Friday, January 23, 2009

Forces gathering to blame the patient

There seems to be much blame to go around for the health care "crisis"-the physician,the hospitals,the insurance companies,the managed care companies, the pharmacy management companies, the Medicare payment system and most recently the patient.

Several factors, influences,movements, and lines of thought leading to the blame-the- patient notion include.

1)Basic human emotions-These tended to boil up in many of us as house officers, when fatigue and frustrations peak and we thought why are we wasting our time (and possibly sleep time) on someone who basically has brought the illness or its severity on themselves. Charges against the patient included; alcohol excess, or negligence, not wearing a seat belt or eating too much and not exercising or smoking or using illicit drugs.

A variation of this theme appears from time to time in comments and blog entries by emergency room docs who lament their interactions with citizens of unsavory character who often populate the ERs.

2.The P4P movement in which physicians are rewarded or not based on group outcomes. Their report card may look bad and their compensation may decrease based on numbers of their patients having the audacity to ignore advice or stubbornly refuse to live according to the healthy life style of the day and thereby arguably not meet their goal for HbA1C, blood pressure or something. If the physician's rating or income suffers from missed appointments or a patient's failure to have a given procedure so may the attitude of the physician towards the patient.

Drs JF Whatan and Daniel Salmasy writing in a JAMA Commentary entitled "Improving the Quality of Health Care.Who is responsible for what" (2009;301(2),215-217 (subscription required for full text of the article) point out the obvious but increasingly ignored fact that physicians have a obligation at an individual patient level but are increasingly judged by group or population level data. They quote Aristole who captured this issue

The doctor does not treat ‘man’ except accidentally; he treats Callius or Socrates or someone else described in this way, who is accidentally ‘man’. So, if someone has grasped the principles of the subject without having any experience, and thus knows the universal without knowing the individuals contained in it, he will often fail in his treatment; for it is the individual who has to be treated.

3.The collectivist-utilitarian mind set that says if the government (or society- even though the two are not the same) is going to pay for your heath care then you should loose your seat at the public trough if you do not comply with the rules it makes to keep you health.

This view has been expressed by several commentators.This one by an internist ( Dr. Chris Rangel on his bloghttp://www.rangelmd.com/index.php/2009/01/10/holding-patients-accountable-with-government-health-care/) explains it this way.

..the state has a practical interest in keeping the workforce healthy and reducing the economic burdens from people who become sick and disabled as a result of unhealthy or risky lifestyles (the reason seat belt and helmet laws). This is a utilitarian principle. Such policies benefit all citizens.

In counterpoint to all of forces blaming the patient or assigning societal obligations to her, I remember the comments of Dr. Lawrence J. Hergott in a JAMA article (JAMA Feb7,2007,vol.297,#5,p 477)

May I never see in the patients anything but a fellow creature in pain.

Not as someone who deserves his dyspnea because of cigarette use defying years of advice to quit, not as someone whose ascites is his just due from profligate use of alcohol, not as someone who should not be in this country at all, not as someone who would not be having the myocardial infarction at all if he had done what his doctors told him to do and not as someone who is taking "scarce medical resources" from someone who deserves them more or for whom the treatment could be more cost effective but as a fellow human whose is in need of what physicians spent so many years of their lives preparing themselves to be able to offer.

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