Sunday, March 28, 2010

Health Care Reform: Who Won and Who Won More?

The Patient Protection and Affordable Care Act was signed into law earlier this week by President Obama. The ceremony was notable for the president’s use of 20 pens to sign the bill, and for a vice-presidential expletive that has gone viral. Biden’s presumed private verbal ‘high five’ to the president was heard and widely circulated. Don’t these guys know that when they’re in public that they are never off mic? Our macho vice-president was emulating his vice-presidential predecessor who dropped a similar verbal bomb onto Senator Patrick Leahy in 2004. Cheney’s muscular rhetoric was no aerial drone attack; he delivered his message face to face to the Vermont senator. I wonder if Dick ever invited Pat on a hunting trip?

Obamacare is now law. Will this lead us to Armageddon or to the Garden of Eden? I confess that I haven’t read the bill, but then neither did the legislators who voted for or against it. Sure, the specifics are important, but what we really crave to know is what the score is. Who won and who lost?   Indeed, the press feeds us daily with their ‘who’s up and who’s down’ reportage. They do it because we demand and consume it voraciously.

I wanted to give my spin on the winners and losers in the contest, but I was stymied. After considering the various players in the game, I realized that everyone won. The health care reform bill is the tide that lifts all boats.  No one loses.  See for yourself.

Entity                      Outcome         Explanation
Hospitals                   Win!               Millions of new customers

Trial Lawyers           Jackpot!        Do you need an explanation?

Pharma                       Win!               Billions from doughnut closure

Uninsured                  Win!               32 million winners

Rush Limbaugh         Win!               'Ditto head' material for years

Press                              Win!              Partisanship is their mother's milk

President Obama       Win!              Pulled off a legislative triumph

Primary Care Docs      Win!             Will reap a windfall of pennies

Government                  Win!             More power and control

Deficit                              Win!             Dems guarantee it!

Health Care Costs        Win!             See above explanation

Affluent Americans     Win!             Pride in paying their fair share.

Medicaid                         Win!              16 million new members

Public                              Win!              Perfect low cost high quality care

Tea Party                        Win!             Awesome recruitment tool

The GOP                          Win!             Wait 'til November

Congratulations to everyone for a spirited race and a great victory.  There's room in the winner's circle for everyone.  No second place finishers here.  In the Obama Health Care Games, every contestant walks away with the gold. 

Why, then, don't I feel victorious? 

There are some choice words and phrases that I've left out of this post.  Perhaps, if I were Vice-President of the United States, then I could fire off my verbal fusillade with impunity.  However, as a small town blogger, I have to be more careful.  I know that I'm not 'off mic'.

Sunday, March 21, 2010

Narcotic Pain Control: Physician Pushers Should Pull Back

Photo Credit Eva Kocher

First, let me state unequivcally that I am against all varieties of pain, foreign and domestic. Indeed, I wish that we could snuff the varmint out every time and place it surfaces. Pain is a wily opponent that can be difficult to vanquish. In recent years, physicians have been resorting to a ‘shock and awe’ strategy of using excessive force against it. While this may be sound military strategy, in the medical arena it has led to unintended and predictable consequences. I think that we physicians are pulling the narc trigger too quickly and too often.

It’s easy to advocate for a more parsimonious approach to pain control, when your humble blogger is pain free. Indeed, my own pain threshold cruises at low altitude, and has never been fairly tested. While this may limit my credibility, I maintain as a physician that my profession, including me, needs some narc reform.

When I was in medical training, during the days when my kids insist that I took the pet stegosaurus out for a walk, we prescribed narcotics for serious pain. Of course, all pain is serious, if you are the sufferer. Nevertheless, in those days we prescribed morphine, and its cousins, in specific clinical situations. We prescribed them in patients who were enduring the agony of kidney stones, myocardial infarctions, intestinal obstructions, acute abdomens, traumatic musculoskeletal injury and post-operatively. These medicines, in general, were reserved for acute pain. This bedrock medical practice has not changed.

Additionally, in those days, we physicians were taught to refrain from prescribing narcotics to manage chronic pain, in order to avoid causing medication addiction. Some doctors were also concerned that writing prescriptions for controlled pain medicines would invite scrutiny from medical boards and other oversight institutions. As the medical speciality of Palliative Care developed, physicians were reeducated that narcotic medications had a necessary role in the treatment of chronic pain, particularly in patients who were suffering from a terminal illness. Palliative Care taught us that we had been overly dogmatic and we needed to loosen up.

Another medical specialty, Pain Management, has emerged in recent years that treats patients with all sorts of chronic pain, often without a specific diagnosis. Gastroenterologists, for example, refer patients with unexplained abdominal pain to these specialists, not for diagnosis, but to manage the pain. This is is tough specialty, as the bulk of their practices are chronic pain patients, most of whom have exhausted other therapeutic alternatives. For many of them, these pain doctors are their last best hope.

Enter Morphine Mission Creep. When I was an intern, gazing out the window at flying pterodactyls, physicians didn’t prescribe enough pain medicines. Now, we have more than made up for our prior pharmacologic stinginess by turning the narcotic hose on full blast. Physicians now prescribe addictive and powerful narcotics routinely to patients with a variety of chronic painful conditions, particularly in the hospital. I witness this regularly on my hospital rounds, and am sure that other physicians can corroborate this observation. Patient come to the emergency room, often already on narcotics, complaining of breakthrough pain. The emergency room physician will then prescibe a stronger agent to be administered intravenously (IV) every 2 or 3 hours. This narc cycle goes on for several days. These folks are so tolerant (‘immune’) to narcotics, that they require high doses to achieve pain relief. Often, these patients will complain that even high doses at frequent intervals are not sufficient. Many of these individuals are truly experiencing pain, although nurses and physicians often observe that some of them seem too comfortable to warrant IV narcotics.

It is now common, for example, to medicate patients with chronic abdominal pain – stomach aches – with IV dilaudid, a powerful and addictive narcotic. Unlike acute pain, which will terminate, chronic pain lives on. Therefore, if a physician opts to prescribe addictive medicines to these patients, then what is the exit strategy? When we physicians go narc, we create an expectation that the patient’s ongoing condition needs narcotics.Over time, the patient becomes tolerant and addicted to these medicines. In many instances, the narcotic dependence and addiction becomes a much more serious disease than the original illness.

The medical profession needs to pull back from fostering narcotic ‘free love’. We all agree that the enemy is pain. Physicians should remain devoted to our mission to relieve pain and suffering in our patients. In many instances, we have been giving patients the wrong tools for the job. I’m not suggesting we adopt a narcotics moratorium on chronic pain, but that we be more judicious about their use. New specialties and medical expertise in pain management and control have many strategies and techniques that can be safer alternatives to chronic narcotics. We need to learn about them from our colleagues.

When we physicians held back pain medicines decades ago, we were wrong. I don’t think that we have it quite right yet.

Sunday, March 14, 2010

Are Feeding Tubes Futile Care or Morally Obligatory?

Hypocrisy : The practice of professing beliefs, feelings, or virtues that one does not hold or possess; falseness.

Which of the following medical tests or procedures do physicians commonly recommend, but state they would never accept themselves?

(1) Cardiac catheterization
(2) Screening colonoscopy
(3) Feeding tube placement
(4) PSA screening for prostate cancer
(5) Hip replacement surgery

Answer appears at the post’s end.

Last week, I was asked by a primary care physician to place a feeding tube in an NNHP, a nonagenarian nursing home patient. The patient had a panoply of active medical issues, and was at the end of life. The feeding tube was advised because the patient’s swallowing function was impaired and he was, therefore, at risk for pneumonia if he ate. These swallowing evaluations are generally performed by speech pathologists, whom I have found to be dedicated and competent professionals. As an aside, they often uncover swallowing defects that suggest that eating regular food may be unsafe, even though I suspect that these ‘defects’ were present for several years. Somehow, these patients ate regular food and survived.

As the patient was not capable of providing informed consent, I contacted the patient’s legal guardian, who is his grandson and a physician. While I was hoping that he would decline the tube and opt for comfort care, he was adamant that the tube be placed. I did so on the following day. Yesterday, a day after the tube was placed, he died, not from a complication of the procedure, but because he had reached the end of his life.

In 20 years, I’ve place over a hundred feeding tubes, primarily in elderly and demented individudals. In most of these cases, I serve as a technician. I am not consulted for my advice on whether a feeding tube is in a patient’s interest, but am asked to insert one after the decision has already been made. More than any other gastro procedure I perform, placing these tubes, called PEGs by physicians, is the most troubling. There is no question that gastroenterologists like me are placing more of these tubes than are medically necessary. Over the past few years, several medical papers have documented that providing tube nutrition for patients at the end of life, or with advanced dementia, provides no benefit. It does not prolong or improve life for many of these patients. Why, then, do we do it so often?

  • We do it because primary care physicians ask us to do it.
  • We do it because families believe that withholding nutrition means they would be starving granny.
  • We do it because nursing homes don’t have the time or manpower to feed patients.
  • We do it because it has become an expected medical recommendation when patients cannot adequately feed themselves.
Because placing these tubes is often the default recommendation, physicians must actively intervene to prevent placing them. Futile care should not have to be abrogated by a physician; it should not be contemplated in the first place. We should assume instead that an individual who is swirling in the latter phases of dementia does not need a feeding tube, unless there are persuasive arguments to the contrary. We should have to justify that a PEG is needed, rather than prove that it is not necessary.

There is a theological aspect to this issue.  Traditional Jewish law mandates nutrition, even by feeding tube, in all instances, with rare and specific exceptions. While I have enormous respect for these religious laws and precepts, I cannot always reconcile them with my own feelings as a physician vis-a-vis individual patients. Judaism teaches that every moment of life has infinite value. I respect this unshakeable conviction in a world with elastic values and slippery slopes. While many advocate changing the definition of death for various reasons, Judaism stands as a bulwark against ethical erosion. Yet, I am personally torn when I am asked to place a feeding tube when I cannot appreciate the benefit that will result from this intervention.

The Catholic view on this issue is similar.  U.S Bishops recently announced feeding tube policies, which obligate feeding in nearly every individual, including those in a permanent vegetative state, with rare exceptions.  This religious directive could conflict with a patient's stated end of life wishes.

There is a double standard at play here.  I cannot count how many physicians have told me they would never have a PEG tube personally, yet they prescribe it regularly for their own patients. What oath did we all take? Was it the Hypocritic Oath?

If you've read this far, then you don't need an answer key to the multiple choice question above.

Wednesday, March 3, 2010

The VIP Patient– “Doctor, What If I Were Your Mom?”

The Intro to the Intro

For those who were hoping for a sober or analytical piece this Sunday morning, be warned that you have entered a No Wonk Zone. Today’s post, hopefully will make a serious point, but it is seasoned with some levity and a little silliness. Of course, just because I think it’s silly, doesn’t mean that you will agree with me. The definitions of silly and serious are highly subjective. One man’s ‘dead serious’ is another man’s ‘deadpan'. For example, after watching the recent health care reform summit, I couldn’t tell if it was a serious policy exchange or a silly infomercial.  Could you?  Yes, I confess that this is an entirely gratuitous jab at the President's daytime TV health care reform special.

The Intro

Every physician has been asked, “Doctor, what would you do if I were your mother?” The patient, who assumes that the doctor likes his mother, erroneously believes that this is a surefire method of receiving premium medical advice. After all, who wouldn’t want to receive the same medical advice that the doctor would give to his own mother? Extending this flawed logic into the realm of absurdity, the patient could generate a range of medical options from his doctor, simply by using the index question above as a template, and substituting other folks in place of ‘mother’. Watch how this works.

The Hypothetical Patient

A patient comes to the doctor with chest pain (CP). The physician recommends a stress test. The patient wants to verify that this recommendation is ideal. In just a few short minutes, the patient can use the fill-in-the blank template technique to produce a spectrum of medical options. Of course, the inquiry , “Doctor, what would you do if I were your mother?”, should come last so that the patient can readily see by comparison that this is the ‘mother'-of-all-medical recommendations. Any option, possession, idea or medical advice gains currency when it is surrounded by inferior alternatives.

The Template Question in Operation

The patient with chest pain poses 10 questions to the physician using the template that appears below. Each question substitutes a different person in the blank space. As you will see, the physician’s advice is different in each case.

“What would you do if I were your _______?”

    Person                             Physician’s Medical Advice

Congressman.....................Sorry, fillibuster is in progress.
Quack................................Take a high colonic STAT!
Telemarketer.....................I’ll call you back at dinnertime.
Customer Service Agent....Your call is important to us...                  
Teenager...........................The CP is the teacher's fault.                   
Personal Trainer................No pain, no gain. Drop and give me 10!
Accountant .......................The pain will depreciate over time.
Lawyer...............................I refuse to answer.
Psychiatrist........................Are you envious of your CP?
Mom..................................Answer appears at this post's end.

Serious Point

I have never responded to the ‘mom’ inquiry directly, but I try to provide the patient with the reassurance that is being sought. Patients ask the mom question to give us doctors a few moments to reflect on our medical advice. This is their version of, “Is this your final answer?” But, of course, the medical advice never changes, and it shouldn’t. Consider this vignette.

Physician: “I think you should have an ultrasound of your gallbladder because your symptoms sound suspicious for gallstones.”

Patient: “What would you do if I were your mother?”

Physician: “Oh, in that case, I think you should have a colonoscopy.”

I am amused when a referring physician notifies me in advance that a patient being sent to me is a rich executive or some other version of a VIP patient. Am I supposed to ramp up my medical quality as if I have multiple standards depending upon the prominence of the patient? Should I make sure the colonoscope is extra clean for all corporate CEOs or high government officials? Do I have 2 different sets of textbooks (remember textbooks?), one for ordinary patients and better ones for special customers?  There have been many commentaries and medical journal articles that point out that VIP patients don't reliably receive 'VIP' medical care - particularly when the patient is a physician.  In these cases, standard medical practices and procedures are often bypassed and corners are cut.  Medicine works best when there is a single high standard of care for every patient. 

I am not my mom’s doctor. I couldn’t possibly answer how I would treat her medically, in response to a patient’s inquiry, because I am her son. I don’t have the necessary objectivity to advise her, and I wouldn’t want the role in any case. There’s a reason that physicians shouldn’t treat their own family, or even close friends, in my view. It’s just too messy and it can contaminate the personal relationships.

The Answer

So, when a patient asks me what I would do if the patient were my mother, I always offer the same response. I’d tell my mom to speak with her own doctor.

My Mom