We have a tendency to substitute the mechanisms we have learned for outcome data. Pharmaceutical detail people major in mechanisms.
Pharmaceutical rep.: “This new medicine – Lipid-lo – scours atheromas at their base, substituting a slick, non-stick Teflon layer while the displaced lipids are carried by the ultra low density lipoproteins to the liver, where they are recycled along with aluminum cans into bone matrix that reduces osteoporosis.”
Doctor: “If my patients take Lipid-lo, is there evidence that their all-cause mortality or morbidity will fall?”
Pharmaceutical rep.: “This study in Stockholm last year, where they've used Lipid-lo for 1000 years, shows that middle-aged men had 22% fewer cardiac events than a control group that did not take the drug.”
Doctor: “I said all-cause. Did the Lipid-lo group have more hepatitis, or cataracts, or renal stones, or such?”
Pharmaceutical rep.: “I have another study here from Ohio in which the cardiac output during acute M.I.'s fell 33% less in the treated group than in the untreated group.”
Doctor: “Wonderful! But, did the treated group on the whole live better or live longer than the untreated group?”
Pharmaceutical rep: “It comes in convenient dose form shaped like a pretzel. See, you can break it in several points to get the right dose without having to switch to a new prescription.”
It's as if we were talking past each other. Mechanism is offered in place of evidence of outcome. Mechanisms are wonderful mnemonic devices, but things that stand to reason do not always stand to evidence.
What has this to do with making ethical decisions? When communicating with our patients, adding our unique input, we should as often as possible speak in terms of net outcome as based upon evidence. In medicine we are prone to focus on numerators.
Excerpt from "Counseling Persons with Questions on Medical Ethics"
Monday, February 25, 2013
Monday, February 18, 2013
Numerator Medicine: Putting Back the Denominators
The infant who comes to the ER badly damaged by being shaken hard by a relative weighs in so heavily with us that we give scant thought to the actual risk. Our state has a program against shaken baby syndrome that is, I believe, ethically ill-conceived.
Now, I am not in favor of shaking babies! But the zeal of those who are out to reduce the damage from this practice has led them to publish a brochure recommending, among other things, that small children not be dandled on an adult's knee! Perhaps somewhere there is a case report or two of a child who had brain damage accurately traced to dandling. I doubt it. But, anything can be dangerous! Children drown in toilets. They fall down back steps. They pick up copperheads in the back yard. What is the net effect of dandling? Are there no good effects from the interaction between toddler and adult? I'm guilty. I've done it with our own children. I plan to be guilty if we have grandchildren. Are there no downside effects from further eroding the confidence of parents to take care of, provide for, to nurture their own children? What is the net effect? To know that you have to slide a denominator beneath the numerator. All children injured by dandling over all children dandled. The fraction must be infinitesimally small. Further, from this small fraction must be subtracted whatever diffuse but definite benefits there are in dandling.
When we are trying to provide medical information to our patients so that they can make an ethical decision, we need to be mindful of the skew our own viewpoint sometimes takes. We don't think normally, sometimes, especially when we are estimating very small numbers – the risk that a given 60 year old woman has a cervical cancer, that a breast lump in a 14 year old girl is a cancer, that an intraocular pressure of 24 represents glaucoma in a 55 year old man. And so on. Are we merchants of fear?
As finite beings who do not know everything, we need to help our patients know relative risks. Life is risk. Health care decisions are often decisions of prioritization. No path is risk-free. We should not so focus upon the most fearful risk and back away from it without looking behind us to see what risks we are backing into. For a Christian, good stewardship means making the most of the resources we have to further the kingdom of God. That means making risk/benefit estimates.
Excerpt from "Counseling Persons with Questions on Medical Ethics"
Now, I am not in favor of shaking babies! But the zeal of those who are out to reduce the damage from this practice has led them to publish a brochure recommending, among other things, that small children not be dandled on an adult's knee! Perhaps somewhere there is a case report or two of a child who had brain damage accurately traced to dandling. I doubt it. But, anything can be dangerous! Children drown in toilets. They fall down back steps. They pick up copperheads in the back yard. What is the net effect of dandling? Are there no good effects from the interaction between toddler and adult? I'm guilty. I've done it with our own children. I plan to be guilty if we have grandchildren. Are there no downside effects from further eroding the confidence of parents to take care of, provide for, to nurture their own children? What is the net effect? To know that you have to slide a denominator beneath the numerator. All children injured by dandling over all children dandled. The fraction must be infinitesimally small. Further, from this small fraction must be subtracted whatever diffuse but definite benefits there are in dandling.
When we are trying to provide medical information to our patients so that they can make an ethical decision, we need to be mindful of the skew our own viewpoint sometimes takes. We don't think normally, sometimes, especially when we are estimating very small numbers – the risk that a given 60 year old woman has a cervical cancer, that a breast lump in a 14 year old girl is a cancer, that an intraocular pressure of 24 represents glaucoma in a 55 year old man. And so on. Are we merchants of fear?
As finite beings who do not know everything, we need to help our patients know relative risks. Life is risk. Health care decisions are often decisions of prioritization. No path is risk-free. We should not so focus upon the most fearful risk and back away from it without looking behind us to see what risks we are backing into. For a Christian, good stewardship means making the most of the resources we have to further the kingdom of God. That means making risk/benefit estimates.
Excerpt from "Counseling Persons with Questions on Medical Ethics"
Monday, February 11, 2013
Consider the Natural History
What do we know of the natural history of disease? We are committed in the United States to doing something. We get paid for doing things. We get praise for doing things. We get a net increase in malpractice protection for doing something. We get credit for all recoveries when we do something, whether the patient got well because of or in spite of our intervention. As a consequence, we become less aware of the course that a disease may take if left alone.
In the population at large, nearly every new symptom, if ignored, will abate without lasting harm. When we get ourselves exercised about “access to care” in the United States, a feature of “distributive justice,” we seem to forget this natural history of commonplace symptoms. In a Medicaid system, created to reduce access barriers, the patients may come into the medical system without regard to the severity, significance, or treatability of their symptoms. The lethal is admixed with copious quantities of the trivial. Since every diagnostic pathway has an error rate, if we increase the proportion of the trivial, we can reach a point where the harm that comes to those who are treated as though their complaint is serious exceeds the benefit of treating those who do have a serious problem. The ethical problems of access are, therefore, not necessarily solved by removing all barriers.
Reasoning from empirical information, we can compare to the biblical ethical standard of good stewardship and achieve ethical advice about “access to care.” Knowing the natural history allows us to put “doing nothing,” or nothing curative, in among the choices for treatments for a patient to consider. Sometimes knowing the natural history or considering more widely what a “cause” is of a disease, allows us to put in a choice that doesn't look very “medical.”
A few years ago I treated a family that had two small boys. Both parents worked, the mother at a job that had health insurance, the father's job did not. The boys had repeated infections – diarrhea, ear aches, pharyngitis, coughs. The mother was grateful for the medical insurance, especially since one of the boys had some high expenses relating to complications from ENT surgery. Of course, the boys stayed in group day care while their parents worked. Finally, I summoned the courage to introduce the possibility – probability – that the boys were picking these things up in day care. The mother had long lamented that she would prefer to stay home with the boys, but was worried how she could manage such bills without health insurance. She quit her job. The infections subsided. Maybe coincidence. It is also possible that she was inadvertently keeping them in a situation that led to illness in order to have money to pay for the illnesses. Chasing your tail.
How is this ethics? If you have ever tried to suggest to some American parents, especially mothers, that they should consider staying home you have risked the very gates of Hell. You risk a clash of beliefs. Beliefs as to which is more important, the benefits from the second family income, or of having a parent at home. One of our major roles as physicians in medical ethics is to provide empirical information. The natural history of disease is one important piece. What is likely to happen if no treatment is provided? In various places in medicine the general answer differs, but in primary care the most likely answer is that the patient will recover rather promptly with no sequelae. Empirical information that bears on the points we are asked about is not really all that easy to come by. When it comes to our contribution in medical ethical decisions, however, it is our unique contribution: we need to know the natural history. We need to know treatment alternatives and how they compare. We need to know costs. We need to know risks of treatment. We need to know the prevalence of diseases. Knowing these things is not easy.
Excerpt from "Counseling Persons with Questions on Medical Ethics"
In the population at large, nearly every new symptom, if ignored, will abate without lasting harm. When we get ourselves exercised about “access to care” in the United States, a feature of “distributive justice,” we seem to forget this natural history of commonplace symptoms. In a Medicaid system, created to reduce access barriers, the patients may come into the medical system without regard to the severity, significance, or treatability of their symptoms. The lethal is admixed with copious quantities of the trivial. Since every diagnostic pathway has an error rate, if we increase the proportion of the trivial, we can reach a point where the harm that comes to those who are treated as though their complaint is serious exceeds the benefit of treating those who do have a serious problem. The ethical problems of access are, therefore, not necessarily solved by removing all barriers.
Reasoning from empirical information, we can compare to the biblical ethical standard of good stewardship and achieve ethical advice about “access to care.” Knowing the natural history allows us to put “doing nothing,” or nothing curative, in among the choices for treatments for a patient to consider. Sometimes knowing the natural history or considering more widely what a “cause” is of a disease, allows us to put in a choice that doesn't look very “medical.”
A few years ago I treated a family that had two small boys. Both parents worked, the mother at a job that had health insurance, the father's job did not. The boys had repeated infections – diarrhea, ear aches, pharyngitis, coughs. The mother was grateful for the medical insurance, especially since one of the boys had some high expenses relating to complications from ENT surgery. Of course, the boys stayed in group day care while their parents worked. Finally, I summoned the courage to introduce the possibility – probability – that the boys were picking these things up in day care. The mother had long lamented that she would prefer to stay home with the boys, but was worried how she could manage such bills without health insurance. She quit her job. The infections subsided. Maybe coincidence. It is also possible that she was inadvertently keeping them in a situation that led to illness in order to have money to pay for the illnesses. Chasing your tail.
How is this ethics? If you have ever tried to suggest to some American parents, especially mothers, that they should consider staying home you have risked the very gates of Hell. You risk a clash of beliefs. Beliefs as to which is more important, the benefits from the second family income, or of having a parent at home. One of our major roles as physicians in medical ethics is to provide empirical information. The natural history of disease is one important piece. What is likely to happen if no treatment is provided? In various places in medicine the general answer differs, but in primary care the most likely answer is that the patient will recover rather promptly with no sequelae. Empirical information that bears on the points we are asked about is not really all that easy to come by. When it comes to our contribution in medical ethical decisions, however, it is our unique contribution: we need to know the natural history. We need to know treatment alternatives and how they compare. We need to know costs. We need to know risks of treatment. We need to know the prevalence of diseases. Knowing these things is not easy.
Excerpt from "Counseling Persons with Questions on Medical Ethics"
Friday, February 8, 2013
'Obamacare' ALREADY forcing doctors to close practices - Washington Times
"If I do open another practice, it's going to be me, the patient and ... no insurance," Dr. Rosenwasser said. "I'm going to treat my patients how I know they should be treated."
'Obamacare' health care reform ALREADY forcing doctors to close practices - Washington Times
'Obamacare' health care reform ALREADY forcing doctors to close practices - Washington Times
Monday, February 4, 2013
Our Brother's Brother
Despite years of sermons to the contrary, we are not our brother’s keeper, in the sense of being a zookeeper. We are to seek our brother’s best interests, and in that sense we are his keeper, but, when he disagrees with us about what is best, we are not generally to try as individuals to coerce him into our way of behaving. We are our brother’s brother (or sister).
Excerpt from "Trusting God or Trusting Ourselves"
Excerpt from "Trusting God or Trusting Ourselves"
Saturday, February 2, 2013
In Memory
Dear Mrs. Terrell,
I wanted you to know what a precious influence Dr. Terrell had in my life and that of my family. As you may remember, I completed the McLeod Family Medicine residency [program]. Dr. Terrell's faith in Christ was such a part of his practice, he became my role model in my effort to integrate my faith and medicine.
The Bible studies we shared as residents with him in your home were particularly meaningful. I treasure and have kept to this day the complete set of his Journal of Biblical Medical Ethics. Dr. Terrell taught me that if we are not careful, much of what we do as physicians is temporary and fleeting, and often inconsequential. He inspired me to try to slow down and think about what I was doing and why I was doing it -- and to remember that my patients were eternal beings: mind, body, and spirit.
He showed me how to take a stand for what I believed in and to be bold in my faith even when it was uncomfortable -- to address the spiritual dimension with patients if they were open to this and to make an an eternal difference. That is the kind of doctor he was and the kind of teacher he was.
And he cared deeply. I will never forget a tender moment with him when he found out I had been named as a defendant in a medical malpractice case. I was still in my first year of residency at McLeod, brand new to the world of medicine. As I discussed my dilemma with him, I noticed his eyes moisten with perhaps some compassion for me -- no words were necessary -- I knew then how much he cared.
His influence endured into the next generation in our home. Let me share with you how much my 15 year-old daughter enjoyed her classes with Dr. Terrell at [our local Christian school]. He truly was her favorite teacher. He was a bit unconventional, and she really loved that. He taught her so much more than Biology. What a special gift to have him as her teacher!
I wish I could turn back the hands of time. Hilton called my wife one day, asking to come visit us during that year he was teaching [our daughter]. We were busy and the house was a mess -- we wanted to straighten up before he came. So, we put it off and let time go by... I wanted to show him my vegetable garden and fruit trees -- you know that he and I shared that interest in growing things. I wish we had him over with a messy house...
He meant a lot to our family -- I just wanted you to know.
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