1.
Featured Article:
False Hope? Bad Science? Biased Researchers?
Overstating the Evidence for Lung Cancer Screening by multiple authors, see below.
The International Early Lung Cancer Action Program
(I-ELCAP) Study
Arch Intern Med. 2007;167(21):2289-2295.
Last year, the New England Journal of
Medicine ran a lead article reporting that patients with lung
cancer had a 10-year survival approaching 90% if detected by
screening spiral computed tomography. The publication garnered
considerable media attention, and some felt that its findings
provided a persuasive case for the immediate initiation of lung
cancer screening. We strongly disagree. In this article, we
highlight 4 reasons why the publication does not make a persuasive
case for screening:
The study had no control group,
it lacked an unbiased outcome measure, it did not consider what is
already known about this topic from previous studies, and it did not
address the harms of screening. We conclude with 2 fundamental
principles that physicians should remember when thinking about
screening: (1) survival is always prolonged by early detection, even
when deaths are not delayed nor any lives saved, and (2) randomized
trials are the only way to reliably determine whether screening does
more good than harm.
To read the authors or disclosures, go to http://archinte.ama-assn.org/cgi/content/abstract/167/21/2289.
To read the full article, sign in at http://archinte.ama-assn.org/cgi/content/full/167/21/2289.
* * * * *
2.
In the News: Can
Hugs Be Good for Patients and for Students?
[Some years ago, the public school teachers in some
districts were forbidden to give the children a hug. Some teachers actually stepped
back when a child came to close for fear of charges of impropriety. Meanwhile,
parochial and private schools knew that kids needed to be touched and caressed
and paid no attention to these restrictions. Similar restrictions occurred in
medicine. Inappropriate touching had sexual connotations and could cause a loss
of licensure. We saw many physicians step back when a patient came to
close. So, it was very refreshing to
read Doctor Wilkes column last week and the reaction from some of the younger
staff. Shouldn't you get a signed consent before you hug a patient?]
Hug can be best medicine By Dr. Michael Wilkes - Sacramento
Bee December 1, 2007
A young mother found her 3-year-old son unconscious in
their backyard swimming pool. Over the next five horrible days, every minute
was spent in the ICU, surrounded by new faces, new beeps and bells, unfamiliar
smells, a profound sense of guilt and remorse, and many discussions with
nurses, social workers and doctors.
Several consultants, including neurologists,
determined that the boy was brain dead –- he had no high-level
brain functions. For Mom, this hard-to-digest fact flew in the face of what she
was seeing –- her son had good skin color and only looked
to be sleeping as he lay hooked up to intravenous lines and a breathing tube.
It was time for the primary care team to hold a
meeting to tell the parents they would need to remove their son from life
support. Clearly, this is one of the hardest conversations in all of medicine.
As the pediatrician walked into the room, he stopped
and hugged the mother. She seemed to welcome the hug, but the simple embrace
generated intense discussions among my medical students. Is a hug from a doctor
of the opposite sex in this emotional setting appropriate? Is it crossing the line
of professionalism? It is taking advantage of a vulnerable woman as the doctor
attempts to meet his own emotional need for a hug?
In the proper setting, there is nothing in the human
experience that can be as comforting, can communicate feelings more powerfully
or can connect two people better than a gentle hug. Presidents and other
politicians often use the hug to send a powerful message –- that they care.
President Bush has publicly hugged hundreds of people: firefighters, police
officers, jockeys, families from Virginia Tech and victims of all sorts of
natural disasters.
Some people find hugging another person –- especially a stranger
–- awkward. And for some
men, hugging an unrelated man is simply unthinkable, as it violates all their
rules of male behavior –- it implies excessive emotion and involves
close physical contact. . .
I'd be hard-pressed to offer any scientific evidence
that the hug actually works, but neither could I find any evidence that it
doesn't. It's just my experience that suggests the hug is often of great
benefit. . .
Some of my colleagues would feel far more comfortable
about this discussion if they could first get a signed consent permitting
hugging if deemed medically indicated. For me, it's a natural part of the art
of medicine and it's what I need to do in certain circumstances to connect with
people. Sometimes the words just don't flow –- or if they do, they
don't come out right.
In the case of the young mother, the doctor's hug
lasted several minutes and was likely of far greater benefit than a Valium or a
sleeping pill. From my perspective, the only harm was that the doctor didn't
also feel comfortable hugging the father.
http://www.sacbee.com/107/story/531591.html
Michael Wilkes, M.D., is a
professor of medicine at the University of California, Davis. Identifying
characteristics of patients mentioned in his column are changed to protect
their confidentiality. Reach him at drwilkes@sacbee.com.
* * * * *
3.
International
Medicine: The Death Struggles of Government Health Care
Death toll from third superbug soars: by Denis
Campbell, health correspondent, The Observer
Pseudomonas infection is resistant to hospital
cleaning - and antibiotics are proving ineffective
Health workers are struggling to control a surge in an
'untreatable' hospital-acquired infection that is estimated to be killing
hundreds of patients a year. The number of cases of Pseudomonas rose by 41 per
cent from 2,605 in 2002 to 3,663 last year, according to Health Protection
Agency figures.
Cleaning agents that hospitals rely on to kill
bacteria are proving inadequate, while most antibiotics that usually help
patients repel infections are ineffective. It often contaminates water and
moisture, so is a particular problem in breathing equipment, intravenous lines
and catheters. One child cancer patient caught it when his lips were sprinkled
with holy water at a Leeds hospital.
The bug is similar to the potentially fatal MRSA and C
difficile infections. MRSA was cited as a cause of death in 1,629 people in
England and Wales in 2005, up from 734 in 2001. C difficile was given as the
reason for the death of 3,807 people in 2005, compared with 1,214 people in
2001.
There are no official statistics on the number of
deaths from Pseudomonas, but Professor Mark Enright, an expert on
healthcare-acquired infections at Imperial College London, estimates that it
kills 'at least hundreds a year', especially those who get blood poisoning as a
result. Previous studies have shown that those who develop septicaemia related
to Pseudomonas have only a 20 per cent chance of survival.
People who have had surgery, who are on a ventilator
in an intensive care unit or who have a condition such as cancer or HIV that
reduces their body's immunity, are especially vulnerable. Some who have had it
but survived have lost a limb, gone blind in one eye or suffered some other
lasting damage to their body.
Alfred Nell almost died during an outbreak of
Pseudomonas at Guy's Hospital in London in late 2005 that killed one woman and
infected him and 17 other patients when they were receiving treatment in the
urological surgery department. He has now asked Edwina Rawson, a medical
negligence solicitor at London lawyers Charles Russell, to investigate if he
can sue for damages.
A senior doctor at the hospital has told Nell, a
40-year-old plumber from Luton, that the near-fatal blood poisoning that he
developed had been started by Pseudomonas carried on a microscope that doctors
put inside him in November 2005 when they were removing a stent inserted during
an earlier kidney stones operation. He ended up in hospital for seven weeks undergoing
treatment.
'I believe that Guy's hospital nearly killed me
because of them not cleaning their instruments properly', said Nell. 'The
microscope was shoved into people before me, was shoved into me and was then
shoved into other people after me. They should clean it every time.' He has
received no letter of apology.
Nell added that he was 'angry because the hospital has
taken away my passions, like my ability to play sport and do certain
recreations with my son and daughter. And I feel quite frustrated because they
haven't admitted to their liability.' He says that he has suffered long-term
damage to his left kidney as a result of getting Pseudomonas which means he can
only drive short distances and not stand for more than 20 minutes without
suffering pain.
'The letters the hospital sent me about my Pseudomonas
referred to it as "a urine infection". I would call it a near-death
experience. I remember the doctors buzzing around my bed talking about how I
was going to lose limbs and they also told my wife, Veronica, at one point that
I was going to die,' said Nell.
A spokeswoman for Guy's said: 'An urgent investigation
identified the most likely cause to be a faulty washer which was immediately
removed from service and subsequently renovated and upgraded prior to the
operating theatre reopening.' The trust says it continues to review its
decontamination processes. . .
To read more, go to http://observer.guardian.co.uk/uk_news/story/0,,2212762,00.html.
The NHS does not give timely
access to Health Care, it only gives access to a waiting list.
The waiting list gives
access to a NHS in deep
trouble, mired in scandal and incompetence.
* * * * *
4.
Medicare: What
Will Medicare Look Like Under John Edwards's Universal System?
A Comrade's
Medical Plan, By INVESTOR'S BUSINESS DAILY, November 29, 2007
Health Care: Don't
want to be part of John Edwards' universal system? Too bad. As he told a group
of reporters Monday, under the Edwards regime, "You don't get that
choice."
Got that? In John Edwards' America, the people will be
forced to be a part of the collective. There's no way out.
Walk into the library and check out a book, you'll get
"signed up" for socialist health care. Pay taxes, get signed up. Send
the kids to school, get signed up.
"Basically every time they come into contact with
either the health care system or the government," Edwards said, ". .
. they will be signed up."
The former senator has modified his position somewhat.
While campaigning in Iowa over the summer, the mandate only went as far as to
require Americans to seek preventive care.
"If you're going to be in the system, you can't
choose not to go to the doctor for 20 years," he said. "You have to
go in and be checked and make sure that you are OK."
His "if" indicated that on some level,
choice was still possible. But Monday's statement cleanly stripped away all
pretense.
It seems clear to us that the penalty for not
"joining" the system - for failing to obey our keepers - would be
imprisonment. But, hey, prisons are government institutions, so they'll
probably sign you up there, too. There is nowhere to escape the long arm of
John Edwards' nanny-state plan.
We agree with the North Carolina trial lawyer that a
government mandate is "the only way to have real universal health
care." But we disagree on the necessity for compelling Americans to turn
over their medical care - and their rights as Americans - to another
bureaucracy.
Besides, if mandates really worked, the government
simply could mandate that no one gets sick or injured and be done with it.
There is no shortage of people who will agree with
Edwards, though. The country is rife with agitators who want the government to
seize the health care sector, which makes up about 17% of the economy.
Some know the effect that will have on our freedoms
and are fine with that; they like the idea of a coercive society where the
government micromanages lives.
The rest are kidding themselves.
Under forced care, physician choice will not exist.
Americans will be assigned a doctor, or allowed to choose from a small group,
much like those who are part of the managed care systems - the same ones that
are so derided by those who support nationalized health care.
This is not a fevered right-wing fantasy. There is a
real-world example: the British system, held up as a model for the U.S. to
follow. It does not let patients see the doctor of their choice. Britons who
use the National Health Service can visit only designated family physician,
whose practice is located near their homes.
Yes, the British can see doctors outside of the NHS.
But, remember, under the Edwards plan, there will be no more private-practice
doctors in the U.S. They'll all be working for the government - which should
frighten anyone who worries about the quality of care.
Canadians and those who support that system think they
have physician choice, but the reality is a bit different. Long waiting times
there, which are well-documented, make a joke of choice. So does the growing
exodus of doctors from that supposed health care haven.
Government interference as proposed by Edwards, Sen.
Hillary Clinton or any of the Democratic candidates will never produce the
quality of care nor the medical advances that have been generated by a system
that rewards excellence. The problems of our current arrangement - both the
real and the many imagined - cannot be cured by instituting a state monopoly.
Destroying private medicine in this country is not the
way we're going to save health care. The best path is to enact public policy
that increases competition.
History shows that has worked in every other sector.
There's no reason it can't work in health care.
Related Topics: Health Care
www.ibdeditorials.com/IBDArticles.aspx?id=281232985281161#
Government
is not the solution to our problems, government is the problem.
- Ronald Reagan
* * * * *
5.
Medical Gluttony:
What's Wrong with Doubling the Cost?
This has been a very popular section with
international responses. Some have asked that the articles be collected in a
book form to repeatedly emphasize the excessive use and abuse in health care.
Week after week, we point out instances of excessive cost, excessive
utilization with no benefit in health outcomes. When we started some six years
ago, we estimated, along with NAHU, that about a third of heath care costs were
of no health benefit. As we point out instance after instance of 100 percent to
1000 percent of over utilization and excessive costs, we can safely say, that
if health care was placed in a free-market environment, we would save one half
of health care costs. Thus in a free-market environment, the tax benefits of
health deduction would pale in comparison to the real reductions in health care
costs.
Why don't more people believe these figures? Probably
for the same reason that a large number of people don't believe that tax cuts
increase government revenues. Each tax cut has produced greater revenue for the
government. You would think that the Tax & Spend people would like the
increase revenue to spend. However, they want to increase taxes again, which
will give them less revenue to restrict freedom and regiment our lives.
Increasing government control with the obvious
increased regimentation of our health care will also bring about the opposite
result than the purported purpose. It will decrease access, increase cost, and
decrease quality of care. Now we have some physicians who believe that they
should be restricted and accept bureaucrats making medical decision. Maybe that
will be the final chapter in eliminating gluttony. Everyone will be on a
waiting list and doctors will go home at 4:30. Just like VA and other
government doctors. And patients will no longer be able to double the costs
just for curiosities sake.
Doctors could get use to the lack of care of socialize
medicine. All that time off and call in sick when you have a tummy ache. But it
will be the ruination of the profession.
* * * * *
6.
Medical Myths:
The Myths of Socialism
Health Alert: Does Socialism Work? Debunking the Myths, by John Goodman, PhD.
David Himmelstein and his wife Steffie Woolhandler are associate professors at Harvard Medical School. Together they are a one-couple team, promoting Canadian national health insurance in the Unites States. They provide the intellectual leadership for the Physicians for a National Health Program. They are about the only academics around whose scholarship routinely gives aid and comfort to the advocates of socialized medicine, unless you count the Commonwealth Fund. They are pleasant (at least to me); they are dedicated; and they are wrong.I first debated David on a college campus about 15 years ago. My most recent debate with them is reprinted in Annals of Thoracic Surgery. In between the two debates I had an epiphany. I discovered that the worst features of the Canadian system are not the differences with our own system, but the similarities. But first things first. Since our last debate, new information has become available that helps debunk three widely touted myths.
The Myth of Low Administrative Costs. In a series of articles, all published in medical journals, Himmelstein and Woolhandler (H&W) claim that the administrative costs of the Canadian system are much lower than our own - so much so that we could insure the uninsured through administrative savings alone. However, H&W are not economists. They count the cost of private insurance premium collection (e.g. advertising, agents' fees, etc.) but they ignore the cost of tax collection to pay for public insurance.
Economic studies show the social cost of collecting taxes is very high. Using the most conservative of these estimates, Ben Zycher has shown that the excess burden of a universal Medicare program would be twice as high as the administrative costs of universal private coverage. The Myth of High Quality. H&W say that Canadian life expectancy is two years longer than ours, implying that the health care systems of the two countries have something to do with that result. Yet as pointed out in a previous Alert, doctors don't control our overeating, overdrinking, etc. Where doctors do make a difference, the comparison does not favor Canada. In an NBER study, David and June O'Neill draw on a large US/Canadian patient survey to show that:
• The percent of middle-aged Canadian women who have never had a mammogram is double the US rate.• The percent of Canadian women who have never had a pap smear is triple the US rate.• More than 8 in 10 Canadian males have never had a PSA test, compared with less than half of US males.• More than 9 in 10 Canadians have never had a colonoscopy, compared with 7 in 10 in the US.These differences in screening may explain why US cancer patients do better than their Canadian counterparts. For example:• The mortality rate for breast cancer is 25% higher in Canada.• The mortality rate for prostate cancer is 18% higher in Canada.• The mortality rate for colorectal cancer among Canadian men and women is about 13% higher than in the US.Amazingly, there are quite a few people in both countries who are not being treated for conditions that clearly require a doctor's attention. However:• Among senior citizens, the fraction of Canadians with asthma, hypertension, and diabetes who are not getting care is twice the rate in the US.• The fraction of Canadian seniors with coronary heart disease who are not being treated is nearly three times the US rate.Apparently, putting everyone in (Canadian) Medicare leads to worse results than having only some people in (US) Medicare - ensconced in an otherwise private system.The Myth of Equal Access. The most common argument for national health insurance is that it will give rich and poor alike the same access to health care. Surprisingly, there is no evidence of that outcome. Indeed, national health insurance in Canada may have created more inequality than otherwise would have existed.
(Similar results have been reported for Britain.) The O'Neill's study shows that:• Both in Canada and in the US health outcomes correlate with income; low-income people are more likely to be in poor health and less likely to be in good health than those with higher incomes.• However, there is apparently more inequality in Canada; among the nonelderly white population of both countries, low-income Canadians are 22% more likely to be in poor health than their American counterparts.References are listed below.Read them and weep.John Goodman, PhD, President, National Center for Policy Analysis
12770 Coit Rd., Suite 800, Dallas, Texas 75251 www.ncpa.org/
For my debate with David Himmelstein and Steffie Woolhandler, go to http://cdhc.ncpa.org/file_download/7.
For Ben Zycher's study of administrative costs, go to www.manhattan-institute.org/pdf/mpr_05.pdf.
For June and David O'Neill's study, go to http://nber15.nber.org/papers/w13429.pdf.
Even though it's several years old, the best overall critique of national health insurance is still my own Lives at Risk, written with Gerry Musgrave and Devon Herrick. Go to www.ncpa.org/shop/index.php?main_page=product_info&products_id=78&zenid=15e142641d7665753362b89df7a7c102.
* * * * *
7. Overheard in the Medical Staff Lounge: The HMO Hidden
Costs.
Dr. Sam: The HMO
was in my office all day yesterday copying 52 charts.
Dr. Ruth: Could
you see patients while they worked? We could only see a half schedule when they
were at our office.
Dr. Sam: We
just gave them one of our two exam rooms and they spread their work on the
doctor's desk, the exam table, the patient's chair, and the extra family member
chair. I guess we were also working at half schedule.
Dr. Dave:
Seems like that is a lot of time and expense?
Dr. Milton: Yes,
time is money and that has not entered the HMO equation. They think nothing of
having us spend an extra six or eight hours in busy work just to help them
monitor our work.
Dr. Yancy: How
many other professions would spend hours without pay to police themselves? And
see half as many patients while they are in the office. It is also a 50 percent
loss of income.
Dr. Milton: That
makes it a huge expense that never shows up in any accounting journal.
Dr. Rosen: The
doctors have just given up. They no longer have any will to either fight or
resist.
Dr. Edwards: Yes,
doctors seem to think the ball game is over and the other team won.
Dr. Sam: The
other team is the government and all the agents of the government. HMOs were a
decree of the government.
Dr. Rosen: And anything
the government does, will never die. They can never admit making a mistake. So
they just add more mistakes on top of the original ones.
Dr. Yancy: And
the Health Insurance Portability and Accountability Act (HIPAA) was part of the
other team to allow the government and their cohorts access to our charts
without any authorization from the patient.
Dr. Michelle:
Isn't it interesting how the letter reads? "We have this right and the
patient need not be informed."
Dr. Rosen: It
seems the patients have also given up.
Dr. Edwards: I
think they don't really understand what is happening to them.
Dr. Rosen: I
think you're right, Ed. When they were copying in our office, a couple of the
patients came in and we had to borrow, can you believe, borrow our own charts
back from the HMO copiers to see the patient. So we thought we'd point this out
to the patient. Several got very upset. One wanted to march into exam room one.
I had to physically stand in the way so he wouldn't make a scene.
Dr. Michelle: That
would also be a rather touchy situation. Maybe the copier would tell the HMO
that Dr. Rosen told the patient her chart was being copied and the HMO would
eliminate part of your incentive for informing the patient.
Dr. Sam: You
don't ever know who your friends or enemies are anymore. Sometimes I get the
feeling that the friendliest are the worst enemies.
Dr. Edwards:
Sometimes even in this room I get rather paranoid. Some doctors are very pro
HMO and government medicine and just sit quietly taking it all in. You wonder
where that might surface some day.
Dr. Sam:
(quietly) Is that Dr. Brutus in the corner over there? Doesn't he have a lean
and hungry look? Me thinks he thinks too much. Such doctors are dangerous.
* * * * *
8.
Voices of Medicine:
A Review of Local and Regional Medical Journals
Orange County Medical Association Bulletin: Viewpoints
- Debunking American Medical Care Myths, By Lytton W. Smith, MD, 8/1/2007
The debate surrounding American medical care prattles
with many unworkable myths. Join me as I examine four of the myths.
Responding to the financial problem in medical care by
creating a new tax system defies history.
When the French commemorate the French Revolution with
Bastille Day on July 14, and we acknowledge the American Revolution with
Independence Day on July 4, the celebrations represent different ideals. The
slogans that drove the two revolutions were also different: "Liberty,
Equality, Fraternity" in France and "No Taxation Without
Representation" in the United States.
Through two centuries of repetition, these slogans
achieved mythical status. Detailed analysis of the revolutions reveals the
complex situations that created the environment igniting each country. French society
evolved differently than American society, and it reflects different attitudes
toward health and medical care. The French, until recently, seemed to prefer a
nationalized, socialized medical system. After the recent election is that a
myth?
Similarly, the debate surrounding American medical
care prattles with many unworkable myths. Join me as I examine four of the
myths.
Myth 1: Healthcare equates to medical care.
When individuals assess their body functions and
conclude they are performing adequately, they presume they are healthy. The
maintenance of our bodies in health remains our choice. Public health systems
are societal measures that enable us to maintain our health.
When a person's body systems fail from any cause, he
seeks the assistance of another to restore the perception of health. That
person is seeking medical care.
Maintenance of an individual's health is generally a
personal financial choice and responsibility. Why do many people think that
that responsibility stops when the individual seeks medical care? Many believe
the myth that one's personal choice to seek medical care in any form absolves
him of any financial responsibility for that medical care.
Myth 2: Medical care should be equal.
Many demand that access and delivery of medical care be equal for all--that the
medical care in Santa Ana equal the care in Beverly Hills. In reality,
inequality exists across the world due to different needs, including rural
location vs. urban location, pediatric care vs. geriatric care, and urban setting
vs. suburban setting.
Achieving equal access to medical care evades all
Western nations. Even in Canada, the prime minister receives different care
than the average citizen. The diversity of American society requires unequal
and different medical solutions for similar medical problems.
Myth 3: Medical care should not be profit-motivated.
When I hear this, I reflect on Winston Churchill's statement, "Capitalism
is the unequal sharing of plenty and communism is the equal sharing of
little." The profit motive created the business success of this country.
Competition within medicine and healthcare abounds as all parties strive to
offer profitable services and products . . .
Myth 4: America suffers from a "healthcare
crisis."
That's the contention in Michael Moore's movie "SiCKO." However, in
reality, Americans enjoy access to the best possible medical care. American
medical care suffers from a financial crisis.
Most Americans, including me, demand the best care
possible, but want someone else to pay for that care. Consequently, third-party
payers created unrealistic expectations in their clients. Similarly, artificial
charges for hospital care ($20,000/day) and simple office charges ($250) bare
little reality to an individual's ability or willingness to pay for these
services.
Market corrections, though painful for some, are the
best method of achieving resolution to the financial crisis in medical care.
Responding to the problem by creating a new taxation system (a single-payer
national health system) defies the American Revolution ideal. . .
Mythological stories shed light on our human condition
. . . However, they rarely offer solutions to problems. The French Revolution
myths cannot compare with the American Revolution myths. Each revolution
charted a different course. The American cry to stop oppressive taxes led to a
divergent solution compared with where the French cry of equality led. When it
comes to our current medical care environment, we must avoid creating solutions
to mythological stories.
Lytton W. Smith, MD, editor for the OCMA, is a
physician practicing family medicine with the St. Jude Heritage Medical Group
in Yorba Linda. Dr. Smith welcomes feedback on his articles and can be reached
at editor@socalphys.com.
* * * * *
9.
Book Review: Why
do physicians fight the wisdom of death?
Final Exam: A Surgeon's Reflections on Mortality, By Pauline W. Chen, MD, KNOPF; 288 PAGES; $23.95
Reviewed by John Vaughn, MD:
During my internship, I cared for a young woman
admitted to the ICU after suffering a catastrophic brain injury during a
routine medical procedure. Her family hovered by her bedside, but communication
was difficult because her son was the only one who spoke a limited, broken
English.
One day a lawyer showed up, taking pictures of her
room and asking for copies of charts as her family stood by wordlessly.
Suddenly, her room became a barren no-man's-land. Daily rounds were terse and
as quick as possible; everyone did his best to avoid nursing calls about her
for fear of having his name on the chart.
When she finally went into cardiac arrest, the
attending physician had the nurse call the entire family into the room so that
they would see that we did everything possible to save her life. I'll never
forget the look on her mother's face as we jolted the lifeless body with chest
compressions and electrical shocks for more than an hour, knowing the whole
time that it was completely useless. It looked like an exhilarating set-piece
from "ER"; it felt like an assault.
Scenes like this are played out in hospitals across
the country every day. Patients in denial without advance directives, families
racked with guilt about losing their loved ones, physicians petrified of being
sued for missing something and everyone feeling an overwhelming need to do
something during a crisis have made many people's last days a needlessly
traumatic, often atrocious experience.
Pauline Chen has written "Final Exam: A Surgeon's
Reflections on Mortality" to explore how modern medicine has come to such
a state.
All physicians deal with death to some degree, but few
face it as directly as Chen. As a liver transplant surgeon, she works at the
grim intersection of young people who've died too soon and nearly dead people
waiting for the donated organs that can save their lives.
That there is an institutional aversion to death in a
profession dedicated to fighting disease seems obvious, even necessary. But
Chen believes that physicians have sublimated this natural aversion to the
point where it expresses itself in an unhealthy "hidden curriculum"
in medical training. Through her experiences and the work of social scientists,
she demonstrates that this curriculum is what causes physicians to fail
patients so miserably at the end of their lives.
Chen covers all the seminal moments in medical
training: dissecting a human cadaver; resuscitating a patient during a
"code"; performing a postmortem examination of someone who dies in
the hospital, talking to the family of the recently deceased. Despite the
occasional lapse into mawkishness -- surgeons "caress patients as no lover
ever could" and terminal young patients are surrounded by a
"halo-like glow" -- her descriptions of these events and their
intentionally desensitizing effects on young physicians are accurate. . .
Our culture is rooted in a tradition of rugged
individualism and unwavering faith in the power of technology to improve our
lives. This deeply ingrained conviction in never giving up, no matter how long
the odds are, makes it a lot easier -- for patient and physician alike -- to
keep a body alive with powerful medications, ventilators and heart pumps than
to look a person in the eye and tell him enough is enough.
"Final Exam" is ultimately about a single
question: How do you want to die? It is a truly awful question, one that
produces an instinctive, practically visceral need to ignore it. But if we're
lucky, it is also a question that each one of us will eventually have a chance
to weigh in on. Pauline Chen has given us her answer. We would all do well to
listen to what she has to say.
John Vaughn is a writer and physician in Columbus,
Ohio. To read the entire review, go to
http://sfgate.com/cgi-bin/article.cgi?file=/c/a/2007/01/21/RVGKDNGCOE1.DTL.
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10. Hippocrates & His Kin: A New Way to Cut Costs -
Have Fathers Deliver Babies
Anne Campbell reports in the UK Metro about a father
who drives to the Maternity Hospital and find no one in attendance and delivers
his daughter in the back seat of his Renault. The mother was able to assist in
unwrapping the umbilical cord from around the baby's neck. After mother and
daughter were safely admitted, they praised the excellent care at Women and
Children's Hospital. The director apologized to the couple. www.metro.co.uk/news/article.html?in_article_id=76719&in_page_id=34
I wonder what else the director gave the couple to
make them think this total absence of care was so good? Maybe a Eurocard with
disappearing balances for life?
The next phase of this disease in this patient is dying.
What's so unnatural about that?
During my longtime pulmonary practice, I felt very
comfortable in frank discussions with the family that the next step in their
loved ones' illness would be dying. In those cases, I recommended that we forgo
the family torture of CPR and let their loved ones pass on in peace. The
suggestion was almost always accepted. However, it was only accomplished if I
was actually in attendance during those final moments since this was the era
before an order for "No CPR" could be written. This was time
consuming on my part, but I felt I restored the dignity of dying in patients
who had been with me for a long time. When I was in attendance, there was
usually an array of RNs, nursing staff, and respiratory therapist with needles,
IV lines, resuscitation masks, and ventilators at the doorway ready to charge
in and take over. I felt my presence on one side of the bed and the family on
the other essentially blocked access by the vultures. One time, as I was turned
to speak with a family member behind me, a respiratory therapist actually got
between me and the patient and I had to reach around and place my hand on the
patient to re-establish my being in charge. But it was the other charge that I
was missing for a long time until a respiratory therapist asked me if I would
at least allow the ventilator inside the ICU curtains so that they could at
least get that first $500 charge for CPR. I later found out that if the entire
team could be established, the hospital was able to charge more than two
thousand dollars for the CPR, even if it only lasted for 15 minutes. There was
a time charge. One therapist told me he thought it was about $500 for each
additional 15 minutes.
With patients and families
being unaware of the economics of dying because of third party payments, it's
no wonder there wasn't a patient-sensitive way of dying for so many years.
The torture chamber seemed to be a hospital gold mining shaft.
To read more HHK vignettes,
go to www.healthcarecom.net/hhk1998.htm.
To read more HMC vignettes,
go to www.delmeyer.net/hmc2001.htm.
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11. Organizations Restoring Accountability in HealthCare,
Government and Society: