Sunday, July 5, 2009

Excuse me?

Here's a good op-ed from Charlotte Allen in the LA Times.

In Barack Obama's June 24th town hall meeting on ABC he was asked by one Jane Sturm, whose 99 year old mother had received a pacemaker and is now thriving at age 105, if consideration ought to be given to a patient's "spirit" for life when making those hard cost effectiveness medical decisions. Here's what he said:
"I don't think that we can make judgments based on people's spirit," Obama said. "That would be a pretty subjective decision to be making. I think we have to have rules that we are going to provide good, quality care for all people."

Um, excuse me Mr. President but that's what doctors do. We make clinical decisions based on a multitude of factors: best evidence, cost, and suitability of the particular patient in question for the treatment strategy. Arguably the most important factor is that human being sitting across from us in the exam room. You cannot divorce the individual patient from the decision-making process. I'll choose to operate on the hale and hearty 85 year old WWII veteran who walks his dog three miles a day over the obese, diabetic 52 year old with a history of angina every single time. Subjectivity is of paramount importance when trying to determine the best course of action. We act on subjective hunches all the time (Mr. X looks "sick", Mrs. Y just "doesn't look right", etc). That subjective clinical judgment develops with experience and time. And those who ultimately acquire it are the ones who make the best doctors; or at least the sort of doctor I want taking care of my family.

Once again, we see the Obama administration trying to railroad through an overintellectuallized, hyperrational alternative to healthcare reform as policy. It's like Obama/Orszag are an elite consulting firm doling out advice on how to streamline operations of an inefficient business enterprise. This isn't a fortune 500 company though. These are real people we treat, gentlemen. Save your models and bureaucratically designed algorithms for the banks and auto industry...


Kateri said...

Great post, thank you!

Anonymous said...

"Subjective decision" in its context most likely means "personal decision." Please don't stretch one's word beyond context and cleverly go "you see!" I don't see anything Obama said in the interview that contradicts your comment. Doctors make objective assessment and subjective decisions in order to formulate a treatment plan that, under the circumstnaces, best aligns individual patient's needs and wishes. That's the art of medicine and the importance of patient's autonomy.

Anonymous said...

The following commentator reality show is gaining popularity across America:

A: I don’t like Obama because _________.
B: More over, I don’t like Obama because _________.
A: Furthermore, I find it distasteful that Obama _________.
B: Very true. Besides that, Obama also _________.
A: I couldn’t agree more. Barack Obama is therefore very _________.

All it takes are two parrots (or drunk monkeys) with large mouth, quick wit and minimum conscience.

“Fault-finder will find fault even in paradise” – Henry David Thoreau

Jeffrey Parks MD FACS said...

In the context of the exchange, I don't think you can interpret Obama's meaning in any way other than to assume he means to limit a physician's subjective decision making capability. That we'd be better off leaving the tough decisions up to some nameless Regulatory Committee (MedPAC anyone?) to arbitrarily draw lines in the sand. That to me is arrogantly uninformed.

And please let's not turn this into a partisan right/left deal. Obama himself appreciates, even welcomes, dissenting opinions. And that's why right leaning moderates like myself appreciate the overall impact he's had on this country since the inauguration...

Anonymous said...

Unless other countries copy America's zealous healthcare of 99 year olds, the country is doomed.

That old lady's social life probably consists of 4 doctors appointments every week.

Way too easy to run up massive bills when someone else is paying for it.

Anonymous said...

Strange days indeed.

Care decisions must remain between physician/nurse and patient/family.

Pain and suffering. I do believe the public needs to be educated. Yes, down and dirty on what medical professionals know, and dread as things they would never have done to themselves or a loved one or a patient if it was just up to them. We need to stop dancing around this issue. This education should occur when life is not in crisis, and should be required for all adults.

I would hope that in many cases, families would be able to make more informed decisions with the gift of knowing. Being able to have a “good death” is a creepy thought for many, but nurses think about it all the time for their patients. Let’s provide anything and everything available to allow that to happen. People will tell you that they don’t fear death. They fear dying. This would take some new thinking on many levels…


Anonymous said...

Every decision carries its weight, for good or for evil. Regardless what we think Obama actually meant by his remark, can we honestly say that all on-site subjective decisions that clinicians make are right on the mark?

I agree. There is no need to turn this into a heated partisan exchange. Obama did express his interest in hearing opposing viewpoints from someone like yourself. Perhaps you would be interested in expressing your concerns and opinions directly to him (link). He does answer some of the questions/comments himself, by the way.

Dan said...

"I'll choose to operate on the hale and hearty 85 year old WWII veteran who walks his dog three miles a day over the obese, diabetic 52 year old with a history of angina every single time."

Is that a judgement of spirit? Is it his heartiness or the fact that the 85 year old has a higher level of physical activity per week? Obesity and diabetic status are also objective criteria, so is age for that matter. And the number of cardiovascular events.

I do agree that the decision should be made by the physician and the family; I'm just not sure that your distaste for criteria holds up based on your example.

Andrew_M_Garland said...

I have read your posts on the arrogance of Mr. Gawande and Mr. Orszag. Their pronouncements are for a complete control of health care. Their motto: Stop the greedy doctors from bleeding the society.

You are right. How can they reduce a complex problem to a bureaucratic solution of measurement, rulemaking, and control? Can a doctor be replaced by a computer program? I don't think so.

Gawande replied to you with intelligent insight into the complexities of the problem. This will make no policy difference at all. The political desire is for control and power. The sophisticated understanding of Obama's advisors will have almost no impact on the implementation of the bureaucracy.

Consider this extract from a post by economist Arnold Kling
Gaining Power Through Public Policy
"The public policy expert is for decoration."