The media is starting to cover a study saying that many people don’t get defibrillated fast enough in the hospital (by docs at my hometown hospital where I worked at the Heart Institute during the summer in college!), and Dr. Wes, our medblogging cardiologist, has already responded . I of course have my own take.

I wonder how many of these cases were slow codes? And what are slow codes?

I had never heard the term until a classmate gave an ethics talk on it last month–and didn’t know they even existed. (Yay Stanford.) From a great article discussing them :

Slow codes, also known as partial, show, light blue, or Hollywood codes, are cardiopulmonary resuscitative efforts that involve a deliberate decision not to attempt aggressively to bring a patient back to life. Either because the full armamentarium of pharmacologic and mechanical interventions is not used, or because the length of the effort is shortened, a full attempt at resuscitation is not made. Unlike a true code, in which time is critical and a state of medical emergency exists, a slow code may seem to occur in slow motion, with staff members stiffly going through the motions, then breathing a collective sigh of relief when the effort is terminated.

They are often done on patients who are thought to be severely terminal, or demented, or whatever else the people running the code view the patient to be. They are anything but ethical. They give false hope to a patient and his or her loved ones that the patient can (and should) be resuscitated–if the act was futile, why would the doctors be performing it at all? They are also certainly futile interventions, and not benign interventions, either.

Why are they done? A couple good lines from the article (which you should really read, it’s quick):

A different rationale is operative when end-of-life wishes have been discussed and the patient or family has stated a wish that “everything” be done to resuscitate the patient. Instead of hearing the request that everything be done as evidence of despair on the part of a patient or family faced with imminent loss, physicians often take such a request at face value. Indeed, the physician may believe that respect for the patient’s autonomy requires an unquestioning acceptance of the patient’s stated wishes. Rather than probing the patient’s fears and concerns and providing reassurance that the patient’s suffering will be treated and that he or she will not be abandoned, a physician may see a slow code as a way out of a dilemma — as having the appearance of respecting a patient’s wishes while lessening the consequent harm.

Patients’ autonomy is frequently cited as the most compelling reason for providing treatment that offers no medical benefit. While some view autonomy in the extreme, as a pure and independent statement of the patient’s wishes, a more encompassing view holds that true autonomy exists only in the context of the physician’s commitment to help a patient achieve that which is in his or her best interest.20 There is also controversy about whether respect for autonomy necessitates the provision of futile interventions. Furthermore, the offer of futile measures can serve to undermine, rather than support, the ability of patients to act autonomously.21

The gist? “Do everything” does not mean a physician must “do everything possible even if the ‘everything’ is going to be futile.” And talk to your patients about their code status, and make sure they and their family members know the severity of their illness. “Do everything” is probably often part of the grieving process (DENIAL), too.

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Wanted to address a few other issues:

Shadowfax comments that perhaps the retainer medicine trend will be a driver of change , saying that in order for change to happen to health care payments and financing, “physicians need to take the hard and painful step of saying, “No, I won’t see you,” to Medicare patients. And that is basically what concierge care is.”

I don’t think this approach that Shadowfax mentions is the right one. There’s a reason that every year, doctors are chosen by Americans as the most trusted profession . Despite some may think of us, they know we work our asses off to care for them. We dedicate our lives to the task. We embody the definition of the true professional: the person that puts the needs of his or her patient ahead of his or her own. We lose that trust from our patients–that we have their interests ahead of our own–and we risk losing much more than just money. (And ignoring economic theory of medical school being an investment in later higher salaries, when you look at it from the average American’s perspective, making $38,000 a year , doctors complaining about only making $150,000 a year will look pretty ridiculous to most of the US.)

I also fail to understand why physicians would be willing to “protest” by joining retainer/concierge practices yet still work within the current health care non-system than “protest” for reforming the entire health care system. Not to go all single-payer on you, but those hundreds of billions of dollars (we can argue if it’s $300B or $100B later) wasted on administrative duplication and entire billing departments in hospitals and clinics sure seem like a great pot of money that we could pay primary care physicians with. Call me crazy. Many do.

And as I’d mentioned before, Josh has been writing a lot about concierge medicine at KevinMD. One post shows a sample practice with a huge reduction in hospital admissions for concierge care-managed patients . That’s great! Fantastic! Awesome! Amazing! I have no doubt that it’s true. If you can spend more time with your patients and watch them closer, you can keep them out of the hospital. Which is good for the patients and great for our health care system. But why should we only provide this to the rich patients (yes, the overwhelming majority of these concierge patients are wealthy) that can afford it? Why not fix our whole health care system so that the diabetic gets a 45 minute visit instead of a 15 minute one?

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We’re having a great debate on the subject of retainer/concierge/whatever medicine, starting with piece by Dr. Centor , an internist I high respect. I fired back this piece and now Dr. Centor has responded . I must give Josh at KevinMD some credit for getting the debate started (but please Josh, post about something else now and then!).

We’ll go through Dr. Centor’s response piece by piece, ’cause I find it’s the best way to address points and give my own thoughts.

Graham is an idealistic 5th year med student (he spent a year doing research.)

Guilty, yes, as charged. I actually describe myself as an “idealist realist” (or “realistic idealist,” take your pick) in that I believe we can always strive to do better and improve: that we should always aim for and want the best. But I grudgingly accept and recognize that reality don’t always jive with that aim. Moving right along.

Upon further reflection, one must evaluate the current status of outpatient internal medicine (because currently the great majority of retainer practices are internal medicine.) Physicians are fleeing from outpatient internal medicine. Our current reimbursement model causes physicians to run on a treadmill, destroys their work life balance, and leads to a constant sense that they are delivering substandard care.

Look at our residents. Very few choose outpatient medicine these days. They either choose subspecialties or hospitalist jobs.

Look at practicing outpatient internists. They are leaving practice at a steady rate. Some switch to hospital medicine. Some go back to do fellowships. Some leave medicine entirely.

I totally agree with you, Dr. Centor. We joke that all the medicine residents at Stanford are going into either Cardiology or GI, because it sure seems that way.

Dr. Centor goes on to talk about the financial disincentives to work in primary care: the poor reimbursement due to third-party payers, the inability to spend the time truly needed with a diabetic, etc. Again, we’re in fully agreement here. I really like this bit:

Most outpatient physicians practice medicine in a way that insidiously harms their self esteem. They know that they are not providing the best care. They know that they cannot provide their patients with the support that they really need.

I believe that most retainer physicians see their practice style as the only tenable solution. I suspect that many of them would have left practice for another job if they did not have this option.

If retainer physicians are unethical, then what about physicians who quit seeing patients entirely and enter medical administration. What about any variety of subspecialists?

And this is where I think Dr. Centor and I are missing each other. My concerns are those from more of a public healthy, health policy lens, whereas Dr. Centor is viewing the situation from an equally valid perspective–that of the primary care doc on the front lines. He makes a great point: if the decision for the primary care physician is between retainer medicine and giving up medicine, that makes the choice seem more reasonable to me. And I have no doubt that many primary care docs believe they simply aren’t able to deliver high-quality care to their patient census. And speaking of ethics, I’m certainly in the guilty field here, as I’m not going into primary care (although I’ll be doing my share of ‘primary care’ in the Emergency Department and seeing uninsured patients, something I love about the field).

Dr. Centor then goes on to talk about how if retainer medicine succeeds, perhaps it will encourage more residents to go into primary care, which would achieve the goals of more primary care physicians in the US.

But hold on here, let’s give my perspective a look with some back of the envelope math. According to the 2006 Bureau of Labor Statistics data , we have
109,400 Family and General Practitioners in the US, and 48,700 General Internists in the US. That’s 158,100 primary care doctors in the US. With about 28% of the US being under 20, that leaves 236,000,000 adults that need a primary care physician. That’s almost 1,500 people per physician.

Say we even took all the physicians in the US–415,630–and told every single one they have to practice primary care. We divide it up again, and it’s still 567 patients per physician.

Let’s be practical here, people–retainer medicine will not work as a model to fix primary care. It will certainly make primary care physicians’ lives better and their wallets thicker (which I’m not opposed to), but it simply won’t fix the problem.

Dr. Centor, the ball’s back in your court.

PS: “Single payer systems do not provide social justice.” Huh? They are certainly far from perfect, but certainly do a better job of providing limited resources equally to all citizens than, say, our system.

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Not sure how much of this is a true increase, but there may be a particularly nasty virus going around that usually just causes the common cold , known as Adenovirus 14. There’s a JAMA report out from the CDC about it just yesterday ; it seems to be causing pretty severe illness in even the young and healthy, putting an 18 year-old in the ICU in Oregon.

Please, wash your hands–no matter if you’re sick or well–before eating, after using the bathroom, before touching your face, all that. And if you’re sick, well, I’m sorry. And that’s what sick days are for. Rest up and get well soon.

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From Med Rants, about retainer medicine:

I urge these authors and their ideological colleagues to look beyond the trappings. I urge them to perform a thought experiment. Why are patients increasingly willing to pay? Why are highly ethical physicians opting for this style of practice? If they are honest, they will find some truths that knee jerk opposition obscures.

Some might argue that these “highly ethical physicians” aren’t so highly ethical by practicing retainer medicine. One ethical framework would suggest if all physicians just practiced retainer medicine, there would not be nearly enough physicians to go around. In that framework, retainer medicine would be viewed as unethical.

(I also don’t really get how Dr. Centor combats the classist and racist arguments he brings up. They’re totally valid, and I can’t help but draw a parallel between retainer medicine and insurance company cherry-picking, the latter I find to be despicable in its bottom-line philosophy. By practicing retainer medicine, you are selecting out for people who can afford to pay extra, and health and SES are intrinsically linked (and also race), so you’re essentially picking out people who are already healthier. If you look at things through an equality and social justice lens, who needs a physician’s help more: the poor, smoking diabetic or the executive with an HDL of 39 who bikes 20 miles a day?) (I however absolutely agree with Dr. Centor that health care financing is a complete and total disaster in the US, but I would argue we need to fundamentally change the system–yes, with all the turmoil and terrible problems and growing pains it would cause–than work within it and continue to try piecemeal approaches we’ve been attempting since the 1970s.)

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A woman with chronic syncope needing pacemaker placement worries about future costs for replacement pacemakers on Ask MeFi . Most posters suggest she move to Canada; one even offers to marry her.

What a mess. Classic example of someone who clearly couldn’t buy her own insurance–it’s doubtful anyone would cover her syncope condition, so she’d be paying hundreds of thousands of dollars over her lifetime for her “pre-existing condition.” Just one of the many problems with an individual mandate.

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Don McCanne points me to To Great A Burden (PDF), a report by Families USA which analyzes data on health care expenditures, and finds some pretty scary numbers and trends (my emphasis below):

• More than four out of five people in families spending more than 10 percent of their pre-tax income on health care costs are insured.
• 50.7 million non-elderly Americans with insurance are in families that will spend more than 10 percent of their pre-tax income on health care costs in 2008.
• More than three out of four people (75.8 percent) in families spending more than 25 percent of their pre-tax income on health care
  costs are insured.
• 13.5 million Americans with insurance are in families that will spend more than 25 percent of their pre-tax income on health care
  costs in 2008.

My point? These are the insured we’re talking about. The people who we quickly call “the covered.” And it’s gotten significantly worse in only 8 years:

Wake up, middle class. You don’t want to risk health care reform when you’re satisfied with your care, but how long until you’re part of the insured millions of families spending 25% of their income on health care?

And wake up, political candidates (and bloggers) that support individual mandates or continuation of the hodgepodge mess of private plans we have here–with their lifetime caps and pre-existing conditions, even the insured here are getting the rationing everyone’s so scared of under some sort of national system.

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Great Op-Ed from David Himmelstein and Steffie Woolhandler in the NYT about single-payer and employer mandates. The latter have been tried many times in many forms, and they still are failing.

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ABSTRACT : Since enacting comprehensive health care reform in 2003, Maine’s Dirigo Health program has helped expand coverage for low- and moderate-income individuals. By September 2006, about 16,100 individuals were enrolled in two coverage initiatives: DirigoChoice, a subsidized insurance product, and a Medicaid eligibility expansion for low-income parents of dependent children. While these programs are making health coverage more affordable to low- income individuals, small firms, and sole proprietors, with subsidies targeting those most in need, by late 2006, the initiatives had enrolled less than 10 percent of previously uninsured residents. To pay for this expanded coverage, Maine has utilized savings in the overall health care system due to lower uncompensated care and cost controls. However, the funds raised thus far are insufficient to pay for greater subsidized enrollment in Dirigo programs, leading to a search for other financing sources to sustain the program.

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Canada’s single-payer system began in 1957, with several revisions years later. Man, 50 years under a socialized medicine, government-run scheme. Canadians with their single-payer system clearly have no motivation to innovate–because where’ the profit? Funny, then, that Canada’s had plenty of medical innovations :

• 1958 World first surgical treatment on cerebral aneurysms. (Lawson Health Research Institute — London, Ontario)
• 1960 First implanted mammary artery into the heart wall in order to restore functionality of the heart. (McGill University Health Centre Research Institute — Montreal, Quebec)
• 1965 First artificial knee joint in the world created. (McGill University Health Centre Research Institute — Montreal, Quebec)
• 1969 Discovery of a carcino-embryonic antigen, a tumour marker for cancer. (McGill University Health Centre Research Institute — Montreal, Quebec)
• 1987 World’s first pacemaker cardioverter defibrillator is implanted. (Lawson Health Research Institute — London, Ontario)
• 1989 Discovery of the gene which, when defective, causes cystic fibrosis, the most fatal genetic disease of Canadian children today. (The Hospital for Sick Children — Toronto, Ontario)

And on and on and on…

(via The Executive Physician)

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