Practicing Three-Star Medicine
[Guest post by DRJ]
Although she practices medicine in Texas, Dr. Stella Fitzgibbons published an Op-Ed in the LA Times today in which she chronicles the hardships she faces each day as her patients demand top-notch care when something less would suffice:
“Consider the case of a man I’ll call Mr. A. At the age of 80, he is admitted to intensive care after a huge stroke. He also has pneumonia and kidney failure. He is too sick to tell us his views on aggressive care at the end of life, but his family is happy to fill the void. They insist we use every tool at our disposal to prolong his life, despite brain scans making it clear that he will never again be able to walk, talk or feed himself. The total bill for the last month of life? Many tens of thousands of dollars.”
Fitzgibbons provides other examples. She refers to this as patients wanting “four-star” medical care when “three-star” care would do. Her message? It sounds like Fitzgibbons want us to know that unless the government dramatically increases funding of ObamaCare, we should get used to a different quality of care.
I think most Americans already see that coming, although some of us have already experienced it with doctors who have plenty of money but a deficit of time and patience.
— DRJ
if we relied of medical savings accounts for paying our own medical bills, the family would then find it easier to make a more reasonable decesion. I personally to not want to live in that condition, that is why I have a living will (or rather a death will?)
rwallis (cb7ef2) — 6/18/2010 @ 3:01 pmIf we had doctors and hospital staff that first demonstrated interest in the patient and the family first rather than getting an answer to “what’s the code status?”, and lawyers who were content to go after malpractice instead of litigation bingo and making every doctor seem like a selfish incompetent, maybe patients and their families wouldn’t feel that they were about to be put adrift in a small boat on a big ocean with no supplies.
It’s amazing what a little bit of human decency will do, at least it seems amazing to those who don’t practice it.
MD in Philly (5a98ff) — 6/18/2010 @ 3:11 pmSometimes, I wish that they did have different levels of care. For difficult, life-threatening or mysterious symptoms/diseases then use 5-star. If you have a belly ache and are looking for the type of medicine practiced about 40 years ago (take an antacid, rest and don’t overeat) then 3 star might just do the trick. Of course the price for the visit needs to be proportionately less.
Why is the Health system the only area of commerce where the responsible person/patient doesn’t know how much a treatment will cost before agreeing to the procedure? Because the costs are adjusted according to the ability to pay and who your insurance provider is.
jakee308 (ace517) — 6/18/2010 @ 3:23 pmFor healthcare to become affordable and fair, prices should be established for procedures or processes of cure that are uniform and transparent. Enough of the cost shifting. (I know, I know. I’ll leave the windmills alone for now and put away my lance. but I’ll be back!)
It seems to me that this doctor likes euthanasia a bit more than I would want from someone taking care of me.
snaggletoothie (ac269d) — 6/18/2010 @ 4:13 pmWhat snaggletoothie said. I would not want this lady anywhere near anyone I love.
nk (db4a41) — 6/18/2010 @ 5:07 pmSo to snaggle and NK… where do you draw the line, particularly when you’re spending other peoples’ money?
Are you paying out-of-pocket for all that end-of-life ICU care? If you were, I don’t think anybody would say one word to you about it.
Unfortunately, insurance, whether public or private, is the use of a common pool of money. The good doctor is lamenting the seemingly unlimited individual choices/demands on that common pool of money, particularly when it’s a pie-in-the-sky, hail-Mary move, and unlikely to do any good. Every physician sees patients like this, where the unrealistic expectation of patient/family/friends leads them to demand “everything be done” in the face of overwhelmingly negative prognosis.
And if you’re not paying the bill… why not?
And no doctor wants to be the one to say “No. Enough” lest they be dragged into court, where weeping family members will point shaking fingers at the doctor from the witness stand, with tear-streaked faces, and wail “and that man killed my father!”
TheNewGuy (114368) — 6/18/2010 @ 5:36 pmIf Mr. A has paid his premiums on time and the procedures are covered, this doctor should mind her own business and give the customer what they damn well paid for. It was always a simple matter of physics that you can’t insure 30 million more people, at the same cost, and without a decrease in quality all at the same time. It’s really pretty elementary but in light of the empty suit we just elected president, we are not the sharpest tools in the shed now are we?
stout77 (c2d8fe) — 6/18/2010 @ 7:00 pmAnd no doctor wants to be the one to say “No. Enough”
– Comment by TheNewGuy
That may be true in your experience, but I have encountered numerous doctors (as a physician and as a patient’s family member) who have no trouble at all doing this.
It is disturbing when the first question in the ER is, “Do you have a living will? Do you really want us to put you through all that stuff if your heart stops beating?” (Yes, hyperbole). I was present when a doctor asked my grandmother, “[Why aren’t you dead yet] Don’t you want to see Jesus?”
So count me triple on snaggletoothie and nk. When a doctor is more interested in knowing a patient and their medical history than asking why they’re “hanging around too long”, then I’ll trust their counsel.
I find the docs’ ranking of 4 star and 3 star treatments a little strange, although perhaps she is thinking in terms of restaurant rankings of price. I usually think of “star rankings” of how good something is.
I prefer 5-star medical care, which means when a person has complaints of a common cold, the amount of time and resources is reasonable for a common cold, not having to do Xrays to CYA; and when a person has multiple complicated problems taking enough time to adequately address them all and hopefully maximize life and minimize hospitalizations. This will be easier as the doc needs to spend less time hagling with the insurance company and more time with the patient.
I think docs should start keeping track of “billable hours” for the time the insurance company wasted their time.
MD in Philly (5a98ff) — 6/18/2010 @ 7:09 pmMD in Philly, the insurance companies don’t only waste your time, they eat your staff’s time as well. I know, you already knew that.
norma (4d2079) — 6/18/2010 @ 9:05 pmto provide four-star medicine when the three-star version is almost as likely to succeed.
— That’s a tricky phrase there: “almost as likely”.
They insist we use every tool at our disposal to prolong his life
Icy Texan (d1faea) — 6/18/2010 @ 10:08 pm— Well, how . . . DARE they try to keep their loved one alive!!! Don’t they know that the needs of the state come first?
This is going to get so much worse than projections.
Our best and brightest are going to opt for something other than med school. And as conditions get worse and clients get ruder (as they do when they feel entitled to Uncle Sugar’s sweetness), even fewer.
The problem with medical care is scarcity. Everything else got cheaper, so more people could afford health care, which got more and more relatively scarce.
A lot of the ones who will persist will simply love helping folks. But a lot of the ones who persist will be a lot like this woman, who are tuned into the idea of settling for what’s best for the ruling class.
Dustin (b54cdc) — 6/18/2010 @ 10:18 pmMy biggest problem with this is the “last six months of life” are the most expensive. My paternal grandmother had a heart attack in 1984. Every Doctor who treated her stated she had 3 weeks to live at the most. She finally died in 1999 and was healthy and active all of those years.
Who deciides when your “last six months” start?
Have Blue (854a6e) — 6/18/2010 @ 10:21 pmWait a minute. Now who is saying you should die quickly?
Arizona Bob (e8af2b) — 6/18/2010 @ 10:22 pmArizona Bob – And the same people who screamed about Republicans saying, “Don’t get sick!” decided that their plan was going to focus on preventitve medicine, as in, “Don’t get sick!”
Have Blue (854a6e) — 6/18/2010 @ 10:26 pmHave Blue,
If the Democrats get their way, they will decide when your last six months start.
Machinist (497786) — 6/18/2010 @ 10:48 pmAnd arguments may be sedition, or at least unpatriotic.
Machinist (497786) — 6/18/2010 @ 10:49 pm13.Wait a minute. Now who is saying you should die quickly? – Comment by Arizona Bob
Doctors of grandmothers, Have Blue’s and mine.
Comment by Have Blue –
MD in Philly (5a98ff) — 6/18/2010 @ 10:58 pmYour grandmother was probably too nice and had better things to do, but a birthday card from her to the doctors every year she was “living beyond her life expectancy” would have been a nice touch and a useful reminder to realize they cannot predict the future.
Very first time I took my father to the ER for his first heart attack, six years before he died, the admitting nurse asked “Full Code?” I said “Intubation only by an anesthesiologist with a laryngoscope. He has ankylosing spondylitis and his neck cannot be manipulated”. He just nodded and wrote it in the chart.
My father was a former Teamster, with Medicare and very good retiree’s insurance from Wyeth. But it was also a Catholic hospital, founded by Polish nuns, who give as much as a 100% discount on the bill for self-pays who make less than 400% the poverty level.
I’ve always liked Catholics and Polish girls, but I gave them a new higher level of respect with my parents’ experiences.
nk (db4a41) — 6/18/2010 @ 11:08 pmIt is disturbing when the first question in the ER is, “Do you have a living will? Do you really want us to put you through all that stuff if your heart stops beating?” (Yes, hyperbole)
That’s disturbing to you? Really? And you’re a physician? What specialty?
Far from being hyperbole… that’s simply something the ER staff needs to know before the issue is forced. Code status is a perfectly legitimate question when somebody rolls into the ER. Going against a patient’s express wishes is assault, and while it’s unlikely to be prosecuted, we should actually care enough to ask what the patient wants, rather than merely paying lip service to the patient-centric model of medicine.
I have a living will. I’ve had one since I was a medical student, primarily because I’ve seen the unspeakable horrors that can be visited on a helpless, terminally-ill person in the last days of their life.
If I’ve made the decision that I’m to be “let go,” and made comfortable, I expect that information to be sussed out and followed… and I’d be pissed as hell at some laryngoscope cowboy who reached for the Etomidate before at least asking the question (assuming somebody is available to answer it)
TheNewGuy (114368) — 6/19/2010 @ 12:28 amThere’s always time to die, New Guy. I believe MD in Philly and I are talking about something else. Both my parents died at home. I was not going to let them go. The day before my father died, he could not raise his hand to stroke his grandaughter but he could look into her eyes and smile. My mother stopped being able to swallow. I would moisten her lips with a swab with water and she would aspirate it. Didn’t matter. Life is a rare and precious thing.
nk (db4a41) — 6/19/2010 @ 12:36 amI will admit that I was very angry with my mother’s treatment at one ICU. But her caregiver and my brother and my sister in law and I took over, spoon-feeding her thickened liquids over the course of an hour that the nurses could not be bothered to do. That’s fine, too.
nk (db4a41) — 6/19/2010 @ 12:45 amFlush out your head gear, New Guy.
I don’t actually have any comment to make, I just like using that line.
Patterico (c218bd) — 6/19/2010 @ 12:48 amHappened early in my career. A lady rolled in the ER looking septic. Awake, but some respiratory distress, crappy BP, acidotic, etc. Husband was right outside in the waiting room, but instead of talking to him, I proceed with the full-court press. On clinical exam, it’s obvious she had terrible Scleroderma, and could barely open her mouth enough to pass an ET tube… forget any kind of laryngoscope. I ended up tubing her sitting up, over a bronchoscope (she was stable enough that we had time to set it up). As we’re getting that all secured, she codes… straight to asystole.
We get her back with some epi, and actually ended up using an epi drip to keep her BP up as we’re pounding her with crystalloid. At this point, feeling a little bit of satisfaction as having succeeded in such a difficult resuscitation, I go out into the waiting room to advise the husband of what’s going on. I explain how sick she is, but advise him she’s on a breathing machine, we’re supporting her blood pressure…
And the husband, a grizzled old WW2 vet, literally collapsed, weeping, right in front of my eyes. Dumbfounded, I went to help him up, and he choked out “but she didn’t want any of that!”
Ever had that “about an inch tall” feeling? Bet it wasn’t as bad as that.
She was a no-code. Actually had stage-4 metastatic breast CA in addition to her end-stage Scleroderma. All of this was known to the husband, and he had the paperwork, but nobody thought to ask. We were too busy doing what we thought she needed, rather than asking what she wanted.
I always ask.
TheNewGuy (114368) — 6/19/2010 @ 1:14 amI dunno. Maybe no feeding tube or intubation through the nose, with Versed to make it tolerable but it makes you not know your loved ones. I dunno. I see my parents in my sleep and I regret nothing I did to keep them with me as long as I could.
nk (db4a41) — 6/19/2010 @ 1:23 amComments by TheNewGuy-
I’m going to assume at the start that we are in more agreement than disagreement, but are approaching it from two different directions. (FWIW, family practice, with a lot of HIV and chronic Hep C patients.)
As you said yourself, in the nightmare case you present, it would have been good for someone to get more history while you and others were in action. Had that been done, perhaps the info could have deen relayed earlier and averted some of the difficulty that came later.
The scenario I have in mind is my grandmother presenting to the local ER, being seen by the cardiologist who was acquainted with her condition, telling me that her blood pressure is low “because her heart just can’t do it anymore, and she’s gone into renal failure”. (She had a long history of significant aortic stenosis but a nml functioning heart by echo and by clinical exam/history). This was a number of hours after she arrived, when my mother called for help because the docs were pressing her on the “no code” issue.
I asked how he knew her heart was failing, if they had done an echo, because I knew about her 10+ year hx of AS and her nml LV function less than 6 months previously. he had no meaningful response, just said, “Well, we know she has bad AS”. When I asked how did they know she was in renal failure, I was told, “Well, she hasn’t made any urine since she’s been here.” I asked what was her creatinine, the answer, “We haven’t done one.”
His main interest still was whether she was to be a “full-code or not”. His real question was, “Should we bother evaluating and treating her?” I tried to tell him, “No, I don’t really want her to be intubated and resuscitated in the event she arrests, but I wanted her to be evaluated and treated, and not dieing because she had an elevated K+ that no one bothered to check. He could not or would not understand my point and demanded a yes or no. Given that choice, I said full code. When she was finally evaluated, her creatine was like 1.3 and her LV function was still completely normal. She had been having nausea and vomiting for 2 days, was taking her usual meds (ACE inhib at high dose) and not eating or drinking; that was why her BP was low and why she was “in renal failure”.
They wanted to let her die without even a proper evaluation. She was about 95 at the time, but had still been mowing her own lawn over age 90 and was no longer living alone only because of her macular degeneration. She was mentally astute and enjoyed interaction with her children, grandchildren, and greatgrandchildren.
It ended up she was suffering from a gallbladder attack with stones blocking the common bile duct. (Her BP and urine output had returned to nml with some IV fuid). The surgeon said (on a Friday morning” that “he could do the operation”, but didn’t think the nurse anaesthetists could handle the case, so “they would need to make a decision”. (Make a decision about what? To not operate or to not operate??) Later in the afternoon they found he was unreachable and had left for the weekend, at which point they called me again.
I contacted a friend in GI, described the case, and asked if she was an appropriate candidate for endoscopic removal of the stones. He basically said, “Sure, we do cases like hers all of the time!”
So, from 600 miles away I contacted the GI department at a Univ. Medical Center, described the case, and was promptly told they would receive her in transfer. That also I arranged. it was there that the Floor admitting attending asked if “She wasn’t ready to see Jesus yet!?!?”. They were more interested in whether they should oppose the procedure than to give her proper pre-op antibiotics, which they almost didn’t.
So, after an additional day of delay, the GI doc took out the stones and relieved the obstruction in less than 45 minutes without any complications.
Yes, it is important to know when a patient is dieing of multiple conditions and wants to be DNR. But it is also important to do a blasted evaluation of someone talking to you before you electively push to not treat.
MD in Philly (5a98ff) — 6/19/2010 @ 12:57 pm