The nation’s so obsessed with how healthcare is structured, we’re barely registering other issues—like the fact that physicians are burning out faster than rock stars. One recent study estimated the prevalence of burnout at “epidemic proportions, now exceeding 50 percent”—in part because today’s doctors have to spend more time recording and quantifying care than actually rendering it. Then there’s the fact that Western medicine is still driven by a heroic quest for cure, and that’s not at all the kind of care aging baby boomers will need most. SLM talked about these emerging issues with two medical ethicists: Dr. Kimbell Kornu, assistant professor of healthcare ethics and palliative medicine at Saint Louis University, and Dr. Ira Kodner, emeritus professor of surgery at the Washington University School of Medicine.
IK: Probably the most challenging thing that’s happened is that medicine has become a business—and we have sat by and allowed this to happen. If doctors want to stay compassionate and ethical, it’s hard to fit the business model. To just take care of sick folks and be paid for doing it is no longer possible. Medicine has become generic. We fear it will result in a shift mentality, where people come in and work their hours and go home. Trainees may get the patient on the operating table, then never see the patient again postop to recognize any complications. And the primary care physicians don’t even make rounds in the hospital; they have to tell a patient, “I can only take care of you if you are not really sick.” The day of a primary care physician knowing everything about a patient and the patient’s family is gone. It’s like having a team with no quarterback.
Then, when your primary care doctor does see you, the appointment’s supposed to take 15 or 20 minutes, max.
KK: And there’s a lot to manage in a primary care patient—physical history, family history, social history, exam, assessing, making a treatment plan, answering questions. The humanistic part can easily be lost, because you just go through the grid to get these things covered. You have to document a lot more and document it well, and if you don’t say that much, then you can’t bill at as high a level, and if you don’t explain your medical reasoning and you get sued… There’s almost this third member in the doctor-patient relationship: the computer. I’ve heard people say, “I don’t think my doctor cares much about me. They don’t ask that many questions, and they’re always looking at the computer screen.”
And then when do you talk about the sensitive stuff, like advance care directives?
KK: Yeah, you need to block off two time slots for that, which doesn’t look good for the manager of the office. So is that high value? Maybe not in RVUs [relative value units, a productivity measure for physicians]. You can bill for time, but you don’t have any of the quality indicators.
IK: Most people in the U.S. don’t think that we ration healthcare, but we do. We ration healthcare by access to the system. In St. Louis, we no longer even have a safety net hospital. Wash. U. and SLU pick up the indigent care, but it’s very difficult for people to get ongoing primary care, especially preventive, and anything for mental health. Also, in order to get full Medicare reimbursement, a hospital has to meet certain criteria of patient satisfaction. Unfortunately, the things that can be measured don’t actually reflect the quality of medical and patient care.
KK: Often the patient wants to see that the hospital is clean, it’s quiet... [In one survey], if you had your name badge clearly showing on your lab coat, that increased patient satisfaction. Well, if you’d had the time to really talk with them, they’d know your name. So what is the deeper issue here?
IK: The insurance industry rules with an iron hand. Too many times, we try to compensate by learning the business jargon. I cannot explain to someone who’s never taken care of a sick human being what it’s like. The people making healthcare decisions think in terms of hundreds of thousands or millions of people. They never have to sit and look one person in the eye and say, “No, you can’t have the surgery you need.”
Physicians are burning out faster than rock stars. One recent study estimated the prevalence of burnout at “epidemic proportions, now exceeding 50 percent.”
KK: Everything is scarce. So how do you have fair distribution? Is healthcare a right, or a privilege? If you think about common good, sick people in your populace isn’t a good thing for anybody, so maybe we should take care of these sick people. [And on the flip side], sometimes we give too much care. There’s this tension between limited resources and this predominantly technological imperative in modern medicine that if you can do it, you should do it.
IK: Our whole basis for teaching medical students is teaching how to cure disease. If cure is no longer the goal, the challenge is what to do? Palliative care is now especially relevant. We have an aging population, and not everything can or should be done for everyone.
KK: In palliative care, we talk about goals, values, what’s important to you. It’s not about giving up; it’s about maximizing the quality of whatever time is left. You can use the science of curative medicine as a tool in palliative care. But because curative is the paradigm, palliative care is still considered as “when we can’t do as much for you.”
And it’s harder to get reimbursed, too.
IK: Meanwhile, the pharmaceutical industry is making out like bandits. The worst thing the media’s done is direct-to-consumer advertising. They advertise the most expensive drugs, and then people go to the doctor insisting on them, and most physicians give in.
KK: It’s all these happy pictures or these innuendoes about how you’re going to get lucky. A fair presentation about what these drugs actually are? You can’t do that in an ad. Already, in the way it’s presented, it’s meant to stoke desire. The drug is a panacea, not just one more thing that could be beneficial in a clinical context—because there is no clinical context.
Speaking of wishful thinking, should physicians always tell the whole truth? Say someone has, for example, a 1-in-10 chance of beating a particular disease. You hear stories of physicians saying bluntly, “Go home and make your will”—giving a prognosis that might even be harsher than the outcome.
IK: That happens a lot. We call it truth dumping. With all the pressures on physicians, it’s a way for the physicians who can’t be compassionate or don’t want to take the time to solve their own conscience: “Here’s the way it is.” Say there’s a young woman with a serious breast cancer. The default is “Well, I lay out all the possibilities, and then I ask her to choose.” And my response is “If you don’t know the best choice, how do you expect someone who is scared to death to make the right decision?” It’s brutal. Used to be, you could call your primary care doctor and say, “Can you help me decide?”
IK: Whenever I would first meet a patient who had a serious illness such as cancer, I would make the deal: “I’m going to tell you the truth as long as you ask me. If you ever get to where you don’t want to know, don’t ask me.” I’ve always found that it’s easier to tell the truth—“Your cancer is more toward the bad than it is toward the good”—but unless my patient’s an engineer, I never use statistics.
KK: I’m in palliative care, so I often break bad news. I could just say, “I’m sorry, you have metastatic lung cancer, and your life expectancy is about a year,” and be done with it. But is that really the best way to do it? I ask questions, like, “Do you know what’s going on with your body? Why you’re having that pain?” And explain and ask follow-up questions: “Does that make sense? Do you know what it means for you to have that disease? Do you want to know how much time we’re talking about?” And some say, “I don’t want to know” or “I’m not ready to hear that right now.”
How do med students react when, after all the emphasis on cure, you try to teach them about the very different goals of palliative care?
IK: Oh, they are terrific. They want that. The risk with students is that they come in with altruistic values, and we beat them out of them by forcing this business model on them. Medicine is not a business. Treating it as one has made the ethical challenges more overwhelming than ever before.
