by Augusto Sarmiento, M.D.
Thursday, April 14th, 2011
The medical profession and the lay community continue to be bombarded on a daily basis with information arising from a myriad of opinions dealing with the escalating costs of care, which according to many, has reached unaffordable and unsustainable levels. Medical care cost has soared to the point where it is responsible for 16% of the national budget expenditures.
The resulting confusion paralyzes progress, while the condition becomes exponentially worse. For people who like me, possessing only limited understanding of the complexity of the issues involved, all we can do is try to gain additional meaningful knowledge so that when we express individual opinions our voices have a better change of being heard. With that attitude in mind, I discuss my perceptions on two issues where the medical profession can play a major role: rationing of medical care and abuse of services.
The mere mention of rationing provokes an immediate and oftentimes violent reaction from which politicians and extremists readily take advantage. This issue, steeped in cultural and traditional religious reasons, has prevented a serious and candid analysis of its true meaning. Furthermore, it precludes efforts to determine whether or not the time has come for the citizenry of this country to consider if a system with elements of rationing, but without abandoning its foundations, can be found. It is rather sophomoric to negate that several other highly advanced counties around the world have done such a soul searching and adopted health-care delivery mechanisms that ration services but have continued to provide good medical care while lowering its costs. This has been done without compromising basic human values and sensitivities. In America, the state of Oregon has had in place during the past few years a system with elements of rationing which other states hopefully are carefully studying.
One area where rationing must be carefully and dispassionately addressed is the so-called end of life care. It has been documented that at this time 95% of healthcare dollars are spent in the last 30 days of life. How it is possible is that such an egregious and incomprehensible figure cannot be brought to the center of the political debate rather than deliberately keeping it away from the discussion table?
To look at rationing only as vehicle to reduce health care cost is not appropriate. Objectivity and common sense in related matters are also very important. As physicians we were told from the first days in medical school that uppermost in our professional life we had the responsibility to use all available means to preserve life, never to give up, and adherence to the principle of “Primum non nocere.” However, we much too often lose objectivity and find it difficult to act in a manner that at first glance seems to run contrary to traditional precepts and values.
A visit to a Surgical Intensive Care Unit is a vivid example of the many times when our commitment to prevent death makes us follow irrational routes. Does it make sense to keep alive for weeks and weeks an octogenarian barely alive, suffering from a long history of debilitating medical conditions, who now suffers from the effects of a stroke? Why is it that these hospital units are always full of patients, many of whom never return home?
The answers given to this reality are not of a universal nature. There are times when the attending physicians sincerely believe that discontinuing the respirator and feeding tubes is not necessarily right since recoveries from the recent event is possible and justify continuing treatment. At other times the treating doctors surrender to pressure from relatives who for reasons dictated by emotion refuse to accept the verdict that life is no longer possible to maintain. Unfortunately, there are other times when keeping such patients under care brings financial benefits to the treating physicians and hospital.
In my case it is difficult to intelligently verify the latter situation because I have never spent time in Intensive Care Units as part of my professional work. I base my suspicion on observations of the manner in which some dishonest surgeons perform major elective surgical procedures, such as total hip or knee replacement, in elderly patients that can be satisfactorily managed symptomatically. Many of these patients die during their hospitalization or shortly afterwards. The greed and avarice of these people result in enriching their pockets.
If a truly confidential polling were to be conducted regarding the need to develop a sensible and humane system to prevent the futility of unrealistic prolongation of life, I suspect the vast majority of people with a modicum of intelligence and education would agree that rationing of some degree would be welcome. Likewise, a comparable means to prevent the performance of unnecessary surgery would be applauded.
Acceptable systems can be structured, though very difficult to gain wide and rapid acceptance. In the case of the end of life issues it would take a coordinated effort where representatives from various segments of the government, religious and educational organizations, the media, the medical profession and society as whole would get together to as dispassionately as possible to educate each other on the seriousness of the problem at hand and the unintended consequences likely to come from a refusal to address it.
When it comes to the abuse of expensive and unnecessary diagnostic and therapeutic modalities and surgeries, the medical profession has the moral power to play a major role in the resolution of the crisis. It would take, however, a deliberate effort to set aside the fruitless perpetuation of the concept that medicine is no longer a profession but a business to be squeezed to the maximum. Organized medicine would play a most pivotal place by divorcing itself from the control of education, research, and patient care that it selfishly relegated to the pharmaceutical and surgical implant industry. Through meaningful mechanisms to prevent continued tolerance of what the Justice Department’s current investigation of what it calls “egregious ethical transgression” in the relationship between orthopaedics and industry, much could be accomplished. Forbidding individuals with conflicts of interest to hold office in organized administrative and educational organizations would be essential.
Dr. Sarmiento is the former Professor and Chairman of Orthopaedics at the Universities of Miami and Southern California, and past-president of the American Academy of Orthopaedic Surgeons. He is a contributor to Implant Identification on OrthopaedicList.com and has guest authored a number of other articles for this blog.