Lost Horizons

Having recently given two presentations on the nature of the physician-patient relationship, it seems only natural to follow in the footsteps of Jon Holmlund as he has been posting on the concept of professionalism.

As an instrument-rated pilot, I recently recognized an analogy between a training maneuver called “unusual attitudes” and the state of medicine today. Under normal flying circumstances, a plane is kept in straight and level flight by reference to the horizon. In situations where the horizon is obscured, one must learn to rely on their instrument panel. In this particular training maneuver, the instructor takes over the controls and confounds the middle ear of a “hooded” pilot through a series of steep turns, climbs, and dives. After adequately disorienting the pilot, the instructor puts the plane in a pre-spin or pre-stall attitude and returns the controls to the disoriented pilot with instructions to put the plane in straight and level flight with reference only to the instrument panel, not to the horizon. In today’s medical environment, physicians, too, have become disoriented by the commodification of the patient encounter and the medicalization of life. We have lost our horizon; we have lost sight of the fact that we are first of all healers.

What is meant by commodification? A commodity is an object for sale or valued for its usefulness to a consumer; and that usefulness and desirability are marketable. Furthermore, a commodity transaction is fungible: both the place and agent of transaction are interchangeable without detriment to the transaction, for the transaction entails no personal interest between buyer and seller apart from the product. Financial considerations govern the interaction.

This is part of the storm cloud that has obscured the medical horizon, disoriented the physicians, and put health care in an “unusual attitude.” And most of it can be traced to legal changes in the 1990’s which allowed “direct to ‘consumer’” advertising. When medical knowledge, products, and procedures become commodities, and when health care is viewed as a commodity transaction, physicians are impelled by financial incentives and disincentives to be purveyors of a commodity. They become moneymakers for themselves and money-savers for their employer or system. Suddenly, the patient and the healing relationship so vital to the medical encounter, has been lost from the horizon.

Furthermore, when health care is seen as a commodity, business ethics take precedence; and business ethics are not governed by beneficence, the principle that has historically governed medical ethics, but rather by non-maleficence. Merely avoiding harm creates a distinctly different timbre in the “transaction” than seeking the good of the patient. Moreover, like any business, medicine has become corporate- or investor-oriented, aimed at pleasing those outside the medical encounter, whether insurance companies or the government payors. The result is that the focus is now on outcomes, practicality, and the bottom line, all of which are easily quantifiable and controllable. The particular patient with their unquantifiable “contextualities” or peculiarities is again lost from the horizon.

But medicine is not a commodity; it is a relationship—not a fungible or interchangeable relationship with a provider or actor, but a relationship of trust between one who is vulnerable and ill and one who professes to be able to provide helping, healing, caring, and curing. As the late Dr Pellegrino has stated, medicine exists as medicine in the clinical encounter where medical knowledge is employed for the Good of the patient—to heal, cure, contain, or prevent human illness. This knowledge must be integrated into the life of the patient through the interpersonal relationship with the physician.

Is this concept of medicine as grounded in the personal encounter achievable or sustainable in today’s health care environment? I fear not. We have, indeed, been taken captive by outside interests, agencies, and agendas; we are no longer self-governing, but instead serve consumer demands and payor profits and interests. Young physicians entering practice have no knowledge of the historical horizon of health care founded on the “gift of hospitality” of religious orders, or of the physician-patient relationship of helping the vulnerable (rather than catering to the autonomous self). They have been deprived of their instruments and are oriented solely to forward progress with no inclination to consider the shoulders on which they stand. They have been nurtured on the sour milk of the “medical-industrial complex” and are flying upside down–they are disoriented and don’t even know it. And those older physicians who, despite loss of the horizon, can rely on their instruments to maintain straight and level flight, are landing and walking away from the storm–prudently, some might add.

I do often wonder whether I am clinging erroneously to an idealized version of the past when I should be riding the edge of the coin (as I mentioned in my last post). Is it possible to ride the edge of this coin maintaining a hold on the good of the traditional understanding of medicine while moving forward in a new paradigm? Or have we already advanced too far into the storm cloud, deprived of the necessary instruments, to even catch a glimpse of horizon much less an adequate grasp of it, one that would enable us to right the plane before it is too late? Can we ever again be first of all healers?

The Farcical Irony of Recertification

Having recently completed the process of taking my board recertification exams in gynecology (and having had no time to think about anything else!) I feel compelled to share my experience of that process which lies somewhere between farce and irony. While, superficially, this topic does not appear to be applicable to bioethics, the interface is in the arena of professionalism—and how our concept of professionalism is changing, for better or for worse.

As originally conceived, board certification was for “life;” once board certified, one was deemed to have achieved a level of mastery over a particular body of knowledge and recertification was felt to be unnecessary. By the late 1980’s, in light of the rapid changes in the body of medical knowledge, that perspective changed and recerification was instituted. At that point, one could choose to recertify by means of a proctored exam every 10 years OR a by a “yearly recertification” process that entailed reading a chosen list of 50 professional articles and taking an “open book” test on those articles. While the process is burdensome and the “examination” questions are annoying–merely seeking to determine that one has read every word and looked at every graph rather than assessing one’s comprehension of important clinical information–the articles, themselves, have been informative and educational.

In 2006, the process changed again. Now there is no choice. In addition to the yearly collection of articles, one must also complete on-line learning modules–whose purpose is to encourage compliance with practice standards, but which are farcical “busywork” and of questionable educational value–AND take a proctored written exam. While the preparation for the examination was beneficial, the content of the exam was surprisingly and disturbingly basic: there was nothing on the exam pertaining to significant changes in our specialty instituted within the last 4-5 years. As a matter of fact, 75% of the questions were so rudimentary and the answers so obvious that a non-specialist could have easily have passed the exam, perhaps even without studying for it. One was left without a sense of accomplishment…

As a pretense, however, it makes practical sense: the fact of the examination compels physicians to study; the public is reassured that their physicians are knowledgeable; but there is little risk that there will be attrition of physicians due to failure to pass the exam. It is in fact a façade.

But what was more disturbing was the actual testing process: it was akin to being booked and jailed. On arrival at the testing center, one enters a locked room, is handed a sheet of paper to read (not one’s “rights” but rules) and is directed to seat with about 10 other examinees. Upon being called to the desk, one is subjected to a “palm vein scan” (analogous to fingerprinting), a “mug-shot,” and then is escorted to a locker in the same small room where all belongings are deposited (including jewelry), pockets are emptied (even of tissues) and turned inside out, and arms are bared. One is then escorted to a second chair, within 10 feet of the first, and awaits another “assistant” for the next 10 foot journey to another desk situated behind a glass wall that looks into a locked room of computer-containing cubicles (the scene is reminiscent of Jeremy Bentham’s panopticon, but this one is enhanced with audio and visual monitors of each cubicle. At that desk one is again subjected to a palm vein scan (not highly effective on a cold, damp, windy October day in Wisconsin when the anxious examinee has Raynaud’s syndrome!) and then escorted into the locked room and seated at the proper computer. If one needs to leave, one is escorted out and back in, complete with multiple palm vein scans. When finished, the process is reversed: the “assistant” closes the computer session, escorts one from the room (with another palm vein scan), on to the locker, and then out the door.

Medicine was once viewed as a “noble profession” whose practitioners were expected to embody and exhibit virtuous character, especially virtues of faithfulness, truthfulness, and trustworthiness. Such character was crucial to the nature of the fiduciary relationship inherent in the medical encounter in which physicians were entrusted with the lives of vulnerable patients in need of care–trusted to make life and death decisions with and for their patients. Now the presumption is that physicians are dishonest individuals who can’t be trusted not to cheat on an exam. How horribly ironic! Quite frankly, the process was depersonalized and degrading. Thankfully—but sadly—it is probably the last time I will subject myself to that process…

Dr. Koop and the Politicization of the Profession

In addition to the many published eulogies for Dr Koop, there was an interesting commentary by Mark Bittman in the NY Times (Feb 20th) entitled “Our M.I.A. Surgeon General.”  The commentary drew comparisons between the current and recent surgeon generals and Dr Koop, whom he felt epitomized what a surgeon general, as “the nations’ doctor,” is to be. The purpose of his comparisons was to illustrate the “evisceration” of the position by political censoring.  Six years ago, three former surgeon generals, Dr. Koop included, testifying before a a congressional committee claimed that the scientific information they wanted to present was often vetted and subjected to political agendas; they were told “what to say and what not to say.” In other words, science was politicized.

While Bittman’s concern was focused on the control (or lack thereof) of a “controllable substance” (refined sugar), his overall perspective bears heeding because it raises even greater quandaries for the profession of medicine which is also becoming progressively politicized. EMR was mandated “from above” in the name of efficiency, without “evidence” that it would actually improve care, and has subsequently reduced that care to the determination of diagnostic and billing codes. Likewise, attempts at mandating  HPV vaccination were tied to money and politics, and while the push to mandate the vaccine has decelerated, it remains so strongly recommended (marketed as a “cancer preventative”–for which, by the way, there is no evidence)  that no informed consent is given because those administering the vaccination lack the information–they are merely doing as they are told.  Another interference from above (political or financial?–sometimes they are difficult to disentangle) is the move by CMS (Center for Medicaid/Medicare Services) to reduce hospital admissions by requiring that many major operations be treated as “outpatient.” As in many instances, CMS makes the declaration and other insurers follow suit, as physicians expend their professional energies, not in patient care but struggling in vain to redefine that care so that it will fall within  predetermined categories of the CMS.

While medical care is not a right, it is a responsibility (if it were truly a “right” could we require that citizens “pay” for it through insurance mandates?). As a technologically developed and wealthy nation (some would object to this categorization, including a Romanian worker here in the US with whom I had the pleasure of conversing on my recent travels), we have a responsibility to see that all citizens are provided with basic health care.  But as a profession, we dropped the ball long ago, and now  the government has picked it up and is running with it. Part of the problem is that neither we as a profession nor we as a nation have been willing or able to define the ends of medicine–what is basic health care?  At this point, it might be preferable for the government to continue carrying the ball, if that meant providing the means to such care, AND if they would be satisfied with mere provision of the means. But that will never happen–they will not provide the means without controlling the ends as well. And since medicine has lost sight of its own ends and is no longer able to define them,  the task of defining those ends will also fall to the ball-carrying government.

And so in the end, medicine and the waning profession will become progressively politicized. Just as the position of surgeon general has been eviscerated, leaving only a facade–one that speaks not for the health of the nation but for political and politicized agendas–so too the profession. It will no longer a be a profession that cares for patients, but a pretense for a big business that treats politicized conditions for politically defined ends.

The Profession that Was

Once upon a time in a land far away, there existed a profession called “medicine,” a profession governed by internally derived standards and values, a profession that relied on both scientific data and experiential knowledge and judgment, a profession that focused on providing excellence in the care of others…
Last week I received a call from “utilization review” concerning the “hospital status” of a woman on whom I had just performed a vaginal hysterectomy by means of morcellation due to its size. The call challenged my decision to admit her for post-operative recovery.
Over the past 25 years we have gradually reduced the length of stay for our post-surgical (hysterectomy) patients from 5-7 days to 1-2. But the current impetus–mandated by insurance reimbursements and led by the governmental agency of the CMS (Center for Medicare-Medicaid Services)—is to require that hysterectomies be performed as an “outpatient” procedure. This entails discharging the patient hours after removal of an intra-abdominal organ with significant collateral circulation. As a default practice, such a mandate is unreasonable and unacceptable. It fails to consider the many contingencies of the individual patient and procedure for which physician judgment is still required.
At the risk of being too graphic, when a vaginal hysterectomy is performed, a major organ is removed through a relatively small orifice, compromising visualization of the surgical field. Inadequately secured blood vessels can retract into the pelvic sidewalls, out of sight, creating a risk of significant post-operative intra-abdominal hemorrhage. Fortunately, such risks materialize infrequently, but the risk still exists and requires a reasonable period of post-operative monitoring and assessment for the safety of the patient. For such bleeding, if it occurs, is potentially disastrous, even more so if the patient is not in the facility.
Over the past decade these same agencies have also become obsessed with pain control for hospitalized patients, developing and utilizing “visual analogue scales” (smiley faces) in an attempt to quantify the subjective and unquantifiable, and insisting that post-surgical patients be “pain-free,” an unreasonable expectation to begin with. Yet now it is proposed that patients be sent home with anesthesia-induced and pain-induced nausea and vomiting that prohibits them from taking their prescribed oral analgesics which results in more pain, more nausea, and more vomiting—a vicious cycle. Moreover, the increased intra-abdominal pressure that occurs with valsalva increases the risk of post-operative hemorrhage. As concerned as the accrediting bodies have been about pain control for hospitalized patients, there is no concern about the adequacy of pain control for patients who are discharged–it seems that it is then no longer their responsibility. But while it may no longer be the “responsibility” of the regulating agency, the pain and care of these patients is still my responsibility and concern.
Over the past few years this has resulted in “insurance-company-mandated-hospital-anxiety-over-lack-of-payment” induced game-playing over hospital status, games characterized by dishonesty and semantics. But these new rules, regulations, and games place physicians in the untenable situation of being morally and legally responsible for patient care that is legislated by a nebulous outside authority, one that lacks knowledge of the particular patient and/or procedural contingencies. Furthermore, as professionals, our calling is to be advocates for our patients and their care. Yet if we advocate for patients by refusing to abide by unreasonable and unacceptable regulations, especially in rural America, the hospitals in which we provide that care are penalized through the withholding of reimbursement and imposition of fines that threaten them with insolvency. Such a situation violates and undermines the concept of professionalism, which by its very nature is governed by internally derived values and standards, not externally imposed regulations.
Medicine is not a game, especially not a zero-sum game. It is a profession defined by excellence in its practices. Or at least it was. How is it that these “authorities” have assumed the right to dictate patient care without assumption of the correlative responsibility for any adverse consequences? I fear that we, ourselves, by shifting our focus from care to compensation, have let the fox into the henhouse. That fox has destroyed the profession…and I fear it is here to stay.