Monday, April 5, 2010

Answer to Question #1 - What is medical consumerism and what factors do you believe exacerbate this issue?

One of the factors keeping us from reaching our goal of universal coverage at a price we can afford is medical consumerism, defined here as the public having unrealistic expectations and demands. There are several reasons for medical consumerism in the U.S. and the blurring of the lines of authority between the patient and the medical team.

A) The concept of patient autonomy is problematical as its limits have not been defined.
B) Many Americans believe that a few hours at a web site is sufficient to adequately learn about a medical subject without understanding the complexities involved.
C) Drug and device advertising to the public promotes the newest most expensive drug/device as superior and your doctor is unaware of this marvelous advance. In reality direct advertising is an attempt by these companies to convince the public that their product is the newest and best when usually older and cheaper drugs/devices are just as effective.(1)
D) Hospitals and doctors have adopted a customer oriented business model to maximize revenue.
E) There are unresolved ambiguities caused by the Patient Self Determination Act (1990) which created the legal framework for advanced directives.(2) Many ethicists and physicians have noted that advanced directives have the potential of turning the physician into a technician following instructions no matter how inappropriate.(3) Questions arise about the limits of therapy in the absence of an advanced directive. Although passed in 1990, these concerns are yet to be addressed by Congress.
F) Physicians practice defensive medicine because of the widespread fear of lawsuits. Our legal history is replete with cases that have demonstrated to the physician community that logic and rationality are secondary to patients’/families’ requests and desires. Two examples of this are the cases of Baby K and Helga Wanglie.

1) In the Baby K case an anencephalic baby (no cerebral cortex – no possibility for consciousness or human activity) was born by caesarian section in 1992. Although the physicians, hospital ethics committee, the court appointed guardian and the child’s father recognized the futility of further care, the child’s mother insisted on continuing care along with mechanical ventilation (breathing tube connected to a machine) if needed and pursued legal action. The trial court misinterpreted the Emergency Medical Treatment and Active Labor Act (EMTLA)(4), by not considering the child as an integrated entity, but rather as a respiratory case. Professor Annas, Chair Department of Health Law, Bioethics & Human Rights at Boston University made several cogent statements about this case:
1) Knowing in advance that the fetus was anencephalic ,before delivery the physicians should have discussed with the mother that they would not use mechanical ventilation after birth.
2) The trial judge misinterpreted the intent of Congress in writing the law.
3) Congress mistakenly did not include wording such as, “within the bounds of good medical practice”.
4) We should be treating patients in light of what is best for them and not as objects to meet the needs of others.
5) To avoid medicine becoming a consumer product like toothpaste and in the process becoming unsustainably expensive, physicians will have to set standards for medical practice and follow them;(5) to this date this has not happened.

2) In the Helga Wanglie case, an 86 y/o women was in a persistent vegetative state for a year in an intensive care unit. The physicians concluded that in this case there was no chance of recovery and that hospice would be better for the patient. Her husband objected and sought relief from the courts, which found in favor of the husband; however, Helga died a few days after the verdict. (6)
What is needed to address medical consumerism and resolve the ambiguities between patient and doctor? I suggest:

1) Congress should amend the Patient Self Determination Act, The Americans with Disabilities Act and the EMTLA to contain the phrase, “within the bounds of good medical practice”. This would facilitate physicians developing and adhering to practice standards.
2) An advance directive should be completed at each hospital admission with guidance from physicians as to what is feasible in light of the patients overall condition, with seasoned physicians and a nurse available to adjudicate conflicts.
1. Angell M. The Truth About the Drug Companies: How They Deceive Us and What to Do About It. Random House N.Y. N.Y. 2004 ISBN: 978-0-375-50846-2
2. The Patient Self-Determination Act (PSDA) was passed by the U.S. Congress in 1990 as an amendment to the Omnibus Budget Reconciliation Act of 1990.
3. Perkins HS. Controlling death: the false promise of advance directives. Annals of Internal Medicine 2007; 147: 51-57 (PMID 17606961)
4. 42 U.S.C. 1395 dd (1994) (amended 1997)
5. Annas GJ. Asking the courts to settle standard of emergency care – the case of Baby K. New England Journal of Medicine 1994; 330: 1542-1545 (PMID 8164726)
6. Angell M. The case of Helga Wanglie; a new kind of “right to die” case. New England Journal of Medicine 1991; 325: 511-512 (PMID 1852185)


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Christopher said...

So you pledge that the doctors should decide whether a patient is capable of surviving instead of a family member? It may save money, but I believe it's a horrible idea. I think it puts too much power in the hands of doctors who may not have the patient's best interests in mind. It will pit doctors against families and will basically become euthanasia. If that's what you want, why don't you just say it?

Doctor Kenneth Fisher said...

Thank you for posting on my blog and for your positive comment. Regards, Kenneth A. Fisher, M.D.

Doctor Kenneth Fisher said...

Thank you for your kind words regarding the content on my blog. I do not believe we share similar objectives. Therefore I do not think we should have reciprocal arrangements. Regards, Kenneth A. Fisher, M.D.

Doctor Kenneth Fisher said...

I welcome your frankness regarding doctors and appropriate care. I am sure others have the same impression. Inappropriate care in this nation is not limited to end of life issues. I believe I have carefully documented on this blog that inappropriate non-beneficial care in the United States extends to all areas of medicine. Most important is that it reflects a tremendous amount of care that is not helpful and frequently hurtful; the dollar amount is secondary. I agree with you that end of life issues are difficult and emotional. My proposal to have a group of doctors and a nurse to adjudicate in the most egregious of cases is to avoid situations I have seen many times and well described by Doctors Jeffrey Drazen, editor-in-chief of the New England Journal of Medicine along with Nihar Desai and Philip Green (N Engl J Med 2009; 360:444-445) where they wrote, “We worried that we were torturing her for little gain.” There is also the issue in cases in which further care will not be of benefit, of using the patient as an object to meet other people’s needs. I do not believe in and have written against euthanasia.
Unfortunately the old fashioned doctor-family relationship has diminished in this age of technology; in that relationship trust was paramount and would avoid many of these difficult situations. I hope you find my response to your concerns helpful. Regards, Kenneth A. Fisher, M.D.