'Whose body is it, anyway?'

"Little more than a decade ago, doctors made the decisions, patients did what they were told. Doctors did not consult patients about their desires and priorities., and routinely withheld information - sometimes crucial information, such as what drugs they were on, what treatments they were being given, and what their diagnosis was" (Complications, 210).

Gawande points out a striking turnaround in attitude towards patient competance and points out a crucial fact later in the same passage--while doctors are the experts on medical knowledge, only patients can have the fianl authority on personal matters. At the junction of these two pools of information, views and values is where the doctor-patient relationship ought to reside. He additionally highlights that patients do not want that autonomy, especially under stressful circumstances. Some sort o fbalance is required respecting botht eh patient's right to information and control in their care as well as the physician's abilities and experiences--without which a doctor would be nothing more than a gatekeeper to prescriptions and procedures. It seems that both patient and doctor need to be open and honest about their preferences and recommendations so that a consensus can be reached between them.

Paternalism as less than Evil

In his article, McKinstry categorizes the doctor-patient relationship into four classes: the autocratic doctor, the paternalistic doctor, doctor as agent, and patient yielding autonomy. Reading through these descriptions, I couldn’t help considering these as rather absurd and highly theoretical lines with little practical applications. As Dr. Pacheco, the family physician who came to speak last week, suggested, many patients actually come to her needing some level of hand-holding. Although we might feel it unfair, as physicians, we’re bound to frequently be asked questions like, “What would you do if it were you or your beloved one?” Especially in a society like modern America, the patients are asking their doctors for a genuine personal opinion, with the fundamental understanding that their ultimate choices are their own.

Therefore, I wonder if “paternalistic” medicine is necessarily something to be bashed. Years ago, in settings where widely accepted customs deified doctors to the levels of figures whose opinions had to be upheld, paternalistic medicine might have been manipulative, even abusive. However, today, “paternalistic medicine” to me sounds a lot less cold and more personal, even more intimate.

McKinstry’s categories of the doctor-patient relationship must all be mixed and balanced. To say that the figures of the autocratic and paternalistic doctor must completely be demolished, however, would be ignore a pragmatic need by today’s human patients.

Paternalism in the Doctor-Patient Relationship

One of the biggest issues in the doctor-patient relationship is the worry about paternalism: are doctors too forceful in their patients’ treatments? What is the appropriate balance between doing what you think is best for a patient, and respecting that patient’s wishes if they don’t agree with your medical opinion?

Paternalism springs from the idea of the “father knows best” physician whose authority is unquestionable. I was moved by Gawande’s book because he reveals doctors as human beings. It is natural to think of a machine as unyielding, but it is hard to believe that is impossible to change a human’s mind. Doctors are under a lot of pressure to deliver, and when a patient’s wishes deviate from their idea of excellent medical treatment, they may feel as though the patient is actually trying to hinder their plans. In order to take on paternalism, we have to decide if the doctor’s obligation to provide the best medical care possible or to respect the patient’s wishes is more important. It’s possible to strike a balance, but the specter of paternalism will always loom so long as these two obligations are in conflict.

This is complicated by the rise of the consumer-patient, who is armed with online medical advice and bombarded by the seductions of DCTA. Many have argued that the age of information has allowed the patient to take greater control of his health and healthcare. However, others worry that this deluge makes patients more susceptible to quackery. It’s important to remember that this kind of changed relationship is only possible among those who have access to these online advice sites in the first place, and who have the confidence to interpret them, giving the doctor-patient relationship new sociopolitical implications. But a similar phenomenon has existed for much longer with regards to so-called “folk” remedies, which were taken not as a form of alternative medicine, but the medical truth. It is paternalism to reject a patient’s right to perform bizarre rituals, or to disallow a patient to pray in lieu of medical treatment, etc.?

As Kiminstry argues, just as it is paternalistic to deny a patient’s wishes, so too is it paternalistic to deny the right of a patient to yield authority. Many patients, especially those who don’t frequent WebMD, still defer to doctors, asking, “What would you do if it was you?” Just because a doctor doesn’t want to be perceived as paternalistic doesn’t mean he should take a hands-off approach and serve only as a distant provider of options—he should be allowed to infuse his medical opinion into that presentation, but realize that it is just that, an opinion.

Paternalism: Are we overreacting?

I think that like all ethics movements, the medical ethics debate can at time take on an extremist stance. There's such a fear in stating medical opinions or best options (among healthcare professionals), that this fear ultimately ends up affecting medical care. I think that doctors should hopefully have the experience and knowledge to ascertain what is the best medical option/treatment for patients.

Dr. Gawande discusses how most "well" people say that they would like to dictate their healthcare decision, while only 12% of cancer patients say they wouldn't want to defer to the advice of their doctor. I think that doctors have a duty to provide explanations about all possible treatment options and to provide objective advice about medical therapies and risks; however, I do think that patients and families appreciate a certain degree of subjectivity and personal preference.

Dr. Gawande recounts his own experience when his youngest child was hospitalized for a respiratory infection and the doctors and him debated whether or not his daughter should be intubated. He emphasizes that he wanted the doctors to be the decision makers so he wasn't forced to feel the guilt of a (possibly) wrong decision. I think it's fair to say that even for non-doctors there is a certain comfort and deference in responsibility in having someone else decide the best healthcare option. As patients we assume that the specialist has more exposure to a various condition and treatment options and we acknowledge that the medical profession exists as a remedy to our own limited knowledge.

I understand the sentiment that patients have a right to know about their medical condition. However, I think it's ironic to note that many families ask doctors to withhold information about a prognosis or disease. But I think that allowing patient's to be "autonomous" decision makers who are embarking on a bad decision creates a whole new frustration for doctors. It goes against medical training and the professional teachings to withhold treatment or allow patients to choose a bad alternative. I think that medical ethicists ought to acknowledge that medical care cannot always be simply reduced to preserving patient autonomy. This becomes clear in Gawande's recount of a patient with pneumonia who was certain to die without ventilation but refused the treatment. Subsequently, when the patient passed out he was intubated. I think that these scenarios are not clear cut and doctors feel a professional obligation to do what they believe is in the "patient's best interest" in spite a patient's explicated desires. If a person presents themself to a doctor or medical institution for care, I think it is fair for doctors to act in a manner to provide them with the best possible outcomes- it seems to be a deference we should make to their training.

Technology in the Doctor-Patient Relationship

It’s no coincidence that both of our selected readings mention advanced medical technology in discussing the doctor-patient relationship. In a field constantly changed and shaped by the biomedical engineering and technology industries, it’s almost as if the doctor, patient, and technology must form a troika to get the job done. Without doubt, even the now-jaded technologies like the phone enables closer-knit patient-doctor relationships. Primary doctors, surgeons, and technicians have the necessary information to contact their patients with updates on diagnoses and treatments at any time. Though this has helped many doctors be more professionally active and personally caring, it’s important to note that only a fraction of doctors actually use the phone to regularly make home calls. There is probably no doctor without a phone in his or her office, and certainly no doctor without a cell phone that can reach any of his or her patients. There are many technologies available out there, and infinite possibilities for advantageous manipulations that can render existing technology even more powerful for interpersonal relationships. Therefore, availability and innovative ideas are not the limiting factor.

More and more physicians are getting board-certified to appeal to potential patients. Private clinics and hospitals flaunt national acknowledgements of their facilities’ cutting-edge technology or renowned house staff. I wonder if there could also be a more standard system for ranking or acknowledging genuinely superior doctor-patient relationships, for either individual doctors or whole institutions. These analysis systems should incorporate a measure of how well medical technology is adapted to strengthen the doctor-patient relationships. To ‘prove’ an honest effort at better doctor-patient relationships, doctors and institutions will surely become pressured to adopt and utilize more measurable tools for effective communication and personal caring. Wider use, higher standards by patients, and continued demand will in turn help the bio-medical technology market to flourish with more economical and innovative technological tools for strengthening doctor-patient relationships.

The Doctor -Patient Relationship

The Doctor-Patient relationship seems to be the most elusive of all of the aspects of medicine that we are seeking to understand and one day participate in. As we looked at in previous weeks, medical schools seem to spend most of their energy teaching students basic sciences, and about normal and diseased human bodies. However, it is often the doctor-patient relationship that has the most impact upon patients and is most sought after by doctors.

In Bedside Manners we read of a patient who, despite every effort put forth by his physician and surgeon, died due to noncompliance. On the other hand, some patients benefit simply from the care and support they receive from an accessible and compassionate physician. How future doctors learn to embody this example? What opportunities are there for those entering into medicine to learn or fine-tune their abilities to communicate, empathize, and collaborate with patients? Is this something that can even be taught?

In our med. student panel last Thursday we heard of a new "doctoring" program in the Alpert Medical School that allows students to follow physicians as well as to practice patient skills on patient-actors. This step is certainly evidence of strides that are being made to answer the questions above, but can students be taught empathy? I've heard of certain phrases offered to medical students to use in difficult situations such as "That must be hard for you" -- does this undermine a doctor's ability to develop genuine relational skills and bonds with their patients by providing a 'one-size-fits-all' script?

Doctor-Patient Relationship

I was very moved by the readings in Bedside Manner this week. The field of medicine itself is so complex, but for me, nothing more so than the doctor-patient relationship. It is important to practice personalized medicine and treat each patient with an open mind while taking into account individual differences that may not necessarily follow the studies or statistics or textbooks one learns in medical school. The misdiagnoses in the cases we read show that people are unpredictable- the book cover may look the same for many books, but we still need to open it and read it in order to understand the entire story.

Modern medicine has definitely seen a general trend on the emphasis of the patient in the doctor-patient relationship. With greater access of medical information to the general public, patients are coming into offices more knowledgeable about their condition. It is interesting to be a pre-medical student who is still a patient, but trying to understand what it is like on the other side of the fence. As a patient, the internet is a useful tool in understanding a physician's diagnosis or (as I personally think many people do) self-diagnose one's symptoms. Self-diagnosis can mean weeks or months without seeing a doctor, which can lead to serious illness that WebMD can't diagnose. This is also contributing to a growing doubt in the skill of a once revered profession. I admit that I have used the internet to find out good questions to ask my doctor, but I draw the line at report cards on my doctor.

Where is the trust in medicine? Are patients putting more trust in technology than in their doctors? It would be difficult for anyone to accept nowadays that even with all the new, advanced technologies and improved teaching of future doctors, medicine is still limited. Who can really say if there is really a difference in prolonging a life 10 days or 10 weeks? I think that there is something wrong if medicine is starting to substitute quantity for quality.

The Doctor-Patient Relationship

I'm currently reading the book Bedside Manners by David Watts and am coming to the conclusion that there really isn't a great reference for what "good doctoring" should be.

Dr. Watts clearly cares about the profession of Medicine and feels an obligation to "do good" for his patients; however, he is torn by the human emotions of frustration, annoyance, and helplessness. There are the patients who are needlessly neurotic, who come in regularly for a barrage of tests that they don't need. There are those who are young and friendly and likable and these tend to be the patients for whom Dr. Watts can do nothing. It's funny that so many of the autobiographical, nonfiction accounts of medicine hark back to Shem's, The House of God, but there tends to be a parallel in that the young and healthy are always the ones to die (and the ones that the doctor's ultimately moved by) and it is the old who tend to have chronic, but tolerable ailments.

The New York Times Piece we read, "Radiologist Adds a Human Touch," it makes sense that the doctor-patient relationship is enhanced by acknowledging the humanity of our patients. But there are only a handful of fields in medicine where doctors are so disconnected from the person.

I do think that Dr. Watts treats his patients like people, he acknowledges their humanity, their idiosyncrasies, and their difficulties and he deals with them in very normal, human ways. I don't think it is fair to assume that doctors will always be able to be overwhelmingly compassionate or tolerant, there are very few people that can behave in this fashion. But I think it's important to realize why your patients behave in certain ways and to try to work with their flaws to provide the best treatment, in hopefully, a professional or even friendly manner.

On a side note I think that the term doctor-patient relationship assumes that the behavior of one party is entirely contingent on that of another. And while I don't think that doctors are obligated to deal with verbal abuse (Dr. Watt's recounts a patient who would constantly criticize him without reproach, but when he criticized his family he stood his ground), I do think that we ought to realize that people often come to us at their most vulnerable and that we need to view our duties as a profession and provide people with the best quality of care regardless of our feeling toward the patient.

musings on the doctor-patient relationship

I was particularly struck by the humility of this week’s reading. Allen implies that doctors are fallible, and because of this, a “good” doctor is not necessarily one who is the best educated or the one with the best reputation, but one who cares, who will worry if they’re providing the best possible care to their patients. I was really amused by this thought, because if the measure of a doctor is his/her ability to worry, then I imagine that I will be among the best doctors in the nation! But seriously, I think this is really true, because a patient who receives the best treatment might leave the doctor’s office feeling somewhat unsatisfied, like there was some part of the relationship that was not fulfilled (“…that’s it?”). This ties into the issue of suing, because patients who have the sneaking suspicion that their doctor doesn’t care and isn’t doing all that he/she can are more likely to accuse their doctor of malpractice, which is an obvious indication of the lack of trust in the doctor-patient relationship. That aside, the meaningfulness that one gets out of the doctor-patient relationship is one of the primary reasons that people go into medicine. A doctor’s relationship with a patient may extend beyond the purely medical to social health, encouragement to engage in the community, and philosophical issues which I am definitely looking forward to.

At the same time, I think that it’s important for doctors to not see themselves as the person directly responsible (or guilty) for their patient’s health. Along with the tendency to worry comes the tendency to try to be a Superman for one’s patient, which may or may not be beneficial. A lot of Sandy’s stress could have been avoided if he had accepted having to wait for the test results, without which he wouldn’t have been able to offer good advice anyway. When can doctors care too much? Sandy wanted to do everything for his patient, but this was not possible. If he had been unable to restrain himself, he might have scared Steve, and also compromised his own authority as physician and been perceived as “unprofessional”—caring for his patients too much. In addition, he adds a lot of stress to himself that sets an even more idealistic standard of care for his patients in the future. Although much has been made of the “macho” tough-guy world of medicine in which doctors don’t admit their mistakes (which is obviously bad), it’s important to also maintain a high level of confidence in one’s own work, which I think naturally leads to increased optimism for the patient’s well-being. It’s in finding the balance that a lot of the controversy over the ideal doctor-patient relationship occurs.

Overdosed America

The points brought up throughout our reading this week pointed again and again to the repeated abuse of physicians' and patients' trust by pharmaceutical companies marketing seemingly useless drugs via schmoozing, bribes, and false advertising. More disturbing to me, though, was our final selection on the effective treatment of America's most common serious illness - diseases such as stroke, cancer, heart disease, and obesity. Not only did the authors show that many of the new - and quite expensive - drugs are minimally effective in treating these conditions, but straightforward lifestyle changes proved astounding success. As the research repeatedly showed, not smoking, exercise, and a healthy diet are the keys to reducing these diseases, but our healthcare system has no means of promoting such measures.

Could a universal healthcare system address these issues? Dr. Murphy posited that this would be the most logical way to motivate all parties involved in healthcare to work to the benefit of the patient. He envisioned a system in which the less medical care a patient required, the more profit all parties received in providing care. If pharmaceutical companies are to be a part of this equation, they must be motivated to seek the best for patients not out of high morals, but because it will benefit their company to do so. As it stands now, these businesses will only increase their profit by making patients sicker, so long as their patient is alive to continue to require their drug. This is why, as Marcia Angell suggested in her speech, pharmaceutical companies target ubiquitous chronic illness rather than diseases with relatively quick and simple cures.

What does this mean for physicians today? The author of Overdosed America, John Abramson, points to an end in physician bribery and pharmaceutical "gifting." But he goes further than asking physicians to simply "say no to drug companies" - Abramson highlights the crucial role of the physician, especially those in primary care, in advising patients in the making proven lifestyle changes before prescribing exorbitant medications.

Big Pharma

It’s ironic that The American Medical Student Association is “the only mainstream medical organization with a principled position against taking industry gifts.” As Carl Elliot suggests, the pharmaceutical companies’ more aggressive market-based tactics are a relatively recent trend. However, it’s surprising that doctors who have been practicing longer and lived through this propaganda shift seem, in this sense, more receptive to pharmaceuticals’ bribing tactics. In contrast to the association of currently powerless (in comparison to physicians) medical students, it’s horrifying to see the American Academy of Family Practice’s response to No Free Lunch. After the initial shock and wave of cynicism, however, I began to take on a more optimistic view of this paradox.

Again, it’s during the late 90’s that this new wave of aggressive tactics by the pharmaceutical companies began. On one hand, the current medical students’ wary stance against pharmaceutical-physician relations indicates a very high level of ethical vigilance instilled in yet young physicians-to-be.

No Free Lunch’s advice to “Just say no to drug reps” all together, made me wonder if this ethically and pragmatically puzzling issue of relationships with pharmaceutical companies should be passed onto the hospital administration-level. This is highly theoretical, since this would require strict forbiddance by hospitals of any medical or hospital staff’s relationship with any pharmaceutical sales rep. The hospital administration would allocate a special force or board in negotiating talks with pharmaceutical representatives, and this board would collaborate with committees dealing with hospital ethics or finances. Would such a system liberate or confine the integrity and pragmatic resources of physicians in the United States?

Carl Elliot also questions the identity of physicians in the current age. As suggested by Lantos’ apt example of shoes without cobblers, healthcare and physicians, while not (yet) mutually exclusive, no longer are synonymous. Since by definition, pharmaceutical companies are profit-driven businesses, I would argue that healthcare needs to be salvaged from a market-minded framework. Physicians are clearly fallible, but they are a human sector whose fundamental drive is, historically and even today, good will. Physicians in the United States are, as Elliot points out, bound by the Hippocratic Oath. Should healthcare move away from the paternalistic shadow that physicians can sometimes represent? Sure, but not when the next Big Brother is Big Pharma.

Big Pharma

As the field of medicine is becoming more industrialized and more impersonal, the hospitals and physicians within it are becoming more machinized as well. With the advent of the 21st century research physician, gone are the traditional doctors carrying their black bags making their way from house to house. The growth of new technologies to fight disease parallels a steady decline of the patient's reliance solely on the doctor's knowledge. The informed patient now has access to online resources such as WebMD that further creates doubt on a doctor's competence. Who then is treating the patient? The doctor or the industry and technology?

In high school, my sister and I both worked in physician offices. I worked in a cardiologist's office as an insurance/billing assistant while my sister worked as a receptionist in a general practitioner's office. When we came home from work, she would gossip about Lisa and the lunch she brought from Atlanta Bread Company, which she mentioned wasn't as good as the lunch Nancy brought Tuesday from Bonefish. Then she would laugh because she didn't put drug reps she didn't like (or as I read it- who didn't bring free lunch) on the general practitioner's schedule. It was interesting to see how much influence my 16-year-old sister had working at the office yet what was more interesting was that she was choosing to help perpetuate one of the largest industries in the world- the pharmaceutical industries.

The pharmaceutical industry recognizes that deep pockets can increase their revenue, but what bothers me the most is not the detailing and the huge sums of money that go to drug reps, doctors, direct-to-consumer advertising, and other forms of marketing. The biggest moral problem for me is the market that pharmaceutical industries are catering to. Although it is important to develop new drugs for diseases, more and more drugs are being developed that can be marketed to a large population in order to make a profit.

Besides the drugs, pharmaceutical drugs are using their deep pockets to influence doctors, whom they know patients trust, to speak on behalf of their drug or prescribe their drug for off-label uses to a larger population and a wider range of problems. In the end, pharmaceutical industries have control in creating a market for their drug. About 50-60 years ago, drugs were being made that were not disease specific and were just "trial-and-error" to see what they could be prescribed to. Nowadays, regulations have made drugs specific to certain diseases, but I believe this is just a formality and that there is a new "trial-and-error" in the methods of pharmaceutical industries- marketing and advertising. As much money as the industry says they spend on R&D, the money spent on marketing and advertising is probably triple that amount if not more. Who should be held accountable?

I see the FDA as more of an advisory role, than regulatory. With over half of its funding coming from pharmaceutical industry user fees, how can one trust a federal agency that is technically being funded by the very industry it is designed to regulate? How can this be fixed? One idea is for Congress to appropriate more funds to the FDA. I have even heard the idea that the Food and Drug be separated in FDA. That way, 70% of the funds will not be unevenly distributed to food regulation. I also think that the FDA should more carefully regulated marketing and direct-to-consumer advertising. Whatever the answer may be, there needs to be action taken to curb the pharmaceutical industries' growth.

Big Pharma (and Marcia Angell's Speech at Brown)

I admittedly have a distaste for the pharmaceutical company and their profit-driven motives and greater investment in drugs to treat superficial diseases, such as erectile dysfunction and acne, then diseases that truly plague patient's well-being (ie Cancer, AIDs, etc). At the same time I recognize that the cohabitation of doctors and pharmaceutical companies (and their minions- the reps)is an unavoidable aspect of modern healthcare.

This past Thursday Marcia Angell, former editor-and-chief of the NEJM came to speak at Brown. She is a vocal critic of the pharmaceutical industry. One of the main criticisms of her speech is the vast discrepancy between their presentation of profits to the public, opposed to their actual profits. The pharmaceutical companies make an 18% profit (numbers into the tens of billions), which far exceeds all other fortune 500 companies. Additionally, even the seemingly benevolent acts are truly trivial from the perspective of the companies. The free drug donations are a very nominal cost to pharmaceutical companies. Dr. Angell also spoke about the morally questionable marketing ploys of pharmaceutical companies, including bribing doctors.

Dr. Angell's speech was countered by Mary Ruwart's analysis of the pharmaceutical company. I found many of the points and data presented to be absolutely absurd. Dr. Ruwart was arguing that the pharmaceutical industry is "over-regulated," which has restricted innovation and let to numerous patient deaths in the wait for FDA approval. I think that presenting such flawed data was repugnant, given that many of the audience members were pre-medical students and ultimately consumers of the healthcare system. It's important to realize why we have regulations in place- the FDA's creation was in response to the thalidomide crisis that marked healthcare and drug development in the 60s. Without any external checks, companys that are profit-driven will often act in ways that are in the best interest of their corporation, not the general public. Also, rigorous drug testing in large populations is essential to determine drug efficacy and safety. If anything I feel that Big Pharma needs to be more highly regulated; the fact that the pharmaceutical company helps to fund the FDA is absurd.

In spite of being a strong proponent of more rigorous safeguards and regulation, I do ultimately believe that the pharmaceutical industry provides good to the world of healthcare. I believe that drug development is an essential component to progressing healthcare in the world but I believe that the government should fund more academic research so institutions can have more freedom to determine which diseases to study. Also, in the midst of lifestyle drugs there have been some incredible discoveries and innovations developed. My ultimate wish for pharmaceutical development, is that the government/society will start demanding that there be greater focus on creating drugs for the truly deletorious diseases.

As Seen on TV

I can't help but think about my first images of medicine - those provided by TV shows. Last week offered us a view into the world of hospital medicine extending contrived, political and hypersexualized view shown in ABC's Grey's Anatomy and priming us for a conversation on Grey's spinoff, Private Practice. This parallel is at once unbelievably corny and disturbingly insightful.

Where Addision Montgomery left the fictional Seattle Grace Hospital for the quieter, better compensated private clinic, today's trends show a migration in the opposite direction - from independent practice to salaried positions in large institutions. In fact, female physicians are more likely than their male counterparts to work in private practice, often for the benefits of fewer hours at work and on call.

Citing rising costs and stagnant reimbursement rates, many physicians are looking to large practices and institutions for security and salaries. Such organizations have the financial capability to invest in cutting-edge equipment and improvements such as Electronic Medical Records (EMR), and the bargaining pwer to garner the best reimbursement rates from insurance companies.

The future of private practice seems uncertain for both patients and physicians. While an article from the New England Journal of Medicine (The Independent Physician: Going, Going...) cites that 9 out of 10 Americans receive care from such providers, new regulations and reimbursement structures, such as Managed Care, make the proverbial dream of house calls, black bags, and the local GP a thing of the past.

international comparisons

Not related at all, but my friend is studying abroad in France, and this is an anecdote from her visit to Avignon...

"It was a long day…the bus pulled out at 7:30, which meant leaving Echirolles a little before 7, and we didn’t get back until midnight. Our first stop was just a rest stop, which one would assume isn’t worth mentioning, since the point was just to use the restroom and get a coffee or what have you. But you would be very wrong. For upon arrival at the rest stop, they were having what appeared to be a flash rave, with tons of people about our age dancing drunkenly in a mob wearing all sorts of costumes, ranging from cowboys to diapers. At 9:00 am. Outside a rest stop. Though nonplussed, we were at bit to groggy at that point to investigate what was going on, but after caffeinating we made our way toward the crowd. Eventually a conversation was struck up with some relatively sober participants, and we learned that apparently this is a tradition as part of med school orientation, in which they spend a couple days of debauchery…presumably traveling around a bit? The reason for the rest stop location was never fully resolved. But we left happy to know what was going on, if a bit concerned for the future of the French medical community."

Independent Physicians and Private Practice

I found the NEJM article on reasons for decreasing numbers of independent doctors insightful. Especially after reading Hospital, and learning more about the increasingly corporate structure and mission of hospitals, it seems that increasing complexity of healthcare delivery is inevitable (however loaded a word that is). Just as organisms became multicellular and evolved more specialized functions to gain a competitive advantage, it seems that the field of medicine and society in general do as well. Independent physicians, while not constrained by bureaucratic policies, must nevertheless struggle with the survival of their business in order to provide healthcare. Without proper management, they will be financially unable to provide care to those who seek it.

It was interesting that the frustrations of private physicians were compared to primary care physicians, who have both historically been the predominant healthcare providers for Americans. Both seem to suffer from longer work hours, more uncertainty in their careers, and lower reimbursements than necessary to stay ahead of malpractice rates. It is important to maintain both groups because they are often able to act more flexibly than physicians employed in a larger system. The American market has long rewarded those who are willing to take the risk of operating their own business, and I think doctors who are willing to start their own practice or at least run a small collaborative practice with other independent physicians should be models of admiration. Exploring the politics of why their interests are not better-represented will be vital to healthcare reform, I think.

In addition, the NYT articles on abortion and palliative care provided glimpses into the struggles that independent physicians may find themselves embroiled in. Abortion and the choice to die are deeply personal decisions that a physician may condone or reject based on personal belief, but I think the message to take away from these two articles is that a doctor has to above all consider the wishes of his/her patient and remain open-minded to all options. A private physician may have more license to refuse treatment to someone. For example, when looking for a permanent primary care physician, I found one woman who seemed great and had good credentials. However, she was also a strongly Catholic physician who would not prescribe birth control pills, and as a potential patient, I felt that this indicated a mindset that was likely to be judgmental, and I kept on looking. (However, not all patients have the ability to choose among multiple doctors that will honor their lifestyles or cultural preferences.) But independent physicians also more license to try experimental or socially taboo procedures (like the late-term abortions).

I think that the abortion doctor was brave in doing what he did, and although I don’t approve of late-term abortions, sometimes these procedures are necessary and I’m sure that the women who received late-term abortions (and earlier abortions) were grateful for his presence in a conservative, prejudiced state. I cannot imagine undergoing the protesting that he did, with people picketing my clinic and receiving death threats on a monthly basis.

End-of-Life Care

I’d not often thought of end-of-life care as encompassing all age groups. I’d categorized hospice care as critical in the fields of gerontology or oncology. However, the heart failure specialist’s patients clearly span all stages of life. This realization makes me question why end-of-life care has not been built in as a cornerstone of standard medical education, just as doctoring or patient-doctor communication classes now largely are.

At the least, it’s comforting to know that the number of educational programs in palliative care is on the rise in hospitals. However, to think that the last weeks of many individuals’ lives, largely spent in the hospital according to the article, are largely in the hands of physicians who feel so completely unprepared for end-of-life care, is alarming. This article reminded me of the last ten days my grandfather spent hospitalized, before he passed away last winter. I spent much of the ten days at his side, with other relatives who were taking turns taking care of him day and night. This was the time when so many important conversations took place, last memories formed, and relationships consolidated. I couldn’t help thinking that, were we to weigh my grandfather’s life in terms of times of importance, these last ten days would surely represent a disproportionate portion. I found it ironic and striking that, at such a critical time in my grandfather’s life, the nurse and intern in charge of my grandfather’s unit of the ward were bigger presences than anyone else that could not be present. For example, my grandmother. My grandfather and she were married for sixty years, raised five children, and lived day-to-day with each other until my grandmother passed away seven years ago. I’m sure that the times my grandfather had with her remained alive as a significant portion of my grandfather’s memories during these ten days, but the reality was that my grandfather was interacting with the intern and nurse at a much more intimate, moment-to-moment basis. Two people that he had never even met before this hospitalization. Two strangers who were of the ages of his grandchildren. How ironic, I thought. But on the other hand, how amazing it was that this nurse and intern were playing such a big role in shaping my grandfather’s life! I almost found myself wondering what kind of people would be those to take care of me as I require end-of-life care in the future.

Through this experience, I couldn’t help thinking: what a privilege. What a privilege and huge, huge job it is to be a physician for a patient approaching the end of his or her life. In medical school and residency, we learn so much about how to keep people alive. However, I do hope that I can be better trained to be fully present for those who will remember me as one of their last friends and care-takers.

Private Practice & Clinics

Dr. Tiller's death this summer is a news story that captivated the nation and served as a forum for discussions about abortion and the challenges that doctors face in America. In many of the medical ethics classes that I've taken at Brown University abortion is discussed in context of the pro-life and pro-choice sectors of the population; however, I've never heard it discussed in terms of the doctor's role.

Last year as I walked past the med school there were anti-abortion activists dressed in white coats handing out information about abortions, presumably because Brown allows students who are interested in learning about the procedure procure the knowledge. While I'm not sure that it is a technique that I would personally desire to learn (in spite of supporting the legalization of abortion) I think that it's important that so long as the practice remains legal that schools offer students the opportunity to learn it.

Reading about Tiller's significance in Kansas and the US, especially given that he was one of the few remaining doctors performing abortions, made the piece and his death even more tragic. I don't think that as future doctors we consider that our job comes with such tremendous risks, and realistically most of us won't be facing this type of controversy. Although abortion is obviously a heated topic in America, the media and ethics discussion rarely discuss the procedure in terms of the risks incurred by the doctors. I think that the tremendous sacrifice that doctors are willing to make to treat those that they believe are under served, whether they be in war zones or abortion clinics, is truly admirable.

Private Practice

What does the future hold in store for private practice? Although there is a steady decline in the number of private practices, I believe there is still a definite need for their services that exists today. Solo or small practice physicians still provide medical to 9 out of 10 Americans receive. This is remarkable that the vast number of patients still go to these practices even if the number of small practices are declining. However, a general trend observed in the country does not always apply to certain geographical areas. A metropolitan area where local hospitals are more common and competition is greater may not have a large need for many private practices. On the other hand as we learned last week in section, private practices are essential to the dynamics of smaller communities where hospitals are farther away.

I do see how working in a larger group within a hospital can be very attractive, but I think private practices are necessary in furthering the role of the 21st century physician. Not only should the physician keep up with the latest medical technology and biopharmaceutical developments, a physician must learn how to run and be in the business of medicine. I do not like to think medicine is a business, but the harsh reality stands that without a doctor that either handles his own insurance claims or without someone to do this for him, doctors will not get paid. It is important for a doctor to have some business-savy. I would suggest medical schools having a class on how to start one's own private practice so that doctors don't go out into the world with a degree in one hand and stethoscope in the other looking for a job. Someone who has gone to medical school and residency theoretically has all the skills he or she needs to open their own practice. What is preventing this? Money. Once one has already accumulated hundreds of thousands of dollars of debt, one needs to take out even more loans to either rent or buy an office, fix it up, hire staff, and work a few years to even be able to pay back what one borrowed to begin with. It isn't easy to open one's own practice, find patients, deal with finances, and a hundred other hats a doctor wears. It is interesting to see the role of the physician as these changes in private practice occur.