I'll be back soon

I haven't done a post for three weeks - the longest postless interlude since I started the blog 3 1/2 years ago. It's due to a combination of travel and a spate of more work than usual. I'm going off again for a week - a family trip to Bermuda and then a meeting in Washington DC. There's always lots to talk about in relation to health system ethics. I'll be back in June.

Is Paul Krugman Right that Patients are not Consumers?

President Harry Truman only sought advice from one-armed economists. He didn't want any of this "on the one hand/on the other hand" stuff. But, unfortunately, that's how I have to answer the question about Paul Krugman's much noted recent column "Patients are Not Consumers."

Here's the essence of Krugman's argument:

Here’s my question: How did it become normal, or for that matter even acceptable, to refer to medical patients as “consumers”? The relationship between patient and doctor used to be considered something special, almost sacred. Now politicians and supposed reformers talk about the act of receiving care as if it were no different from a commercial transaction, like buying a car — and their only complaint is that it isn’t commercial enough...

Medical care, after all, is an area in which crucial decisions — life and death decisions — must be made. Yet making such decisions intelligently requires a vast amount of specialized knowledge. Furthermore, those decisions often must be made under conditions in which the patient is incapacitated, under severe stress, or needs action immediately, with no time for discussion, let alone comparison shopping.

That’s why we have medical ethics. That’s why doctors have traditionally both been viewed as something special and been expected to behave according to higher standards than the average professional. There’s a reason we have TV series about heroic doctors, while we don’t have TV series about heroic middle managers...

The idea that all this can be reduced to money — that doctors are just “providers” selling services to health care “consumers” — is, well, sickening. And the prevalence of this kind of language is a sign that something has gone very wrong not just with this discussion, but with our society’s values.

I've never met a doctor or nurse for whom the concept of "consumer" felt right as a way of thinking about their patients. Medical care is a calling, and the call isn't to set up shop to hawk consumer goods. Portraying the doctor/patient relationship as one between provider and consumer is a grotesque parody of the moral core of health professionalism. The comments on Krugman's column overwhelmingly agreed that what a patients expect from doctors and nurses isn't a commercial relationship governed by caveat emptor.

A good doctor loves his patients (in the right way). Patients deserve to feel this kind of regard. The language of "consumer" and "provider" completely leaves out the soul of medicine.

But it's not that simple. In 1999 my friend Julia Neuberger argued that we should chuck out the word "patient" and replace it with a term that better conveys equality, collaboration, and active participation. She favored "user" over "consumer." In the same spirit, my psychologist colleagues use the word "client." Though calling my patients "consumers" or "users of care" sticks in my throat, I completely agree with Julia's view of the clinical relationship. It's clear that while for me, and for the clinicians I respect most, "patient" connotes equality, collaboration, and activism, for many folks "patient" means "passive" and "subservient."

Insofar as the concept of "consumer" is necessary to convey that clinicians want, and need, patients to think for themselves and take an active role in the clinical transaction, then the people we clinicians care for should be thought of as "consumers" as well as "patients"!

The Manners Mother Taught Us

Theresa Brown, an oncology nurse in Pittsburgh, didn't connect her column in today's New York Times to Mother's Day. But I did.

Ms. Brown tells this story about a recent event at her hospital:

It was morning rounds in the hospital and the entire medical team stood in the patient’s room. A test result was late, and the patient, a friendly, middle-aged man, jokingly asked his doctor whom he should yell at.

Turning and pointing at the patient’s nurse, the doctor replied, “If you want to scream at anyone, scream at her.”

Ms. Brown was the nurse, and the column, written with the doctor's permission, is her response.

Bad interpersonal behavior creates patient safety risks. Nurses, and young physicians, stop raising questions or sounding alerts. But Ms. Brown observes that the most corrosive form of bullying isn't the loud tantrum - it's "passive, like not answering pages or phone calls, and tends toward the subtle: condescension rather than outright abuse, and aggressive or sarcastic remarks rather than straightforward insults."

I have the privilege of teaching medical ethics to first year Harvard Medical students. We discuss the deep moral conundrums in which cherished values compete and clash. These are the "capital E" ethical issues that make the evening news. But the "small e" ethics that Theresa Brown writes about are more important for every day patient care.

In the feedback I received from patient surveys over the years I was impressed with how many of the comments focused on behaviors that ultimately derived from the lessons in "good manners" that my mother (and father) taught me as a young child. I remember their saying "if you make an appointment, don't be late." There was no occasion to teach about returning phone calls promptly, but when the mother of my best friend in fourth grade died, they insisted that I call him. And the one time I remember my father spanking me (with a hairbrush, no less!) was after I'd treated someone doing housecleaning for the family with disrespect.

Albert Schweitzer taught that "Example is not the main thing in influencing others. It is the only thing." Ms. Brown follows Schweitzer's lead. The milieu of hospitals and other health organizations will improve when "alongside uniform, well-enforced rules, doctors themselves set a new tone in the hospital corridors, policing their colleagues and letting new doctors know what kind of behavior is expected of them."

This isn't the ethics taught in medical ethics classes. It's closer to the good manners we were taught, or should have been taught, as kids. If we're lucky, the behaviors have become second nature, automatic. But the right kind of example among our teachers and peers can reinforce or reduce our propensity to treat patients and colleagues with ordinary human decency.

I'm sorry my mother isn't alive so that I could thank her for lessons I often groused about as a kid. Insofar as I imbibed the practice of considerate behavior, it's served me as well as any of the fancier lessons I learned later on!

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."

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!

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!

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.)