At some time in your life you’ll be faced with the very painful decision-making processes discussed in today’s Health Tip. Most likely it will involve an aged relative, but because death and dying are so random, you might be making similar decisions about your life partner, yourself, or (hopefully never) a child.
You’ve probably seen the unsurprising statistic that during the last few months of a person’s life health care costs skyrocket. During final illnesses, especially in a hospital setting, it’s assumed by most members of the medical profession that patients and their families want everything done to rescue the person from the jaws of death.
Everything can be very, very expensive. And for the patient, agonizing.
This idea naturally evolves into: at what point are we doing too much? These important themes are brilliantly addressed in Being Mortal by Atul Gawande, MD, subtitled “Medicine and What Matters in the End.” As Dr. Gawande relates stories about his patients and his own family, you’ll learn that none of us–physicians, families, patients themselves–have really come to terms with what medicine can and cannot do. What’s especially unfortunate is that doctors, already uncomfortable when death becomes a possible consideration, cover themselves by offering false hope and treatments that not only may be useless, but can render the patient’s final months a living hell. A word of warning. When reading Being Mortal, prepare yourself for that painful sensation in the back of your throat, the first warning that tears are coming.
Treatment vs comfort care
Stopping treatment and replacing it with end-of-life palliative care (comfort care) is a subject that’s been grievously overlooked during most medical education. The reasons for this are complex, but a major obstacle is that 98% of training occurs in an acute-care hospital setting, and this seriously skews a physician’s views about what constitutes good medicine…and what’s bad.
Big hospitals are so fixated on saving the patient at all costs that DNR (do not resuscitate) orders to withhold CPR (cardiopulmonary resuscitation) are not uncommonly ignored by hospital staff who fear the wrath of an angry family member (“You didn’t do everything you could for mom!”) or a malpractice suit.
A valiant effort to simplify this multifaceted issue was published in Harvard Magazine, which reported the results of Harvard and Dartmouth economists who were investigating why per-patient Medicare costs averaged $6,876 in La Crosse, Wisconsin, and $13,414 in Miami.
Why were Miami Medicare recipients receiving twice the health care of La Crosse recipients? What was happening (or not happening) in Miami that doubled the health costs of La Crosse?
Cowboys and comforters
Based on highly complex surveys among physicians themselves, the economists concluded that doctors could be divided into two groups: the cowboys (do everything possible!) and the comforters (let’s do less and help prepare for the inevitable).
The cowboys were mainly male, primary care physicians with access to endless specialists. They were all conventionally trained. Interestingly, they received no financial benefit from doing everything. Rather, they were simply doing what they’d learned in medical school (“I can’t accept the patient is dying and there’s nothing I can do. I’ve got to do something”). The study didn’t mention that the specialists these doctors referred patients to did make money, and often a great deal of it, by doing everything.
The article selected La Crosse as its example of reduced health care costs, but didn’t mention that this city is home to Respecting Choices Advanced Care Planning, the nation’s first ever model to integrate family/patient decision-making into endoflife care. The comforter physicians described in the Harvard article are unique physicians, trained to give comfort rather than take action. And while Palliative Care is now a recognized medical specialty, the number of such specialists is woefully small.
Wisconsin rates an A on the palliative care report card. Florida, whose Medicare population is enormous in comparison to Wisconsin, gets a C. Also, keep in mind that in Wisconsin an elderly person’s family is often living in the area. In Florida, the vastly overworked primary care physician seeing far more patients than she’s comfortable with usually communicates via long-distance phone calls with family members scattered throughout the country who themselves may disagree on what’s best for mom. With internecine warfare among family members, the doctor is left with no option except to do as much as possible.
This dividing of physicians into cowboys and comforters is thought provoking. If there are just too many “do everything” cowboys, they’re the product of our current medical education system and patient expectations/demands plus a punitive medical malpractice system. And if there aren’t enough palliative care physician comforters (currently one palliative care specialist for every 20,000 patients with a chronic or terminal illness), then we need to rethink medical education altogether.
Palliative care and geriatric specialists report the lowest incomes of any specialty field. If a primary care doc goes on to fellowship training and becomes board certified in palliative care, her income will actually drop!
I can guarantee that at some point you’ll come face-to-face with a doctor’s cowboy thinking. The patient in question won’t even need to be suffering a particularly serious condition. If you (or someone you care about) turn into a human ping pong ball, bouncing from one specialist to another, scheduling multiple invasive tests or surgeries, you’ve arrived.
And if you get a call from Florida to tell you your 90-year-old wheelchair-bound, demented mother or grandmother is being scheduled for a hip replacement once she’s off the ventilator, which was needed when she developed pneumonia because of her immune-suppressing cancer chemotherapy, you’ll know for certain the voice on the other end belongs to one of the cowboys.
David Edelberg, MD