Map of life expectancy at birth from Global Education Project.

Thursday, January 12, 2012

Where was I yesterday?

Answer: I was transferring my driver's license and motor vehicle registration from Massachusetts to Connecticut. It turns out this is approximately like getting a top security clearance. Because my passport gives my name as Cervantes, Jr., and my birth certificate lacks the "Jr." it became a federal case. I was there for 3 1/2 hours before I finally managed to avoid getting sent to Gitmo. After all that I didn't feel like doing a blog post.

Anyhow, I owe the world one so here are two essays in the new JAMA that have something to do with each other, one on patients who request interventions their physicians believe are useless or potentially harmful, the other on court involvement in disputes about end-of-life care, focusing mostly on families who refuse to pull the plug when their doctors want to (the other category being disputes between family members, a la Terry Schiavo, but that's another kettle of fish).

What both of these discussions highlight is the evolving conception of the physician's ethical obligations and the physician-patient relationship. We have experienced a major shift in cultural expectations since I first studied medical sociology some 20 years ago. On the one hand, from Talcott Parons's conception of the "sick role," in which one of the obligations of the sick person was to obey "doctor's orders," we have moved to an ideal of "patient centered" medicine in which patients make informed choices on their own behalf. (I said that's the ideal -- it isn't so much the reality. I will have a good deal to say about that down the road.)

On the other hand, while we once presumed that the physician's sole ethical responsibility was to the individual patient, given the unsustainable growth in medical spending, physicians are increasingly expected to be stewards of society's, or at least the health plan's resources. They are expected, and in some cases paid, to limit medical spending. Now, that doesn't necessarily conflict with the individual patient's interest. In fact, it's generally maintained that the obligation is to maximize both efficiency and patient welfare, and that there is no paradox because right now, much medical intervention is not justified by the balance of risk and benefit.

This is certainly true, but as these essays indicate, conflict does often arise between the ideal of appropriately limited medicine and patient autonomy. Whether they are husbanding society's resources or interpreting patients' interests according to their own calculus, physicians may conclude that beneficence conflicts with patient choice. This puts them in an uncomfortable position. Many simply acquiesce, as by prescribing antibiotics for cold symptoms or ordering imaging or other tests that patients demand, but for which no benefit is expected.

While the authors of both pieces say that physicians should take the time to have better discussions of these issues with patients and families, they don't address the reasons why this doesn't happen. There are at least two. One, they don't get paid to do it. They get paid a standard (and inadequate) amount for an office visit, whether they take extra time for a discussion or not; and they get paid to do procedures -- which is exactly the wrong incentive. Second, they don't know how to do it. Physicians are taught the biological science of medicine, but the interpersonal art gets short shrift.

We can't solve this problem just by writing about it and exhortation. We need basic change in both the organizing and financing of medicine; and the culture of medical training and practice. That's like sweeping the beach. But we must do it.


roger said...

"Physicians are taught the biological science of medicine, but the interpersonal art gets short shrift."

kinda like college profs with no training or knowledge of teaching.

Cervantes said...

Good point. Many institutions are trying to do something about that, but it's a minor movement.

kathy a. said...

these are exactly the kinds of discussions that were urged in the health care reform debate, and villified as "death panels." if i recall correctly.

i'm sure the docs who are good interpersonally have found ways to fit such discussions into approved billing categories -- and also, that they consider the discussions important enough that they eat some billable time doing them.

that doesn't solve the underlying problems of not having good training to conduct these difficult discussions, and having structural disincentives (procedures = $; too much time talking to patients =/= $.)

i think a place to start is with better training about talking to patients -- and listening -- and addressing their concerns both factually and compassionately. i attended law school, not medical school, but it is not my impression that either profession is very good at teaching these basic skills.

my guess is that these professional programs were set up with the idea that graduates would learn from "on the job training," but if one's exposure is to mentors who don't have the interpersonal skills, one's chances of developing them are lessened.

i was lucky enough to have some good mentors, and also to attend some excellent trainings over the years -- on my own time, not required -- about working with clients.

i have some favorite doctors from a few difficult personal situations, too, who were honest and caring and descriptive and informative at critical points when a loved one was not going to recover. they were in stark contrast to doctors who just ordered more stuff to be done, or had no time because they were such busy and important people -- major grudges against some of those.

the training tools are not that hard to put together. bookwork emphasizing communications is a start. being able to observe examples of good interactions; participating in mock sessions with feedback; practicing with an experienced backup who can jump in as necessary -- those are really critical for helping professionals learn to manage such critical communications with patients and clients.

(my theory, and i stand by it, is that certain DMV employees could stand to learn in the same way.)

Cervantes said...

You're right, medical training is essentially an apprenticeship system. How a doctor interprets professionalism depends on his or her mentors. That makes it very difficult to change because nobody is really in charge.