Monday, December 27, 2010

Compensating Physicians for End of Life Decisions - not Ending Life

Once again those who oppose Presidents Obama's initiative to improve our health system are creating anxiety and fear by crassly labeling as "death panels" time spent by patients and their physicians discussing 'end of life decisions'. Such conversations, for primary care physicians such as myself, are part and parcel of our practice. Longitudinal care is particularly unique to our specialty. It is appropriate and expected that people whom we have cared for years, sometimes decades, while they were enjoying good health, and death was a nebulous abstract, look to us to coach them thru the maze of complex, trying, and uncomfortable efforts to ‘treat’ their untreatable illnesses. They look to the physician they have trusted their health for years to decide when treatment no longer is beneficial or desired.

These conversations cannot be complete if postponed until the final hospital admission. There is not enough time. By then the patient who is too ill to express wishes for the care they want, and too weak to articulate their choices to the unfamiliar physicians whose priority is selecting treatments to retard or control, but rarely cure, the illness. Under these circumstances, patients have little choice but to defer choices of treatment to doctors whom they barely know.

To equate these intimate conversations to death panels is to extract all dignity from the process of dying. Those who suggest that physicians who have these conversations with their patients are ‘death panels’ not only disparages the physicians and the medical community, but more importantly, negates patients their right to decide the manner in which they wish to have their life end.

Re-embursing physicians for time spent in these discussions will encourage physicians to allocate their time and resources to assist their patients with these most difficulty medical decisions. It is only when a patient encounter is specifically committed to this most personal issue that the patient has the opportunity to express his/her desires and the physician has the necessary time to listen. Without these opportunities, patients will be committed to a death that is too frequently postponed to a time when there is no honor to life or dignity in death.

Monday, December 20, 2010

Bread Lines then, Health Lines Now

Three weeks ago, I traveled to Charlotte to volunteer as physician at my seventh (Little Rock, Kansas City, Hartford, Atlanta, Washington DC, New Orleans) free medical clinic for people without health insurance. As previously, there were over 1000 people cared for during the one day clinic. It has now been a full year since I attended my first clinic. Except for Kansas City and New Orleans that were two day clinics, each of these clinics have been for one day. Simply, I taken nine days from my own primary care practice to participate with other providers volunteering their time to care for over 9000 patients none of whom had health insurance and most had the chronic illness of adult Americans ( diabetes, hypertension, hyperlipidemia, coronary heart disease, obesity and arthritis) but had not seen a physician for more than a year even though most had been prescribed several medication by the last physician they had seen.

They arrived with bottles of medications empty because they could not afford to refill them or could not afford a doctor’s appointment to re-write the prescriptions. The stories of the residents of Charlotte were identical to those of the other cities that had hosted the other clinics. They either were self employed and could not afford health insurance for themselves or their family; they had lost their jobs and with that lost their health insurance; or they had part time or temporary jobs that did not provide health benefits.

As if rehearsed, the patients at Charlotte, explained the reason they had not seen a physician in such a long time with a ‘mantra’ that I had first heard in Little Rock and echoed in each of the other clinics and again in Charlotte “ I do not have health insurance, so I have no physician, and have no health care”.

Without access to care without ability to refill or pay for their prescriptions, again I saw patients with blood pressure out of control. Of the several dozen patients I personally cared for, the lowest diastolic pressure was 94. Most were above 100, some over 110. Diabetes was equally poorly controlled. The same was the situation for cholesterol. More than two thirds of the patients were obese but almost none had had seen a nutritionist.

As mentioned, Charlotte was the seventh free clinic where I had precipitated, so none of these clinical observations were surprising. What was surprising, was that there was such similarity of the stories of patients in each of these seven cities.

Reflecting on the entirety of my experiences, the Americans, most who never had previously sought free services of any sort, but now overcame their personal pride, signed up for appointment at these free clinics and then waited on line for many hours to be seen, reminded me of the long lines of people waiting on the bread lines of the great depression.

Then food was the essential. In the 1930’s medicine was something not expected by the lower and middle class and for those who did have access to care, the care they received was limited and of minimal benefit. There were no antibiotics, no intensive care, insulin had just become available for a few. The people waiting on the lines on the 1930’s did not consider health care something the government would or should provide for them. However, they did look to the government and charities to provide food.

Today, food is readily available and most people can afford to purchase, or are eligible to receive government subsidies for adequate food. In the eighty years since the bread lines, medicine has become something not recognizable by those who waited in the cold. Medical care has also become much more accessible - if one has health insurance or personal wealth.

However, the over 50,000,000 Americans who do not have health insurance they are unable avoid the complications of their chronic illnesses because they cannot benefit from the tremendous advances in medicine over the past eight decades. Without access to medical care of the twenty first century, the health of status of those we have seen at these free clinics, is not too different than the health status of the thousands of Americans who stood on the food lines.

Then many people relied on charity to put food in their stomach and food on their kitchen tables for their family. Today many people must rely on charity for medical care. Is there really much difference? Both are essential. In each instance, very large proportions of our citizens have become marginalized and their lives vulnerable.