House calls and Hippocrates

Last week I was in the “piney woods” of northern Louisiana.  I had thought I would write a blog entry from there, but time and internet access were scarce, so I’m doing it this week. My wife and I were visiting her parents, Aaron and Betty.  I have always enjoyed being with them and this trip was no exception.  It was also a time to check on how they were doing.  They are both in their 80s and have some significant health problems.

On Tuesday Betty’s visiting nurse came to see her, and it made me think of the part of the Hippocratic Oath that says “Into whatever houses I enter, I will go into them for the benefit of the sick.”  Physicians don’t take care of their patients in their homes very much any more.  There are good reasons why things have changed, but there are things that have been lost.

The nurse who comes out to see Betty is becoming part of the family.  They offer her tea and cake and Aaron teases her like he does his daughter.

In the sterile environment of the hospital or office a patient can become a diabetic or an arthritic or a stroke victim.  In her home she is the person she really is and it is harder to miss that.  Those of us who care for the sick need to remember that what we are doing should be for the benefit of those we care for.  Those who receive our care are real people with homes and families who are welcoming the physicians and nurses and others who care for them into their lives just like they would welcome us into their homes.

We need to enter into their lives as respectfully as we would enter their homes and realize we are being accepted as a part of their family.

Safe Passage

I came across this description of the duties of a physician, from an 1858 lecture to medical students:  diagnosis, treatment, the relief of symptoms, and the provision of safe passage.

The provision of safe passage struck me as a concept we would do well to rehabilitate.  It is an evocative phrase:  protecting and helping someone on a long voyage.  That is generally not how we are taught to think about death in medical school.  Death is failure!  It is a cliff, a precipice to be avoided, rather than a voyage that everyone ultimately has to make.  We have a tendency to approach the precipice in one of three ways:  most often, we try to keep the dying patient from falling over the edge, wrapping them up and pulling them back  from the brink with ventilator hoses and feeding tubes and intravenous drips and every heroically inappropriate medical intervention and test we can conceive of;  or we realize that there’s nothing we can do, so we abandon them;  or, increasingly, in the name of “compassion,” we push them over the edge with physician-assisted suicide.  What a difference it could make if, instead of treating death as a precipice from which we attempt to keep a patient indefinitely, we understood death as a voyage each person will have to make.  What a difference if, instead of being trained to stave off the inevitable at any cost, doctors were trained to recognize — and to help patients recognize — when the voyage is approaching, how to help patients to prepare for it, and how to help them to make it a “safe passage,” a good death for them and their families.

 

I Pledge Myself

I asked several young doctors who have completed medical school in the last 5-10 years which oath they took upon graduation.  No one could remember, and some weren’t sure whether they took an oath at all.  Really, an oath of any kind is out of place in a culture that doesn’t value making a statement that binds oneself.  There is very little agreement on what theory of medical practice to which one might adhere.  One of my professors mentioned in her Hippocratic Oath lecture that the prohibition against giving “a woman a pessary to cause an abortion” was not really a prohibition against performing abortions.   In the days following World War II, the Physician’s Oath of the World Medical Association pledged “even under threat, I will not use my medical knowledge contrary to the laws of humanity.”  Today, the American Medical Association, a WMA member, recognizes there is disagreement on the usefulness of the Hippocratic Oath, states that it’s Principles of Ethics define behavior but are not laws, and notes that regulatory agencies—which do not administer oaths—have the real means to respond to physician behavior.

Albert Jonsen, et. al’s Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine states that “physicians must avoid exploitation of patients for their own profit or reputation.”  It’s hard to understand how such a platitude is to play out in the real world if physicians do not pledge themselves to it.  I heard a doctor once refer to the lucrative nature of a pulmonology specialty as “the gravy train.”  Many frame their practice in terms of which procedures bring in income.  This seems odd; because according to this model, the absence of illness is a business failure.  As Maimonides would say, “the enemies of truth and philanthropy could easily deceive me and make me forgetful of my lofty aim of doing good to Thy children.”

 

 

Stop those prying doctors!

 

Florida residents have their saviors in the Florida legislature to thank for shielding them from the insidious “prying into personal lives” that doctors have shamelessly been inflicting upon patients.

Apparently, doctors have been asking their patients questions about whether they own guns, and – prepare yourself for a shock – if the patient answers in the affirmative, some doctors have actually been counseling patients on how to store the guns safely and protect any other people in the home, particularly children, from accidental harm.

Fortunately, some attentive citizens were alerted to this disgusting practice and enlisted the NRA in helping them to get the Florida legislature to pass, and the Florida governor to sign on June 2nd, HB 155, which prohibits physicians from making written or oral inquiries regarding firearms ownership or recording such information in a patient’s chart (unless the doc believes “that this information is relevant to the patient’s medical care or safety, or the safety of others”).

It is a great relief to see that the physician-patient relationship — too long the purview of a suspiciously-dressed clique of highly-trained, dedicated professionals and their trusting patients, too long full of “prying into personal lives” as exemplified by questions like, “How do you feel?” “Does that hurt?”  “What do you use for contraception?” and “Did anybody in your family ever have cancer?” — is at last being exposed and regulated by those people we all trust way more than we do our doctors, the elected representatives in our legislatures.  My only regret is that some of the original provisions of the bill, such as the stipulation that a violation would amount to a third-degree felony punishable by up to five years in prison and a fine as high as $5 million, did not make it into the final legislation.

Encouraged by the NRA’s success, other bodies are stepping up to protect the unsuspecting public from some of the horrifying practices that routinely take place behind the closed doors of the consulting room.  The Tobacco Growers Coalition is promoting legislation to ban doctors from making inquiries about smoking, the GFFFA (Greasy Fried Fast Food Alliance) is working to make it illegal for doctors to counsel their patients about healthy diets, the NARL is drafting laws to ensure that doctors don’t counsel pregnant patients against abortion, and the Colombian drug cartels are looking for ways to prevent doctors from advising patients against using their special brand of products.

Sound too ridiculous to be true?  OK, I made that last paragraph up.  But read this.

Lest anyone misunderstand, this post is not about gun ownership, nor do I have anything against the NRA.  This post is about unwarranted encroachment upon the sanctity of the central economy of the medical profession, the physician-patient relationship;  and about what sort of Rubicon has been crossed when the paranoid intrusion and constraint represented by this bill is placed upon the good will and judgment of a doctor — and enshrined in the law of the land.

Going where no man should go

In a recent article titled “Extreme Science” (August, 2011), Wired magazine broaches a topic that few mainstream publications would be willing to touch.  What could be accomplished if scientists were prepared to set aside the “moral compass” that guides them (assuming there is one)?  Imagine the advances waiting to be made.  As Wired observes, in the real world (as opposed to the sci-fi world), “Most scientists will assure you that ethical rules never hinder good research – that there’s always a virtuous path to testing any important hypothesis.  But ask them in private… and they’ll confess that the dark side does have its appeal.”  http://www.wired.com/magazine/2011/07/ff_swr/

For example, scientists could separate sets of twins at birth in order to control and monitor their individual environments right from the start.  The gain from such an experiment is a possible solution to the nature vs. nurture dilemma.  Think about a twin study in which both individuals are eventually identified as gay, regardless of their distinct upbringing.  This could offer proof that homosexuality is all nature and not nurture.  In another example, Wired considers the possibility of “womb swapping,” i.e., switching “the embryos of obese women with those of thin women.”  Again, the experiment would determine whether environment or genetic factors determine an individual’s weight.  Then there is an experiment right out of a science fiction movie, one that cross-breeds a human with a chimpanzee.  Wired reports that the technique would be “frighteningly easy” and it would teach us much about human development.

But what actually prevents unethical research from happening?  It could be argued that these experiments are blatant violations of individual autonomy.  But the fact of the matter is that human autonomy is already disregarded with other procedures (e.g., human embryonic stem cell research, abortion, etc.).  In other words, what is the essential moral difference between destroying an early embryo in lieu of subjecting it to controlled research?  One may even maintain that the twins, separated at birth, are at least alive as opposed to embryos that are destroyed.

Then again, one could argue that the main difference is that twins will eventually come to understand their situation and realize that their autonomy has been violated.  On the other hand, destroyed embryos will never know their fate.  Fair enough.  But if morality is governed by utilitarian concerns, as it already is, it would seem that the value gained by subjecting embryos to questionable research outweighs their future concern for autonomy.  And if “awareness of one’s autonomy” is the key moral criterion, then research could be extended to any human lacking awareness (e.g., newborns, coma patients, etc.).

In short, humans have the rational capacity to consider all options to achieve an objective.  Humans have also demonstrated a natural tendency to push the moral envelope, to give priority to what can be done over what should be done.  Time will tell whether experiments which are now considered unethical will one day be the norm.

Black Americans and Healthcare

The USA Today recently reported on the difficulties faced by African-Americans seeking healthcare in Alabama.  Death rates are higher for most categories of illness in black communities.  Oftentimes, physicians are unfamiliar with the obstacles encountered by residents in a particular neighborhood, such as the lack of fresh, healthy food in the grocery stores.  USA Today touts a new federal Health and Human Services program as a first step in identifying health disparities.  Churches provide support groups that assist in educating people about their health.  However, there is little time or money being spent by the Christian community to build clinics in communities such as this one in Alabama.  An overall infrastructure for providing charitable ministries is missing.

In Texas, it is common for people to say that if a person wants to have good healthcare they need to pull themselves up by their bootstraps.  An African-American friend of mine at Trinity once told me in response, “The problem is, some people don’t have any straps.”

Is a CT Scan an Ethical Issue?

All third-year students at Texas A&M are required to attend Saturday-morning radiology lectures, and I was surprised to hear my professor speak for the final 30 minutes yesterday on when not to order imaging.   Radiology is his life’s calling, but he recognizes that imaging studies like the CT scan can be harmful.  Of the $2.3 trillion spent on healthcare in the U.S., the largest share is spent on imaging, totaling $800 million.  CT scans have become a part of the American vernacular, but it is estimated that 1/3 of them are unnecessary.  What ethical issues concern the use of imaging in healthcare?

  • Patient Safety: Concerning chest scans, an X-Ray exposes the patient to 0.1-0.2 mSv of radiation, but the CT dose is 8.0 mSv.  At 50 mSv a person is at increased risk of cancer, so minimizing the number of exposures to a CT scan should be an important goal in healthcare.
  • Cost: Some of the ballooning in healthcare costs over the last decade is due to tests ordered by physicians.  Many doctors order tests not because they are indicated by the patient’s symptoms but because they serve as an extra layer of protection in the case of a lawsuit.  The irony of such defensive medicine is that one day a doctor may find himself in court for exposing the patient to too much radiation.  Patients never see the thousands of dollars of imaging charges, so they often authorize such studies and let the insurance companies handle the rest.
  • Physicians Lining Their Pockets: Research has shown that physicians increase the number of scans ordered when they are able to bill for the use of their own equipment.  One gastroenterologist related to me how his clinic moves a number of unnecessary endoscopies through his office for various reasons.  An endoscopy does entail some risk and is certainly not comfortable, but every CT scan is sure to expose the patient to radiation.  Physicians should refrain from allowing revenue strategies to trump good medical practice.

For more information on radiology, visit www.radiologyinfo.org.

Cover-ups

Recently I have been reading the account of David’s life in first and second Samuel. Although he had a close relationship with God, David had his ethical failings. Much of his problems started with his adultery with Bathsheba which he tried to cover up when she became pregnant. His first cover-up attempt failed when he called her husband Uriah back from battle, but he refused to spend the night with his wife while his companions were at war. Next he tried to cover it up by having Uriah killed and taking Bathsheba as his wife. The consequences in David’s life and in his family were devastating.

Cover-ups have been a part of the fallen human response to errors and wrongdoing from the garden of Eden to Watergate.

One of the common ethical issues in medicine is how to deal with medical errors. For most of us our first response is to cover it up. Explaining to a patient that an error was made that has had or could have a bad effect is not an easy thing to do, but reading about David reminds us how bad a cover-up can be.

First Day in the ICU

As I write this I am sitting in an ICU family waiting room.  I have often sat in rooms like this, comforting families and explaining to them what is happening to their loved one or discussing treatment options. Today, it is my family I am sitting with, and my family member in neurosurgery.  The ten of us are sitting in a circle.  The comfort of being together is inexpressible.  We sit and talk alternately of trivialities and of life and death.  One knits, another is on the laptop posting updates to Facebook, I am writing a blog entry.  The surgeon figured it would take three hours.  That was over four hours ago.

This was in none of our plans for the weekend.

***

The surgeon finally came out.  It was worse than he anticipated.  He was trying to be positive, but let slip words like “heroic measures” and “if she makes it.”

It is all very surreal.  Someone says, “I feel like I’m watching a movie.”  The whole gamut of emotions pours out, opposites juxtaposed incongruously:  shocked looks, tears, laughter at a suddenly resurrected old joke.  We pray.

***

The surgeon just came back out, a few minutes later.  A terse, hurried report this time:  the post-op CT scan shows swelling, and they need to do emergency surgery now to relieve it.  Silence, everybody together but alone with their own thoughts.  Someone passes out snacks.

***

I hate being a doctor and knowing what’s going on.  Or maybe I just hate what’s going on.  Is it more terrifying to hear cryptic references to “dilated pupils” and “midline shift” and have no idea what they mean, or to know exactly what they mean, and their implications, and get a queasy feeling of impending doom?

***

Some of us eat snacks.  Some read waiting room magazines.  Every once in a while an attempt at small talk, an attempt at normalcy.  Mostly quiet.  I’m glad we’re all together.

***

It’s been another hour, and no word.  That can’t be a good sign.

***

Hurry up and wait.  Another half hour has passed.  We’re a little more lively group now, laughing and kidding each other.  It’s hard to maintain that serious aspect through the long, anxious watch.

***

 

At last — the surgeon has come back.  He is guardedly optimistic.  He looks weary.  I walk out with him for a doctor-to-doctor talk out of everybody else’s earshot.  He is more frank about how he feels;  in some way, we can understand each other.  When I return to the group, the atmosphere is much more relaxed.  Not that the news is that great, but at least the uncertain waiting is over.  One round of waiting, that is;  everything depends now on how she will wake up, and how she does over the next couple of weeks.

***

 

The next moment of truth;  the nurse has just come out, and told us that in about ten minutes the family can come in to see her, two at a time.  Deep breaths:  we’re about to dive in, and God only knows what the water will feel like.

***

Psalm 121.   I lift up my eyes to the hills — where does my help come from?   My help comes from the LORD, the Maker of heaven and earth.   He will not let your foot slip — he who watches over you will not slumber;   indeed, he who watches over Israel will neither slumber nor sleep.   The LORD watches over you — the LORD is your shade at your right hand;   the sun will not harm you by day, nor the moon by night.   The LORD will keep you from all harm — he will watch over your life;   the LORD will watch over your coming and going both now and forevermore. (NIV)

***

Just back from visiting her room.  The ICU smell!  Intubated, sedated, tubes everywhere, the Darth-Vader hiss of the ventilator, monitors, drips, her head wrapped with a little blood seeping through the right side of the bandage . . . I talk to her as if she can hear, I kiss her on the side where she still has cranium.  I come back to the waiting room and I am trembling.

***

Exhaustion.  I was tired before this started;  I am almost numb and staring now.  If this were a novel, I would have to fight turning to the last page to find out how it ends.  It is a little like a novel, or a movie.  Sometimes I want life to have a plot.  Well, it does today:  suspense, unexpected turns, hope and despair and snatches from the jaws of death, heroic actions, a beautiful damsel in mortal peril.  God knew what he was doing when he made life full of more routine than plot.  I don’t think we could take too much of plot.

***

***

It is too easy as a busy physician to forget in the rush that all patients have stories, have families.  It is all too easy to objectify people, to think of them as their disease, to fall into thinking of “the asthmatic in room 39” instead of “Mr. Brown, who is a forester with a wife and three children and who has just been laid off and is here because his asthma is worse.”  Or to say, “The drunk is back” instead of “Mrs. Smith, who desperately wants to stop drinking but her daughter came over with a bottle and she couldn’t resist so she is back here looking for help and does she ever feel awful.”  It is a good reminder, this being on the other side of medical care.  I have cried (and laughed) a little bit more readily with my patients this last week.  I don’t think that’s a bad thing.

The Business of Drugs

I went to my first drug rep dinner the other night at Smith & Wollensky in Houston’s Highland Village.  The high-end steaks and 20+ bottles of wine left nothing to be desired by the nurses and physicians in attendance.   Research shows that being wowed with a nice meal influences later decision-making.  Yes, I could see how the memory of one of those juicy steaks could prompt a doctor to select a particular medication.

Special thanks to Joe Gibes for bringing to light how pharma business practices stymie important medical treatments.  I worked in business for over 7 years, and I saw two types of businesspeople.  One type focused on presenting the merits of the product and gave the buyer room to evaluate it and make a decision on a purchase.  This person would refrain from the pressure sales pitch and would frankly state what the product could and could not do.  Sometimes this went so far as recommending a competitor who sold a product that fit the customer’s needs better.  The other type of salesman I encountered had a different approach.   Marketing techniques were more about allurement rather than presenting one’s ware.  These folks were jovial types always given to conversation, but all the backslapping often left the customer with an uneasy feeling.

Business reform in general is needed in our country, but more is at stake when unethical business practices impact the field of medicine.  Since a person’s well-being is in the balance, extra care and protections must be employed.  I often hear medical students comment, “I can’t really do anything about the drug business.  It’s just the way things are.  I might as well enjoy the free meal.”  But don’t we owe it to our patients to remove any taint from medical care when their very lives are concerned?  Our Savior was a humble man, and there is no doubt his humility opened the door for His effective healing ministry.  Such a disposition sets an entirely different tone for healthcare, which our medical system desperately needs.