Monday, April 16, 2012

I'm Sorry I Have to Sue You

I felt sad when I went to make rounds in the hospital.  One of my patients, a colleague, had been readmitted in poor condition for recurrence of a primary lung sarcoma.  I spent a few minutes examining Dennis and chatting.  He then, with a quizzical look, said, "Jim, I'm going to have to sue you.  I know I'm dying.  My wife Alice and the kids are still pretty young."  He saw my look of surprise and added, "You know, I don't have much life insurance or other very significant funds for them to live on.  It's nothing personal.  I know you've given me good care, but my wife is upset and tends to blame you for the outcome.  I guess the hospital and others will be named."  There wasn't much more for me to say at the time except, "Dennis I can find another attending for you if you'd like."  He replied, "No, I want to stay with you."

Dennis was a well liked family doctor.  About five years earlier a "coin lesion" was discovered on a chest X-Ray.  This 2cm spot in the right upper lobe had a smooth rounded border and didn't contain calcium.  A CT scan showed no enlarged lymph nodes and no other spots elsewhere.  A needle biopsy of the spot was not diagnostic.  We knew the spot was new because an X-Ray five years earlier was normal.  He hadn't traveled to an area where Valley Fever or other fungal infections were common.

At surgery, the right upper lobe was removed along with local lymph nodes.  The lesion turned out to be a primary lung sarcoma, a quite unusual type of lung cancer.  One of the lymph nodes was positive.  We sent Dennis to local experts on sarcoma and several opinions from cancer specialists were obtained.  The consensus at that time was that sarcomas don't respond very well to either chemo or radiation therapy, but after further opinions, Dennis had a series of radiation treatments.

After that it was waiting.  For three years, there was little change.  Then fluid began to accumulate in the right lung cavity and some density in the area of radiation (often radiation changes).  I drained the fluid from Dennis' chest several times.  No cancer cells were found.  After more signs of progression but no proof of recurrence, I sent Dennis to the top academic chest surgeon in the area who admitted Dennis to the hospital.  After more conferencing there, he attempted a complete removal of the right lung in order to try to remove all the residual tumor.  Dennis had a very stormy post-op course and required ICU care and a ventilator for almost three months before being successfully weaned off.  However, the sarcoma was never completely removed, thus still progressing.

He was then transferred back to my hospital where I met with Alice.  Somehow I was the focus of her anger about her husbands tragic illness, and extensive suffering especially over the past year with heroic attempts to deal with the recurring sarcoma.  We had social service and others involved.  To say the least it was awkward to remain involved knowing that a legal threat was in the air.

Hospice met with Dennis and Alice.  They mercifully stepped in and provided their healing palliative care.  Although plans were made to have hospice at home, Alice balked.  After a few weeks Dennis died peacefully in a hospital hospice unit.

Comment:  As I think about Dennis and Alice, I wonder what I could have done better in communication.  I'm not sure.  I did find out that Alice tried to find a plaintiff's attorney to file suit.  They had several experts review the records, but they all advised her that she had no reasonable grounds to forge ahead legally with her complaints.  I felt Dennis' care had been good and wasn't very concerned, but was reminded that it often takes several things to bring about a medical malpractice claim:  a poor outcome, communication breakdown, anger, and a mistake or oversight of consequence.  Our tort system is cumbersome and expensive.  It's not the major factor driving medical costs these days, but is significant and will need reform.  But can we ever get there?

Saturday, April 7, 2012

Health Care Costs - the Leaky Bucket

Recently I was sent this commentary on the issue of health care costs.  It seemed like a pretty good summary of the problem to me, though it didn't delve into solutions or the current controversy about the Affordable Health Care Act.  In our country, we've built up a huge medical-industrial system that can do lots of good but at a huge cost.  It seems that we are on the brink of a "health care-cost bubble" because we are now dragging down economic growth with continued double digit rising insurance rates.  Individuals, small businesses, corporations, and government entities are all crying for relief from this health care cost burden.  An example of the medical-industrial complex is in the area of sleep apnea treatment.

A splashy story about a successful company in San Diego, ResMed, was published in the Union Tribune recently.  Not much was said about their medical devices but their CEO  has "spent $10 million so far for art in the company's 18 locations around the world".  Apparently it's felt that these millions spent for art help to inspire the workers.  This is a small example of the extraordinary spending in the medical-industrial complex.  Multiple profitable health care businesses are benefiting from the "piggy-bank" bulging with growing health care dollars.  Many MD's in top administrative positions in non-profit hospitals make more than one million dollars.  Now, I understand that most of the drug companies, device makers, glass and steel hospitals, procedure doctors, medical directors, CEO's, scanners, robotic devices, etc. are wonderful, but just not wonderful in their current excesses.  The challenge is to change incentives in order to bring costs down.

There are a number of possibilities for improvement, and one of the smartest of the innovators is Dr. Donald Berwick.  This Harvard Pediatrician recently had to step down after about a year and a half as the head of the Center for Medicare and Medicaid Services.  He was a recess appointee by President Obama and had no chance for a permanent appointment by the US Congress.  Kaiser Health News recently noted the top five accomplishments at CMS by Dr. Berwick.  His leaving is certainly a set-back to accelerating reform, however he remains a nationally respected promoter of quality improvement.

The Hastings Center, a non-profit which deals with ethical issues, has published a Health Care Costs Monitor containing several articles with different takes on the issue.  One by ethicist Daniel Callahan deals with the cost of end-of-life care, a problem in every ICU in every hospital in the USA. 

Recently the New Yorker reported that, "Yet, strange as it may sound, the federal government does not have a spending problem per se. What it has is a health-care problem. The cost of most budget items typically rises at a reasonable rate, if at all, but the cost of Medicare, Medicaid, and the tax subsidy for employer-provided insurance has been rising much faster than everything else..."

Dr. Berwick has shown that there's good evidence that we can still maintain and improve quality while trimming costs.  But do we have the political will?  Every dollar spent is "benefiting" someone.  In the equation are the patient, doctor, administrator, nurse, other providers, clinics, hospitals, device manufacturers, drug companies, lobbyists, research tanks, politicians, pharmacies, nursing homes, unions, AARP, insurance companies, Wall Street, etc.

Some doctors and medical specialty societies are addressing the problem of overuse of technology.  These physicians look at the research evidence and encourage limiting unnecessary testing and treatment.  Although this isn't rocket science, it is quite hard to implement change in both lucrative medical procedures and the desire by some patients to "do everything."

It seems like a huge bucket of largely poorly controlled health dollars is being sprinkled around with often ineffective and wasteful administrative attempts at control.  Let's hope we find ways to get a much less leaky bucket soon.  Our medical-industrial system is long overdue for a real wake-up and shakeup.  Here's an example from an interview with Stanford economist Victor Fuchs.

Monday, April 2, 2012

Leaving a Legacy

Have you ever thought about what you want to leave behind.  I'm not really referring to estate planning or legal documents.  I'd like us to think about a legacy of values and ideas, something that is uniquely you that you'd like others to know about.  Perhaps you could be an influence on another life as yours may be ending.  In the past, oral tradition played the major role, then written letters, now it's digital media. 

A non-profit called StoryCorps is doing a very nice job of bridging the generational divide by providing the opporunity of record, share, and preserve stories of our lives.  A currently featured story is a conversation between a son and father, as the latter is facing metastatic incurable cancer.

Another way of communicating is to prepare an Ethical Will.  This can both be a spiritual or moral legacy as well as a way of stating your values.  This document can be incorporated into your advance directives for end of life decision making.

StoryCorps reminds us that very important conversations not only need to take place, but that recording them provides a special way to link to present and future generations.

The funeral as we know it is becoming a relic — just in time for a death boom

By   Karen Heller April 15 Ed note: Funerals are changing in ways that will bring culture shock and a shake of the head of s...