Tuesday, June 30, 2009

Medicare Open to All (3)

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

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

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

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

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

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

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

Sunday, June 28, 2009

David Rothman on Medical Professionalism

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Tuesday, June 23, 2009

The Ethical Culture of Medicine

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

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

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

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

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

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

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

Sunday, June 21, 2009

Drs. Elton and Sanchez Get it Right

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

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

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

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

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

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

Eric Elton, M.D.

Evanston, Ill., June 15

To the Editor:

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

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

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

Dallas, June 17

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

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

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

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

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

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

Saturday, June 20, 2009

The Ethics of an Individual Mandate

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

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

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

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

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

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

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

Friday, June 19, 2009

Patient Access to the Doctor's Notes

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

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

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

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

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

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

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

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

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