Having recently read the book 'The Hippocratic Myth' by M.Gregg Bloche, the striking subtext states "Why doctors are under pressure to ration care, practice politics and compromise their promise to heal". The author makes a convincing case for his thesis that the current political and economic climate and laws push doctors into juggling contradictory roles as caregivers and cost-cutters, in effect making a sort of mockery of the Hippocratic oath's injunction to 'enter every house only for the good of the patient'.
And yet, the costs of maintaining this kind of selfless, patient-centered care keep rising year after year, till it becomes all but unaffordable to the richest. At what point does it become necessary to bend this curve away from exclusivity towards inclusiveness? What are the costs we will incur, as a society, and can that cost be borne?
One anecdote in the book is about a daughter fighting to maintain the expensive drug regimen her 80+ year old mother needs to survive. "Who are these doctors to ration my mother's care?", to paraphrase her words as she argues that they cannot assume that her mother still has a foot in the grave, even without the drugs that she needs. The mother went on to a full recovery and more years of life, despite having had a life expectancy of about a week when the crisis occurred.
Another is a heartrending story of a low income pregnant mother whose cancer is missed in time because the physician attending didn't feel that a CT scan was warranted until it was too late and led to a cascade of events that crippled her. She might have been able to retain more faculties if it had been caught sooner.
The common thread was that of the doctor acting as a gatekeeper to the spending and clearly highlights an area that is now beginning to be discussed seriously, even as demagoguery about cutting back on Medicare, death panels and more are waved in front of voters to push them either towards the Democrats or Republicans.
The discussion has now started in earnest, as it well should, despite all the simplistic notions being flung around.
This NYT op-ed by Rita Redberg outlines many of the procedures that Medicare covers without questions asked, colonoscopies, prostate cancer screenings, drug-coated stents, all in patient populations that derive no significant benefit from having these procedures, and other inefficiencies in the payout model to private suppliers that currently run up a tab 75-150 billion dollars.
So how do we reconcile the outcry that is sure to be raised when there is a push to move from such procedures towards better preventive care and 'evidence-based' medicine based on appropriate epidemiological recommendations? We already see evidence of it in the backlash against the recommendation that women not at hereditary risk for breast cancer postpone mammograms till the age of 50, rather than starting them at age 40.
In the battle of emotion and personal anecdotes with nebulous abstract statistical analyses, it will always be the former that wins. It's so much easier to be dispassionate about some other larger amorphous group's health than one's own, or one's near and dear.
And yet, bend the curve we must, if the costs are to be contained. This means the unpleasant discussion about rationing care, trying to ensure that the broadest swath of people are covered by the limited budget, rather than trying to cover all treatments for all people.
Some experiments are already starting, like setting up ACOs (Accountable Care Organizations), but the recent evidence for their effectiveness isn't encouraging, suggesting relatively little savings and higher costs and inconveniences to providers than expected.
There were other ways suggested, as well, and provided for in the Affordable Health Care Act, but it remains to be seen whether these will help move the spiralling health care costs into a zone where rises are under control. Only then can a rational discussion ensue on how to dispense medical care to the larger public without making doctors violate the Hippocratic oath to provide the best care they can to the individual patient.
It is true that when it comes to health care, our personal fears are sometimes far different from what we would otherwise consider rational public policy. Even those of us who in our healthy states confidently declare that if such-and-such were to happen, we would not ask for such-and-such medical interventions. But if the scenario actually unfolds, we often change our minds and demand the best and the latest for ourselves and our loved ones.
Cost of health care would come down a lot if preventive care were accessible for the young and the healthy irrespective of income and palliative care rather than heroic efforts to "replace and renew" for the old and the terminally ill, were to become the norm.
Dr. Kevorkian who died recently had the right idea about those who are terminally ill, in great pain and in reasonable control of their faculties. I think he did a great disservice with his theatrics about assisted suicide by preventing a sober discussion to ensue among medical experts, ethicists and lawmakers. I may have linked to this article in The New Yorker by Atul Gawande once before. The 13 page essay is worth looking at in assessing what constitutes unnecessary health care expenditure.
Posted by: Ruchira | June 08, 2011 at 07:26 AM
The Gawande article is excellent, and lists more heartrending stories on wrenching end-of-life decisions : to hospice or not to hospice, along with some evidence that allowing patients with terminal illnesses to opt both for curative as well as hospice without excluding one or the other yields better overall cost improvement than forcing them to opt for one without the other. Maybe that should be one of the areas targeted , but will take a delicate touch in implementation as part of public health policy.
Posted by: Sujatha | June 08, 2011 at 04:38 PM
This discussion provokes a lot of thought and emotion in me. The telling sentence in the long Gawande piece, heartwarming but very sad, is this: "That last month, he said, the family simply focussed on being together, and it proved to be the most meaningful time they'd ever spent." In a way, the article makes a case for not fretting so much about the cost or extent of medical care in the face of looming mortality.
Posted by: Dean C. Rowan | June 08, 2011 at 06:38 PM
I wonder whether the making of public health policy by a group of people trained to look at the statistics and base their recommendation is, in a way, a good thing for the taxpayers. If those tasked with recommending policy bring their own personal stories of watching a loved one face death with or without unnecessary intervention into their deliberations, the human mind being what it is, is largely going to go for the emotion-based response rather than colder calculations. I wonder how they are able to dissociate. Or maybe it isn't so hard if they can somehow train themselves to view this as all happening to a vast and unrelated hoi-polloi.
Dean: A lot of these decisions are built on so many factors, family dynamics, culture, religion and attitudes towards death in general. But the question of cost and extent cannot be wished away. In India, where extreme measures to prolong life are prohibitively expensive, many families choose to abandon such efforts, while here in the US, where such treatments are available, it is more or less taken for granted that such interventions wiil be used to prolong the life, be it for just another day or another week.
Posted by: Sujatha | June 09, 2011 at 05:31 AM
Sujatha: I'm not arguing for wishing away the financial aspect. I'm suggesting that obsessing over medical care shouldn't be a priority. Instead, the focus on being together should be paramount, if that's where meaning and fulfillment will be had. The marathon dash to the end, the effort to squeeze out another day or two of "life," loses its value.
My experience with my father's last weeks, days, and hours, by the way, did not have much at all to do with mere prolonging of life. Instead, the emphasis was on so-called palliative care. But as I suggested in my first comment, I have a lot to sort through when it comes to these matters.
Posted by: Dean C. Rowan | June 09, 2011 at 10:30 AM
Sujatha, there are instances of prolonging life through extraordinary measures in the absence of any reasonable hope in India also although I submit that due to scarcer resources, such cases are far fewer than in the US. The patient in this recent report, is being kept alive not due to her wealth or a family who can't let go, but because of the determined and heroic efforts of her colleagues in the hospital where she still "lives." Aruna Shanbaug used to be a nurse and came to be in her present vegetative state in tragic and brutal circumstances. Please read the Indian Supreme Court's decision on a petitioner's legal challenge to keeping her alive.
I think I understand what Dean is saying and I don't think that he is disagreeing with or dismissing the issue of cost. There comes a time in life for most of us when quality is far more important than quantity. We just have to go through a process of success, failures, hope and disappointment before we come to terms with that realization. But I have seen very old and feeble people in considerable pain wanting to cling to life and much younger ones in hopeless conditions refusing further treatment. Our will to live is a peculiar thing; we can't predict what we will do when the moment of decision arrives for our loved ones or ourselves. That is why it is very important to talk about pain, suffering and palliative care way ahead of the actual event.
Posted by: Ruchira | June 09, 2011 at 03:45 PM
Dean, I'm sorry for misunderstanding your statement. Having no proximate experiences to yours, where you had a painful loss of your father recently, I was rather insensitive in trying to steer the conversation back to the 'cost' factor. As you say, it's the being together and quality of life at the end that matter, not the cost. Again, my apologies.
Ruchira: The issue of palliative care is trickier than most, especially in India. One of my mother's closest friends was dying of inoperable cancer, but kept in the dark by her family about it, until a month before the end. They denied her even the palliative care that could have kept her in lesser pain, just because they didn't want her to know how bad the cancer was. It was a horrible, horrible death.
With all the medical advances made, I sometimes wonder whether the earlier days of 'going out quickly' due to massive heart attacks,with not much possible by the way of interventions, wasn't a more merciful way of passing. Though, it would definitely have deprived the near and dear of a chance to say goodbye.
Posted by: Sujatha | June 10, 2011 at 05:31 AM
Sujatha, There is no need at all to apologize. I didn't feel you were being insensitive. I only wanted to refocus the discussion based on my reading of the Gawande piece, which highlighted a value at the end of life that isn't so easy to quantify. If we believe that, then we should promote meaningful togetherness well before a medical crisis demands it and, likely, upsets any stability that would support it. Like you, I wonder how merciful medically assisted slow death really is for everybody involved.
Posted by: Dean C. Rowan | June 10, 2011 at 11:34 AM