I think it’s been said before, but what you are all missing is the value of fighting for the last bit.
First of all, we as mere mortals never know when that last moment will come. I have fought for older people in the ED any number of times, and sent them to the floor totally expecting they will die in the next 24-36 hours - only to see them walk out of the hospital under their own power maybe 5 days later. I could have decided to let them “die with ‘dignity’” - but then they would have actually died. Today too many lazy physicians just won’t fight for a patient.
Second, many of these “useless exercises in keeping people alive” can have totally unintended consequences - like discovering a new treatment that can give meaningful extensions on life to the patient.
Third, hospice or palliative care is neither prolonging nor shortening a person’s life. It is, rather, giving care to the afflicted in their hour of need. Perhaps they’ll die, perhaps not. But those are, neither of them, the goals of palliative care.
Lastly, I’m not God or even anything even remotely like. him (except perhaps in His image.). My job here on earth as a physician is to do my best to keep everyone alive - and then God decides whether my efforts were worthy or fit His plan. Not me. When I was a soldier, my job was to end the lives of any who threatened me (and I was good at it). But that changed when I started working as a doc. And for the record, both those jobs were hard on the soul.
I subscribe to much of what you say and in the ED setting, often with limited information, it may be reasonable to err on the side of acting to prolong life. However, there is always a second component required for physicians to act, and that is patient consent.
My living will, for example, is written so as to limit physicians’ possible choices as to treatment only if I am at the end of a clearly fatal illness and am no longer able to speak for myself; it also applies to a permanent vegetative state (that one circumstance may require some time to pass to reasonably conclude the state is permanent. In neither of those circumstances would I be likely to be brought to your ED. So you are on solid ground, both ethically and practically, in your circumstance.
You and I sit in a different place than the non-medical people. We have seen both ends of the process. It has been a long haul.
When I started as a physician, back in the “Stone Age of Medicine” (the 70’s), we didn’t have many of today’s taken-for-granted aids. Your main tools were a good physical and history, and Harrisons. You thought about your problems, considered oddballs, looked for little things that fell out of place. Today medicine is algorithms - great for PA’s masquerading as physicians, but not how real medicine is practiced. My favorite old saying was, “You only found what you looked for; you only looked for what you know.”
There are many similar cases, but the one that pops most clearly into my head is breast cancer. When I started, that was a death sentence - 6 mos to a year at most! Today breast cancer patients survive many, many more meaningful years. If they had your approach to end-of-life, many of these life-saving treatments wouldn’t exist.
I know these are hard questions to answer. On occasion they are pretty obvious, but frequently not. And if you don’t fight, then ?how do you know you did your best for this person. And I’m not speaking of the 100 y/o emaciated cancer-ridden person who comes in septic, hypotensive, and with completely screwed up electrolytes, and whose existence in the nursing home was “vegitative” at best. Those compassion says you don’t "code, nor really do much but make them comfortable. You’re a rat fink if you work on them just to prove you know bodily chemistry well. I have done that only ONCE - old man arrested in the ICU late Christmas night (like 11P). I worked on him while all the nurses looked at me like I was crazy. But I had a purpose - I waited until 0005, then called it - and the family had the slight comfort of knowing Grandpa had not died on Christmas. It was officially 12/26.
But outside of those obvious issues, ?when do you quit. ?When do you throw in the towel. My experience says that most physicians knew when to stop; today I’m not so sure anymore. Too many I run across seem to give up on the patient way too early, pretty much guarranteeing a “poor outcome”. ?But would it have been so if they’d been aggressive. I can’t remember when I was so angry as when I resuscitated a 33 y/o who had bled from a leg wound, almost bleeding dry. He came in cardiac arrest. I transfused him 23 units of blood in the ED - AND got a pulse and pressure back. Only to have the floor doc let them die - because “they wouldn’t have made it anyway.” ?Seriously! ?Who made her God. ?Who gave her the right to just not do anything because… well, it is too emotionally irritating to me to go on. But you get the idea.
Was a time we trusted physicians to "do the right thing’. I believe by and large they did. They had the patient’s best interests at heart. Today they have often ceased to be physicians and become “providers” - or just another cog in the “business” of medicine. i, for one, miss the old days, when you were “the patient’s advocate”.
I so agree dear @Devereaux , coming from a line of doctors and having married one.
It’s 3, maybe 4 years ago now that some doctor in NY tried to gentle my BMD into just letting my brother-in-law “go”.
Wellsir: he’s still alive.
And life is all any of us have.
Life! L’chaim!
Thank you for your writing, which I see as a tribute to doctors of my father’s generation and of my husband’s and brother’s generation.
@Hypatia quote=“Hypatia, post:25, topic:5860”]
It’s 3, maybe 4 years ago now that some doctor in NY tried to gentle my BMD into just letting my brother-in-law “go”.
Wellsir: he’s still alive.
[/quote]
Precisely @Hypatia! This and a myriad of similar examples show that we know a little about the body and how it works but we’re nowhere near good enough to know who will live and who will die.
Thank you for your comments and your example. We need more people to see life as something we should try to preserve, rather than listen to Nietzsche and try to be god (with a little “g”).
I really appreciate what you have done professionally, Devereaux. The emotional toll from dealing with seriously sick & injured human beings must be intense.
Without meaning any disrespect to that experience, can we look through the other end of the telescope for a moment? Medicine involves resources as well as the medical professional’s skill, dedication, and hard work. Resources are always limited, and those resources have to come from somewhere.
Let me share the ongoing experience of an extended family I know in a “Second World” country, where there is good medical attention for anyone who can put cash on the operating table.
One of the elderly ladies in the extended family had a stroke recently. Family took her to hospital, where she went into the Intensive Care Unit and (to the family’s relief) survived. Now there is the matter of paying the bill. Six of the relatives in the extended family have taken on the burden – and it is a burden. One set of relatives drew down almost their entire savings … which will have future impacts. Another set went into debt … which they will be paying off for several years. The saddest case is the family whose pride & joy was their daughter at college – she will have to leave college and get a job, since the family can no longer afford the costs of her continuing education.
Obviously, what people choose to do with their own resources is their own business. The issue we cannot avoid is that decisions on medical matters do have material consequences. In the Second World setting, those consequences are borne upfront & personally by the decision-makers; in the West, those costs are mostly socialized and not felt directly by those involved … but those costs still exist.
If we take Kulak’s figure of $3 Trillion for US social security/medical expenditures, that corresponds very roughly to about $20,000 per year from each taxpayer. That resource expenditure is indirect, but real. I don’t think it is unreasonable to recognize that the good things done through medicine have very serious costs which are certainly impacting many other desirable goals for everyone.
And if I can throw in a personal peeve, we know that a significant chunk of medical costs in the West today derive from lifestyle choices: too many of us eat too much, especially too much of the wrong things; we don’t exercise enough; have far too many sexual partners; and abuse various substances. Is it fair to spread the costs of the medical consequences of those kinds of behavior to the rest of society?
There are several underlying ethical principles here, which ought to be stated and discussed widely. They generally are not discussed. These apply to end of life decisions, medical decisions and many other policy decisions with significant social impact.
The systematic medical momentum which reflexively says “Whatever can be done, must be done”. This has become society-wide.
Individual autonomy, based in actual informed consent. See, e.g. “Doctors Die Differently”
Resource allocation resulting in economic dislocations from the cumulative effect of a relatively small number of extremely resource-intense decisions. Under our system of paying for such decisions, all too often, those who decide have no skin in the game when it comes to cost - as has been pointed out.
Each of these is an important consideration. Taken together, they require difficult balancing. Reasonable people of good will and defensible moral/ethical principles will differ as to where lines ought to be drawn in individual cases. “Do everything for grandma” spoken in uninformed emotion by a guilty offspring simply cannot be controlling in every case, unless we are willing to further stress an already-failing health services financing system. We are clearly at the point of negative returns (not merely diminishing returns) for marginal health services dollars spent.
Such deeply uninformed decisions, in a system which automatically rewards doing more rather than less (and rarely asks, should we do this?) - must become more rational and balanced; this depends upon large discussions of the underlying principles. Most fatal diseases do reach points beyond which “lifesaving” therapies are futile. In their experience, doctors understand this and that is why they die differently.
You are posing “the other end of the process” But as CW says, there are many, many other things that go left unsaid or perhaps even unknown, because we are today such a huge bureaucracy pretty much no one knows what all happens (willfully or not).
Most of my contemporary ED physicians quit worrying about things like cost long ago. You skimp and save here and there, cutting corners on what you order, and then one law suit comes along and wipes out all you’ve saved, and then some. ?So why bother saving, especially since the law suit is usually about something you did to lessen the economic impact. I for one found it far more satisfying just having one. standard by. which I treated every patient, and not take ability to pay into consideration. On occasion some patient would ask me to remove, say, a CT as it was too expensive for him. I would then explain this wasn’t jail, he could do whatever he wished but just these were the consequences that could happen, and if he still wanted it removed, I would do so. That way I felt he had at least had informed reasons for doing or not doing something.
Couple things to be said about all that (and I include CW’s last, very appropriate post). People are not things. They are not widgets you count how many you “made” and so what your costs are and what your profit is. People are people. They should all be treated with respect and dignity, and not just viewed as a “profit center”, which I am becoming terribly sure is today’s “physician’s” view. Too much of your kind of analysis, Gavin, and too little care about the Hippocrates Oath we once took.
Second, we frequently look at and are aghast at “the costs” of medicine. But our analysis is generally like yours - how we can “contain or constrain” these costs, not why are they so high. So let me expound upon that for a while.
When I began practicing, I was an internist, the field of “Emergency Medicine” not yet existing. But right off the bat I worked in ED’s as a way of making enough money to live on, as a new practice doesn’t make any money. One of our first impressions was that residency did nothing to prepare us for setting up fee schedules, etc. (That’s different now), So we charged what we thought were reasonable prices. Then we discovered that Medicare (still a relatively new thing) published new charging guidelines yearly. So you can look up how much, eg., a CT head reading should charge for, according to Medicare. What we also discovered was that if we didn’t raise our fees yearly, in accordance with Medicare published rates, the following year we were not ALLOWED to raise our rates. Needless to say, every year thereafter we raised our fee schedule.
After a few years of moonlighting in ED’s to make enough money, I quit the practice and moved to full time ED. Got grandfathered for hours worked, took the boards, and became a boarded ED doc. I worked in a number of ED’s, often in dual slots of working physician and an administrator (such as ED Medical Director, Vice Chairman, and later Area and Regional Medical Director - roles where I became quite familiar with the business side of the ED. ?Did you know that a “good ED contract” was any contract that paid out anything at or above 50% of your charges. About the best I worked was paying about 70% of charges. I have also supervised ED’s where the pay was 11% of charges (in NYC). Clearly there was supplemental money provided by the hospital.
You are shocked at the “cost” of medicine, but ?did you ever consider why it’s so expensive. ?Why does a hospital charge so much for its services. Well, one, because it can (Medicare - which has become the de jure fee standard for ALL insurance, it being less than often charged), and two, because all its equipment is so expensive. Again, government. ?Ever notice that a stupid two way radio that costs civilians about $120 suddenly becomes a piece of “avionics” when installed in an aircraft - at about $1500-2000 apiece. CT scanners shouldn’t be nearly as costly as they are, yet here we are. And every newer or bigger hospital has to have the newest, latest-and-greatest version. Thank you government regulation.
Doctors in Mexico cost less than doctors here. You can buy Keflex, Azithromycin, penicillin, amoxicillin, etc. over-the-counter at any drug store - no script needed. Here all those items are regulated. The purpose of ALL regulation is to limit the number of regulated items in the community. Recreational drug - regulated to limit their availability. Ivermectin - recently regulated so it wasn’t available and spoilt the lie that there was no treatment for WuFlu.
So while you gentlemen have valid points about costs, perhaps we should begin by “rationing” the amount of regulation we allow instead of the rather drastic, and soul crushing process of rationing out the care.
You are singing my song about deregulation, Sir. And not just in medicine!
Your point about rationing is very well taken. The reality of “free” systems like England’s National Health System is that they control costs by putting patients on long (many months) waiting lists for life-saving operations – in the unspoken expectation that many of the patients will die before any more money has to be spent on them.
As the economists say, wants are infinite and supplies are finite. To balance that, we usually get rationing by price, and sometimes rationing by government. It seems you are suggesting, Dr. D., that there might be a third way to ration health care – and that would be to trust medical professionals to provide the appropriate treatment, ideally without rapacious Big Law treating medicine as a major profit opportunity. Within living memory, that was the core of the medical system … and average lifespans were longer (!)
Repeal most of the regulations, fire most of the regulators, hang most of the lawyers … and we are on the same page!
Indeed, layer upon layer of increasingly unrealistic regulation is a big part of the problem. An equally large part is the threat of lawsuit for NOT doing every imaginable thing. This is an absurd and unsustainable manner of making decisions about anything - especially health matters. This, in turn is a result of an out-of-control and out-of-touch with reality legal system combined with a complete unwillingness of citizens and their supposed representatives to make sensible decisions about how much health services are required and how to implement these decisions. In other words failure: of medical profession, legal profession and governance. Final collapse pending.
“Defensive medicine” costs money. And not money to keep a person alive, but money for testing that you do because you might be sued later for not doing it. Usually that’s some kind of scan, and scans are unrealistically expensive.
Canada and Great Britain ration medical costs by delaying the use of “costly” things until you die, after which it’s no longer an issue. We OTOH ration care by “double secret syspension” - to wit, Medicare changes the criteria by which it decides to pay. BUT physicians are not allowed to change practice because of changes in Medicare requirements. So You order a test, it comes back denied, you are not allowed to charge the patient and you won’t get paid for the test. After a while you figure out the new “requirements” and Medicare is back to where iit was, but they saved a ton of money for the 3-4 months it took to figure out what they wanted and how best to fulfill the requirement.
Law suits make up a real if not talked about much part of medicine. Unfortunately things are easier now with algorhythm-driven treatments. Usually the things you should be sued for you aren’t because the courts have accepted the business-related algorhythm-driven treatment plans as acceptable when all they’re doing is gambling with patients’ lives for the sake of profit. The things you get sued for are stupid things - NOT ordering some image usually, when it really doesn’t help. So, eg., glass in the hand has to have an x-ray. If you don’t do one, and some glass is found in the hand later, you will be sued - and probably lose. But x-ray does an incredibly poor job of locating glass in the hand. ?So why are you x-raying the hand when you already know you won’t see anything. Well, because you’re “suppose to”.
You can’t admit a patient with the diagnosis of pneumonia unless you have an image of a lung infiltrate. BUT chest x-rays notoriously DON’T SHOW an infiltrate until about 4-5 days later. And radiologists won’t do a CT of chest for infiltrate unless there is a negative CXR, if even then. The answer is you order a Chest CT for PE. You get a lot of gobbledegook about no occlusion seen in any of the vessels, AND incidental finding of an infiltrate in the RLL. No one calls you on ordering the CT for PE because that’s way too hard to diagnose without the CT and it is a possible cause of pneumonia-like symptoms. BUT you have your infiltrate and admit the patient with what he really has.
Public Aid is often a joke. When we first started in practice, my partner and I agreed not to bill Public Aid (Medicaid) as it was way too much effort and you didn’t get paid much. Then our office manager came to us and said we had 5 patients in the ICU on Medicaid and we ought to at least try to get paid something. So I said OK. She took about a week to work up charges of something just over $2500. Medicaid rejected them as they were not in the “correct format”. She spent another week reformatting all the charges. Three weeks later we get a huge envelope with a multi-page explanation of. benefits and a check for …. $25! So I framed the check along with the front page of EOB and told Mary that THIS was why we didn’t bill Medicaid. We were out the time we spent caring for the patient; now we were out the time PLUS what we spent on her salary for 2 weeks worth of work.
Physicians should be qualified, ?right. So, there are national tests to ascertain you have enough knowledge to treat people. AND a state will issue you a license based upon a certified copy of your diploma, another of your residency. You go to another state. THEY now issue you a license based upon the same criteria, plus a work history (so, your CV). You go to Iowa, Texas, Florida, or California, and your license depends upon an acceptable CV - listing every moment of your life since finishing residency! They want were you worked, when. you started and stopped by month-day-and year. AND what you did for any times you weren’t actively working somewhere! If you were a locums for 20-some years after an initial 24 years in 6 hospitals, it gets to be quite a hassle. And it really doesn’t addd anything to your data other than the irritation factor. ONE reason it’s so hard to get an appointment with a doctor here in Dallas.
Physicians have always had wide latitude in practicing medicine. One reason it’s an art, not a science. Then the military found it couldn’t recruit doctors (because their pay scales were miserable by any. civilian standards) so. they renamed physicians “providers”. THEN they classified anyone who provided independent medical care a “provider”. So now docs, NP’s, and even PA’s, were ALL “providers” in the military. That caught on in business medicine - and just like that doctors lost their independence and became “employees” - another cog in the business cycle. So now when doctors tried to prescribe Ivermectin for WuFlu, the state boards took their licenses in a number of cases - because the FDA had now pronounced Ivermectin to be an “animal drug”, to protect the Pharma companies making the COVID vaccine. Ivermectin had previously been on the WHO list of “essential drugs” a developing nation should have for many, many years.
“Regulation” can be insidious. You don’t always know or see its effect but it’s always there, and rarely does it do anything to help you.
The Doctor loses; everyone who directly or indirectly pays into the doctor’s insurance company loses; the patient gets a pittance; and the Lawyer makes out like a bandit. That is appropriate, because most of them are bandits.
Simple solution to malpractice would be that a doctor who commits serious malpractice should lose his or her licence – that is it! No financial compensation to the patient. Because the patient has a duty to select a competent doctor in the first place, if the treatment is non-emergency. And if the patient is wheeled unconscious into an Emergency Room, she should be grateful that anyone at all is treating her instead of just leaving her to die.
If we made suing doctors illegal, the only losers would be overpaid lawyers, who would have to find real productive jobs.
Since we are talking about doctors and lawyers, may I share this little gem:
Surgeon Talk
Five surgeons were talking about the best patients…
First surgeon says, “Accountants are best to operate on because when you open them up everything on the inside is numbered.”
Second surgeon says, “Nah… Librarians are the best. Everything inside them is in alphabetical order.”
Third surgeon replies, “Try electricians man! Everything inside them is color coded!”
Fourth surgeon intercedes, “I prefer lawyers. They’re heartless, spineless, gutless, and their heads and butts are interchangeable.”
To which the fifth surgeon, who has been quietly listening to the conversation, says, “I like engineers. They always understand when you have a few parts left over at the end.”
A family practice doc, an internist, a surgeon, and a pathologist go duck hunting.
First. bird rises. Family doc say, “Looks like a duck, flies like a duck,” and BOOM - he shoots the bird down.
Second bird rises, internist says, “Looks like a duck, flies like a duck, too small to be a condor, not coloured correctly to be a cardinal, too small to be a goose….” - and the bird flies away.
Third bird rises, surgeon mounts his shotgun and shoots the bird. Then he turns to the pathologist and says, “Go see if it’s a duck.”
isn’t enough for that comment, Dev: 