If it was your mom what would you do?

Is the Hippocratic oath at risk?

I was summoned to the cold, cubed, windowless “family” room on the 4th floor of our suburban hospital. I was greeted by the young Hospitalist assigned to the floor, an older seasoned doctor specializing in end of life medicine, (hospice care) and a sprite social worker. “Your mother has end stage disease, she is lethargic, barley responsive, and is going to die soon” said the curt, clearly rushed Hospitalist. “It is time for a decision, we recommend comfort care.” “What is comfort care?” I hesitantly asked. The seasoned Specialist softly responded, “It is hospice, end of life, care, we make sure she is comfortable. We stop all fluids, antibiotics, blood draws, tube feeds. But we provide as much pain medicine as needed for her ultimate comfort as she passes on.” “But she is now responsive, she was alert and oriented yesterday. I think she may be improving!” I optimistically pushed back. “Can we keep her in house for a few more days and see if she progresses?” The trio in lockstep canvassed back, “Your optimism is noted and nice but we have seen this before, she is not going to recover.” “But, yesterday she met with family and friends and she explicitly told us she does not want to die.” I shot back. I then lobbed back in a bit of an accusatory manner, “If we put her in hospice against her wishes, isn’t that euthanasia?” The mature Specialist, quieted down, the deer in headlight social worker was lost, but the cock sure young Hospitalist, automaton back, “I want to do what is in the best interest of your mom and family. And I recommend she be transferred to hospice care.” You saw her for less than three minutes yesterday, while she was sleeping, and since then she has woken up, she visited with her grandchildren, she passed a swallow test. She is wanting and fighting to live!” I protectively sparred back. “Ok, but I can no longer justify her stay in the hospital.” The Hospitalist commanded. “Justify to whom?” I quipped. “Well let’s just say her staying in the hospital is not any one of our decisions…” “Huh??? What!?? Did you say it is not our decision? Well then just exactly who’s decision is it?” I shockingly responded. “The people who pay the bills.” “Those who pay the bills, I choked.” “In who’s best interest are you acting on? “Didn’t we both take the same Hippocratic oath?”

When did we as physicians, so easily concede away the right to make decisions? Clearly my mom is very sick and I am grappling with end of life issues that most eventually have to confront. And no doubt there are tough decisions to be made. But every well trained physicians knows that each situation poses a unique set of circumstances that requires a unique set of decisions. At the helm powering the US towards the best health care in the world has been a system that trains young physician in the art and skill of decision making. The reason why medical doctors go through such intense training for an extended period of time is to learn how to make a tough call when the answer is not clear. Medical schools have an abundance of the intellectually brilliant as well as many with superb hand eye coordination but the minimum to using these skills in a clinical setting can be learned in an abbreviated course. The essence of what makes a good doctor is knowing when to use these skill. This is learned during the endless nights on call in the hospital or the sleepless nights ruminating on patient care.  Physicians are decision makers that is what we do best and what we are trained to do. We learn to weigh all the potential options, best and worse- case scenarios and then make a decision in a fiduciary manner always putting the patient’s interest first. This has been the hallmark of medical education in the US since the Flexner report in 1910. As someone who has descended from this lineage it is hard for me to hear a physician so indifferently admit that the decision isn’t hers. And while she had no problem goose stepping this answer what dismays even more is the seasoned hospice doctor deflatingly fall into his chair accepting the same fate. And this not to overlook the naive social worker not even in the same universe realizing the loss of gravity in medicine. A watershed moment has occurred in medicine and it didn’t happen overnight. A dripping collectivism has eroded through the rock of medicine. The previous generation warned us it was coming and my generation let it slip away. Medicine has been institutionalized, corporatized and rationalized. The Hippocratic oath taken by every graduating medical student has perhaps fallen into nothing more than meaningless prose read at a ceremony better served as a photo- op setting for an Instagram post. Institutionalized medicine favors US physicians as interchangeable parts, unequipped to disrupt and void of decision making concerns protective of the individual. The institution’s goal is to satiate the appetite of the collective good. As doctors continue their devolvement they can get dressed up for the reception welcoming in their replacements, the less expensive and easier to control adjunct providers. It is not as if there is a malicious conspiracy by institutions and corporations to ruin what was best about medicine. They are challenged by an equally set of difficult issues. Health care cost are skyrocketing. In 2011, the United States spent $2.7 trillion on health care, more than double what was spent in 2000. It is projected that, by 2040, 1 of every 3 dollars spent in the United States will be spent on health care. (1) And putting a strain on a bloated system is the 13% of those dollars spent for those in the last year of their life. And yes corporate boards and leaders have to make tough decision delivering health care most efficiently to the greatest amount of people. But it would be less than honest to not admit that at times their decisions are counter to the Hippocratic oath. As physicians let’s just be frank with ourselves and our patients, corporate institutionalized medicine is motivated by profits and turns a blind eye toward euthanasia and rationed care. Just last week a primary care provider friend of mine told me he is not permitted to refer to a hand specialist outside of his hospital network…even though that specialist is known to be one of the best in the country. When I asked him who he would send his family member to he was quick to say the forbidden specialist. Isn’t there something wrong when we don’t refer patients to who we think is the best and most appropriate physician for their care?  Why did we acquiesce away that right so easily? Perhaps a US populous voicing their desire for institutionalized medicine was unknowing of its consequences. And while we knew what was to come, a weak defense was mounted for our profession and our patients. We have clearly lost the battle. A new normal has come of age in medicine and it does not discriminate. It is seen and felt similarly in affluent suburban hospitals as well as rural and inner city ones. All of medicines has been neutered… except for perhaps one last remaining stronghold, Aesthetic Medicine. 

I am glad I chose a field of medicine with an unencumbered framework that facilitates and encourages delivery of the best and most appropriate care. And while a fee for service system to an outsider may seem to have confounding motives it is actually the opposite. The free market of aesthetic medicine propels doctors who act in the best interests of their patients and flattens those who take advantage of their patients or delegate patient care decisions to non- physician boards. Aesthetic medicine attracts many of the best and brightest minds in medical schools precisely for the reason that it is the last bastion of medicine to preserve the sanctimony of the doctor patient relationship. Aesthetic providers are not forced to mill through herds of patients or be burdened with over documenting justification for their decision. Therefore they are privileged with the gift of time to share with their patients. Aesthetic medicine seekers are free to choose the best specialist for their particular condition. And the competitive marketplace reigns in price inflation. While over the last decade US spending on healthcare has disproportionately grown out of control aesthetic medicine fees have barely risen and in many cases have gone down. Certainly unlike today nobody was offering Botox at four dollars a unity in 2008. And while the majority of the US populous has voted their opinion for institutionalized medicine, I am going to predict that Aesthetic Medicine and its members will be the flag bearers guiding the movement back toward protecting the doctor patient relationship. I foresee an alternative where corporate bean counters and nameless bureaucrats are stripped from their rights to impose cook book predetermined decisions on their doctors. Already I am seeing many patients in my clinic electing to go outside of their third party recommendations and payers for their MOHS reconstruction, nasal breathing surgery and lesion removal. Procedures that are traditionally covered for and provided by doctors within their networks. I believe we will likely see the emergence of a two tier system where institutionalized medicine will continue to focus on the lowest common denominator juxtaposed by private hospitals and doctors who will provide individualized fee for service medicine. All specialties from Pediatrics to Cardiac surgery will be represented. Prices will be controlled by competition and these hospitals will attract the best in medicine. Physicians will clamor to gain privileges at these hospital for the express ability to give the best in care for a patient in the manner that they deem most appropriate and without being pressured to provide less than ideal care. The new private system will be a beacon calling all doctors who understand the true and implied meaning behind those ancient words carved in stone. The words that have defined the ethical standards for millenniums of doctors, the words we know as the Hippocratic oath. 

-Steve Dayan, MD

Eldridge M. Kelley AS The Myth Regarding the High Cost of End-of-Life Care End-of-Life Care. American Journal of Public Health December 2015;105:12:2411- 2415.