The needs of the many outweigh the needs of the few.
-- Spock, stardate 8130.4 (or thereabouts)
One of the biggest unspoken challenges currently facing all of medicine is a simple question: who do we serve? This seems obvious at first glance; we serve the patient. But who is our patient? Do we consider only the person who is in front of us right at this very second? Or should we step back for a second and consider all the other patients currently under our care, or all the teeming millions who might someday need our help? And if we think about them, what obligation do we have to them when we're thinking about what we do for the guy or gal in front of us?
We can argue until we're blue in the face about how much health care should be as a percentage of GDP, or what amount of taxes is fair to ensure universal coverage, or how much any given drug should cost. The answer to any of those doesn't change the general truth that resources are finite. An academic center may have six CT scanners, but it has six, not twelve. When my patient slips and bumps his head at eleven PM, does he or does he not get a CT of his brain? If all I care about is his individual welfare, chances are he gets the CT. The radiation dose poses relatively low risk compared to the potential harm of a bleed in his head, to say nothing of the potential harm to me and my hospital if he had said head bleed and I chose not to look for it[1]. But, let's stop and think for a second about those six scanners. We have a busy emergency department. If my patient is in the scanner when a trauma or a stroke rolls in the door, that's fifteen minutes longer they're waiting for their turn. Fifteen minutes in a stroke is a hell of a lot of potentially dead brain tissue, and that CT scan is critical to determining whether the patient can get clot-busting drugs. Fifteen minutes in a severe abdominal bleed is life versus death, or at the very least a question of several extra days in an ICU. Is this likely to happen from ordering one extra CT scan? Of course not. But an inpatient physician will order thousands of such scans over the course of a career. Roll the dice enough times and you're bound to make a losing roll eventually.
Even when the scan doesn't tie up resources someone else needs, it still uses resources. There's techs, and orderlies, and nurses. Their time gets billed for. IV meds get billed for. Wear and tear on the scanner gets amortized. Somebody's gotta pay. Sometimes it's the patient. More often, it's their insurer, which ultimately means, it's everyone else in their patient pool. That's a penny or less to the other patients, but multiply a penny times the number of patients your insurer covers, and that's Real Money. Either your premium goes up (which stresses you, causes you to cut back in other areas, and generally worsens your health) or your insurer cuts costs elsewhere (which deprives you of a benefit you otherwise might have gotten). This is a serious deal. With one relatively cavalier penstroke, I and every other doctor in this country can start off cascading events that seriously mess up the lives of large numbers of people.
Which brings me back to the question: am I, ethically speaking, required to take that into account? The Declaration of Geneva[2] says "the health of my patient will be my first consideration". The majority of attendings (the ones who aren't themselves relatively fresh from residency) are of the opinion that my patient is My Patient, that it is my moral obligation to provide whatsoever they might need, and to not do so is a breach of fiduciary duty. I, coming from a background in policy, as well as being the sort of annoying person who'll pick other people's soda cans up to throw them in the recycling, lean more towards conserving resources for the people who truly need them. The result is that I am either a very good doctor, or a very bad doctor, depending on your personal values.
This comes up a lot, especially in psychiatry. Psychiatry attendings haven't practiced general internal medicine in years. They thus have a relatively high level of anxiety about medical symptoms evidenced by psychiatric inpatients, and will almost always err on the side of getting a consult, or doing a test, or otherwise intervening. This tends to bother me. On the other hand, I am an intern, so therefore (A) don't know Jack and (B) am not the one whose posterior is on the line. Thus, I tend to shut up and order what is suggested. It causes me a great deal of internal conflict, hence this post.
When we talk about "controlling health care costs", one of the things we're talking about is finding ways of enforcing this idea that the collective good outweighs the marginal benefit that might accrue to any one individual patient. That means cutting back in some way on doctors' autonomy, and it means changing a value so ingrained in medicine that it might as well be one of the Ten Commandments. It also means realizing that the guy in the white coat isn't going to be 100% on your side anymore (if he ever was). It's likely to happen. It might even be inevitable. Still, for most people, that's not a happy proposition.
[1] Some may argue that the liability issue is really the thing driving my decision to scan. They are probably not wrong.
[2] The artist formerly known as the Hippocratic Oath.
Thursday, October 8, 2009
Tuesday, October 6, 2009
Mike and the Demon Rum
The recent blogging hiatus is because your humble narrator was off getting married. That is now accomplished. In the calendar year of 2009, I'll have lived for three months in the Third World, moved across country, started a new job, gotten married, and possibly have sold my house (condo). No wonder I feel exhausted. At any rate, I'm committed to getting back in the blogging saddle and putting more ideas into words.
To set today's scene, I'd like you to pretend you're sitting in an emergency room. This is not the bright lights and bustle you see on "ER". A psych emergency center involves small, windowless rooms without furniture, wall fixtures, or much of anything else. You bring in a plastic lawn chair to interview. At the moment, it's about 2 AM, and you're sitting across from a guy we'll call Mike. Mike is here because he's feeling suicidal. He's been here a while; when he came in, he had a blood alcohol of 450, and you've been waiting for him to sober up enough so you can talk. (For reference, at 200 mg/dL, a "normal" person should be staggering, falling-down, blacking-out drunk. At 400, you or I would be comatose and on our way to dead. Mike was walking and talking, albeit incoherently.)
Sometimes Mike is fat, sometimes he's thin. He's usually in his 40s. He often has tattoos. He's always alone. The story has some variations, but in the aggregate, it goes like this: Mike started drinking young. Sometimes his daddy did too. But, at the start, Mike had a job, a wife, usually kids. Eventually, though, he was hitting it harder and harder, and he lost his job. So he went into treatment, finally. That got him sober -- for a few months, tops. Lather, rinse, repeat. After two or three cycles of this, his wife finally left him. He moved around a bit, staying with family and friends, repeatedly trying to get it together. Slowly, inevitably, he burnt out those supports too, and ended up living in his car. When the car stopped running, got stolen, or just plain got lost, he joined the ranks of Seattle's homeless.
Mike has been in every kind of hospital you can imagine. Outpatient chemical dependency treatment. AA. Inpatient treatment, sometimes for months. Sometimes he's even tried aversion therapies, where they forced him to drink while administering a medication that makes it painful to ingest alcohol. In the hospital, he gets clean. He wants to be clean. He really does want to give it a try. But, when he gets released on that final day, he gets nervous. He thinks of all the times he's tried this and it hasn't worked. He thinks of how alone he is now, of everything he's lost. That old, familiar anxiety worries at him, and a few hours later, he's opening that can of beer or that bottle of cheap liquor.
Mike's problem now is that, even though he's on public assistance, the county will only pay for so much inpatient time each year. So, chances of him getting inpatient detox, inpatient alcohol rehab, or even ordinary inpatient psych are pretty slim. Your task now, in the middle of the night, is to figure out what to do with him. He did say he was suicidal -- but according to the notes in the computer, he always gets suicidal when he's been drinking, and wants to live again when he sobers up. There's also the fact that withdrawing from alcohol might kill him. You see, while alcohol might not be as addictive as heroin or crack, it can be far more deadly. Withdrawing from most street drugs is painful, but ultimately just involves feeling like an utter wreck for a week. Withdrawing from alcohol involves tremors and an altered mental state -- the legendary delirium tremens. If your brain is sufficiently dependent on alcohol, we progress to seizures, and then to seizures of the autonomic nervous system that regulates your circulation. Either you get some alcohol in you, you get a sedative that acts on the same receptors, or your wildly-firing brain actually drives your heart to stop beating.
So, in theory, you could just let Mike hang out in the ER for a bit until he decides to leave. He won't seize immediately -- it takes a day or two to get there. If he leaves, he'll drink, which will solve the problem of withdrawal. If you're feeling like he has a good story and you have time to argue on the phone with insurance authorization, maybe you can bring him in. He can get meds to ease withdrawal and taper himself back to sobriety, then get discharged to a halfway house. Of course, if you think you're going to magically break his addiction, you're more delusional than the patients. Alternatively, you can let him go. He'll drink, and eventually he'll be publicly drunk and get arrested. Jail will sober him out and maybe even court-order him back into treatment. That is, assuming he doesn't fall off a wall, or in front of a car, or into the bay. Or drink, get suicidal, and take that final step off the Aurora Avenue Bridge. Options aplenty, but good options are scarce.
Everyone, including Mike, wants him not to drink. The problem is, nobody understands why he does. You or I don't do this. There is something in his neurons, something specifically tuned to alcohol, that pulls him to drink like a magnet. It's not just personal weakness. This is beyond that -- it's a need that's almost as bad as the need to keep breathing. Some of it is certainly inborn. If we caught it early enough, maybe we could have undone the rewiring, kept the brain from learning this deep dependency on the drug. Instead, as Mike kept drinking through his 20s, it burned itself in deeper and deeper. As one after another social support burned out and cut him off, the restoring forces that would pull him back to sobriety disappeared.
There's no moral or easy answer at the end of this story. I don't know what to do with the Mikes who show up at my door. I try to get them referrals, and if they want to come into the hospital, I usually let them. The only thing it really changes is helping me feel like I've done something for a fellow human. It also reminds me why I wanted to be a research psychiatrist as opposed to primarily a clinician -- there's a whole lot of Mike out there, and right now, we're letting them down.
To set today's scene, I'd like you to pretend you're sitting in an emergency room. This is not the bright lights and bustle you see on "ER". A psych emergency center involves small, windowless rooms without furniture, wall fixtures, or much of anything else. You bring in a plastic lawn chair to interview. At the moment, it's about 2 AM, and you're sitting across from a guy we'll call Mike. Mike is here because he's feeling suicidal. He's been here a while; when he came in, he had a blood alcohol of 450, and you've been waiting for him to sober up enough so you can talk. (For reference, at 200 mg/dL, a "normal" person should be staggering, falling-down, blacking-out drunk. At 400, you or I would be comatose and on our way to dead. Mike was walking and talking, albeit incoherently.)
Sometimes Mike is fat, sometimes he's thin. He's usually in his 40s. He often has tattoos. He's always alone. The story has some variations, but in the aggregate, it goes like this: Mike started drinking young. Sometimes his daddy did too. But, at the start, Mike had a job, a wife, usually kids. Eventually, though, he was hitting it harder and harder, and he lost his job. So he went into treatment, finally. That got him sober -- for a few months, tops. Lather, rinse, repeat. After two or three cycles of this, his wife finally left him. He moved around a bit, staying with family and friends, repeatedly trying to get it together. Slowly, inevitably, he burnt out those supports too, and ended up living in his car. When the car stopped running, got stolen, or just plain got lost, he joined the ranks of Seattle's homeless.
Mike has been in every kind of hospital you can imagine. Outpatient chemical dependency treatment. AA. Inpatient treatment, sometimes for months. Sometimes he's even tried aversion therapies, where they forced him to drink while administering a medication that makes it painful to ingest alcohol. In the hospital, he gets clean. He wants to be clean. He really does want to give it a try. But, when he gets released on that final day, he gets nervous. He thinks of all the times he's tried this and it hasn't worked. He thinks of how alone he is now, of everything he's lost. That old, familiar anxiety worries at him, and a few hours later, he's opening that can of beer or that bottle of cheap liquor.
Mike's problem now is that, even though he's on public assistance, the county will only pay for so much inpatient time each year. So, chances of him getting inpatient detox, inpatient alcohol rehab, or even ordinary inpatient psych are pretty slim. Your task now, in the middle of the night, is to figure out what to do with him. He did say he was suicidal -- but according to the notes in the computer, he always gets suicidal when he's been drinking, and wants to live again when he sobers up. There's also the fact that withdrawing from alcohol might kill him. You see, while alcohol might not be as addictive as heroin or crack, it can be far more deadly. Withdrawing from most street drugs is painful, but ultimately just involves feeling like an utter wreck for a week. Withdrawing from alcohol involves tremors and an altered mental state -- the legendary delirium tremens. If your brain is sufficiently dependent on alcohol, we progress to seizures, and then to seizures of the autonomic nervous system that regulates your circulation. Either you get some alcohol in you, you get a sedative that acts on the same receptors, or your wildly-firing brain actually drives your heart to stop beating.
So, in theory, you could just let Mike hang out in the ER for a bit until he decides to leave. He won't seize immediately -- it takes a day or two to get there. If he leaves, he'll drink, which will solve the problem of withdrawal. If you're feeling like he has a good story and you have time to argue on the phone with insurance authorization, maybe you can bring him in. He can get meds to ease withdrawal and taper himself back to sobriety, then get discharged to a halfway house. Of course, if you think you're going to magically break his addiction, you're more delusional than the patients. Alternatively, you can let him go. He'll drink, and eventually he'll be publicly drunk and get arrested. Jail will sober him out and maybe even court-order him back into treatment. That is, assuming he doesn't fall off a wall, or in front of a car, or into the bay. Or drink, get suicidal, and take that final step off the Aurora Avenue Bridge. Options aplenty, but good options are scarce.
Everyone, including Mike, wants him not to drink. The problem is, nobody understands why he does. You or I don't do this. There is something in his neurons, something specifically tuned to alcohol, that pulls him to drink like a magnet. It's not just personal weakness. This is beyond that -- it's a need that's almost as bad as the need to keep breathing. Some of it is certainly inborn. If we caught it early enough, maybe we could have undone the rewiring, kept the brain from learning this deep dependency on the drug. Instead, as Mike kept drinking through his 20s, it burned itself in deeper and deeper. As one after another social support burned out and cut him off, the restoring forces that would pull him back to sobriety disappeared.
There's no moral or easy answer at the end of this story. I don't know what to do with the Mikes who show up at my door. I try to get them referrals, and if they want to come into the hospital, I usually let them. The only thing it really changes is helping me feel like I've done something for a fellow human. It also reminds me why I wanted to be a research psychiatrist as opposed to primarily a clinician -- there's a whole lot of Mike out there, and right now, we're letting them down.
Subscribe to:
Posts (Atom)