The Needs of... Who?

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.

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[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.