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Demystifying Medicine One Month at a Time

Category: medical ethics (page 2 of 9)

RIP: Richard Fine (1940-2015)

I didn’t know him, but was inspired by the life story of Richard Fine, which I came across while reading his obituary in the San Francisco Chronicle.

Dr. Fine grew up in Cincinnati, and was educated at Cornell — first the college in upstate New York, then the medical school in New York City. He moved to California in 1966 for medical training, and never left.

920x920Like Zelig or Forrest Gump, he was seemingly ubiquitous at major historical events around that time: He volunteered to provide medical care at Altamont, where the Hell’s Angels, working as security for the Rolling Stones, killed a concert goer. He served as a physician to members of the Black Panthers, who were unable to get medical care in more traditional venues. He also ran a clinic for American Indians during the siege of Alcatraz from 1969-1971.

In addition to his medical leadership, he was widely known for his casual dress (bowling or mechanic’s shirts) and riding a motorcycle as his main form of conveyance.

He challenged the leadership of San Francisco General Hospital to provide care for the poor and uninsured, something we take for granted today but wasn’t at all a given when he was starting out. He was instrumental in helping start both a clinic and a residency program to train young doctors in the principles of social medicine — looking beyond the direct biological causes of illness to social causes, institutional discrimination, and beyond.

As you might imagine, he championed the cause of AIDS victims during the early part of the epidemic when other facilities would find excuses not to care for those infected with HIV. He also was known for improving the care of those jailed in San Francisco, making the case that incarcerated individuals still need care. When Type I diabetics were denied insulin and wound up hospitalized or dead, it made more sense for city supervisors to allow Dr. Fine and his trainees to develop better and more humane care plans for those in jail.

I was touched to read that Dr. Fine’s proteges at UCSF and San Francisco General Hospital were able to name their clinic in his honor. They announced that to him at the debut showing of a documentary film made about him last summer, so he was able to learn of the honor before his death due to cancer.

#MacLean15

IMG_0536Recently I attended the annual conference of the MacLean Center for Clinical Medical Ethics at the University of Chicago. I was a fellow there a decade ago, spending a year steeped in study of the history and mechanisms of making complicated medical choices and attempting to resolve seemingly irreconcilable choices.

The center began in the 1980s, and has trained nearly three decades worth of fellows. As such, the annual event brings back many alumni but also outside speakers and attendees from across not only the U.S and Canada, but also from Europe and Australia. The conference took place at the University’s Law School, where I snapped the accompanying photo of one of the Law School’s most noted former lecturers outside of Classroom V, which was apparently his favorite place to teach.

There were many interesting topics covered at the conference. Among them:

  • Persons donating kidneys are more likely to eventually need dialysis and transplant themselves, and should be informed of such. (Sounds intuitive, but had not been scientifically proven before.)
  • In spite of massive effort, compliance rates for hand washing in hospitals continues to hover near 30% of available opportunities.
  • Frustration with insurance companies approving expensive drugs for conditions like inflammatory bowel disease led one doctor-researcher to ask, “Do insurance companies have medical ethical standards?” (Apparently not; they only have ‘business’ ethical standards.) He used social media to positive effect for some of his patients to get them ‘restricted’ but indicated medication.
  • A physician with a strong humanist bent shared how his frustrations with the practice of modern medicine (productivity constraints, feeling more like a widget in a system than a professional) were put in context by a trainee of his undergoing excruciating treatment for cancer who maintained a wonderful attitude about his life despite his suffering.
  • Several sessions focused on the struggles of the most vulnerable — and providing care for them — children, elderly, veterans, the mentally ill.

That is only a sample of the presentations. Since the center and the conference are underwritten by benefactors, attendance is free and only requires registration.

The Inflection Point(s) of Aging

A new column of mine has been posted on NPR’s website about “de-prescribing,” the art of pruning medications from older adults that take too many of them, a condition we refer to as polypharmacy.

Katherine Streeter for NPR

Katherine Streeter for NPR

It’s well-known that being on too many medications can lead to more side effects and drug-drug interactions, so anything medical professionals can do to minimize such negative outcomes is welcome. Thus we revert to our Hippocratic doctrine: First, do no harm.

Contrast that with the competing ethical imperative toward beneficence — to do good for patients. Medical science teaches us that many (though far from all) of the medications we prescribe for chronic illnesses (e.g. cardiovascular conditions) lead to fewer ‘events’ (think heart attacks & strokes), which prolong lives.

As a result, doctors wind up prescribing a lot of stuff — and decades of medical practice and now guidelines and quality metrics push us to do this even further.

One area I’d like to see science help us is in identifying “The Inflection Point of Aging,” which I define as the point in a person’s life when we can pare down ‘aggressive’ treatment of chronic conditions because it becomes counterproductive: when taking the “medically proper” action is likely to cause more harm than good.

This whole notion arises out of recent discourse: As I recently blogged, the SPRINT Trial, which was stopped early because it showed that treating blood pressure even more aggressively than we’d previously thought leads to fewer bad ‘events.’ How low, I wonder, is too low?

Also, an article in the Atlantic by medical pundit Ezekiel Emanuel titled “Why I Hope to Die at 75” emphasized this idea.

Emanuel is a known iconoclast, but I appreciate his efforts to stir up dialogue and get us talking about important issues that we are otherwise reluctant to discuss. In this case, I think his editors at the Atlantic did him a disservice, because the provocative headline of the article caused a furor and detracted from his real message, which was simply this: There comes a point where undergoing standard medical practices no longer makes sense. That point is different for everybody and is dependent on a person’s values as much as their physiology. Emanuel never said he wants to die at 75, merely that he plans to stop seeking medical interventions at that age — two very different ideas.

If you click over to the NPR column, you can see that anecdotally, we care for patients for whom physiology does change — and it therefore doesn’t make sense to keep doing the same things over and over. It’s trite to say it (and you’d be amazed at how challenging it can be to fight medical inertia), but we must think about each patient individually and truly weigh the risks and benefits of adhering to population-based norms and recommendations when goals and bodies change.

A Fundamental Health Disparity is Reduced

tulsa_disparityWhen we talk about disparities in health care, there are many: access to care; the costs of care; the quality of care; and of course, the outcomes of our crazy, ill-designed, patchwork health care “system.”

Perhaps no disparity is more stark than that revealed by a regional analysis of how long people live on average, compiled by zip code. Our life spans, after all, are a complicated product of our health —determined as much (more!) by societal and economic forces as well as health care.

A decade ago in Tulsa county, we found that the life expectancy of people born in zip code 74126 was on average fourteen years less than those born in zip code 74137.

This is not unique to Oklahoma. The Robert Wood Johnson Foundation conducted similar analyses for other metro areas and found gaps of fourteen years in Kansas City, and an astonishing twenty-five years in New Orleans.

Knowing what we now know about the importance of early childhood in brain development, educational attainment, and health outcomes, many think that improving this fundamental disparity will take generations.

Some good news, then: the Tulsa Health Department re-did the analysis-by-zip-code and found that the gap had diminished–by three years!

The analysis only reports the outcome of a reduced life-expectancy gap. As to the reasons why, we can only speculate.

One editorialist looks at the community’s openness about its failings and its collective investment: $46 million over the last decade from public and private sources to build infrastructure (clinics, offices, etc.) and bring health care professionals to areas that lacked them.

This is pretty heady stuff, to be honest. It shows that collective action in pursuit of a complicated goal has to be pursued on many fronts. And most importantly, that we still have a long way to go.

Truth Is Stranger Than Fiction

220px-Michael_ShadidThe year was 1929. Bad economic times were upon our land, and would only worsen.

A doctor born in far-away Lebanon found his calling helping distraught Midwestern farmers find their way to health care, where previously they’d had almost none.

For years the doctor had been haunted by the fact that hundreds of farm families scattered throughout the Great Plains country were not getting adequate medical attention. He saw first hand the tragedies among medically forgotten rural Oklahoma and Texas: farmers dying of ruptured appendixes, their wives and children defenseless against the ravages of pneumonia, diabetes and tuberculosis.

In tiny Elk City, Oklahoma, he helped open a cooperative hospital, where farmers from ten surrounding counties each chipped in to become shareholders in the new enterprise so that they and their families could receive heretofore unaffordable medical care. He had based his idea on farm cooperatives, in which farmers would collectively fund costly items like a cotton gin.

For his efforts, Dr. Michael Shadid was pilloried by his fellow doctors and the local medical society:

He almost lost his medical license for the unethical solicitation of patients. Doctors were reluctant to work for the Community Hospital if it meant defying the medical establishment. But the farmers who relied on the hospital rallied behind Shadid. “We think more of the few dollars invested in the Community Hospital than any investment we have ever made,” said one farmer. “I think this bunch fighting [Shadid] should be sat down so hard it would jar their ancestors for four generations.”

Change is hard, and unfortunately its disruptions often release vehement emotions. 

Hat tip for this post goes to Mr. Garrison Keillor.

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