ACP Internist Blog


Wednesday, March 29, 2017

Affordable, accessible, universal care for goodness’ sake

We all know and probably all periodically use the expression “for goodness' sake“! Perhaps it represents well the prevailing cynicisms of modern living that when we say “for goodness' sake” these days, we don't really mean doing something for the sake of its intrinsic goodness. Rather, we use “for goodness' sake,” when we aren't using less savory language, to vent exasperation.

I will borrow both the original denotation, and the current connotation of this idiom to make a case for universal health care coverage. Connotation, because yes, as a public health professional, I am more than a little exasperated with us. Denotation, because yes- this is something we should do for the sake of goodness first and foremost.

So, let's start with actual goodness, which maybe should come first routinely for its own sake. Our public discourse, and more often discord, about health care coverage rarely seems to consider it. But the provision of universally accessible medical care is first and foremost about goodness at a fundamentally human level.

We all agree, so far as I know, and across the expanses of politics and party, priorities and preferences, that any acute medical calamity warrants an acute response not subject to a financial test. The pedestrian struck by a car; the victim of a car crash, or shark attack; and the more frequent, sudden drop from heart attack or stroke precipitate emergency responses, and emergency care. The bill eventually comes due, and is generally very high- but it's not a factor in the initial delivery of care.

By itself, that makes so-called “health care,” and more aptly “disease and injury” care, different from any other free-market choice. There is nothing else we “shop” for while unconscious; very little else we must “buy,” or die immediately.

Such basic exigencies as these make health care unique relative to anything else we purchase. But not unique relative to everything; it falls in a category. That category is public good.

Our protection by police is a public good. So, too the protection of our homes and forests by fire fighters. And of course, so is the protection of our borders by the military. The U.S. military cannot possibly defend our borders for some of us without doing so for all of us; it is a public good.

So, too, are the diverse components of first and emergency medical response.

Emergency medical care is a public good. The only alternative to that is a society where a financial test is applied before care is rendered to an 8-year-old hit by a car on the way to school. I hope and trust our common humanity recoils at the prospect. Assuming it does, then urgent and emergency medical care becomes a human right. We should treat it as such.

Once we do, there are two immediate implications that nudge us toward a short but slippery slope. The first is that we are going to cover the costs of emergency care for all who need it one way or another, either rationally, or irrationally. The second is that universal coverage of emergency care without universal coverage of preventive care is a guarantee of more emergency care needed, at higher cost. It is the classic case of penny wise, and pound foolish- the failure to obviate costly pounds of cure with ounces of prevention. Let's briefly consider both.

If the ethical positioning of emergency medical care as a human right is formally recognized, it permits us to plan accordingly. We could acknowledge that such care will be provided both to those who can pay for it, and those who cannot. This, in turn, allows us to determine in advance how best to distribute those costs. The answer is the obvious one, derived from the most relevant precedents: much the way we cover the costs of our military protection. Costs for a given year are estimated and projected, and all who can pay, do- in our taxes. We understand and apparently accept that the military protection our taxes cover will cover those with no means to pay any taxes, too. Such is the nature of public goods.

This approach does not, of course, spare us the need to pay for others along with ourselves. But it does distribute those costs widely, and in the most equitable manner possible. The alternative, applied uniquely to health care, is to make no advance plans for distributing the costs incurred by those unable to pay, and then directing those costs haphazardly after the fact. The results generally range from painfully irrational, to overtly tragic- as when a much-needed hospital serving an indigent community is put out of business.

The costs of emergency care for all cannot be avoided by any society of the decent and humane. The only choice is to handle them rationally, or irrationally. The U.S. has opted for an irrational approach, paying for the folly of it in both dollars and lives. Even the Affordable Care Act is only a partial correction, but vastly better than the absence of any correction at all.

The second key consideration as noted is the choice between penny wise, pound foolish, and in-for-a-penny, in-for-a-pound. The latter is the obviously logical of the two for health care, as for other public goods.

Imagine, for instance, if we all agreed that military defense was a public good we, the people, should pay for on behalf of all, but only in response to emergencies. This would mean we would cover military responses to attacks, but we would not cover intelligence gathering or surveillance of any kind, because these are preventive measures. We would not pay to prevent the next 9/11, we would just pay to clean it up.

Such are the implications of covering emergency medical care for all, without covering preventive care. Preventive care, from cancer screening to immunization, is to medicine what surveillance, treaties, NATO, the United Nations, and intelligence gathering are to the military. Viewed that way, the folly of leaving them out of the planning for public good is, I trust, self-evident. Imagine a military that never did anything at all until after we were attacked and imperiled, and ask yourself if that's a satisfactory use of your tax dollars.

In case you are wondering, yes, we do have a source of the reliably evidence-based preventive services that contribute meaningfully, and cost-effectively, to the public good. The verdicts of the U.S. Preventive Services Task Force do not tell us everything we need to know, but we certainly need to know, and should cover, everything they tell us.

What stands in the way of progress and rationality is a toxic blend of cultural arrogance, misguided ideology, and selective blindness. The United States spends more on health care to achieve worse outcomes than many of our peer countries around the world, yet the arrogance of a “not invented here” mentality seems to preclude us from examining and adopting elements of best practices developed elsewhere. The contention that universal health care coverage is in any way more socialistic than universal military protection is not just ideological nonsense, but nonsense inconsistently applied. The failure to note the place for medical care among other public goods is selective, cultural blindness induced by the glare of ideology where epidemiology should be, and often by willful distractions, distortions, and overt deceptions.

The fate of the Affordable Care Act specifically, and health care coverage in the U.S. generally, are highly uncertain at present. All of the dialogue, however, seemingly begins with medical care as a discretionary commodity, and that is egregiously misguided. The ACA is less than it might be because it was the most that could be done in a culture that has never managed to position medical care where it obviously belongs, among other public goods. Doing so would open the door to innovative models that could shop the world's pearls, and string them in a uniquely American way.

Any such system, promoting preventive care for all, would save lives. By reducing the burden of preventable disease, such a system would save money. By applying best practices from elsewhere, such a system would add years to lives as well as life to years. By distributing inescapable costs rationally, such a system would save hospitals.

Such possibilities begin with a cultural reorientation: medical care is a public good. There are many good reasons to preserve and improve the Affordable Care Act, and dollars figure among them. But first and foremost, we should do it for goodness' sake.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.
Tuesday, March 28, 2017

Coffee, tea and heart disease

Patients often wonder if it is safe to drink coffee. Since coffee and tea are two of the most common drinks in the world, it's valid to question their safety. A new analysis of many studies (called a meta-analysis) answers this important question. It was published in The American Journal of Medicine (Am J of Medicine, Vol. 130, No. 2, February 2017).

The researchers looked 6,508 participants in various studies and analyzed their coffee and tea usage over time. They measured coronary artery calcium progression and coronary events. The study found that drinking coffee had no negative effects on heart disease or heart attacks compared with non-coffee drinkers. And even better news; tea drinkers had less progression of coronary disease and fewer coronary events than non-tea drinkers.

My first thought was “How much coffee or tea”? We all know too much of anything can be bad. They didn't differentiate between black or green tea or decaf or caffeinated black coffee. They found that caffeine itself did not lead to greater coronary artery calcium progression. They found that being a regular tea drinker (over one cup every day) was associated with less coronary disease and heart attacks. Being an occasional coffee drinker, compared with never drinkers, increased the incidence of cardiac events but regular (daily) coffee drinkers did not have more events or coronary artery blockage. It was neutral.

So what can you make of this? Regular tea drinking can be part of a heart healthy diet. Regular coffee drinking is probably safe and past studies have certainly shown this.

Keep in mind that good heart health is never just one thing and it is a combination of many choices like not smoking, eating a heart healthy diet and regular activity. But it's good to know we can have our morning Cup o’ Joe and sip on tea all day long.

This post originally appeared at Everything Health. Toni Brayer, MD, FACP, is an ACP Internist editorial board member who blogs at EverythingHealth, designed to address the rapid changes in science, medicine, health and healing in the 21st Century.
Monday, March 27, 2017

Shot callers

He was estranged from his family. No one could fully put their finger on just why that was but all of the notes in the chart underscored that fact. Even though I knew he'd been living in shelters, I wanted to hear it from him. “Where do you live?” I asked. He didn't answer.

Wait. I take that back.

He mumbled something that I couldn't understand. His eyes were at half-mast when he spoke but then slowly drifted downward afterward leaving a teeny slit of the muddy whites of his eyes. And that? That was how most conversations with him went. Questions answered in shaky, garbled replies that slipped out of his mouth, rolled onto the floor and under the bed out of grasp.

Yeah.

According to the chart, he'd never been here. Well, unless you count the one fleeting visit he had to the ER triage some seven years back, he hadn't. And that made it just that much more difficult. His medical history gave us no point of reference upon which to reflect. No elaborate note from an earnest intern or dutiful social worker explaining all that had gone awry in his life and some glimmer of a clue about his mind or his world. Nope. There was none of that.

None at all.

And perhaps this wouldn't be such huge deal if he wasn't so sick. Not just sick. But sick-sick in that way that conveys an imminent demise unless some act of God occurs. The kind that calls for family members sitting around tables with long faces and troubled glances while doctors clear their throats and try their hardest to use only empathic body language. But, see, that wasn't happening in his case. Because there was no family to call.

Nope.

None. As in, not one person who could step in and help navigate all of this awful while at his side. No worried soul wringing their hands or scowling suspiciously in my direction. And especially, there wasn't any person to step in and speak up for him should his mind not allow full decision making capacity.

Yep.

By the time I came along, that's what was happening. His indiscernible speech sounded nonsensical during most interactions and had been deemed a lack of competence to make his own medical decisions, which basically left us with tied hands since there was no one. No one at all.

Our social worker data mined and found a phone number for a granddaughter. After speaking to her once or twice, it became clear that she wouldn't be the go-to person. The follow up calls went straight to voice mail.

And so. It went very predictably day after day. Him sick-sick and muttering inaudible replies to our questions and us chasing our tails trying to figure out what to do. The overall prognosis progressively dismal, without any clear evidence of meaningful recovery anywhere in sight. So, really, death with dignity appeared to be the best option. At this point, that could be achieved only through a decision to do nothing heroic. But that? That calls for a shot-caller. A person who not only knows and loves the patient well enough to know their wishes. But especially who's also willing to step in as an advocate to assure the patient the gets the treatment they'd want. Or, in this case, doesn't get the treatment that they wouldn't want. He didn't have that, though.

Nope.

So what it meant was a full court press. Doing it all even if it was mostly futile.

And wait. Let me be clear. No, I don't fancy myself the angel of death. I do think miracles can happen. That said, since I am a believer of said miracles, I know that they don't follow rhyme nor reason and happen regardless of what we do. Otherwise it's not as much a miracle as it is an intervention, you know?

So yeah, that's my thoughts on that.

Anyways. The point of this is really what happened the last time I saw the patient on rounds. We came in and it was that same thing as always. But at the very, very end of the encounter, something happened. He said something that struck a cord and gave me pause. “I'm all out of tears today.” It was still gargly but this time, it was enough for me to understand.

“Wait. What did you say?” And he repeated it. This time it was unmistakable. I rested my arm on the rail of the bed and spoke again, this time more softly. “This is a lot, I know.” And when I said that he nodded, a tear trickling from his eye and rolling under his chin.

Wait. Huh?

I paused to see if he'd say more but he didn't. “Sir? I am going to come back to talk to you some more, okay?” He grumbled an affirmative response.

We stepped out in the hall together. The interns and the med student studied my puzzled face. One finally bit and asked me what was on my mind.

“That last statement,” I said. “It was abstract.”

“What do you mean?” a student asked.

“I think he gets it. He knows what is going on. Like he's decisional.”

One intern squinted an eye. “You think?”

“I do think.”

And that was all I said.

We finished up our rounds and I returned to him as promised. This time, I pulled up a chair and sat as close to him as I could so I wouldn't miss a single word. “Hey there.”

He looked both surprised and happy that I'd actually returned. He smiled, bony cheeks rising high on his face and lips so dry that they cracked a tiny tear revealing glistening drops of blood when he did.

“I came back to talk to you some more.”

A string of sounds came out in response. I asked him to repeat what he'd just said and recognized it to be, ”‘preciate you for that.” And so. I dug down deep to pull out all the patience I could to hold what I hoped could be a meaningful conversation with this man. A discussion that everyone said he was incapable of managing. Trusting my gut, trying to see if this hunch I'd had earlier that he was still in there might be true.

Yeah.

So we talked. Or rather, I asked questions and he mumbled responses. But this time I was listening more carefully and asking for instant replays on the pieces I didn't get. Eventually, he said something that couldn't be confused for anything else:

“M-m-m-my body sick. Y-y-you c-c-can't find nobody ‘cause-cause-cause I bes to myself. B-b-but I’on't n-n-need nobody calling my shots. I-I-I can c-c-call’em my own self.”

I asked to hear that again just make sure. And he said the exact same thing again. He sure did.

Was he a quirky man? Sure. And had his life taken the rocky terrain of never-stable housing and disconnection from family? Definitely. But that didn't mean he couldn't understand his health problems for himself and have his own say. No, it did not.

The chart had note after note that said he had no capacity to make decisions. Over and over again that's what was written. By important people with lots of knowledge in this area. And honestly, I could see how that happened to some degree. But now I knew otherwise. He was decisional. And yes, reversing all that had been said and determined about him would likely be super difficult and a huge headache.

But still.

First, I documented our conversation. Then I started dredging through what I knew would be a painstaking process with a lot of push back. Except something happened. It wasn't hard, actually. I called my psychiatry colleagues and the social workers and the physician who saw him before me and told them what he'd told me. And all of those people were happy, not prideful or resistant. Happy that this man would be able to call his own shots--for his own self.

Wow.

He was discharged the very next day to the hospice care center that he chose himself. And it was seamless and free of any road blocks. He was smiling on his way out, this time without the cracked lips since somebody had slathered them down with petroleum jelly.

I learned a simple lesson and had another reinforced. The first was that I shouldn't assume things will be difficult. I mean, it's good to be aware and pragmatic, but I'm talking about dreading something to the point of thinking it's not worth the fight. A lot of times, it isn't as impossible as it looks. I think I'll fight harder for patients given that insight recognizing that I am not the only person who wants the patient to win.

And last is one I've always known but can always stand to think about again: Listen and decide for yourself. Clinical inertia is a mighty, mighty thing. You hear things and are told things that are life changing for patients. I was reminded to not let the exhaustion of a busy service of patients make me pull back and not look and listen with my own eyes and ears.

Yeah.

I hope if I'm ever in a situation where I'm up in age and very sick-sick but deep down inside can make my own decisions about my health that someone listens to me. I hope someone somewhere fights for me to call shots for my own self. I really do. And you know what else? If my lips get chapped, I hope they rub a little Vaseline on me, too.

Yeah.

Kimberly Manning, MD, FACP, FAAP is an associate professor of medicine at Emory University School of Medicine in Atlanta, Georgia where she teaches medical students and residents at Grady Hospital. This post is <"http://www.gradydoctor.com/2017/02/shot-callers.html">adapted from Reflections of a Grady Doctor, Dr. Manning’s blog about teaching, learning, caring and growing in medicine and life. It has been adapted and reprinted with permission. Identifying information has been changed to protect individuals’ privacy.

Do doctors have a right to free speech? Hippocrates weighs in

Free speech is one of our bedrock constitutional rights. The debate and battle of what constitutes lawful free speech is ongoing. The issue is more complex than I can grasp with legal distinctions separating political speech, commercial speech and non-commercial speech. And, of course the right of speech does not permit the free expression of obscenity or “fighting words,” along with some other exclusions. And, there is no right to free speech in a private work place, where an employee can be fired for speaking his or her mind. While worker in a private shop may claim that he had a right to call his boss a flippin’ jerk, he would likely find that he suddenly has an abundance of free time to contemplate his prior utterance.

Leaving aside the First Amendment, physicians have always enjoyed free speech in our offices. We ask our patients questions of the most private and intimate nature. And, they answer us. We ask such questions because, under appropriate circumstances, we need the information in order to provide our best medical advice. We ask about specific sexual practices. We ask about prior or current substance abuse. We ask if patients are alcoholics. We ask if patients are suffering from abuse or neglect.

While we may not invariably receive truthful responses from these inquires, often we do. Patients trust us to respect their confidentiality, which has been embedded into medical culture and practice since the time of Hippocrates,who said, “And whatsoever I shall see or hear in the course of my profession, as well as outside my profession in my intercourse with men, if it be what should not be published abroad, I will never divulge, holding such things to be holy secrets.”

His admonition holds true nearly 2,500 years later. How's that for meeting the test of time?

In 2011, the Florida Republican legislature, with the approval of the governor, passed a law that restricted physicians from inquiring of their patients about gun ownership and safety. Physicians found to be in violation risked loss of their professional licenses or fines. Nearly two weeks ago, an appeals court struck this silly law down. Not only was such a law an obvious encroachment on physicians' First Amendment rights, but also posed a barrier preventing doctors from doing their jobs. Should a pediatrician, for example, be prevented from asking a parent if firearms in the home are properly secured? This is not a political or partisan issue, it's a medical and safety issue.

Of course, the appeals court got it right in a case that I regard as a judicial lay-up. But, how did such a ridiculous law get passed in the first place?

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.