Thursday, March 31, 2011

Over Treatment

With utter dismay I've been following President Obama's unconscionable usurpation of limitless executive power with regards to the War in Libya. And let us clear: The bombing of Libyan ground targets, the arming of rebels, and CIA presence on Libyan soil (in an advisory capacity, so they say) all represent aggressive acts of war. This is a third war we have now embarked upon in a Muslim country. Absurdly, once again, American missiles are being fired at a country that poses absolutely zero threat to our national security. And this time our Commander in Chief has committed us to war by executive fiat. No congressional approval. No meaningful debate. Not even a symbolic vote by the legislature to at least give the pretense of abiding by the dictates of Article I of the US Constitution. Everything this man campaigned on---- hope and change, the dawn of a post-partisan era, the end of the Imperial Presidency-----all a complete fraud.

I'm no foreign policy guru. I'm not there in the Situation Room. I don't presume to think that my feelings wouldn't be different if I had access to all the relevant information that the national security council has. But such a monumental decision cannot be contingent on personal feelings. It's one thing to help avert a potential slaughter, such as at Benghazi (although such rationale appears to be somewhat arbitrary; otherwise why aren't there bombs raining down in the Ivory Coast, Yemen and Bahrain?) It's quite another to unilaterally assert the right to bomb the bejeesus out of a foreign land. We are not a nation of Great Benevolent Men. We are rather a nation of laws. Believe it or not, even the President of the United States must abide.

I see parallels in this current military overreach with what is happening in healthcare. We spend 30% of a person's lifetime Medicare outlays on care provided during the last year of his or her life. We spent $50 billion of Medicare dollars last year on dying patients' last two months of life. Why are we doing this? Why has that 30% number remained unchanged for almost 30 years? Why do I continue to see consults on demented 89 year olds in the ICU who are intubated and unresponsive and suffering from multiple organ failure? And they linger for days and days. And the chart contains consults from numerous highly trained specialists, all dutifully offering the best that American health care can provide.

Is it greed? In our procedure-oriented, profit-driven health care culture, you eat what you kill. Why spend an hour doing a thorough history and physical examination, talking with family members and concluding that no further treatment is warranted when you can send your PA to do a quick consult, sign her note, and schedule the patient for a lucrative procedure the next day. Are we in Libyan merely to protect Italian oil interests? Are we there just to safeguard British Petroleum investments? Or is it truly a "humanitarian" venture?

Do we do it just because we can? Hey, we have a pulmonologist on staff. That 94 year old is dying of congestive heart failure. Send him down to the ICU, consult the pulmonologist who then orders the patient intubated based on an ABG that the nurse gives him over the phone. Then get the interventional cardiologist involved. And did you know, the hospital just recruited a new endocrinologist. The patient has a blood sugar of 356. Consult the new guy so we can tweak his insulin dosage. And on and on. Similarly, here we are sitting on the greatest military arsenal the world has ever seen. American military spending in 2010 was over $650 billion. That's 7 times more than the second highest national military budget (China). All this ordnance and materiel that, which each passing year, becomes more and more obsolete, necessitating even more spending in the future---might as well use it whenever a vaguely justifiable reason develops somewhere in the world, right?

Is it our arrogance? As doctors, do we presume to be the arbiters of life and death? Has our power to save and extend life been corrupted by an overweening sense of infallibility and righteousness? Has the American Hegemon unequivocally declared itself the Exceptional, Indispensable Nation? Do we truly believe we know what is "best" for every other group of human beings scattered across the expanse of the globe? Has the condescension of the White Man's Burden been passed on to 21st century America?

It's probably a combination of all those reasons, to some extent. Fundamentally something is rotten at the core of our nation. We define things in superficial terms. We demonize with catch phrases and sound bytes--- i.e. "death panels" and "they hate us for our freedom". We dare not look under the surface into the complexity and confusion and unpredictability of reality. We close our eyes to the discomfort of uncertainty and nuance. We would rather wear flag pins and dress up like 18th century New Englanders and sing God Bless America and publish papers on the effectiveness of colon surgery on nonagenarians. Death and decline prey upon us all---individual and nation as a whole. Nothing lasts forever. Clinging to a platitudinous nationalism, a jingoistic pride, a sense of professional omnipotence---these are all forms of an incipient dishonesty that threatens our collective soul. Death and decline are not to be feared. We can't save all patients. We can't rule the world forever. There are limits to human achievement. There is nothing shameful about recognizing futility. It's time we summoned the courage to look a little deeper, to find a sliver of humility through self analysis, and to reconcile ourselves to our ineluctable imperfection in this fallen world.


Lucky Jack said...

I agree with you completely on the medical side of this post - something is rotten at the core of our healthcare system, and I hope to that it gets better and not worse from here. However, I have to disagree with you on the Libya issue. Contrary to your post, this was not a "unilateral" action. This was us standing behind France, the UK, and Italy, who all wanted to take the lead in preventing a slaughter. I dont deny the possibility of alterior motives, but I truly those were secondary, in this case, to the primary humanitarian objective. Our current administration is not trying to police the world, but the UN recently adopted a resolution mandating intervention to prevent genocide. This is not a war between nations, and I think we did the right thing.

Does that mean that we should go intervene everywhere that there are humanitarian crises? Well, probably not- it's not practical. But when a multilateral action is already in motion, I think it is the responsibility of the USA to join up to save human lives. Just my two cents. I'm thoroughly enjoying your blog by the way!

Jeffrey Parks MD FACS said...

By "unilateral" I was just referring to the President's decision to insert our armed forces into the Libyan civil war without Congressional approval or oversight. Thanks.

Anonymous said...

Hey, the Cavs won a game!!!!!!!!!!!
beat there Meat, I mean the Heat..
and its not an April Fools joke...
Only 44 more and they'll be at .500!!!!


Attorney Andy said...

Holy crap, you definitely spent some time in the garage coming up with this post. I agree completely with your opinions. At a time in this country where dishonest Tea Party congressmen scream about deficits as a justification for dismantling the right to collectively bargain for the middle class, perhaps we should ask ourselves why it is acceptable to continue outrageous defense spending to support three illegal wars. I fell victim to the optimism surrounding Obama's campaign, and now feel nothing but complete disdain for our political system. Perhaps it's time for a massive revolution in this country. Check out this article:

Anonymous said...

Sometimes it's just so freaking obvious which docs have a few aggressive sales reps, I mean PA/NPs out there to source new market potential, I mean assure the best of patient care.


Anonymous said...

You havent had a decent record since "Use your Illusion".
and I just noticed, but "Axl Rose" is just "Oral Sex" rearranged...

Frank "One in a Million" Drackman

tom said...

We will gain no friends in Libya regardless of the outcome-this a civil war and we know little if anything about the side we support. Expect what ever arms we provide to used against us in the future.
Regarding how we spend our health care dollar, most folks do what they are incentivized to do-in this case "provide care" irrespective of its value to the patient. When pushing the pedal stops yielding a food pellet, the pedal will cease to be pushed.
Does anyone actually tell the family, "what I am going to do will not return to you the (fill in the blank)you knew." The best I can do is prolong his/her existence.
BTW Obama is transparent-you can see right through him

Anonymous said...

Physicians need to stop death prolonging care. Many people want to die at home with loved ones, but supporting a family to make that possible is harder to pay for then state of the art care. Plus primary care folks don't make housecalls, are joining large institutions, and are probably less likely to know families well in high tech, large practice environments when a totally different doc like hospitalist cares for the family during acute illness. Maybe a palliative care nurse assigned to patient families would help. What happens if you refuse to consult on the patient?

Dr. Dave said...

While I have yet to obtain the clinical experience to further understand end of life health care costs I have noticed a potential problem with arguments dismissive of such care.

The hard to define culture of the United States does in general treat the elderly and speak of them as less valuable human beings.

One example I have noticed again and again is the errant dismissal of symptoms, a.k.a. LOL in NAD leading to unnecessary suffering and outright poor medicine.

I suggest we improve medicine at what we now think is end of life costs while keeping in mind that a few decades ago the unsurvivable end of life maladies are now survivable, often with a return to an excellent quality of life.

With the onset of an elderly demographic consuming more and more financial resources of their own and the government's, I for one, will advocate for close scrutiny of plans to save money at the expense of treatment. Otherwise, we may unwittingly overreach our roles as physicians by writing off patients before their time.

Anonymous said...

Did you really think there were two parties who stood for different ideals?

EA, San Francisco said...

As a med school applicant, future surgeon and conscious American, this is probably one of the greatest blog posts I have ever read. I have shared many of your thoughts along these lines, and it is nice to know that you not only have them too but can articulate so directly these broad reaching societal structures. And still get up every day and help sick people, some of whom get better and are utterly grateful. Life in this world is complex and certainly not getting any simpler any time soon, but I love medicine despite all of the difficult issues, as it is obvious you do too. You are an inspiration and I thank you for leading the way for those of us entering the treacherous road ahead.