselves as collaborators in supporting the advance of medical knowledge we're encouraging them to add a sense of social responsibility to the guiding ethic of care and to recognize the limits of what we know. These would be salutary changes.

With regard to health plans, hospitals and medical groups, the perspective Avins and Goldberg argue for invites all participants in health care to recognize that we have a shared responsibility to contribute to generating the evidence required for "evidence-based practice." This outlook urges us to make the organizations we are part of true learning communities.

A campaign to create a culture of research as envisioned by Avins and Goldberg would have a constructive effect on the ethics of our health system as well. I'm ready to sign on!

Ethics at the Swami Vivekananda Hospital

I'm in Mysore, in the South Indian state of Karnataka, for eight days, at the Vivekananda Institute of Indian Studies. The Institute is part of a remarkable twenty five year old non-governmental organization - Swami Vivekananda Youth Movement (SVYM).

I visited for two days at the hospital the NGO runs in Saragur, a rural community forty miles southwest of Mysore. The visit provided a rich perspective on the ethics of health care and health organizations. I've organized my initial thoughts around two questions, both involving the concept of health care as a calling:

1. If health care is a calling, where does the call come from? Dr. R. Balasubramianiam ("Balu"), currently president of the NGO, led a group of medical students at Mysore Medical College who founded SVYM in 1984. Balu described how at 17 he was "ragged" so harshly by the senior students at the engineering college he had enrolled in that he decided not to go back. Since simply staying at home wasn't an option, to cover up the fact that he wasn't at school he started to spend the hours he would have been at the engineering college at an ashram, where he encountered the teachings of Swami Vivekananda (1863 - 1902) and was inspired by Vivekananda's vision of service to the rural poor and of making India an educated, healthy, harmonious society. Medicine, in the form of service to the rural poor, became his calling.

Balu's narration of his traumatic experience at the engineering college teaches one lesson about the origins of medical calling. It typically has strong personal roots. Virtually all of the physicians, nurses and other health care professionals who (a) I admire and (b) I know well enough to ask about their path to health care (c) cite meaningful personal origins of their calling. These vary tremendously, but have in common being intensely important to the individual.

Pictures of Swami Vivekananda and placards with his most quotable sayings are all around the hospital. When an associate of the NGO told me that he himself was an atheist I asked him "if Swami Vivekananda were here and heard you say that - what would he say?" The response was - "the Swami was an atheist himself - he thought that any god who allowed so much suffering didn't deserve to be worshipped. He taught that the religious spirit was shown in service, not in ritual practices."

Dr. Sridevi Seetharam, a physician deeply involved with medical ethics, explained that in Sanskrit terms, the gentleman I quoted in the previous paragraph was talking about the devotional path known as Karma Yoga - "selfless service to others in one's chosen profession or area of work." Vivekananda was Hindu by birth, but taught that all religions are in some sense "true." In addition to the personal origins of each person's calling to health care, the hospital's inspiration, Swami Vivekananda, and the ancient tradition of devotion through a Karma Yoga, which can be entirely non-sectarian and non-theistic, provides an external pillar for the calling.

In the U.S. people of faith can, if they choose, base their calling on their religious beliefs. But the kind of framework the doctrine of Karma Yoga provides, is not part of our secular ethos. The professionals I most admire act as if they were carrying out a devotional process, but if asked to explain the foundation that underlies their care giving, they're often at a loss to articulate it, or say something like "this may sound like a cliche but..."

2. How does calling manifest itself at the organizational level? My time at the Vivekananda Hospital was limited, but:

* The hospital and its outpatient clinic serve a rural population that includes tribal people who are only recently out of the forest. There is a huge social gap between many of the patients and the well educated professional staff. But the professionals evinced an interest in and warmth towards the people they serve that seemed more like love than technical "cultural competence." The physicians we spoke with evinced deep empathy with the patients. One manifestation of this empathy was creation of a strong role for "patient care managers" who come from the rural population and guide patients through their interaction with the care program in a side by side manner. Empathy is also manifested by providing free lodging for family members who cannot go back to their villages at night because there are no buses after 5:00 PM.

* Physicians were remarkably knowledgeable about traditional Ayurvedic treatment methods and Ayurvedic clinicians were part of the staff. Patients whose traditions and beliefs included Ayurveda had access to this approach in a way that was integrated with the allopathic services they received.

* A holistic view of health as involving more than medical relief of pathological states led the hospital staff to initiate a range of other activities including health and hygiene education in the villages, support for school improvement, and promotion of a clean water supply.

* Finally, and most remarkable from an American perspective, the hospital holds a twice a week non-sectarian prayer meeting attended by all of the staff and all of the patients. I was not present for a prayer meeting, and I do not see it as a format that would fit into a secular U.S. institution, but finding acceptable ways of recognizing the calling that all are participating in is a desirable path to follow.

Hatred of Insurance Companies

The Obama transition team is sponsoring 4,200 house party-based grass roots discussions of health care in December. Today's New York Times reported on one of them.

In my work on health system ethics I've often invoked the need for a "societal learning curve" with regard to the health system. The Obama health care house parties will provide HHS Secretary Tom Daschle with a huge opportunity to see where the U.S. public is coming from in its understanding of the health system.

Here are some excerpts from the account of the health care house party, followed by my comments in italics. The report suggests just how much teaching and leadership we need from Secretary Daschle and President Obama:

"When a dozen consumers gathered over the weekend to discuss health care at the behest of President-elect Barack Obama, they quickly agreed on one point: they despise health insurance companies.

They also agreed that health care was a right; that insurance should cover 'everything,' not just some services..."

I run the ethics program at Harvard Pilgrim Health Care. It's a not for profit health insurance company that insures a million people. For the past four years it has been rated #1 in member satisfaction and quality of care by U.S. News and World Report and the National Committee for Quality Assurance. I respect and admire the organization.

That said, health insurance companies are in an unenviable and perhaps impossible position, poised between (a) employers and government agencies frantic to control what they pay for health insurance (b) providers who are largely not held accountable for costs, (c) insurees who want "everything" covered, in a context of (d) severely limited public and political understanding of how health care really works.

"Dr. Lawrence M. Nelson, a scientist at the National Institutes of Health who emphasized that he was speaking as a private citizen, said: 'The incentives in the current health insurance system are upside down. The less care you provide, the bigger your profits.'"

In the 1990s, public policy asked insurers to mediate the gap between what payers wanted to pay, providers wanted to provide and patients wanted to receive by determining which proposed interventions were "medically necessary." That role wouldn't be easy for anyone - even Mother Theresa or Dr. Schweitzer. Insurance companies, especially for profit companies, were ultimately pilloried for setting limits. They've backed off from taking that role. Costs, of course, are skyrocketing again.

But Dr. Nelson's comment suggests just how tough a teaching job Secretary Daschle will face. Less care is often (a) as good as more care or (b) better. That's a counterintuitive lesson for much of the public. Entities that profit from providing less care aren't able to teach it. The Secretary has to find ways to help us learn.

The Obama transition team did not ask people how a new health care system should be financed, but several people here said that individuals and businesses should have to pay a small health care tax — some preferred to call it a “contribution” — so that everyone could be covered.

Not asking how the health system should be financed strikes me as a major error. There is no way we will come to grips with health care costs until we set a true budget for the health system. The idea that "small contributions" might get us to where we need to go suggests how much we are still living in lala land with regard to health care finances.

If Secretary Daschle uses the health care house parties as an opportunity to refine his agenda for leadership they will provide valuable insight. But if the house parties are used to define the content of proposals we'll just continue down the same path of inexorable cost increases we are on now. Our political leaders - always excepting former Oregon Governor John Kitzhaber - haven't had the guts to help us face the need for limits and to begin to understand health care in a more nuanced way. It remains to be seen whether the new administration is up to the task.

Mayo Clinic Skipped Written Informed Consent - Bravo!

A headline caught my eye this morning - "Mayo Skipped Written Consent."

Before I say more I have to acknowledge a conflict of interest. I admire the Mayo Clinic. I've never been there, but I respect the thoughtfulness of the medical program as reflected in documented outcomes and publications, and the values Mayo has been known for.

Here's the story. George R. Studnicka, a federal prisoner, developed lymphatic cancer. He was referred to the Mayo Clinic for treatment. Mr. Studnicka subsequently claimed that Dr. Daniel Pinheiro operated on him without consent and Dr. Yolanda Garces performed radiation therapy on him, also without consent. (See here for the US District Court Appeal opinion.) Mr. Studnicka's lawyer found no signed informed consent form in the record and complained to the state. An on-site inspection of 12 records showed that none contained signed consent forms.

Mayo wasn't defensive. An administrator told the inspectors "There is no written surgical consent...We don't use them here." The state inspectors reported that Mayo officials told them they "didn't agree with the federal definition of written consent."

Bravo!

The March 2008 issue of the "Proceedings of the Mayo Clinic" had an article on "Medical Informed Consent:General Considerations for Physicians." I don't know whether the timing of the article was coincidental or whether it was meant to present Mayo's philosophy of informed consent. Here's the key summary table from the article:

TABLE 2. Prudent Behaviors of Physicians Engaged in the Process of Medical Informed Consent
* The physician directly involved in the proposed treatment should conduct the informed consent discussion. The discussion should include the treatment, the risks and benefits of treatment, and alternative therapies with associated risks and benefits
* The physician directly involved in the proposed treatment should discuss the most likely outcome with no treatment, on the basis of the best available medical or surgical evidence
* The physician directly involved in the proposed treatment should always discuss the severe risks, such as death, paralysis, loss of cognition, or loss of a limb, even if the probability of occurrences is negligible
* The physician involved in the proposed treatment should always disclose less severe risks that occur frequently. Courts do not place emphasis solely on consequences; they recognize frequency as an important component of risk
* The physician directly involved in the proposed treatment should discuss informed consent in language the patient can understand, and treatment should not proceed until the physician believes the patient understands the risks and benefits and has made a rational decision
* The physician directly involved in the proposed treatment must understand that the medical consent form is not medical consent; it represents evidence that the consent process occurred. The dialogue between the patient and physician is the essence of the consent process (emphasis added)
* The physician directly involved in the proposed treatment should document all patient-imposed restrictions in the medical record and the discussion with the patient about how the restrictions limit the physician’s ability to provide standard medical care...
* When physicians and patients take medical informed consent seriously, the patient-physician relationship becomes a partnership, with shared authority, decision making, and responsibility for outcomes The physician directly involved in the proposed treatment can enhance the informed consent process through appropriate use of additional learning materials, such as pamphlets and video, and through involvement of support staff, such as physician assistants, in providing information that can be discussed by the responsible physician

In my view this represents an exemplary approach to informed consent. The recurrent reference to "the physician directly involved..." and the concluding bullet correctly portray informed consent as a crucial clinical process between clinician and patient, not as a bureaucratic event between pen and paper. Sadly, medical students I've taught have described being sent onto the hospital ward to "consent the patient" - i.e., get the patient to sign a document, which demeans informed consent and invites the student to become cynical.

Apparently, and not surprisingly, the level of documentation in Mayo charts was variable. That's not acceptable. And apparently federal regulations require signed forms in certain circumstances. Mayo agreed to implement a written consent form. I hope the Clinic does this in the clinically sensitive spirit embodied in the passage I quoted.

Hospital Branding, Money, and Ethics

A recent article by the Boston Globe investigative "Spotlight Team" about the differential payments Partners Health Care receives ("A Healthcare System Badly Out Of Balance") has the Massachusetts health policy community in an uproar.

The gist of the article is that Partners hospitals (most notably Brigham and Women's and Massachusetts General) and physicians are paid 15% - 45% more for treatment not demonstrably better than other facilities provide. Since (a) Massachusetts, like other states, is choking on high health care costs and (b) hospital and physician billing accounts for more than 85% of insurance costs, the story is causing waves.

What struck me most about the article is how much investigation was required for an area of public interest that should be transparent. The Spotlight Team had to rely on private insurance data revealed by one or a series of Deep Throat sources. Although the Massachusetts Health Care Reform law created a Quality and Cost Council, because of technical difficulties and controversy about the quality of the data there have thus far been no reports.

With a new administration coming to Washington in two months we will soon see a new level of challenge to our faith-based reliance on market forces to improve health care quality and cost. Less than a month ago former Federal Reserve chair Alan Greenspan acknowledged "shock" that his faith that market self-regulation would serve the public good was "flawed." Proponents of giving market mechanisms more time to control runaway health spending will have to produce evidence for the likelihood of success rather than simply invoking the sacred truths of ideology.

The U.S. has thus far been reluctant to venture far into tiered networks of hospitals and physicians. It's technically difficult to assess quality and efficiency. But we haven't been reluctant to transfer financial risk to individual patients in the form of high deductibles, asking them to do what we typically ask health plans, Medicare and Medicaid not to do!

Between the economic crisis and heightened skepticism about market solutions for the health care system we can expect to see a mixture of (a) an accelerated, last ditch effort to use market mechanisms like tiered insurance networks in which patients have access to all providers but pay much more for those judged to be lower in quality and efficiency and (b) heightened regulation, including the possibility of moving to a single national insurance plan.

Let's hope for more thoughtful and in-depth deliberation about health policy choices than we have seen for the last eight years.

Hospitals, Ethics, and the Uninsured

Three cheers for print journalism!

For a rich understanding of the human impact of not having health insurance, look at the superb (but long - 5,000 words each) articles in Sunday's Washington Post and New York Times.

The Post describes a three day "medical camp" at the Wise County fairground in southwest Virginia run by the Remote Area Medical Volunteer Corps. The Corps provides free medical services to under served rural areas - initially in developing countries, but now in the U.S. as well.

Wise County is poor. Coal industry jobs are dwindling. The average income is $14,000. Medical care is scarce. Uninsurance is high. 2,700 people were treated during the three day camp. A 60 year old woman was treated for out-of-control diabetes. A man in his 50s had an egg sized cyst removed from his face. So did his son! A 31 year old woman who was born with a cleft palate and had not been able to afford dental care as an adult had her diseased teeth removed and was fitted with a special denture.

Rotting teeth, a disfiguring facial cyst, and out-of-control diabetes are shameful anywhere, but especially in a developed country. But the Times' description of how uninsured immigrants are often shipped home is more shameful yet. Sister Margaret McBride, a vice president at St. Joseph's hospital, from where 19 year old Antonio Torres was sent back to Mexico in a coma, put the dilemma this way:

"We're trying to be good stewards of the resources we have...We're trying to make sure that the acute care hospital is available for individuals who need acute care...We can't keep someone forever."

There's no overall policy or common approach to the situation and little support for institutions caught in the middle. Each hospital is on its own.

The volunteers who provide free outpatient services in Appalachia can make a gift of their own time. But hospitals have to pay for the beds that are occupied out of their limited resources.

I doubt that Sister Margaret is a worse human being than the volunteer surgeon who removed the egg sized cyst. From the St. Joseph website I learned that it is a 113 year old not-for-profit hospital. Here are excerpts from its mission and vision statements:

"[St. Joseph's]...affirms the dignity of the human person and the sacredness of all life. We exist to foster the healing ministry of the Catholic Church...we will:

* Deliver compassionate, high quality, affordable health services

* Provide direct services to the poor and advocate on their behalf

* Create partnerships that improve community health.

We believe:

...In the sacredness of all life, and therefore in the dignity of the human person and the promotion of human wholeness;

In a spirit of mercy that cares for the suffering and the dying;

In a spirit of hospitality that welcomes all in need;

In the rights of all persons to quality health care and our responsibility to act as advocates for the poor and those with special needs;

In the stewardship of resources for the enhancement of human life..."

I'm not cynical about St. Joseph's values. But if all they did was ship Antonio back to Mexico without picketing the state house they have failed their own commitments. Hospitals like St. Joseph's are in an impossible situation. They can't on their own make up for what our national and local safety net doesn't provide. But sending a comatose young man out in an ambulance isn't just harmful to him - it's corrupting to those who carry out the process.

We in the U.S. need to take responsibility for situations like Antonio's in a systematic manner, rather than leaving things to each institution and hoping for miracles. Happily, on Monday the AMA House of Delegates voted to gather the facts about forced repatriation and develop a policy to advocate for.

Hospitals can't solve the problem by printing money. But health care institutions can't repatriate sick people without losing a piece of their soul with each episode.