Sunday, January 07, 2007

Rationale





I've written in this blog, and in a certain book I've been known to hype, about the pleasures of doing an operation when it all comes together. I've compared it to music: the transcendent feeling that derives from the sense that the team is flowing together, from being able to ply the craft with no distractions. No need to wait for an instrument, to ask for something you always use; having people assembled who know you, and what your intent is and who can nearly wordlessly join the orchestration of effort, uplifted by the knowledge that you have been invited into the essence of another human being. Because, for many reasons, it's rare to work with the same team over and over, achieving that kind of soaring synergy is uncommon -- when it happens it's invigorating beyond words. When it doesn't, the lack is ruefully noted at best; deeply disturbing at worst. That an operation is carried out by a team is an understatement, which brings me to the off-the-wall point of this post. As much as I love it when able to do surgery in a way that I consider some sort of artistry, and as much as I realize that being able to do so is the result of the efforts of nearly countless people, there are times when I've had a moment of disconnection (or is it clarity perhaps?) and have wondered if it's all insanity.

For an operation of anything more than the most minimal magnitude, the team consists of at least five people -- and often more: anesthetist, surgeon, assistant, scrub nurse or tech, and circulator (meaning the person who runs around getting stuff, more or less) but it's always in fact way more than that: anesthesia tech, people in the sterile core, in the pre-op holding area, admitting, in the recovery room. Central supply techs, assistants to set up and turn the rooms over between cases. Schedulers, people at the front desk keeping the day in synch. And these are just some of the folks surrounding the operation itself. One-on-one or one-on-two nursing in the intensive care unit, around the clock. Nurses, aides, assistants on the surgical floor; physical therapists, social workers, unit managers and clerks. Pharmacists, lab techs. The number of people involved in supporting an operation on any individual is staggering. Clearly, for the patient and his/her family, it seems worth it. But is it crazy to wonder if it makes sense, economically? Or even, given limited resources, ethically? Thinking of so many people involved in the care of a single individual makes me wonder, sometimes, if societies would be better off if that effort and treasure were directed in ways that would benefit more people. Is surgery an example of our fundamental instincts to help one another; or a sign of misguided priorities? Do we allow such lop-sided economics because, at bottom, we want that effort when it's our turn, damn the cost? I'm no philosopher, nor an economist. I don't suppose societies ought to behave only on the basis of cost-effectiveness: some values are reflected in ways that don't fit bottom-line thinking. Still, there are times when I look at all the effort involved in supporting what I do, and it gives me pause. Funny thing is, I've never regarded any patient -- famous or infamous, wealthy or destitute, brilliant or slow -- as unworthy of that effort. It's only when I think of myself lying on an OR table, and of all the people called upon to do whatever they'd be doing to accomplish whatever operation I'd be getting, that I think of it as somehow unseemly. But that's just me, I guess.

* * * * * *

Well now, as luck would have it, while I'm putting the finishing touches on this post, there appears an article in the local paper about an eight-year-old boy receiving an intestinal transplant. So maybe it's destiny that this becomes about something larger (as I implied in a recent post, we're not in charge of our thoughts anyway.) The pictures show it: he's a really cute kid, and he's looking forward to being able to eat. It's heartwarming; it really is. And yet. The operations that gave me pause above are in the most minor of leagues compared to this sort of thing. Dozens of OR personnel, people involved in the harvesting, the maintenance of the organ; lab folks. The immediate post-operative care is highly labor-intensive; the drugs, the after-care. And oh, the dollars.

I recall watching Ronald Reagan many years ago, as he made a very public show of donating to the fund for a liver transplant for some cute little kid, during a time in his presidency when he'd been loudly decrying the costs of health care. There's a huge disconnect: who isn't moved by this beautiful child, who would admit to begrudging him whatever it takes? And who, if in a darkened room away from prying eyes and ears, if not given the particulars of any individual, if crunching numbers trying to balance budgets, would argue for paying a million bucks or more for a procedure whose long-term survival is discussed in terms of three-year alloquots? But if it were their child...?

It seems inevitable that at some point the US will join the rest of the western world and provide some form of universal healthcare. I wonder when, in the process of discussing it, the R-word will finally be raised and addressed head on? Unless there's agreement that healthcare is the sort of priority that gets all the money it takes to provide all the care possible to everyone in need no matter the details, sooner or later "RATIONING" (call it whatever you prefer) has to be part of the mix. Somewhere along the line, we will have to say THIS is how much or our federal budget we're willing to spend on healthcare; THESE are the things we're willing to pay for; and HERE is how we'll pay it. It's way too important to leave to the insurance companies, and it's way too difficult to think politicians would tackle it seriously, let alone with an eye to finding actual solutions. (They're all too busy electing themselves and playing power games -- and have been for several years.) If anyone asks me, I'll tell them we need to convene a dedicated group of economists, health-care experts, maybe toss in a politician or two if any can be found willing to out-stick their necks, business folk, consumers. Maybe lock 'em in a room with hardtack and water, don't let them out until they come up with a plan and a price; maybe a couple of them. And then let everyone think about it for awhile, and put it to a vote. It's long overdue. Meanwhile, out of concern for your money, I promise not to have an intestinal transplant.

12 comments:

Steven said...

I'd think the environmental impact of a surgery is also a cause for concern that should be factored into these decisions.

scalpel said...

I wouldn't want an intestinal transplant either. But I'd probably want one for my kid. Great post.

jb said...

A large segment of the progress that our civilization has made has occurred when individuals decided to try something that previously was considered crazy, impossible, against the will of God, counter-intuitive, or too expensive. In most cases, the prevailing view was correct, but we also have things like airplanes, surgery, computers, near universal vaccination, and everything else that separates us from the cave men on the GEICO ads as a result of these delusion folks who didn’t take no for an answer. If we want to continue making progress, we have to make sure that no “…dedicated group of economists, health-care experts, maybe toss in a politician or two if any can be found willing to out-stick their necks, business folk, consumers…” or anyone else gets to determine what a visionary person can do with his or her crazy idea. Instead of locking those folks in the room that you envision, lock up (forever) the innovation-stifling know-it-alls who fix prices in medicine to discourage anyone who thinks of a better way to do something from doing it if it costs an extra nickel. That committee can decide how much of its own money it wants to spend on intestinal transplants, but if it tries to tell everyone else that, sorry, its just too expensive and we can’t do that sort of thing in our society, that will guarantee that people die needlessly because no one will be able to figure out how to do them cheaply and reliably. You have posted wondrous tales of operations that once were gee-whiz and now are done routinely on an outpatient basis (at one time, every operation was gee-whiz, and not so long ago). Let’s not stop now. Let the free market do the rationing. It has worked pretty well so far.

Sid Schwab said...

jb: excellent comment. The good news is no one will pay any attention to my ideas. On the other hand, I'm not sure that some sort of universal healthcare plan will stifle innovation: in fact, maybe if the costs of general care can be brought under control, funding for research can be brought back to where it was when you (guessing here that I might know you) and I trained. Nor am I sure I entirely agree that the free market is working all that well of late: if the numbers are to be believed, there are tens of millions without healthcare coverage, and the costs in the US relative to budgets is higher than anywhere else, producing middling results as judged by such parameters as infant death, longevity, etc. Of course, not knowing much about medical economics allows me the full freedom to shoot off about it. But it's something that needs facing much more seriously than has been done to date, politically /economically/socially speaking.

Anonymous said...

I believe that when we discuss health care reform, we have to keep in mind what it is that makes our country unique. I think that our society's strength arises from the basic premise that the individual has precedence over the masses / government / "state". Another way to think of this is that the good of the one may outweigh the needs of the many.

An ideal government will supposedly find the perfect balance between the rights and well being of the individual while preserving the continuity and safety of its society. Recent history (as well as current events) has shown us what happens when governments subtly or overtly teach its citizens an individual must be ready to make personal sacrifices for the sake of their country - that an individual's life in the scheme of world history is irrelevant. I think that talking about rationing in health care is a subtle way of teaching us our well being must be subordinated to some greater good - which scares me. And I do not think it is being egotistical to think that my life is sacred because I live, nor do I think it is false humility to have a sense of awe when I contemplate the effort that goes into saving one life - to wonder what makes me so special to get this attention, effort, expenditure. But can we not apply that to all our modern conveniences? How about roads.....all the people and resources that go into making and maintaining roads - should we just limit roads to certain areas that meet some determinants? more populated for example? or electricity, etc.

And is health care not a way to stimulate the economy? Does it always have to be looked at as a deficit? I wonder why we have been taught to look at the rising cost of health care as an inherently bad thing, rather than an example of the superiority of our society. Isn't population longevity and wellbeing a marker of a superior society? The money that is spent, circulates - keeps our economy going. Much more than trade (?) - because the money spent is mostly kept in the country (unless insurance companies expand their practice of sending people to other countries for cheaper treatment becomes more common). Will it be so bad if it ends up that most of us make our living from providing health care to others, directly or indirectly? Is a country that is service oriented more economically healthy than a country that is based on manufacturing and consumerism? (I am getting off point, but these are some of things I think of when the discussion of health care reform comes up). Maybe that is our future - becoming the worlds capital of health care!

When I contemplate why our country has been spared the chaos and tragedy of what seems so common to other societies I attribute it to our ancestor's approach that government exists to promote the well being of the individual. To me, a discussion of health care reform must start there and work up to finding the perfect balance between the "many" and the "one". If we start the discussion from the perspective of what is good for society as a whole then try to incorporate the good of the individual we risk shifting a core value of our country and slipping into the belief each person has value based on a sliding scale of what the society needs at the time the worth is being assigned. Which makes value a relative principle rather than an absolute. Once we assign relativity to an moral value, we can rationalize any decision we make - which absolves us of responsibility - gives us a way out - to pass the buck.

(Which is why I am not a fan of the P4P concept - which is another subject)

I know that there are no easy answers to this complex issue, but it can't be unsolvable.

Rita Schwab - MSSPNexus said...

Good post. In particular I question the way our society spends money on end-of-life care.

And yet, if it were someone I loved...

No easy answers indeed.

NCurse said...

You have a good style in writing. I loved those passages of your book. :)

Anyway, I add you to my blogroll. Keep up the good work.

Anonymous said...

Free market in health care?? Such a concept exists in the field of Plastic Surgery and perhaps Dermatology, but in my mind that's about it.

Free markets suggest that competition within the market will establish value for a service.

I find it unlikely that any one provider will ever plan to corner the market on the un-insured

emmy said...

A case to ponder: My niece was born with a diaphramatic hernia and because there was a brand spanking new ECMO machine at University of Alabama Hospital and two rather cavalier surgeons on board who were willing to operate, and use synthetic materials to replace the hole in her diaphram she has survived 14 years. The day before she was born she would have been placed in her mothers arms to die in whatever short amount of time she would have naturally had. In the last 14 years she has had about 21 surgeries and Medicade has spent close to a million dollars on her. Is her life worth that? She doesn't understand yet that there are people who would seek to deny her the life she's lived on arguments of costs and quality of life issues. However, everytime she has undergone a surgery or procedure, her doctors have learned more about what it takes to keep children like her alive and thriving. I carpool with a man whose 5 year old daughter was also born with a diaphramatic hernia, and while her's was mild compared to my neice's, what they learned on my neice has kept her alive. Can you tell me if that million was well spent? Children are easy. Nobody wants to say "that child isn't worth saving". It becomes more problematic when you are discussing the elderly, though I would venture to say that many of them would contend that their lives are worthwhile. I've seen many octogenarians in the infusion room of the cancer center that I go to. This is where the arguments get stickier, is a targeted therapy that costs $100,000 a year and may extend my life for another 6 months worth the cost? Is it wise to place stents into the heart of a 98 year old man that in all likelihood will die within months anyway? Or take for instance Keith at Digital Doorway's patient who at 50 is a chronically ill alcoholic who refuses any help whether self or otherwise. Is he worth the money spent to keep him alive? Who would make these decisions?

Prof Scrub said...

Dear Surgeon,

I agree - the pleasures of surgery are often undescribable. Often when I teach about surgical techniques to my adoring students, I liken it to making love to a beautiful woman.

Firstly, there is the anticipation, as one gowns up into the finest clothes. Secondly, there is the preparation as one preps the necessary parts of the female anatomy with adequate cleaning solution (I use betadine).

Thirdly comes the act itself, an intense and focussed procedure, often clinical, producing the desired outcome.

And lastly the climax, where one sews up and takes the woman off the table for her recovery period.

Your fellow surgeon,
Prof Scrub
http://www.scrubbingup.com/blogs/profscrub/blog.asp

Milk & Two Sugars said...

Hello all! I'm an Australian medical student, and these are my two cents:

First cent: Dr Schwab, you have suggested that the rationing of health care would come in only after a universal health care system is instituted in America. But America's resources are finite now, which necessarily means that rationing is already occurring; my understanding is that this is carried out by insurance companies in their weird and wonderful ways.

Second cent: it is unreasonable to expect a country such as America to thrive by creating an internal economy based around the provision of health care for many reasons, but here are the big ones:
- Overall, money spent on health care keeps people alive well into their retirement years, when they don't contribute enough taxes to even offset the cost of their medical care. It does not put money back into the economy; there is no monetary profit.
- Governments need to spend money on defense, agriculture, civil works (roads, buildings, etc), and manufacturing for trade. They cannot limit themselves to a single driving economic expenditure.
- Whilst insular economies can work, the US is the least insular economy I know of; a drastic change seems unlikely.
- Economists consider a country in danger of unbalance in its expenditure when it spends more than 10% of its Gross National Product (money spent in one year) on a single entity. The US government is currently spending 16% of its GNP on health care, despite the free market model which health care provision is based on. The drastic effects of spending way too much of one's GNP on a single entity are examplified in poor African nations, some of whom spend upwards of 60% of the GNP trying to pay off debt.

Well, there they were. I'm confident in the figures I've quoted, as they come directly from Australia's leading health economists (Australia currently spends just under 9% of its GNP on health care; unless reform occurs soon we're headed for trouble, so the subject is contentious here too).

I hope this has added some useful data to the topic!

Anonymous said...

Paediatric intestinal transplant vs. Michael DeBakey's thoracic aorta aneurysm repair
- see one of NHS Doctor's recent blogs.