Double Agent

 Yesterday, I heard Dr. Glenn Treisman talk at the Department of Psychiatry's  Grand Rounds at Johns Hopkins on "What is a Doctor."  You'd think we'd all know what a doctor is, but Dr. Treisman always has a unique and humorous slant to those obvious slices of life.  His talk was about the forces pulling physicians to look out for the best interests of the patient, while also looking out for the best financial interests of the institution they work for as well as the best financial interests of society.  He threw in some historical references and his talks are always entertaining as well as informative.

At the beginning of any professional presentation, the doctor must "disclose" any conflicts of interest -- in other words, if he receiving any money from pharmaceutical companies.  Dr. Treisman started his talk with a series of Disclosure slides which reflected both his wit and a statement of the problem.  He let me borrow them to reprint here:
 

First slide:

•I am engaged in Doctor-Patient relationships that I was taught ethically constrain me to work in the best interest of my patient

•I work in an institution that was founded by Johns Hopkins to provide care to the poor and indigent of East Baltimore

•I have been instructed to provide “Excellence” in my work

Second slide:

•I am paid by Johns Hopkins which has directed me to:

–Decrease the time patients are in the hospital

–Maximize reimbursement for hospitalization

–Maximize the revenue I generate

I am barraged by “cost-saving” efforts by insurance companies that use bullying insurance reviewers and time wasting paperwork barriers to decrease the delivery of the care I recommend for my patients.

Third slide:

I have been recently informed that I am a “steward of resources” and that I need to conserve medical resources

•I have been recently informed that “Patient satisfaction is the coin of the realm”

I have been informed that my Ryan White funding is contingent on efficient care (shorter visits) and improved measurable outcome targets 

Fourth slide:

•  I have been informed that I am to use “Evidence-based interventions” and follow guidelines and protocols that I find less than optimal for many of my patients

•Some of these conflicts of interest may have affected the views and information presented in this presentation, or perhaps are the subject

  

Ah, Dr. Treisman has a lot of "disclosures," touched with a little sarcasm, but he does a good job of illustrating the conflicting pressures doctors are being put under to act as agents for society and institutions in ways that conflict with being the advocate for the best interest of the patient.  So that you know, he works with AIDS patients in an outpatient clinic, and with inpatients on one of the country's two psychiatric inpatient pain units.  His patients travel from all over the country to be admitted to this unit, often arrive in a state of desperation, and the struggles with insurance companies to permit their care are considerable.

Just a word on the graphic: it's from a show called Get Smart (the 1970's perhaps) about a spy named Maxwell Smart who had his phone in his shoe.  It's where I learned about "double agents."  I figured I needed to explain this one.

  

 

Saying the Right Thing

I just read a very touching article on the New York Times Well blog by an oncologist who talks about a visit with a deceased patient's wife and children.  I finished the article, The Widow's Doctor Visit  and thought, if I ever have that illness, I want this man to be my doctor.  I never think that, but this oncologist's insight into what a grieving family is going through is remarkable, as is his willingness to openly discuss it.  He tells the widow that the patient was lucky to have such a supportive wife.  He tells the son his father wore the same shoes, so he too must be a spiffy dresser, like his dad (oh, actually the writer said 'fancy' but I like spiffy better).  He tells the children that it's okay if they are a little glad that they don't have to watch their father suffer and to have their worlds revolve his medical condition.  He has some sense of what it is that families are looking for,  and that's nice.

But it isn't actually true that I would want this guy to be my doctor.  The truth is, if I had a bad illness, I'd want the doctor with the best outcomes, not the doctor with the best beside manner.  And really, I know the I know this doctor can write a moving article (this is worth a few points in my book) but it doesn't mean that his interpersonal delivery is wonderful -- it may be and I certainly liked him from what I read. But if I had a chronic illness, or one where a bad outcome was virtually guaranteed, then I'd want the best bedside manner and the doctor who could pad the ride with some kindness and sensitivity.

They don't teach you in medical school to tell the wife who has just cared for a terribly ill husband that he was lucky to have her.  They should. 

What do you think?  Oh, and do surf over to the Well blog and read the article. 

Then, if you want, surf over to KevinMD and read this article and let me know if I was mistaken to find it offensive.  I just couldn't get a feel for the author's tone.

Those Privacy-Invading Pediatricians, Silenced!

A while back, Roy blogged about proposed legislation in Florida that would make it illegal for physicians to ask patients if they own guns. What the??? Since when do we legislate what people can ask each other, outside of discrimination issues for jobs? And is there any precedent for legislating the conversation that occurs between a doctor and patient? So apparently this is going to pass, and Greg Allen writes in "Florida Bill Could Muzzle Doctors on Gun Safety,"

Florida Gov. Rick Scott is expected to sign a bill that will make the state the first in the nation to prohibit doctors from asking patients if they own guns. The bill is aimed particularly at pediatricians, who routinely ask new parents if they have guns at home and if they're stored safely.

Pediatricians say it's about preventing accidental injuries. Gun rights advocates say the doctors have a political agenda.

Ah, it's not about us shrinks, it's okay to ask if there is a question of danger. It's about the pediatricians. Personally, I think the pediatricians should fight back: if they can't ask who owns a gun and target their gun safety remarks, they should give extensive gun safety instructions and literature to every parent at every visit. Perhaps as a statement of unity, all pediatricians in all states should discuss gun safety with every patient, no questions asked.