Tag: medicine

The Crisis in American Medicine: Limited and Costly


This morning my wife shared a letter just received from her former health care provider in Santa Fe, New Mexico. She writes that she’ll no longer bill insurance, with the exception of Medicare. To continue with her, she asks that you join her health community at $4100 annually. Medicare recipients must also join.

I ran into this same thing two years ago when I saw a specialist for a leg ailment. In the future, her clients would need to pay a $3700 annual retainer fee. That was two years ago. I’m reasonably sure with inflation her fee has increased.

I want to warn you that American medicine, formerly the finest in the world, is likely to become more expensive, limited and inequitable. Increasingly with the rise of corporate medicine, the emphasis is on quantity rather than quality. On average, you may need to wait several months before accessing your primary care physician, and even more to see a specialist, and when you do, it’s a physician’s assistant.

Concurrently, private insurance coverage is becoming more discriminating in what it pays for and how much. Medicare payout to physicians suffered a 4% cut this year, with an additional 4.5 anticipated cut for next year unless Congress intervenes before its adjournment next month.

Cuts like these result in reduced treatment, hiring of staff, and implementation of new technologies.

In response, doctors are increasingly resorting to concierge medicine, i.e., retainer fee medicine, now averaging $4000 annually per individual. Obviously, this will accelerate the already large number of Americans foregoing or delaying medical treatment, resulting in tardy diagnosis of mortality threatening illnesses.

As for hospitals, Mayo Clinic, accepts Medicare, but will bill you for the difference between original billing and Medicare payout. I fear this may become a growing trend.

—rj

Being Mortal

gawandeI’ve just finished reading Being Mortal: What Matters in the End by Dr. Atul Gawande.

I had read his previous Complications about life as a surgeon several years ago, greatly impressed.

Both books have been highly praised, with the present book listed by the New York Times as among must reads of 2014.

As a surgeon at Massachusetts General Hospital, Gawande knows what he’s writing about.

And he writes well, often movingly, in layman’s language, of death scenarios with their accompanying challenges that need to be individualized, since we’re all different.

I suspect many readers will opt to avoid a seemingly morbid subject, but that’s a mistake, for   mortality knows no exceptions and our best approach is one that, through knowledge, provides us with options.

And Gawande, a writer for the prestigious New Yorker as well as a physician, delivers–deftly, compassionately, and always with eloquence, on a difficult subject.

Moreover, his book preeminently addresses the medical community, often committed to treatment paradigms that work against the patient’s welfare.

Physicians are trained to see themselves as enhancers of health and survival. They are not taught how to handle lingering illness devoid of remedy:

…within a few years, when I came to experience surgical training and practice, I encountered patients forced to confront the realities of decline and mortality, and it did not take long to realize how unready I was to help them (3).

If your problem is fixable, we know just what to do.  But if it’s not? The fact that we have had no adequate answers to this question is troubling and has caused callousness, inhumanity, and extraordinary suffering (8).

What’s the point, anyway, of continuing chemotherapy, radiation, and surgery in terminal cases when such methodologies may involve great risk and, often, increase duress?

When, in short, should doctors, not just patients, let go?

Patients cling to hope and doctors knowingly feed into this, when frequently no regimen can procure that miracle of restoring health and dignity.

Or as Gawande vividly makes clear in his allusion to Tolstoy’s powerful tale, The Death of Ivan Ilyitch:

What tormented Ivan Ilyitch most was the deception, the lie, which for some reason they all accepted, that he was not dying but was simply ill, and he only need keep quiet and undergo a treatment and then something very good would result (2).

The ultimate challenge for physicians is to accept the restraints of biology and assist their patients to come to terms when that moment arrives

Otherwise, they can inflict considerable, even barbaric, suffering.

Doctors need to be patient-centered, addressing the patient’s best interests, and sometimes the greatest kindness entails being candid..

Ultimately, it’s about providing patients with options that preserve dignity, lessen suffering, and are in accord with the patient’s priorities.

We’ve made some progress in the now universal acceptance of Advanced Directives, though initially contested. But what about options for the terminal patient, still conscious, who lingers, often in great pain, and with perhaps even greater to come?

Gawande says that there are two dominating physician protocols: the one patronizing (this is what you should do); the other, informative (here are your scenarios).

Doctors do better when they ask the right questions of their patients in such contexts:

Whenever serious sickness or injury strikes and your body breaks down, the vital questions are the same: What is your understanding of the situation and its potential outcomes? What are your fears and what are your hopes? What are the trade-offs you are willing to make or not willing to make? And what is the course of action that best serves this understanding? (259)

Palliative care, for example, may well be a better option to further surgery, chemotherapy and radiation when the outcome may make matters worse.

On the other hand, indulging patient fantasy may invoke “a prolonged and terrible death” (4).

Gawande carries out what he advocates. For me, his account of his father’s lingering passage into mortality is deeply moving, which I think many of us can identify with in our own wrestlings with the demise of those we love.

In addition to all of you, I wish every medical practitioner would read this book.

Death isn’t an enemy, but the natural order of things.

How much better it would be in our final moments to have someone like Gawande attending–a physician, with compassion, listening and helping us discern those best options that enhance our dignity and lessen our suffering.

–rj

 

 

 

 

Medicine’s Desertion of the Elderly

elderly“There’s no escaping the tragedy of life, which is that we are all aging from the day we are born,” writes Dr. Atul Gawande in his latest book, Being Mortal: Medicine and What Matters in the End.

Accordingly, I’ve reached that point in life when I wish I could consult with a geriatrician, or specialist on the aging process. Given that we are increasingly an aging population, you’d surmise it’s no problem finding one.

Count yourself lucky, if you do. And if you do, that you’ll get in.

I live in a city of 300,000, and home of a major university with a respected medical school and first class hospitals. Still, I couldn’t find one.

In fact, it may surprise you to learn that geriatricians are an increasingly rare breed.

Take the University of Minnesota, for instance. It recently shut down its Department of Geriatrics, despite its success in enhancing the quality of life for many seniors, reducing disability, both physical and mental, remarkably and, what’s more, the need for costly home services.

Unfortunately, treatment costs exceeded any savings (Gawande 45).

Other medical centers have followed suit, reducing or eliminating their geriatric services.

The medical establishment prides itself on fixing things, when for the elderly it’s management, not healing, that should define appropriate treatment.

Technology, however, is where the big bucks are and even Medicare, tailored for those 65 and over, falls short in paying for services specific to seniors.

Additionally, doctors often feel overwhelmed by elders coming to them with not one, but several ailments. Think hypertension, diabetes, asthma, arthritis, anemia, failing hearing and eyesight, etc.

in the meantime, most Americans will ultimately spend at least a year in a nursing home at considerable expense, which quality geriatric care might well have preempted.

I can’t help but think this sorry state of affairs is somehow related to our general disregard of older people in America, often the butt of jokes or derision.

One study indicates that 68% of the elderly believe that the public is indifferent to its older citizenry.

I don’t think it was always this way. I grew up in a time when we revered age. It’s still this way in countries like China, Japan, Korea and in Latin America. China recently enacted an Elderly Rights Law, mandating its citizens “never snub or neglect the elderly.”

In Korea, turning 60 and 70 are celebrated events.

In contrast, American culture–as in other Western countries–is youth-centric, with emphasis on independence.

Maybe it’s because, thanks to many of modern medicine’s achievements, there are too many of us now, with 20% of Americans projected to be over 65 in the next twenty years.

Currently, those over 65 constitute 26% of all doctor visits, 47% of all hospital stays, 34% of all prescriptions, and 90% of all nursing home stays (Institute of Medicine Report: Retooling for an Aging America).

Unfortunately, there are only 7,000 geriatricians, and that number is declining. As such, it’s only half of what’s needed to meet a growing need (americangeriatrics.org).

The elderly often have emotional as well as physical needs. Sadly, only 3% of psychologists devote the majority of their practice to those over 65.

Geriatric psychiatrists number only about 2,000 and, like geriatricians at large, that number is declining, according to the American Association for Geriatric Psychology.

How foolhardy all of this is, since the elderly constitute a minority most of us are destined to join.

Most of us don’t like to go there when it comes to thinking about growing old and confronting our mortality. Certainly, we don’t prepare ourselves for it very well, though it may be closing in on us sooner than we think.

The UN associates age 60 with elderly status.

In the USA, several states use the same criterion.

The bottom line is that sound medicine isn’t about money. It’s about compassion

–rj

A Court decision with deadly consequences

pigsWe should all be concerned about Thursday’s 2-1 decision by the U.S. Court of Appeals for the 2nd District that the FDA needn’t consider the banning of antibiotics in healthy food producing animals.

Given the growing menace of antibiotic resistant infections among humans and the inveterate use of antibiotics in the meat industry to promote weight gain or combat disease, we draw closer to a pandemic in which even a minor wound or infection could prove deadly.

As is, the Centers for Disease Control and Prevention (CDC) informs us that at least two million Americans are sickened with anti-resistant pathogens annually

I may have been one of them, having just recently recovered from an extended bout with a staph infection that ultimately required daily IV.

I naively had told my infectious disease physician that I didn’t really want to leave the hospital until I was over the infection. His rejoinder was that a hospital wasn’t the safest place to be, given the infection rate incurred among patients (one out of three).

The Centers for Disease Control and Prevention comments that “much of antibiotic use in animals is unnecessary and inappropriate and makes everyone less safe.”

More than 70% of all antibiotics are administered to animals, even when healthy.

To be fair, I can’t say what all the factors were in the court’s split decision, except that it imperils all of us.

I do know that according to the World Health Organization (April 2014), antimicrobial bacteria resistance increasingly threatens public health worldwide, “a problem so serious that it threatens the achievements of modern medicine. A post-antibiotic era, in which common infections and minor injuries can kill, far from being an apocalyptic fantasy, is instead a very real possibility for the 21st century.”

Consider that Carbapenem antibiotics used as a fallback in treating life-threatening infections from a common intestinal bacterium are now ineffective for nearly half of those treated in some countries. This bacterium is a major source of hospital acquired infections such as pneumonia, bloodstream infections and infections among newborns and intensive care patients.

Likewise, our best antibiotics for treating urinary tract infections caused by E. coli are now ineffective in more than half the cases.

Ten countries are now reporting that their last resort antibiotic for gonorrhea no longer works.

Unfortunately, while the FDA did ask pharmaceuticals, animal producers and vets to  exercise restraint in employing antibiotics that are also used for humans, the FDA appealed an earlier court ruling banning penicillin and two kinds of tetracyclides promoting growth, unless users can provide evidence it won’t produce drug resistant microbes. Thus, the Court’s decision in favor of the FDA’s appeal.

Overseas, the EU has banned the use of antibiotics in animal feed (2006) and now South Korea has done the same. In China, however, the use of antibiotics in animal production is widespread.

That animal and human health are linked was decisively demonstrated in outbreaks of multi resistant Salmonella in 2011, 2012 and 2013, traced back to ground beef and poultry sources (National Antimicrobial Resistance Monitoring System).

As physician David Angus admonishes in his best selling The End of Illness (2011),

Wealthy countries take for granted the triumph of science over bacteria, but increasingly doctors are battling infections that can only be quelled by the most powerful antibiotics known to medicine–or, at worst, by none of them at all. In the United States alone, antibiotic-resistant infections cause roughly 100,000 deaths a year. Imagine a world in which antibiotics produce toxic effects and unpredictable outcomes instead of the guaranteed cures we have come to expect–and you can understand what keeps epidemiologists awake at night (298-99).

 The Court’s decision brings that day much closer.

–rj

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Meditation Goes Mainstream: Western Medicine says Yes

meditation

It’s just me in the sunroom before breakfast, sprawled out on my yoga mat, doing meditation for 15 or 20 minutes.  A series of deep breaths and letting my limbs go slack, a visualizing of a good moment.  The hard part is getting the habit, but having a time and place helps a lot..

The best motivator, however, is how relaxed it makes me feel, and coming from, me, I don’t say that lightly.  As a child raised in an alcohol ravaged home, security wasn’t a given and each day meant finding my place under the sun.  I used to think I was simply a chronic worrier and worried even about that.  Children of alcoholics often try to control their environment to maintain stability.  They find it difficult to tolerate loss or uncertainty.  They like their parameters tightly drawn.

You can take benzies like Valium or Xanax for anxiety and while they’ll work in the short run, they treat symptoms only and, worse, are often addictive.  As for anti-depressants, they may work for some, but then how intact do they leave the user?  I prefer taking a different route, sovereign over my psyche rather than pharmaceutically lobotomized.  I suspect they’re overly prescribed anyway.  And then there are the side-effects that sometimes make matters worse.

Anxiety is triggered by our perceiving danger.  This needn’t be limited to a threat to our safety, but losing our financial way through job loss, investments turned bad, the sudden onset of illness.  Sometimes it’s the loss of a friend or loved one that pulls the trigger.  The common denominator, no matter the source, rests within the mind, or the way we think about things.  Nothing can threaten us unless we give it permission.  We are what we think about.  Anxiety is future saturated, or our thinking fearfully about what may happen to us; depression is present tense.  We think the worst has already happened.

Meditation quiets our panic, producing a mindfulness that can sort out, clarify and more cogently respond to what troubles us.  When we’re stressed fear takes ascendancy, preempting alternative, positive ways of responding to crisis.

Meditation has now increasingly become a part of the medicinal arsenal that had traditionally been limited to pharmaceuticals and surgery in Western medicine.  We know that meditation has restorative benefits for the body when we incorporate the mind into our notion of the corporeal.   In fact, we can measure its physiological results in lowered metabolism, heart and breathing rates and replicate those results.  For a fascinating exploration and summary of the empirical data, pick-up The Relaxation Response by renowned Harvard cardiologist, Herbert Benson.

I happen to be a subscriber to Mind, Mood & Memory, a newsletter put out by one of the world’s internationally acclaimed medical facilities, Massachusetts General Hospital.  In its most recent issue (September 2013), Ann Webster, PhD., Director of MGH’s Program for Successful Aging at Benson-Henry Institute, informs us that “among these strategies for successful aging, perhaps the most effective is engaging in practices such as meditation, yoga, deep breathing, or repetitive prayer that help elicit the relaxation response.  Regular experience of the RR helps counteract stress and other factors linked with higher risk for illness and aging, and causes enormously positive physical, emotional, and cognitive changes.”

This doesn’t mean a trained counselor becomes superfluous.  A good psychologist can target needs and offer ameliorative insights to enhance reduction of stress and promote physical and mental health.  The best medicine is always integrative.

And what do I feel like when I open my eyes and put my mat away?  Hard to put into words, but something similar to the snowflake calm that descends when I play Enya and  find my bullying ghosts have fled..

–rj

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Intolerance: Medicine’s Nemesis

Medical Statue at Semmelweiss Medical Museum
Medical Statue at Semmelweiss Medical Museum (Photo credit: Curious Expeditions)

I had grown up thinking medicine was free of the prejudices, if not sheer ignorance, rampant in the everyday world where resistance to anything new seems a given.  Let’s face it:  we humans don’t like having the security of our assumptions challenged.  The truth is that the history of medicine shows the same proclivity for stubbornness or subordination to the weight of custom as elsewhere.

In his riveting study, Doctors: The Biography of Medicine, physician Sherwin Nulan recounts the story of Ignac Semmelweiss, a young Viennese physician in the 1840s, who observed that women delivering their babies in hospitals died of puerperal, or bed fever, considerably more frequently than those delivering at home.  He did his own research to find out why, ultimately discovering a link between medical student routine and maternal deaths.

Each day,  students and profs would examine cadavers in between visiting patients. Although they didn’t have any notion of germs back then, Semmelweiss ultimately concluded that “invisible cadaver particles” on the hands of students and attending physicians was the source.  In short, he had discovered the role of infection in promoting illness.  

Instituting a protocol of his students’ washing their hands in a chlorine solution, he saw a dramatic drop-off in mortality.  His colleagues, however weren’t amused by this young upstart, whose research implicated them in so many deaths.  Consequently, Semmelweiss didn’t publish his research for fifteen years.

Dr. Joseph Lister
Dr. Joseph Lister

By the 1860s,  Louis Pasteur’s germ theory had entered into medicine, though it initially wasn’t widely accepted.  In Britain, Dr. Joseph Lister decided to apply the notion to post surgical infections, which were nearly always fatal.  Discovering that a neighbor city had poured carbolic acid down its drains to eliminate a potent sewer stench, he concluded that the acid had killed microorganisms similar to those Pasteur had identified.  Applying this concept to surgery, he employed wound dressings saturated in carbolic acid.  Later, he added spraying the entire surgical area with the solution.  Ultimately, he expanded the solution to washing his hands and instruments.  Lister published his successful results in 1867, inaugurating the formal beginnings of antisepsis.  It would be another generation, however, before Lister’s innovations became universal.

It was only in the 1880s that doctors had finally moved beyond a solely antiseptic solution to changing their clothes and boiling their instruments, sutures, towels, and sponges and adopting a ritual of vigorous hand washing.  In 1893,  Dr. William Halsted  became the first surgeon to wear a surgical mask.  In the 1920s, white garments and linens became universal, though the former now seems to be giving way to darker shades again.

Infection still remains a serious threat and the shorter your hospital stay, the better your odds.  Each year, nearly 2 million patients experience infection and 100,000 die.

Even with today’s antibiotics, infection looms as a serious menace, complicated by the increasing rise of resistant, highly contagious bacteria strains.

The bottom line in medicine is that what we don’t know often governs more than what we know.   After several thousand years, we overwhelmingly treat symptoms, not causes.  Now and then, however, a Semmelweiss or Lister appears like some new Columbus, charting a vastly different terrain leading to a New World.  Thus, it behooves medicine to be open to self-scrutiny, forfeit vested authority, tradition, and prejudice.  Only in this way can we find the breakthroughs that advance our safety, promote our healing, and perhaps offer sovereignty over some of our most chronic diseases like cancer.

–rj

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The Fountain of Youth: We are all Ponce de Leon

medical-symbol1As a 12-year old Florida school boy, I was introduced early to the 16th century Spanish explorer Ponce de Leon, whom legend says came to Florida in quest of the Fountain of Youth.  Drink or bathe in its waters and you could be young again.  A story-line like this isn’t unique, finding its replay in myth and legend throughout the world. 

Its insistence  doesn’t surprise us at all, since it mirrors our consummate dream to stay young, not for its own sake, but because we associate youth with beauty, vigor, and libido, or from another angle, the absence of chronic ills like coronary disease, cancer, arthritis, and God only knows what, that often define our later years.  All the parts are new and they work well and at 25 we may sometimes think ourselves immortal.  We dream not just ordinary dreams, but visionary ones that say I can and I will.

Sooner or later, we are all Ponce de Leon, clutching to “the splendors in the grass” (Wordsworth).  Our ads promulgate our folly with promised effulgences of youth’s attributes, abolishing gray, dissolving winkles, restoring passion.

But even medicine itself increasingly wanders into the Ponce de Leon camp these days, some doctors proffering we may soon banish the ills of our human sojourn, advancing our life span dramatically into the 100 year range what with the promise of genetics making individualized therapies possible, perhaps a pill as it were targeting your specific ill, say cancer.

This is pretty much the message of Dr. David Agus’ fascinating The End of Illness, sort of what we do now at the car shop or electronics outlet, plugging into a computer that in seconds spits out solution.  He tells the story of 44-year old Bill Weir, host of ABC’s Nightline, who volunteered to go live, or cameras rolling in prime time, as the newest medical technology imputed his medical data at USC University Hospital.

It was the whole works, including not only blood tests and CT scans, but DNA analysis to assess his hereditary risk for illnesses such as heart disease, Alzheimer’s disease, colon cancer and about 32 other disease scenarios.  A CT uncovered substantial calcium build-up in Weir’s coronary arteries, narrowing his arteries and portending a possible heart attack in the next several years.  He had seemed a very healthy man until testing found him out.

The point is that we can increasingly predict and find impending diseases, and employing  intervention therapy, reduce if not eliminate, their threat.  Because of the high expense, sounds to me like you want to make sure you and your loved ones have the best possible medical coverage.  In the end, prevention may well be less costly than treating a patient with cancer, heart disease or diabetes.

Here I agree with those in Agus’ camp.  Take those prescribed pills, undergo the recommended testings, etc.  Consider pancreatic cancer, for example, a disease that takes no prisoners and recently killed actor Patrick Swayze, astronaut Sally Ride, and Apple’s Steve Jobs.  It’s an insidious illness that manifests its symptoms when it’s usually too late.  Still, you can undergo an annual complete abdominal ultrasound, MRI, or CT and gain a chance to nip the culprit in the bud.

But do I think medicine in the next 25 years will largely eliminate illness?  I will only say I think the jury’s still out on this one, though I’m doubtful. There is the expense; human inertia; new diseases in an increasingly global village appearing, impervious to our best antibiotics and the lengthy interval in developing new ones.  Even Agus contradicts his own optimism in predicting the inevitability of a pandemic:

The swine flu scare that occurred in 2009 will someday be dwarfed by a real epidemic that will spread rapidly through virgin immune systems and kill millions in its path (as happened, for example, in the flu epidemic of 1918, when an estimated 50 million to 100 million people died) (p. 277).

And I think the title of his book extravagant.  It may spawn sales, but little else, for fragile beings that we are, fraught with mortality, we share the fate of all living creatures, governed in the end by entropy.  We will never arrest illness completely, though we may at times lessen its impacting, and even its timing, by employing health enhancing strategies that will also lend quality to our lives.

At present, the American medical establishment is in breakdown mode.  While heart disease has shown a decrease, cancer continues to plague us.  Apart from disease, our doctors kill up to 200,000 patients yearly by way of medical mistakes; 50 million of us have no insurance; 25 million of us are underinsured.  Meanwhile, our unhealthy lifestyle continues to menace both our health and our wallets.  We have more diabetics than ever, for example.  Many of us are just plain fat.

I’d like to continue this subject in a later post and tell you things you can do specifically to help safeguard the health of yourself and loved ones, though I can’t promise you centenarian status.  Only 1 in 20,000 achieves that!

–rj

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