Our Duty to Patients or Our Duty to Society?

How a Patient-Centered Model Can Reconcile the Two

by Ramy Sedhom MD and Daniel Sedhom MD

Healthcare in the United States is expensive, with one of the highest rates of per capita spending worldwide, and the cost continues to increase every year. There is a continuing national dialogue regarding fiscal responsibility, efficient spending, and ethical debates about resource allocation. Medical providers are asked to examine their own personal practice patterns and contributions to the overall burden of health care costs. As physicians, we find ethically worrisome the pressure to make some of these decisions at the bedside in an ad hoc manner, especially when cost concerns seem to deprioritize our duties to our patients. Shared decision making, with the patient selecting the health outcome of highest priority to them, is an important guideline and should be considered in future payment models.

Physicians today face a paradox, where they find themselves Hippocratically bound to serve the best interests of their patients (“First, do no harm”) while under mounting pressure to consider the continuously increasing costs of treatment and therapeutics.

Every day on rounds, residents and clinicians discuss the evidence-basis, cost, and benefit of the therapies which we offer to patients. Practicing in an academic institution, we’ve grown to appreciate the expense of healthcare. We find it startling (and unfair) that the current expectation in medicine is to consider cost containment primarily at the bedside. Clinical medicine is historically thought of as a public service, something about individual patients rather than a matter of public policy or macroeconomics.

Through the scientific approach to medical problems, we learn from population health. We ask questions, critically consider evidence, and tailor treatments to individual patients. The art of medicine is all about using this approach effectively. We have learned from good mentors to ask about personal circumstances, tolerance for adverse events, therapeutic adherence, values, support, and personal preferences. A critical component of good clinical practice is through building a relationship with one’s patient, and not just seeing them as a complex of data points and pathologies.  Ethicists have long insisted that medicine is not a market product or a commodity. The respected medical ethicist W. Osler wrote, “the practice of medicine is an art, not a trade; a calling, not a business” ([1]).

The reality of medical care presupposes that patients are able to trust that their doctor is acting in their own individual benefit. We are thankful that as a resident physicians, we have not been asked to decide which patients are worthy of expensive therapy. The value of medicine cannot be measured in dollars. Today, many physicians face an ethical “zero-sum situation”, where rising health care costs threaten to limit other social goods. The salient question is: how do we control costs without compromising professional ethics and accountability?

Bedside rationing is misguided. We are astounded that insurance companies offer bonuses for cost-minimizing care and, even worse, penalize high-cost utilizations when treating the sick. This practice can lead to distrust of physicians and the healthcare system. Without the implementation of an explicit ethical standard, we fear that bedside rationing will be at the expense of the poor and marginalized. This constitutes a grave injustice, balancing the cost ledgers on the backs of those with fewer capabilities to object.

We call on physicians to be more politically engaged, to advocate for their patients as human beings rather than impediments to profit. Societal shifts would allow us to interpret the literature not just for statistical significance but clinical importance. We question the “value” of medications that statistically add weeks to life. It is not to the domain of physicians alone to decide at the bedside which tests or treatments to ration, nor it is up to groups administrators, or medical societies. It is ultimately up to patients, and it is important to bring the needs of the patient back to the focus of health care.

Washington has recently considered remuneration proposals to reform the current “fee for service” model, which incentivizes physicians for the number of visits and procedures instead of better health outcomes. A shift from “volume to value” is commonly cited today. Unfortunately, the proposed measures to determine “quality”, in terms of task-based care, diminishes the value and individuality in the patient/doctor relationship. It assumes a universal appropriateness to individuals based on health demographics. As we all can imagine, what is good for one patient may not hold true for another. True health care reform should be patient centered. By shifting to a person-centered, high-value health care, we can avoid creating systems that rob clinicians of the value and meaning of partnering with patients to create health. “Quality of life”, the end goal with any medical treatment, can mean different things to different people, and there are measures other than hemoglobin A1c, disease-free survival, and overall mortality that we need to consider.

An ideal approach for healthcare reform would focus on individual health goals. Disease-specific outcomes often compete and do not align with patient preferences. Patients may elect to forego some treatments if they do not help achieve their goals. For example, a cardiovascular patient in his 90s may have a higher priority in remaining independent at home. He may choose to forego anti-hypertensive treatment, because the risk of falling from orthostasis is of greater concern than the remote risk of stroke. An elderly lady living alone with chronic kidney disease might elect for more liberal blood sugars to avoid a potentially fatal hypoglycemic episode. Shared decision making, with the patient selecting the health outcome of highest priority is important and should be rewarded in future payment models. We imagine that both patients and physicians would benefit from goal-directed therapy.

In today’s system health care, keeping our elderly patient from falling or developing hypoglycemia would not be rewarded. Even worse, physicians would likely be penalized for poor disease related outcomes, because the patient’s progression did not meet the expectations delineated by some uninvolved party. Quality metrics that reflect individual outcomes must be developed as we move toward more goal-directed, patient-centered decision making. Good medicine is about doing what is right for the patient. It is important to bring the patient back to the center of health-care and critical thinking back to the bedside.

 

[1] Osler W: The master word in medicine, in Aequanimias with Other Addresses to Medical Students, nurses, and Practitioners of Medicine (ed 3). New York, NY, Blakiston/McGraw-Hill, 1932, pp 349-371.

Contact:

  1. Ramy Sedhom – sedhomr@gmail.com , 1 Robert Wood Johnson Pl, New Brunswick, NJ 08901
  2. Daniel Sedhom – Daniel.sedhom1@gmail.com, 1 Robert Wood Johnson Pl, New Brunswick, NJ 08901
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