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Learning from the 2017 Oscar fiasco
It was a “never event.” At the very end of the 2017 Academy Awards presentation, the winner for Best Picture was announced. It was wrong. Two and a half minutes later it was corrected. The true winner was “Moonlight,” not “La La Land.” But by then much damage had been done.
I watched it happen live on TV and reviewed it again on YouTube. Several news agencies investigated and reported on what happened. I don’t have any inside information beyond that, but my engineering perspective can illuminate how to reduce mistakes.
The first lesson is how quickly people seek to assign blame after something goes wrong. I saw various online news agencies say Warren Beatty had announced the wrong winner. While he opened the envelope, it was Faye Dunaway who actually made the announcement of “La La Land.” Furthermore, Warren and Faye were merely reading the card. Warren had been given the wrong envelope, as high resolution photographs prove. The envelope was a duplicate for the prize announced just before them for the Best Actress award. The card said Emma Stone and in a smaller font “La La Land,” the film in which she starred. Warren hesitated because of how this was written on the card. Faye thought he was trying to pause as a shtick to increase suspense so she glanced at the card and blurted out “La La Land.”
Experts in quality improvement have learned that the best way to reduce errors is to resist this tendency to assign blame. A better approach is to assume, absent evidence to the contrary, that everyone is acting responsibly and sincerely to help the patient. Hear both sides of the story before jumping to any conclusions. Find systemic factors that contributed to a human error. Then focus on ameliorating systemic weaknesses.
One contributing factor for the error at the Oscars was that there were two copies of the set of award envelopes, with one set available on each side of the stage. This way the presenters can enter from either side of the stage. They are handed an envelope by one of the two auditors from PricewaterhouseCoopers, who are the only ones who know the contents.
A key component of safety is having check backs. The envelopes have the name of the award on the outside. One might hope the presenter would double check that they are being given the correct envelope by the auditor. But backstage is a very nervous and hectic place for the presenters. Actors are not professionals dedicated to safety.
Medical care is different. Before giving a transfusion, one nurse reads the number on the bag of blood to another nurse, who confirms that it matches a paper form. That simple act can prevent mistakes. Perhaps the auditor handing the envelope to the Oscar presenter should ask the presenter, who knows which award s/he is scheduled to announce, to read out loud the award title on the front of the envelope.
Clearly, Warren Beatty was confused by the contents of the envelope. He was expecting a card to have the name of a film, not the name of an actress with the film’s name in small print below it. He didn’t know what action to take and hesitated. Faye Dunaway plunged forward and misinterpreted the card. A key component of quality is making it safe for anyone, if they are not confident in what is happening, to stop the proceeding, ask questions, and challenge plans. For example, there are time-outs prior to surgery. A second component is presenting information in a form less likely to be misinterpreted. Medicine has a problem with many sound-alike and look-alike drug names, so sometimes these words are spelled with particular letters capitalized, to distinguish them. I wish EHRs would present lab results in large, bold font.
Another contributing factor here was that Faye misinterpreted Warren’s behaviors as a joke. Major airlines utilize the “sterile cockpit.” During the few minutes that they are running through the preflight checklist, the pilot and copilot do not discuss last night’s football game, crack jokes, or engage in any other extraneous conversations. They avoid interruptions and distractions, focusing solely on the task. Sign outs in medicine need to adopt this habit.
There is a concern that one of the auditors tweeted a picture of Emma Stone backstage holding her Oscar at the same time the fiasco was happening on stage. In the modern world, cell phones and selfies are a key source of distraction, errors, and car accidents.
Per the Army, “Prior planning prevents poor performance.” A couple days before the Oscar fiasco, the auditors were interviewed and they revealed that they didn’t have an action plan to deal with the situation of a mistaken announcement. They figured it was extremely unlikely and that the circumstances would determine the best response.
Experience has shown that in the hours leading up to a pediatric code, there may be several opportunities to recognize the risk and intervene so that blame cannot be assigned to a single person or action. Mock codes prepare people to think on their feet. And it is important to have a clearly designated person in charge of a code. Leadership matters.
In the Oscar fiasco, the damage was quickly limited by the gracious words of a “La La Land” producer He assessed the situation, announced the mistake, beckoned the “Moonlight” cast and crew to the stage, graciously complimented them, showed the correct award envelope and card to the camera, and offered the statue to the correct producer. Then he hastened his team off the stage. These actions of responsibility, truthfulness, transparency, and grace staunched the bleeding, minimized the damage, and as best as possible, remediated the error. Movie producers are experts at dealing with crises and catastrophes. Medical staff, when revealing errors to patients, can learn from this role model.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@frontlinemedcom.com.
It was a “never event.” At the very end of the 2017 Academy Awards presentation, the winner for Best Picture was announced. It was wrong. Two and a half minutes later it was corrected. The true winner was “Moonlight,” not “La La Land.” But by then much damage had been done.
I watched it happen live on TV and reviewed it again on YouTube. Several news agencies investigated and reported on what happened. I don’t have any inside information beyond that, but my engineering perspective can illuminate how to reduce mistakes.
The first lesson is how quickly people seek to assign blame after something goes wrong. I saw various online news agencies say Warren Beatty had announced the wrong winner. While he opened the envelope, it was Faye Dunaway who actually made the announcement of “La La Land.” Furthermore, Warren and Faye were merely reading the card. Warren had been given the wrong envelope, as high resolution photographs prove. The envelope was a duplicate for the prize announced just before them for the Best Actress award. The card said Emma Stone and in a smaller font “La La Land,” the film in which she starred. Warren hesitated because of how this was written on the card. Faye thought he was trying to pause as a shtick to increase suspense so she glanced at the card and blurted out “La La Land.”
Experts in quality improvement have learned that the best way to reduce errors is to resist this tendency to assign blame. A better approach is to assume, absent evidence to the contrary, that everyone is acting responsibly and sincerely to help the patient. Hear both sides of the story before jumping to any conclusions. Find systemic factors that contributed to a human error. Then focus on ameliorating systemic weaknesses.
One contributing factor for the error at the Oscars was that there were two copies of the set of award envelopes, with one set available on each side of the stage. This way the presenters can enter from either side of the stage. They are handed an envelope by one of the two auditors from PricewaterhouseCoopers, who are the only ones who know the contents.
A key component of safety is having check backs. The envelopes have the name of the award on the outside. One might hope the presenter would double check that they are being given the correct envelope by the auditor. But backstage is a very nervous and hectic place for the presenters. Actors are not professionals dedicated to safety.
Medical care is different. Before giving a transfusion, one nurse reads the number on the bag of blood to another nurse, who confirms that it matches a paper form. That simple act can prevent mistakes. Perhaps the auditor handing the envelope to the Oscar presenter should ask the presenter, who knows which award s/he is scheduled to announce, to read out loud the award title on the front of the envelope.
Clearly, Warren Beatty was confused by the contents of the envelope. He was expecting a card to have the name of a film, not the name of an actress with the film’s name in small print below it. He didn’t know what action to take and hesitated. Faye Dunaway plunged forward and misinterpreted the card. A key component of quality is making it safe for anyone, if they are not confident in what is happening, to stop the proceeding, ask questions, and challenge plans. For example, there are time-outs prior to surgery. A second component is presenting information in a form less likely to be misinterpreted. Medicine has a problem with many sound-alike and look-alike drug names, so sometimes these words are spelled with particular letters capitalized, to distinguish them. I wish EHRs would present lab results in large, bold font.
Another contributing factor here was that Faye misinterpreted Warren’s behaviors as a joke. Major airlines utilize the “sterile cockpit.” During the few minutes that they are running through the preflight checklist, the pilot and copilot do not discuss last night’s football game, crack jokes, or engage in any other extraneous conversations. They avoid interruptions and distractions, focusing solely on the task. Sign outs in medicine need to adopt this habit.
There is a concern that one of the auditors tweeted a picture of Emma Stone backstage holding her Oscar at the same time the fiasco was happening on stage. In the modern world, cell phones and selfies are a key source of distraction, errors, and car accidents.
Per the Army, “Prior planning prevents poor performance.” A couple days before the Oscar fiasco, the auditors were interviewed and they revealed that they didn’t have an action plan to deal with the situation of a mistaken announcement. They figured it was extremely unlikely and that the circumstances would determine the best response.
Experience has shown that in the hours leading up to a pediatric code, there may be several opportunities to recognize the risk and intervene so that blame cannot be assigned to a single person or action. Mock codes prepare people to think on their feet. And it is important to have a clearly designated person in charge of a code. Leadership matters.
In the Oscar fiasco, the damage was quickly limited by the gracious words of a “La La Land” producer He assessed the situation, announced the mistake, beckoned the “Moonlight” cast and crew to the stage, graciously complimented them, showed the correct award envelope and card to the camera, and offered the statue to the correct producer. Then he hastened his team off the stage. These actions of responsibility, truthfulness, transparency, and grace staunched the bleeding, minimized the damage, and as best as possible, remediated the error. Movie producers are experts at dealing with crises and catastrophes. Medical staff, when revealing errors to patients, can learn from this role model.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@frontlinemedcom.com.
It was a “never event.” At the very end of the 2017 Academy Awards presentation, the winner for Best Picture was announced. It was wrong. Two and a half minutes later it was corrected. The true winner was “Moonlight,” not “La La Land.” But by then much damage had been done.
I watched it happen live on TV and reviewed it again on YouTube. Several news agencies investigated and reported on what happened. I don’t have any inside information beyond that, but my engineering perspective can illuminate how to reduce mistakes.
The first lesson is how quickly people seek to assign blame after something goes wrong. I saw various online news agencies say Warren Beatty had announced the wrong winner. While he opened the envelope, it was Faye Dunaway who actually made the announcement of “La La Land.” Furthermore, Warren and Faye were merely reading the card. Warren had been given the wrong envelope, as high resolution photographs prove. The envelope was a duplicate for the prize announced just before them for the Best Actress award. The card said Emma Stone and in a smaller font “La La Land,” the film in which she starred. Warren hesitated because of how this was written on the card. Faye thought he was trying to pause as a shtick to increase suspense so she glanced at the card and blurted out “La La Land.”
Experts in quality improvement have learned that the best way to reduce errors is to resist this tendency to assign blame. A better approach is to assume, absent evidence to the contrary, that everyone is acting responsibly and sincerely to help the patient. Hear both sides of the story before jumping to any conclusions. Find systemic factors that contributed to a human error. Then focus on ameliorating systemic weaknesses.
One contributing factor for the error at the Oscars was that there were two copies of the set of award envelopes, with one set available on each side of the stage. This way the presenters can enter from either side of the stage. They are handed an envelope by one of the two auditors from PricewaterhouseCoopers, who are the only ones who know the contents.
A key component of safety is having check backs. The envelopes have the name of the award on the outside. One might hope the presenter would double check that they are being given the correct envelope by the auditor. But backstage is a very nervous and hectic place for the presenters. Actors are not professionals dedicated to safety.
Medical care is different. Before giving a transfusion, one nurse reads the number on the bag of blood to another nurse, who confirms that it matches a paper form. That simple act can prevent mistakes. Perhaps the auditor handing the envelope to the Oscar presenter should ask the presenter, who knows which award s/he is scheduled to announce, to read out loud the award title on the front of the envelope.
Clearly, Warren Beatty was confused by the contents of the envelope. He was expecting a card to have the name of a film, not the name of an actress with the film’s name in small print below it. He didn’t know what action to take and hesitated. Faye Dunaway plunged forward and misinterpreted the card. A key component of quality is making it safe for anyone, if they are not confident in what is happening, to stop the proceeding, ask questions, and challenge plans. For example, there are time-outs prior to surgery. A second component is presenting information in a form less likely to be misinterpreted. Medicine has a problem with many sound-alike and look-alike drug names, so sometimes these words are spelled with particular letters capitalized, to distinguish them. I wish EHRs would present lab results in large, bold font.
Another contributing factor here was that Faye misinterpreted Warren’s behaviors as a joke. Major airlines utilize the “sterile cockpit.” During the few minutes that they are running through the preflight checklist, the pilot and copilot do not discuss last night’s football game, crack jokes, or engage in any other extraneous conversations. They avoid interruptions and distractions, focusing solely on the task. Sign outs in medicine need to adopt this habit.
There is a concern that one of the auditors tweeted a picture of Emma Stone backstage holding her Oscar at the same time the fiasco was happening on stage. In the modern world, cell phones and selfies are a key source of distraction, errors, and car accidents.
Per the Army, “Prior planning prevents poor performance.” A couple days before the Oscar fiasco, the auditors were interviewed and they revealed that they didn’t have an action plan to deal with the situation of a mistaken announcement. They figured it was extremely unlikely and that the circumstances would determine the best response.
Experience has shown that in the hours leading up to a pediatric code, there may be several opportunities to recognize the risk and intervene so that blame cannot be assigned to a single person or action. Mock codes prepare people to think on their feet. And it is important to have a clearly designated person in charge of a code. Leadership matters.
In the Oscar fiasco, the damage was quickly limited by the gracious words of a “La La Land” producer He assessed the situation, announced the mistake, beckoned the “Moonlight” cast and crew to the stage, graciously complimented them, showed the correct award envelope and card to the camera, and offered the statue to the correct producer. Then he hastened his team off the stage. These actions of responsibility, truthfulness, transparency, and grace staunched the bleeding, minimized the damage, and as best as possible, remediated the error. Movie producers are experts at dealing with crises and catastrophes. Medical staff, when revealing errors to patients, can learn from this role model.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@frontlinemedcom.com.
Toy stethoscopes
Many of my articles are inspired when I observe discordant things juxtaposed. As we move deep into winter, once again I am confronted with the issue of infection control in the office and on the ward. Hospitals have gowns, gloves, masks, and toy stethoscopes. My outpatient offices rarely used more than the sink. In urgent care clinic, each evening I would swab three or four throats for strep, with one or two turning positive. I thought nothing of it, other than being glad when gagging a patient that I wear glasses. In the hospital, I must gown, glove, and mask for a patient with strep throat. The variations in practice between hospitals (I’ve been credentialed in 30) do not make me confident in the evidence base for infection control practices. I mentioned the Red Book to a second-year resident last week. He said he had seen it on a shelf but never actually used it.
In medical school, I was taught that the most important part of a stethoscope is between the ears. I believe that statement is true, but in a similar way to how I choose wines. My palate can’t tell the difference between a $15 and a $50 bottle of wine, so buying more expensive wine is a waste. However, a $3 bottle of wine is clearly inferior, if not undrinkable. There are oenophiles (one a distant cousin in Norway) who have trained their palates to tell the difference in wines, just as there are audiophiles who support the sales of $1,000 stereo speakers. Some fraction of those snobs may have justification. So, if cardiologists have strong opinions on stethoscopes, I won’t begrudge them their choice of a more expensive model. Their tastes do not mean that the average person should spend that much on wine, speakers, or stethoscopes. I will assert that there was a time when I could tell a day or two in advance that my otoscope bulb was going to burn out. The color balance was wrong. I carried a pocket otoscope for a few years when rounding in the hospital, but never found it as accurate as my original one. Every craftsman gets accustomed to their best tools.
A professional should be aware of the minimum quality of tool needed to get the job done.
Toy isolation stethoscopes ($3 each retail in bulk) add nothing to my discernment of an infant with bronchiolitis who is distressed, so I consider that equipment a waste of money and polluting to the environment. I typically use my stethoscope and foam it on leaving the room. There is evidence that either foam or alcohol pads are effective1 in killing germs, but no proof that this hygiene makes a difference clinically.2 The myriad researchers who have published about stethoscope contamination have stopped at padding their academic portfolios with something easy to publish, which basically is a high school science project using agar plates. They then make insinuations about policy, without any cost-benefit analysis. They really haven’t been bothered enough to advance the science of clinical medicine and actually measure a clinical impact of these policies. It is a corruption of science created by the publish-or-perish environment.
One survey found that 45% of physicians disinfect their stethoscope annually or less. Laundering of white coats follows a similar pattern, which is why the British National Health Service banned lab coats for physicians 10 years ago. No ties or long sleeve shirts either. I am smug knowing that my sartorial sense was ahead of my time in this regard.
The quality-improvement work of Ignaz Semmelweis should be required reading for all physicians. The control chart3 he published on puerperal fever in Vienna in the 1840s is spectacular. Infection control is important. Modern medical science cannot produce a similar control chart to justify the amount of dollars spent annually on gowns, gloves, masks, and toy stethoscopes. Sad.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@frontlinemedcom.com.
References
1. Am J Infect Control. 2009 Apr;37(3):241-3.
2. J Hosp Infect. 2015 Sep;91(1):1-7.
3. https://en.wikipedia.org/wiki/Historical_mortality_rates_of_puerperal_fever
Many of my articles are inspired when I observe discordant things juxtaposed. As we move deep into winter, once again I am confronted with the issue of infection control in the office and on the ward. Hospitals have gowns, gloves, masks, and toy stethoscopes. My outpatient offices rarely used more than the sink. In urgent care clinic, each evening I would swab three or four throats for strep, with one or two turning positive. I thought nothing of it, other than being glad when gagging a patient that I wear glasses. In the hospital, I must gown, glove, and mask for a patient with strep throat. The variations in practice between hospitals (I’ve been credentialed in 30) do not make me confident in the evidence base for infection control practices. I mentioned the Red Book to a second-year resident last week. He said he had seen it on a shelf but never actually used it.
In medical school, I was taught that the most important part of a stethoscope is between the ears. I believe that statement is true, but in a similar way to how I choose wines. My palate can’t tell the difference between a $15 and a $50 bottle of wine, so buying more expensive wine is a waste. However, a $3 bottle of wine is clearly inferior, if not undrinkable. There are oenophiles (one a distant cousin in Norway) who have trained their palates to tell the difference in wines, just as there are audiophiles who support the sales of $1,000 stereo speakers. Some fraction of those snobs may have justification. So, if cardiologists have strong opinions on stethoscopes, I won’t begrudge them their choice of a more expensive model. Their tastes do not mean that the average person should spend that much on wine, speakers, or stethoscopes. I will assert that there was a time when I could tell a day or two in advance that my otoscope bulb was going to burn out. The color balance was wrong. I carried a pocket otoscope for a few years when rounding in the hospital, but never found it as accurate as my original one. Every craftsman gets accustomed to their best tools.
A professional should be aware of the minimum quality of tool needed to get the job done.
Toy isolation stethoscopes ($3 each retail in bulk) add nothing to my discernment of an infant with bronchiolitis who is distressed, so I consider that equipment a waste of money and polluting to the environment. I typically use my stethoscope and foam it on leaving the room. There is evidence that either foam or alcohol pads are effective1 in killing germs, but no proof that this hygiene makes a difference clinically.2 The myriad researchers who have published about stethoscope contamination have stopped at padding their academic portfolios with something easy to publish, which basically is a high school science project using agar plates. They then make insinuations about policy, without any cost-benefit analysis. They really haven’t been bothered enough to advance the science of clinical medicine and actually measure a clinical impact of these policies. It is a corruption of science created by the publish-or-perish environment.
One survey found that 45% of physicians disinfect their stethoscope annually or less. Laundering of white coats follows a similar pattern, which is why the British National Health Service banned lab coats for physicians 10 years ago. No ties or long sleeve shirts either. I am smug knowing that my sartorial sense was ahead of my time in this regard.
The quality-improvement work of Ignaz Semmelweis should be required reading for all physicians. The control chart3 he published on puerperal fever in Vienna in the 1840s is spectacular. Infection control is important. Modern medical science cannot produce a similar control chart to justify the amount of dollars spent annually on gowns, gloves, masks, and toy stethoscopes. Sad.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@frontlinemedcom.com.
References
1. Am J Infect Control. 2009 Apr;37(3):241-3.
2. J Hosp Infect. 2015 Sep;91(1):1-7.
3. https://en.wikipedia.org/wiki/Historical_mortality_rates_of_puerperal_fever
Many of my articles are inspired when I observe discordant things juxtaposed. As we move deep into winter, once again I am confronted with the issue of infection control in the office and on the ward. Hospitals have gowns, gloves, masks, and toy stethoscopes. My outpatient offices rarely used more than the sink. In urgent care clinic, each evening I would swab three or four throats for strep, with one or two turning positive. I thought nothing of it, other than being glad when gagging a patient that I wear glasses. In the hospital, I must gown, glove, and mask for a patient with strep throat. The variations in practice between hospitals (I’ve been credentialed in 30) do not make me confident in the evidence base for infection control practices. I mentioned the Red Book to a second-year resident last week. He said he had seen it on a shelf but never actually used it.
In medical school, I was taught that the most important part of a stethoscope is between the ears. I believe that statement is true, but in a similar way to how I choose wines. My palate can’t tell the difference between a $15 and a $50 bottle of wine, so buying more expensive wine is a waste. However, a $3 bottle of wine is clearly inferior, if not undrinkable. There are oenophiles (one a distant cousin in Norway) who have trained their palates to tell the difference in wines, just as there are audiophiles who support the sales of $1,000 stereo speakers. Some fraction of those snobs may have justification. So, if cardiologists have strong opinions on stethoscopes, I won’t begrudge them their choice of a more expensive model. Their tastes do not mean that the average person should spend that much on wine, speakers, or stethoscopes. I will assert that there was a time when I could tell a day or two in advance that my otoscope bulb was going to burn out. The color balance was wrong. I carried a pocket otoscope for a few years when rounding in the hospital, but never found it as accurate as my original one. Every craftsman gets accustomed to their best tools.
A professional should be aware of the minimum quality of tool needed to get the job done.
Toy isolation stethoscopes ($3 each retail in bulk) add nothing to my discernment of an infant with bronchiolitis who is distressed, so I consider that equipment a waste of money and polluting to the environment. I typically use my stethoscope and foam it on leaving the room. There is evidence that either foam or alcohol pads are effective1 in killing germs, but no proof that this hygiene makes a difference clinically.2 The myriad researchers who have published about stethoscope contamination have stopped at padding their academic portfolios with something easy to publish, which basically is a high school science project using agar plates. They then make insinuations about policy, without any cost-benefit analysis. They really haven’t been bothered enough to advance the science of clinical medicine and actually measure a clinical impact of these policies. It is a corruption of science created by the publish-or-perish environment.
One survey found that 45% of physicians disinfect their stethoscope annually or less. Laundering of white coats follows a similar pattern, which is why the British National Health Service banned lab coats for physicians 10 years ago. No ties or long sleeve shirts either. I am smug knowing that my sartorial sense was ahead of my time in this regard.
The quality-improvement work of Ignaz Semmelweis should be required reading for all physicians. The control chart3 he published on puerperal fever in Vienna in the 1840s is spectacular. Infection control is important. Modern medical science cannot produce a similar control chart to justify the amount of dollars spent annually on gowns, gloves, masks, and toy stethoscopes. Sad.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@frontlinemedcom.com.
References
1. Am J Infect Control. 2009 Apr;37(3):241-3.
2. J Hosp Infect. 2015 Sep;91(1):1-7.
3. https://en.wikipedia.org/wiki/Historical_mortality_rates_of_puerperal_fever
Guidelines are not cookbooks
For many years I have counseled medical students and residents that half of what I was taught in medical school has since been proven obsolete or frankly wrong. I counsel them that I have no reason to believe that I am any better than my professors were. So I wish them luck sorting out what is true. Earlier in my career, that warning was mild hyperbole, but not anymore.
Upper respiratory infections (URIs) are the most common reason for an office visit during the winter. Bronchiolitis is the most frequent diagnosis for a winter admission of an infant to a community hospital. Pediatricians have nuanced assessments and many options when treating these diseases. Best practices have changed frequently over the past 3 decades, mostly by eliminating previously espoused treatments as ineffective. In infants and young children, those obsolete treatments include decongestants and cough suppressants for young children with common colds, inhaled beta-agonists and steroids for infants with bronchiolitis, and antibiotics for simple otitis media in older children. In other words, most of what I was originally taught.
There is a discontinuity between guidelines that forbid routine steroids and beta-agonists for bronchiolitis in infants, and guidelines that strongly prescribe steroids, metered dose inhalers, and asthma action plans for all discharged wheezers over age 2 years. When I worked as a hospitalist in the pulmonology department, I frequently diagnosed asthma under age 1 year. As a general pediatric hospitalist, one winter I twice ran afoul of a hospital quality metric that benchmarked 100% compliance with providing steroids, inhaled corticosteroids, and asthma action plans on discharge for all wheezers over age 2. Fortunately for both me and the quality team working on that quality dashboard, my thorough documentation of why I didn’t think a particular wheezer had asthma was detailed enough to satisfy peer review.
Historically, medical knowledge has been dependent upon these types of observation which then are taught to the next generation of physicians and, if confirmed repeatedly, become memes with some degree of reliability. An all-too-typical Cochrane library entry may challenge these memes by looking at 200 articles, finding 20 relevant studies, selecting only 2 underpowered studies as meeting their randomized controlled trial criteria, and then concluding that there is “insufficient evidence” to prove the treatment works. But absence of proof is not proof of absence. Twenty five years after coining the phrase “evidence-based medicine,” our medical knowledge base has not been purified.
In medicine, absolute certainty isn’t possible. Using 95% confidence intervals for a research paper does not even mean it is 95% likely to be right. So part of (which is tainted with confirmation bias.) It is a very imperfect art.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@frontlinemedcom.com.
For many years I have counseled medical students and residents that half of what I was taught in medical school has since been proven obsolete or frankly wrong. I counsel them that I have no reason to believe that I am any better than my professors were. So I wish them luck sorting out what is true. Earlier in my career, that warning was mild hyperbole, but not anymore.
Upper respiratory infections (URIs) are the most common reason for an office visit during the winter. Bronchiolitis is the most frequent diagnosis for a winter admission of an infant to a community hospital. Pediatricians have nuanced assessments and many options when treating these diseases. Best practices have changed frequently over the past 3 decades, mostly by eliminating previously espoused treatments as ineffective. In infants and young children, those obsolete treatments include decongestants and cough suppressants for young children with common colds, inhaled beta-agonists and steroids for infants with bronchiolitis, and antibiotics for simple otitis media in older children. In other words, most of what I was originally taught.
There is a discontinuity between guidelines that forbid routine steroids and beta-agonists for bronchiolitis in infants, and guidelines that strongly prescribe steroids, metered dose inhalers, and asthma action plans for all discharged wheezers over age 2 years. When I worked as a hospitalist in the pulmonology department, I frequently diagnosed asthma under age 1 year. As a general pediatric hospitalist, one winter I twice ran afoul of a hospital quality metric that benchmarked 100% compliance with providing steroids, inhaled corticosteroids, and asthma action plans on discharge for all wheezers over age 2. Fortunately for both me and the quality team working on that quality dashboard, my thorough documentation of why I didn’t think a particular wheezer had asthma was detailed enough to satisfy peer review.
Historically, medical knowledge has been dependent upon these types of observation which then are taught to the next generation of physicians and, if confirmed repeatedly, become memes with some degree of reliability. An all-too-typical Cochrane library entry may challenge these memes by looking at 200 articles, finding 20 relevant studies, selecting only 2 underpowered studies as meeting their randomized controlled trial criteria, and then concluding that there is “insufficient evidence” to prove the treatment works. But absence of proof is not proof of absence. Twenty five years after coining the phrase “evidence-based medicine,” our medical knowledge base has not been purified.
In medicine, absolute certainty isn’t possible. Using 95% confidence intervals for a research paper does not even mean it is 95% likely to be right. So part of (which is tainted with confirmation bias.) It is a very imperfect art.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@frontlinemedcom.com.
For many years I have counseled medical students and residents that half of what I was taught in medical school has since been proven obsolete or frankly wrong. I counsel them that I have no reason to believe that I am any better than my professors were. So I wish them luck sorting out what is true. Earlier in my career, that warning was mild hyperbole, but not anymore.
Upper respiratory infections (URIs) are the most common reason for an office visit during the winter. Bronchiolitis is the most frequent diagnosis for a winter admission of an infant to a community hospital. Pediatricians have nuanced assessments and many options when treating these diseases. Best practices have changed frequently over the past 3 decades, mostly by eliminating previously espoused treatments as ineffective. In infants and young children, those obsolete treatments include decongestants and cough suppressants for young children with common colds, inhaled beta-agonists and steroids for infants with bronchiolitis, and antibiotics for simple otitis media in older children. In other words, most of what I was originally taught.
There is a discontinuity between guidelines that forbid routine steroids and beta-agonists for bronchiolitis in infants, and guidelines that strongly prescribe steroids, metered dose inhalers, and asthma action plans for all discharged wheezers over age 2 years. When I worked as a hospitalist in the pulmonology department, I frequently diagnosed asthma under age 1 year. As a general pediatric hospitalist, one winter I twice ran afoul of a hospital quality metric that benchmarked 100% compliance with providing steroids, inhaled corticosteroids, and asthma action plans on discharge for all wheezers over age 2. Fortunately for both me and the quality team working on that quality dashboard, my thorough documentation of why I didn’t think a particular wheezer had asthma was detailed enough to satisfy peer review.
Historically, medical knowledge has been dependent upon these types of observation which then are taught to the next generation of physicians and, if confirmed repeatedly, become memes with some degree of reliability. An all-too-typical Cochrane library entry may challenge these memes by looking at 200 articles, finding 20 relevant studies, selecting only 2 underpowered studies as meeting their randomized controlled trial criteria, and then concluding that there is “insufficient evidence” to prove the treatment works. But absence of proof is not proof of absence. Twenty five years after coining the phrase “evidence-based medicine,” our medical knowledge base has not been purified.
In medicine, absolute certainty isn’t possible. Using 95% confidence intervals for a research paper does not even mean it is 95% likely to be right. So part of (which is tainted with confirmation bias.) It is a very imperfect art.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@frontlinemedcom.com.
The cost of experimental medicine
It has been a remarkable summer of milestones and crises for high-technology medicine.
An FDA panel has unanimously approved a gene therapy: The patient’s own immune cells are taken from his or her body, genetically modified, and reinfused to attack cancer. While the treatment has some dangers, it can be worth trying when conventional therapy has failed, and it appears to be curative when it works. Final FDA approval is expected in September.
While those breakthroughs were occurring, the parents of Charlie Gard, an infant in England with a very rare and devastating mitochondrial disease, were seeking experimental therapy for their child. The medical staff disagreed with the parents: They recommended that the best thing for Charlie would be to stop the ventilator and allow him to die, rather than let him to continue to suffer. Three British courts reviewed Charlie’s case and concurred with the medical staff; on appeal, the European Court of Human Rights also denied the parents’ wishes.
End of life cases similar to Charlie’s are not rare. In modern medicine, parents sometimes must make the heart-wrenching decision to stop aggressive therapies and accept that death is imminent and unavoidable. Many factors go into making that decision. Both the courts and medical staff presume that parents are the best decision makers. Generally, medical staff provide emotional and spiritual support to the parents, along with a tincture of time. In the vast majority of cases, parents and physicians come to agree on the course of care, but sometimes, there are irreconcilable disagreements.
It is rare for courts to overrule parents. The government typically intervenes only when the harm from a parent’s choice exceeds some threshold. For instance, it is not in a child’s best interest to be put in a car during a blizzard and driven to the store to get cigarettes. But neither is it wise to have an intrusive government reviewing every choice a parent makes. The potential harm must be large enough, likely enough, and imminent enough before most judges will intervene. The law will insist the child be in a car seat at least.
In Charlie’s case, the medical staff and the judges all explicitly said that the cost of therapy did not factor into their decision making; they looked solely at what was best for Charlie. The focus was on whether the unproven potential benefits of experimental therapy outweighed the risk of suffering caused by the therapy and continued intensive medical care.
Even when a bedside decision ignores the financial impact, money often structures which therapeutic choices are available. There are also issues of equitable access to be raised and weighed. Expenditures impact other social choices.
Money influenced the actions of Martin Shkreli, who is best known as the pharmacy company executive who markedly increased the price of a drug. Mr. Shkreli was recently convicted on three of eight charges for securities fraud, and sentencing is pending; the convictions were not related to the price increase.
The United States has created some amazing technologies to save individual, identifiable lives, but they come at a high price that often costs lives in ways more subtle than the incident in India. At some point, the government and the public are responsible for either financing or rationing care, but that doesn’t absolve the scientists completely. The Russell-Einstein (Pugwash) Manifesto established that scientists have a moral accountability for the negative consequences of creating new technology, and that includes the financial aspects.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@frontlinemedcom.com
It has been a remarkable summer of milestones and crises for high-technology medicine.
An FDA panel has unanimously approved a gene therapy: The patient’s own immune cells are taken from his or her body, genetically modified, and reinfused to attack cancer. While the treatment has some dangers, it can be worth trying when conventional therapy has failed, and it appears to be curative when it works. Final FDA approval is expected in September.
While those breakthroughs were occurring, the parents of Charlie Gard, an infant in England with a very rare and devastating mitochondrial disease, were seeking experimental therapy for their child. The medical staff disagreed with the parents: They recommended that the best thing for Charlie would be to stop the ventilator and allow him to die, rather than let him to continue to suffer. Three British courts reviewed Charlie’s case and concurred with the medical staff; on appeal, the European Court of Human Rights also denied the parents’ wishes.
End of life cases similar to Charlie’s are not rare. In modern medicine, parents sometimes must make the heart-wrenching decision to stop aggressive therapies and accept that death is imminent and unavoidable. Many factors go into making that decision. Both the courts and medical staff presume that parents are the best decision makers. Generally, medical staff provide emotional and spiritual support to the parents, along with a tincture of time. In the vast majority of cases, parents and physicians come to agree on the course of care, but sometimes, there are irreconcilable disagreements.
It is rare for courts to overrule parents. The government typically intervenes only when the harm from a parent’s choice exceeds some threshold. For instance, it is not in a child’s best interest to be put in a car during a blizzard and driven to the store to get cigarettes. But neither is it wise to have an intrusive government reviewing every choice a parent makes. The potential harm must be large enough, likely enough, and imminent enough before most judges will intervene. The law will insist the child be in a car seat at least.
In Charlie’s case, the medical staff and the judges all explicitly said that the cost of therapy did not factor into their decision making; they looked solely at what was best for Charlie. The focus was on whether the unproven potential benefits of experimental therapy outweighed the risk of suffering caused by the therapy and continued intensive medical care.
Even when a bedside decision ignores the financial impact, money often structures which therapeutic choices are available. There are also issues of equitable access to be raised and weighed. Expenditures impact other social choices.
Money influenced the actions of Martin Shkreli, who is best known as the pharmacy company executive who markedly increased the price of a drug. Mr. Shkreli was recently convicted on three of eight charges for securities fraud, and sentencing is pending; the convictions were not related to the price increase.
The United States has created some amazing technologies to save individual, identifiable lives, but they come at a high price that often costs lives in ways more subtle than the incident in India. At some point, the government and the public are responsible for either financing or rationing care, but that doesn’t absolve the scientists completely. The Russell-Einstein (Pugwash) Manifesto established that scientists have a moral accountability for the negative consequences of creating new technology, and that includes the financial aspects.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@frontlinemedcom.com
It has been a remarkable summer of milestones and crises for high-technology medicine.
An FDA panel has unanimously approved a gene therapy: The patient’s own immune cells are taken from his or her body, genetically modified, and reinfused to attack cancer. While the treatment has some dangers, it can be worth trying when conventional therapy has failed, and it appears to be curative when it works. Final FDA approval is expected in September.
While those breakthroughs were occurring, the parents of Charlie Gard, an infant in England with a very rare and devastating mitochondrial disease, were seeking experimental therapy for their child. The medical staff disagreed with the parents: They recommended that the best thing for Charlie would be to stop the ventilator and allow him to die, rather than let him to continue to suffer. Three British courts reviewed Charlie’s case and concurred with the medical staff; on appeal, the European Court of Human Rights also denied the parents’ wishes.
End of life cases similar to Charlie’s are not rare. In modern medicine, parents sometimes must make the heart-wrenching decision to stop aggressive therapies and accept that death is imminent and unavoidable. Many factors go into making that decision. Both the courts and medical staff presume that parents are the best decision makers. Generally, medical staff provide emotional and spiritual support to the parents, along with a tincture of time. In the vast majority of cases, parents and physicians come to agree on the course of care, but sometimes, there are irreconcilable disagreements.
It is rare for courts to overrule parents. The government typically intervenes only when the harm from a parent’s choice exceeds some threshold. For instance, it is not in a child’s best interest to be put in a car during a blizzard and driven to the store to get cigarettes. But neither is it wise to have an intrusive government reviewing every choice a parent makes. The potential harm must be large enough, likely enough, and imminent enough before most judges will intervene. The law will insist the child be in a car seat at least.
In Charlie’s case, the medical staff and the judges all explicitly said that the cost of therapy did not factor into their decision making; they looked solely at what was best for Charlie. The focus was on whether the unproven potential benefits of experimental therapy outweighed the risk of suffering caused by the therapy and continued intensive medical care.
Even when a bedside decision ignores the financial impact, money often structures which therapeutic choices are available. There are also issues of equitable access to be raised and weighed. Expenditures impact other social choices.
Money influenced the actions of Martin Shkreli, who is best known as the pharmacy company executive who markedly increased the price of a drug. Mr. Shkreli was recently convicted on three of eight charges for securities fraud, and sentencing is pending; the convictions were not related to the price increase.
The United States has created some amazing technologies to save individual, identifiable lives, but they come at a high price that often costs lives in ways more subtle than the incident in India. At some point, the government and the public are responsible for either financing or rationing care, but that doesn’t absolve the scientists completely. The Russell-Einstein (Pugwash) Manifesto established that scientists have a moral accountability for the negative consequences of creating new technology, and that includes the financial aspects.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@frontlinemedcom.com
Privacy and maternal records
At the undergraduate level, classes on medical ethics tend to focus on the big ticket items like abortion, euthanasia, and social justice. Personally, I find the more interesting clinical cases involve relatively minor issues that accumulate to create problems. Privacy is one example.
A large amount of information in the mother’s prenatal records potentially impacts a newborn’s care. Ideally, the EHR is transferring data to the newborn’s chart, but not everything automatically populates in the newborn record, so there will be times when a pediatrician needs to review the mother’s chart.
- The criteria for selecting which mothers’ charts to review involve racial profiling.
- Access to mental health records involving addiction treatment requires special authorization. State laws and hospital policies will vary.
- Mom is a Hollywood celebrity and, while reviewing her chart, prurient curiosity extends the search to records of her cosmetic surgeries.
In my opinion, most of what is and isn’t permissible is determined by medical custom and not by statutes. The judiciary reserves the power to intervene, so medical custom should be informed by laws and by legal principles. But, the primary basis for these decisions should be a commitment to patient advocacy and to common sense, which in this situation means, “Would the typical reasonable person be upset if she learned I had done something without telling her?” If the answer to that question is yes, or in any way equivocal, I think ethics would dictate obtaining consent or at least assent.
Opiate addiction has quadrupled in the past 15 years. Almost all states now have prescription registries to help detect doctor shopping, multiple prescribers, and misdirection. If you are prescribing an opiate, it is ethically reasonable (and now the law) for you to make writing the prescription contingent on your patient agreeing to your consulting the registry. No consent, no prescription.
I think the facts of that case (writing a prescription) can be distinguished (a legal term) from the case of a neonatologist accessing the narcotic registry of the mother while on a fishing expedition to find evidence that might help the baby. Perhaps it is okay with the mother’s uncoerced consent, but otherwise I think that practice reeks as an unreasonable search. Ethically and legally, it has parallels to Ferguson v. City of Charleston (SCOTUS 2001).
That was a 6-3 Supreme Court decision, so, while I agree with the majority, you may find hospital lawyers who disagree. Overall, I assert that consent and privacy are best considered ethically as advocacy for the patient and not as legalistic forms that the physician must complete.
The reverse situation also occurs. Sometimes maternal health information is placed into the newborn’s chart that doesn’t need to be there. For example, common practice has been to designate mom, after delivery, as G4P2022. This contains the information that mother has had two therapeutic abortions. Does that information belong in a newborn’s chart? Especially in the era of the EHR where this information will hang around forever and will be easily obtained by the baby 16 years later when she can access all her medical information online. Will the mother be upset for her teenage daughter to learn that mom has had two abortions? Is that private information, belonging to the mother, that was given in confidence to her obstetrician? I advocate respecting privacy.
I have similar concerns about STD information being transferred from maternal charts to the newborn’s EHR. A maternal history of gonorrhea treated 8 years previously is unlikely to be relevant and should not populate the newborn’s EHR. I can make an argument that chlamydia detected and treated during the pregnancy might be useful to the baby’s pediatrician because neither treatment nor tests of cure are perfect. Perhaps, it could exist as a Snapchat-type record and disappear from the newborn’s record in a year if no respiratory symptoms occur.
I’m aware of efforts to destigmatize abortion and STDs, but, until that occurs, sensitive information should be handled delicately to preserve privacy. That is a major component of the Hippocratic Oath.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis.
At the undergraduate level, classes on medical ethics tend to focus on the big ticket items like abortion, euthanasia, and social justice. Personally, I find the more interesting clinical cases involve relatively minor issues that accumulate to create problems. Privacy is one example.
A large amount of information in the mother’s prenatal records potentially impacts a newborn’s care. Ideally, the EHR is transferring data to the newborn’s chart, but not everything automatically populates in the newborn record, so there will be times when a pediatrician needs to review the mother’s chart.
- The criteria for selecting which mothers’ charts to review involve racial profiling.
- Access to mental health records involving addiction treatment requires special authorization. State laws and hospital policies will vary.
- Mom is a Hollywood celebrity and, while reviewing her chart, prurient curiosity extends the search to records of her cosmetic surgeries.
In my opinion, most of what is and isn’t permissible is determined by medical custom and not by statutes. The judiciary reserves the power to intervene, so medical custom should be informed by laws and by legal principles. But, the primary basis for these decisions should be a commitment to patient advocacy and to common sense, which in this situation means, “Would the typical reasonable person be upset if she learned I had done something without telling her?” If the answer to that question is yes, or in any way equivocal, I think ethics would dictate obtaining consent or at least assent.
Opiate addiction has quadrupled in the past 15 years. Almost all states now have prescription registries to help detect doctor shopping, multiple prescribers, and misdirection. If you are prescribing an opiate, it is ethically reasonable (and now the law) for you to make writing the prescription contingent on your patient agreeing to your consulting the registry. No consent, no prescription.
I think the facts of that case (writing a prescription) can be distinguished (a legal term) from the case of a neonatologist accessing the narcotic registry of the mother while on a fishing expedition to find evidence that might help the baby. Perhaps it is okay with the mother’s uncoerced consent, but otherwise I think that practice reeks as an unreasonable search. Ethically and legally, it has parallels to Ferguson v. City of Charleston (SCOTUS 2001).
That was a 6-3 Supreme Court decision, so, while I agree with the majority, you may find hospital lawyers who disagree. Overall, I assert that consent and privacy are best considered ethically as advocacy for the patient and not as legalistic forms that the physician must complete.
The reverse situation also occurs. Sometimes maternal health information is placed into the newborn’s chart that doesn’t need to be there. For example, common practice has been to designate mom, after delivery, as G4P2022. This contains the information that mother has had two therapeutic abortions. Does that information belong in a newborn’s chart? Especially in the era of the EHR where this information will hang around forever and will be easily obtained by the baby 16 years later when she can access all her medical information online. Will the mother be upset for her teenage daughter to learn that mom has had two abortions? Is that private information, belonging to the mother, that was given in confidence to her obstetrician? I advocate respecting privacy.
I have similar concerns about STD information being transferred from maternal charts to the newborn’s EHR. A maternal history of gonorrhea treated 8 years previously is unlikely to be relevant and should not populate the newborn’s EHR. I can make an argument that chlamydia detected and treated during the pregnancy might be useful to the baby’s pediatrician because neither treatment nor tests of cure are perfect. Perhaps, it could exist as a Snapchat-type record and disappear from the newborn’s record in a year if no respiratory symptoms occur.
I’m aware of efforts to destigmatize abortion and STDs, but, until that occurs, sensitive information should be handled delicately to preserve privacy. That is a major component of the Hippocratic Oath.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis.
At the undergraduate level, classes on medical ethics tend to focus on the big ticket items like abortion, euthanasia, and social justice. Personally, I find the more interesting clinical cases involve relatively minor issues that accumulate to create problems. Privacy is one example.
A large amount of information in the mother’s prenatal records potentially impacts a newborn’s care. Ideally, the EHR is transferring data to the newborn’s chart, but not everything automatically populates in the newborn record, so there will be times when a pediatrician needs to review the mother’s chart.
- The criteria for selecting which mothers’ charts to review involve racial profiling.
- Access to mental health records involving addiction treatment requires special authorization. State laws and hospital policies will vary.
- Mom is a Hollywood celebrity and, while reviewing her chart, prurient curiosity extends the search to records of her cosmetic surgeries.
In my opinion, most of what is and isn’t permissible is determined by medical custom and not by statutes. The judiciary reserves the power to intervene, so medical custom should be informed by laws and by legal principles. But, the primary basis for these decisions should be a commitment to patient advocacy and to common sense, which in this situation means, “Would the typical reasonable person be upset if she learned I had done something without telling her?” If the answer to that question is yes, or in any way equivocal, I think ethics would dictate obtaining consent or at least assent.
Opiate addiction has quadrupled in the past 15 years. Almost all states now have prescription registries to help detect doctor shopping, multiple prescribers, and misdirection. If you are prescribing an opiate, it is ethically reasonable (and now the law) for you to make writing the prescription contingent on your patient agreeing to your consulting the registry. No consent, no prescription.
I think the facts of that case (writing a prescription) can be distinguished (a legal term) from the case of a neonatologist accessing the narcotic registry of the mother while on a fishing expedition to find evidence that might help the baby. Perhaps it is okay with the mother’s uncoerced consent, but otherwise I think that practice reeks as an unreasonable search. Ethically and legally, it has parallels to Ferguson v. City of Charleston (SCOTUS 2001).
That was a 6-3 Supreme Court decision, so, while I agree with the majority, you may find hospital lawyers who disagree. Overall, I assert that consent and privacy are best considered ethically as advocacy for the patient and not as legalistic forms that the physician must complete.
The reverse situation also occurs. Sometimes maternal health information is placed into the newborn’s chart that doesn’t need to be there. For example, common practice has been to designate mom, after delivery, as G4P2022. This contains the information that mother has had two therapeutic abortions. Does that information belong in a newborn’s chart? Especially in the era of the EHR where this information will hang around forever and will be easily obtained by the baby 16 years later when she can access all her medical information online. Will the mother be upset for her teenage daughter to learn that mom has had two abortions? Is that private information, belonging to the mother, that was given in confidence to her obstetrician? I advocate respecting privacy.
I have similar concerns about STD information being transferred from maternal charts to the newborn’s EHR. A maternal history of gonorrhea treated 8 years previously is unlikely to be relevant and should not populate the newborn’s EHR. I can make an argument that chlamydia detected and treated during the pregnancy might be useful to the baby’s pediatrician because neither treatment nor tests of cure are perfect. Perhaps, it could exist as a Snapchat-type record and disappear from the newborn’s record in a year if no respiratory symptoms occur.
I’m aware of efforts to destigmatize abortion and STDs, but, until that occurs, sensitive information should be handled delicately to preserve privacy. That is a major component of the Hippocratic Oath.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis.
Changing ethics of pediatric health care: The last 50 years
The ethics of pediatric health care have changed radically in the past 50 years. “History,” they say, “is written by the victors.” So, if you are not careful, you will only get part of the story. Clinical ethicists learn to seek out, involve, and empower the voices of all stakeholders. To fully appreciate how much things have changed, you must learn more than one side of the story. Indeed, piecing together the history of medical ethics reminds me of the Indian story of five blind men describing an elephant, in which each can only describe a part of an ultimately much bigger animal.
If you ask philosophers about the history of medical ethics, they will point to events 50 years ago as the beginning of the modern era. In the 1960s, physicians tended to be paternalistic authoritarians. Some considered it best not to even tell a patient that he had cancer. There was minimal patient education provided. Medications were prescribed as orders for the patient to follow. Medical research had harmed volunteers, and new protections were needed.
In 1995, the American Academy of Pediatrics Section on Bioethics emphasized the importance of obtaining the child’s assent in addition to the parent’s consent.2 Most states have passed laws permitting minors to give consent for treatment for pregnancy, sexually transmitted diseases, drug addiction, and mental health care.
Technology alters ethics
At the same time, technology has been changing medicine. New life sustaining technologies in the 1960s – such as dialysis and ventilators – created new issues of extreme financial cost, allocation of scarce resources, and even the existential question of when life ends. In 1968, an ad hoc committee at Harvard created criteria for what is colloquially called “brain death.”3 Many landmark legal cases further developed the ethics of end-of-life care.
The boundaries were even less clear at the beginning of life. Technological advances in ventilators, improvements in nursing care by neonatal intensive care unit nurses, and the whole new subspecialty of neonatology progressively lowered the gestational age for survival. The distinction between clinical care and experimental care was again blurry as neonatologists sought to overcome previously unknown complications, like retinopathy of prematurity resulting from too much oxygen and bronchopulmonary dysplasia from the ventilator. Many babies survived with profound physical and neurological compromise. The ethical dilemmas were continuously present.
Change in the status of children
There is more to the story than philosophy, law, and technology. Pediatric ethics has been profoundly impacted by a change in the status of the children. One change from 50 years ago has been the social response to child abuse.4 Norms changed. Before, fathers pretty much could raise their children any way they saw fit, including corporal punishment. Neighbors didn’t intervene. The proverb was “spare the rod and spoil the child,” but abuse was not motivated by discipline. It was cruel, authoritarian, and demeaning. The landmark article describing the Battered Child Syndrome was published in 1962.5 By 1967, the local Society for the Prevention of Cruelty to Children had become nearly obsolete, but understaffed local government agencies were just beginning to respond. In 1974, federal action produced the Child Abuse Prevention and Treatment Act.6 Medical personnel became mandatory reporters, developed expertise, and, in 2009, child abuse became a boarded subspecialty in pediatrics.
Then, in 1971, a documentary “Who Should Survive?” explored the ethical decision making for babies with birth defects.7 The harms of institutionalization became recognized. The benefits of early intervention and special education have been established. Support for an Individual Education Plan has progressed through successive laws beginning in 1975 until the Individuals with Disabilities Education Improvement Act of 2004.
This is just another example of how ethics develops from a philosophical ideal to a change in social status, followed by consciousness raising, civil rights legislation, enabling legislation, funding, and program development and implementation.
It takes a village of philosophers, activists, lawyers, legislators, physicians, and other experts to implement ethics. There are also countervailing forces. The mainstreaming of children with disabilities is one factor in the movement of children into private schools and the pressure for a voucher system, as advocated by the new Secretary of Education, Betty DeVos.
There also has been a change in the status of children as future providers. Historically, children were relied upon to provide for the parents in their old age. With decreases in infant mortality, the availability of birth control, and legalized abortions, smaller families became the social norm. Worldwide, there has been a marked drop in fertility rates in developed nations. Governmental programs such as Social Security, particularly with the introduction of Medicare in 1965, meant that the elderly were less dependent on their descendants. China found that acceptance of the One Child policy was heavily dependent on convincing parents that the State would provide for them in their old age. The modern political state has assumed duties previously performed by the family.
More recent changes
Pediatric health care is strongly impacted by public health measures. Infant mortality has been reduced by improved nutrition and public health, not medication and surgery. Mass immunization programs were viewed as an appropriate function of civic government.
The introduction of polio vaccine in the 1950s made a large impact. Families lined up at any opportunity to get the vaccine. Polio went from hundreds of thousands of cases of paralysis each summer down to zero cases of wild polio transmitted within the western hemisphere. Measles cases went from 450,000 cases a year in the early 1960s down to zero, until a fraudulent link to autism led to a significant number of parents not immunizing their children. Vaccine refusal, previously a rare ethical issue related to religious liberty, became corrupted by efforts at boutique medicine and alternative facts. In modern America, the ethics of individualism and personal rights have eclipsed civic responsibility. With herd immunity compromised, a blip up to 100 cases of measles per year was histrionically described as a huge epidemic. That spin shows ignorance of the historical record, but the risk was enough for the liberal state of California in 2015 to ban philosophical exemptions to vaccination with one of the strictest state laws in the nation.
Ethics is about values. So, as I look at the changes over 50 years, the areas that have failed to make progress are illuminating. Mental health care for children has not made the same progress achieved with vaccines and cancer therapy. My most recent clinical ethics case involved a teenager who had made a suicidal gesture by taking a handful of pills. The nurses were caught between caring for their patient and meeting the demands of an upset, authoritarian parent in a world where customer satisfaction is critical. I spent much of the night exploring hospital policy and state law. I solicited and listened to widely disparate interpretations of law, medical ethics, and hospital policy from the floor nurse, the nursing supervisor, the nursing staff on the adult inpatient psychiatric unit, three ED docs, a social worker, a government agency, and a judge’s representative. The physician of 1967 was captain of the ship and would not recognize the chaotic teamwork of modern medicine. The exercise showed me how little progress we have made in mental health care for adolescents during my 25 years of practice.
It also reminded me that I have the luxury to debate ethical minutia like vaccine hesitancy and adolescent consent in a world with Syrian refugee camps and starvation in South Sudan. Mahatma Gandhi said, “There are people in the world so hungry that God cannot appear to them except in the form of bread.” That, unfortunately, has not changed in 50 years.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@frontlinemedcom.com.
References
1. www.hhs.gov/ohrp/regulations-and-policy/belmont-report/
2. Pediatrics 1995;95:314-7.
3. JAMA. 1968;205(6):337-40.
4. Family Law Quarterly. 2008 Fall;42(3):449-63.
5. JAMA. 1962;181(1):17-24.
6. National Child Abuse and Neglect Training and Publications Project (2014). The Child Abuse Prevention and Treatment Act: 40 years of safeguarding America’s children. Washington: U.S. Department of Health and Human Services, Children’s Bureau.
7. Kennedy Inst Ethics J. 2006 Sep;16(3):205-24.
The ethics of pediatric health care have changed radically in the past 50 years. “History,” they say, “is written by the victors.” So, if you are not careful, you will only get part of the story. Clinical ethicists learn to seek out, involve, and empower the voices of all stakeholders. To fully appreciate how much things have changed, you must learn more than one side of the story. Indeed, piecing together the history of medical ethics reminds me of the Indian story of five blind men describing an elephant, in which each can only describe a part of an ultimately much bigger animal.
If you ask philosophers about the history of medical ethics, they will point to events 50 years ago as the beginning of the modern era. In the 1960s, physicians tended to be paternalistic authoritarians. Some considered it best not to even tell a patient that he had cancer. There was minimal patient education provided. Medications were prescribed as orders for the patient to follow. Medical research had harmed volunteers, and new protections were needed.
In 1995, the American Academy of Pediatrics Section on Bioethics emphasized the importance of obtaining the child’s assent in addition to the parent’s consent.2 Most states have passed laws permitting minors to give consent for treatment for pregnancy, sexually transmitted diseases, drug addiction, and mental health care.
Technology alters ethics
At the same time, technology has been changing medicine. New life sustaining technologies in the 1960s – such as dialysis and ventilators – created new issues of extreme financial cost, allocation of scarce resources, and even the existential question of when life ends. In 1968, an ad hoc committee at Harvard created criteria for what is colloquially called “brain death.”3 Many landmark legal cases further developed the ethics of end-of-life care.
The boundaries were even less clear at the beginning of life. Technological advances in ventilators, improvements in nursing care by neonatal intensive care unit nurses, and the whole new subspecialty of neonatology progressively lowered the gestational age for survival. The distinction between clinical care and experimental care was again blurry as neonatologists sought to overcome previously unknown complications, like retinopathy of prematurity resulting from too much oxygen and bronchopulmonary dysplasia from the ventilator. Many babies survived with profound physical and neurological compromise. The ethical dilemmas were continuously present.
Change in the status of children
There is more to the story than philosophy, law, and technology. Pediatric ethics has been profoundly impacted by a change in the status of the children. One change from 50 years ago has been the social response to child abuse.4 Norms changed. Before, fathers pretty much could raise their children any way they saw fit, including corporal punishment. Neighbors didn’t intervene. The proverb was “spare the rod and spoil the child,” but abuse was not motivated by discipline. It was cruel, authoritarian, and demeaning. The landmark article describing the Battered Child Syndrome was published in 1962.5 By 1967, the local Society for the Prevention of Cruelty to Children had become nearly obsolete, but understaffed local government agencies were just beginning to respond. In 1974, federal action produced the Child Abuse Prevention and Treatment Act.6 Medical personnel became mandatory reporters, developed expertise, and, in 2009, child abuse became a boarded subspecialty in pediatrics.
Then, in 1971, a documentary “Who Should Survive?” explored the ethical decision making for babies with birth defects.7 The harms of institutionalization became recognized. The benefits of early intervention and special education have been established. Support for an Individual Education Plan has progressed through successive laws beginning in 1975 until the Individuals with Disabilities Education Improvement Act of 2004.
This is just another example of how ethics develops from a philosophical ideal to a change in social status, followed by consciousness raising, civil rights legislation, enabling legislation, funding, and program development and implementation.
It takes a village of philosophers, activists, lawyers, legislators, physicians, and other experts to implement ethics. There are also countervailing forces. The mainstreaming of children with disabilities is one factor in the movement of children into private schools and the pressure for a voucher system, as advocated by the new Secretary of Education, Betty DeVos.
There also has been a change in the status of children as future providers. Historically, children were relied upon to provide for the parents in their old age. With decreases in infant mortality, the availability of birth control, and legalized abortions, smaller families became the social norm. Worldwide, there has been a marked drop in fertility rates in developed nations. Governmental programs such as Social Security, particularly with the introduction of Medicare in 1965, meant that the elderly were less dependent on their descendants. China found that acceptance of the One Child policy was heavily dependent on convincing parents that the State would provide for them in their old age. The modern political state has assumed duties previously performed by the family.
More recent changes
Pediatric health care is strongly impacted by public health measures. Infant mortality has been reduced by improved nutrition and public health, not medication and surgery. Mass immunization programs were viewed as an appropriate function of civic government.
The introduction of polio vaccine in the 1950s made a large impact. Families lined up at any opportunity to get the vaccine. Polio went from hundreds of thousands of cases of paralysis each summer down to zero cases of wild polio transmitted within the western hemisphere. Measles cases went from 450,000 cases a year in the early 1960s down to zero, until a fraudulent link to autism led to a significant number of parents not immunizing their children. Vaccine refusal, previously a rare ethical issue related to religious liberty, became corrupted by efforts at boutique medicine and alternative facts. In modern America, the ethics of individualism and personal rights have eclipsed civic responsibility. With herd immunity compromised, a blip up to 100 cases of measles per year was histrionically described as a huge epidemic. That spin shows ignorance of the historical record, but the risk was enough for the liberal state of California in 2015 to ban philosophical exemptions to vaccination with one of the strictest state laws in the nation.
Ethics is about values. So, as I look at the changes over 50 years, the areas that have failed to make progress are illuminating. Mental health care for children has not made the same progress achieved with vaccines and cancer therapy. My most recent clinical ethics case involved a teenager who had made a suicidal gesture by taking a handful of pills. The nurses were caught between caring for their patient and meeting the demands of an upset, authoritarian parent in a world where customer satisfaction is critical. I spent much of the night exploring hospital policy and state law. I solicited and listened to widely disparate interpretations of law, medical ethics, and hospital policy from the floor nurse, the nursing supervisor, the nursing staff on the adult inpatient psychiatric unit, three ED docs, a social worker, a government agency, and a judge’s representative. The physician of 1967 was captain of the ship and would not recognize the chaotic teamwork of modern medicine. The exercise showed me how little progress we have made in mental health care for adolescents during my 25 years of practice.
It also reminded me that I have the luxury to debate ethical minutia like vaccine hesitancy and adolescent consent in a world with Syrian refugee camps and starvation in South Sudan. Mahatma Gandhi said, “There are people in the world so hungry that God cannot appear to them except in the form of bread.” That, unfortunately, has not changed in 50 years.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@frontlinemedcom.com.
References
1. www.hhs.gov/ohrp/regulations-and-policy/belmont-report/
2. Pediatrics 1995;95:314-7.
3. JAMA. 1968;205(6):337-40.
4. Family Law Quarterly. 2008 Fall;42(3):449-63.
5. JAMA. 1962;181(1):17-24.
6. National Child Abuse and Neglect Training and Publications Project (2014). The Child Abuse Prevention and Treatment Act: 40 years of safeguarding America’s children. Washington: U.S. Department of Health and Human Services, Children’s Bureau.
7. Kennedy Inst Ethics J. 2006 Sep;16(3):205-24.
The ethics of pediatric health care have changed radically in the past 50 years. “History,” they say, “is written by the victors.” So, if you are not careful, you will only get part of the story. Clinical ethicists learn to seek out, involve, and empower the voices of all stakeholders. To fully appreciate how much things have changed, you must learn more than one side of the story. Indeed, piecing together the history of medical ethics reminds me of the Indian story of five blind men describing an elephant, in which each can only describe a part of an ultimately much bigger animal.
If you ask philosophers about the history of medical ethics, they will point to events 50 years ago as the beginning of the modern era. In the 1960s, physicians tended to be paternalistic authoritarians. Some considered it best not to even tell a patient that he had cancer. There was minimal patient education provided. Medications were prescribed as orders for the patient to follow. Medical research had harmed volunteers, and new protections were needed.
In 1995, the American Academy of Pediatrics Section on Bioethics emphasized the importance of obtaining the child’s assent in addition to the parent’s consent.2 Most states have passed laws permitting minors to give consent for treatment for pregnancy, sexually transmitted diseases, drug addiction, and mental health care.
Technology alters ethics
At the same time, technology has been changing medicine. New life sustaining technologies in the 1960s – such as dialysis and ventilators – created new issues of extreme financial cost, allocation of scarce resources, and even the existential question of when life ends. In 1968, an ad hoc committee at Harvard created criteria for what is colloquially called “brain death.”3 Many landmark legal cases further developed the ethics of end-of-life care.
The boundaries were even less clear at the beginning of life. Technological advances in ventilators, improvements in nursing care by neonatal intensive care unit nurses, and the whole new subspecialty of neonatology progressively lowered the gestational age for survival. The distinction between clinical care and experimental care was again blurry as neonatologists sought to overcome previously unknown complications, like retinopathy of prematurity resulting from too much oxygen and bronchopulmonary dysplasia from the ventilator. Many babies survived with profound physical and neurological compromise. The ethical dilemmas were continuously present.
Change in the status of children
There is more to the story than philosophy, law, and technology. Pediatric ethics has been profoundly impacted by a change in the status of the children. One change from 50 years ago has been the social response to child abuse.4 Norms changed. Before, fathers pretty much could raise their children any way they saw fit, including corporal punishment. Neighbors didn’t intervene. The proverb was “spare the rod and spoil the child,” but abuse was not motivated by discipline. It was cruel, authoritarian, and demeaning. The landmark article describing the Battered Child Syndrome was published in 1962.5 By 1967, the local Society for the Prevention of Cruelty to Children had become nearly obsolete, but understaffed local government agencies were just beginning to respond. In 1974, federal action produced the Child Abuse Prevention and Treatment Act.6 Medical personnel became mandatory reporters, developed expertise, and, in 2009, child abuse became a boarded subspecialty in pediatrics.
Then, in 1971, a documentary “Who Should Survive?” explored the ethical decision making for babies with birth defects.7 The harms of institutionalization became recognized. The benefits of early intervention and special education have been established. Support for an Individual Education Plan has progressed through successive laws beginning in 1975 until the Individuals with Disabilities Education Improvement Act of 2004.
This is just another example of how ethics develops from a philosophical ideal to a change in social status, followed by consciousness raising, civil rights legislation, enabling legislation, funding, and program development and implementation.
It takes a village of philosophers, activists, lawyers, legislators, physicians, and other experts to implement ethics. There are also countervailing forces. The mainstreaming of children with disabilities is one factor in the movement of children into private schools and the pressure for a voucher system, as advocated by the new Secretary of Education, Betty DeVos.
There also has been a change in the status of children as future providers. Historically, children were relied upon to provide for the parents in their old age. With decreases in infant mortality, the availability of birth control, and legalized abortions, smaller families became the social norm. Worldwide, there has been a marked drop in fertility rates in developed nations. Governmental programs such as Social Security, particularly with the introduction of Medicare in 1965, meant that the elderly were less dependent on their descendants. China found that acceptance of the One Child policy was heavily dependent on convincing parents that the State would provide for them in their old age. The modern political state has assumed duties previously performed by the family.
More recent changes
Pediatric health care is strongly impacted by public health measures. Infant mortality has been reduced by improved nutrition and public health, not medication and surgery. Mass immunization programs were viewed as an appropriate function of civic government.
The introduction of polio vaccine in the 1950s made a large impact. Families lined up at any opportunity to get the vaccine. Polio went from hundreds of thousands of cases of paralysis each summer down to zero cases of wild polio transmitted within the western hemisphere. Measles cases went from 450,000 cases a year in the early 1960s down to zero, until a fraudulent link to autism led to a significant number of parents not immunizing their children. Vaccine refusal, previously a rare ethical issue related to religious liberty, became corrupted by efforts at boutique medicine and alternative facts. In modern America, the ethics of individualism and personal rights have eclipsed civic responsibility. With herd immunity compromised, a blip up to 100 cases of measles per year was histrionically described as a huge epidemic. That spin shows ignorance of the historical record, but the risk was enough for the liberal state of California in 2015 to ban philosophical exemptions to vaccination with one of the strictest state laws in the nation.
Ethics is about values. So, as I look at the changes over 50 years, the areas that have failed to make progress are illuminating. Mental health care for children has not made the same progress achieved with vaccines and cancer therapy. My most recent clinical ethics case involved a teenager who had made a suicidal gesture by taking a handful of pills. The nurses were caught between caring for their patient and meeting the demands of an upset, authoritarian parent in a world where customer satisfaction is critical. I spent much of the night exploring hospital policy and state law. I solicited and listened to widely disparate interpretations of law, medical ethics, and hospital policy from the floor nurse, the nursing supervisor, the nursing staff on the adult inpatient psychiatric unit, three ED docs, a social worker, a government agency, and a judge’s representative. The physician of 1967 was captain of the ship and would not recognize the chaotic teamwork of modern medicine. The exercise showed me how little progress we have made in mental health care for adolescents during my 25 years of practice.
It also reminded me that I have the luxury to debate ethical minutia like vaccine hesitancy and adolescent consent in a world with Syrian refugee camps and starvation in South Sudan. Mahatma Gandhi said, “There are people in the world so hungry that God cannot appear to them except in the form of bread.” That, unfortunately, has not changed in 50 years.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@frontlinemedcom.com.
References
1. www.hhs.gov/ohrp/regulations-and-policy/belmont-report/
2. Pediatrics 1995;95:314-7.
3. JAMA. 1968;205(6):337-40.
4. Family Law Quarterly. 2008 Fall;42(3):449-63.
5. JAMA. 1962;181(1):17-24.
6. National Child Abuse and Neglect Training and Publications Project (2014). The Child Abuse Prevention and Treatment Act: 40 years of safeguarding America’s children. Washington: U.S. Department of Health and Human Services, Children’s Bureau.
7. Kennedy Inst Ethics J. 2006 Sep;16(3):205-24.
Cooperation must overcome polarization
Each profession has its own core set of knowledge, skills, and values. For physicians, the core set of knowledge is anatomy, pathophysiology, and pharmacology. Skills include taking a history, the physical exam, and surgical procedures. The core values traditionally have been compassion and altruism. For modern medical practice, I urge adding cooperation as a core value. Medical school and the apprenticeship of residency are designed to teach, role model, foster, develop, and groom these core competencies.
Getting into medical school is highly competitive. Medical training uses methods that are very different than those used to train elite Olympic and professional athletes. Some competitiveness persists in medical school, but in general the faculty emphasizes cooperation rather than competition. The metric is not whether one student or resident is better than another. Gold and silver medals are not awarded. It is about whether each physician-to-be has passed the milestones needed to practice medicine.
But American health care is threatened by the continued polarization of our government and our society. For years both Cleveland Clinic and Dana Farber have held annual fundraising events at Mar-a-Lago. In February 2017, because of that location’s association with President Trump, some people associated with the organizations advocated boycotting those important fund-raisers. These past few months, it seems every action and every purchase has become a political statement. One restaurant mentioned immigrants on its receipt. The action went viral and caused other people to advocate boycotting the restaurant or not tipping the wait staff (“The new political battleground: Your restaurant receipt,” The Washington Post, by Maura Judkis, Feb. 14, 2017).
Secondary boycotts are an ethical quandary. In labor disputes, organized unions can go on strike. In the 1970s, Japanese cars were not welcome in the employee parking lot of a Ford assembly plant. People do vote with their pocketbook. But in labor disputes, there are legal restrictions on secondary boycotts against other companies. People do need to get along with their neighbors and so do businesses. Politics is the art of encouraging cooperation on one project amongst people who disagree about the goals of many other proposed projects. The Preamble to the United States Constitution enumerates the benefits of cooperation.
In any large-scale human endeavor, conflicts arise that may limit cooperation. Accommodating conscientious objection is the safety valve that permits cooperation when dealing with contested government endeavors such as war, abortion, and physician-assisted suicide. It is meant as a last ditch effort to maintain cohesion of both societal and individual moral integrity. But if every proposed action is met with votes divided along party lines, conscientious objection loses its moral high ground.
Judge Neil Gorsuch, the nominee for the U.S. Supreme Court, has a record of supporting religious freedom in Yellowbear v. Lambert (10th Cir. 2014). He would likely support conscientious objection in relation to assisted dying by physicians, contrary to the arguments made recently by bioethicists Julian Savulescu and Udo Schuklenk. In related news, the liberty of physicians to address gun safety was affirmed when a Florida appeals court upheld the overturning of the state’s Privacy of Firearm Owners Act.
Summing up a tumultuous month of medical ethics, I leave you with the words of Voltaire: “Cherish those who seek the truth but beware of those who find it.”
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@frontlinemedcom.com.
Each profession has its own core set of knowledge, skills, and values. For physicians, the core set of knowledge is anatomy, pathophysiology, and pharmacology. Skills include taking a history, the physical exam, and surgical procedures. The core values traditionally have been compassion and altruism. For modern medical practice, I urge adding cooperation as a core value. Medical school and the apprenticeship of residency are designed to teach, role model, foster, develop, and groom these core competencies.
Getting into medical school is highly competitive. Medical training uses methods that are very different than those used to train elite Olympic and professional athletes. Some competitiveness persists in medical school, but in general the faculty emphasizes cooperation rather than competition. The metric is not whether one student or resident is better than another. Gold and silver medals are not awarded. It is about whether each physician-to-be has passed the milestones needed to practice medicine.
But American health care is threatened by the continued polarization of our government and our society. For years both Cleveland Clinic and Dana Farber have held annual fundraising events at Mar-a-Lago. In February 2017, because of that location’s association with President Trump, some people associated with the organizations advocated boycotting those important fund-raisers. These past few months, it seems every action and every purchase has become a political statement. One restaurant mentioned immigrants on its receipt. The action went viral and caused other people to advocate boycotting the restaurant or not tipping the wait staff (“The new political battleground: Your restaurant receipt,” The Washington Post, by Maura Judkis, Feb. 14, 2017).
Secondary boycotts are an ethical quandary. In labor disputes, organized unions can go on strike. In the 1970s, Japanese cars were not welcome in the employee parking lot of a Ford assembly plant. People do vote with their pocketbook. But in labor disputes, there are legal restrictions on secondary boycotts against other companies. People do need to get along with their neighbors and so do businesses. Politics is the art of encouraging cooperation on one project amongst people who disagree about the goals of many other proposed projects. The Preamble to the United States Constitution enumerates the benefits of cooperation.
In any large-scale human endeavor, conflicts arise that may limit cooperation. Accommodating conscientious objection is the safety valve that permits cooperation when dealing with contested government endeavors such as war, abortion, and physician-assisted suicide. It is meant as a last ditch effort to maintain cohesion of both societal and individual moral integrity. But if every proposed action is met with votes divided along party lines, conscientious objection loses its moral high ground.
Judge Neil Gorsuch, the nominee for the U.S. Supreme Court, has a record of supporting religious freedom in Yellowbear v. Lambert (10th Cir. 2014). He would likely support conscientious objection in relation to assisted dying by physicians, contrary to the arguments made recently by bioethicists Julian Savulescu and Udo Schuklenk. In related news, the liberty of physicians to address gun safety was affirmed when a Florida appeals court upheld the overturning of the state’s Privacy of Firearm Owners Act.
Summing up a tumultuous month of medical ethics, I leave you with the words of Voltaire: “Cherish those who seek the truth but beware of those who find it.”
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@frontlinemedcom.com.
Each profession has its own core set of knowledge, skills, and values. For physicians, the core set of knowledge is anatomy, pathophysiology, and pharmacology. Skills include taking a history, the physical exam, and surgical procedures. The core values traditionally have been compassion and altruism. For modern medical practice, I urge adding cooperation as a core value. Medical school and the apprenticeship of residency are designed to teach, role model, foster, develop, and groom these core competencies.
Getting into medical school is highly competitive. Medical training uses methods that are very different than those used to train elite Olympic and professional athletes. Some competitiveness persists in medical school, but in general the faculty emphasizes cooperation rather than competition. The metric is not whether one student or resident is better than another. Gold and silver medals are not awarded. It is about whether each physician-to-be has passed the milestones needed to practice medicine.
But American health care is threatened by the continued polarization of our government and our society. For years both Cleveland Clinic and Dana Farber have held annual fundraising events at Mar-a-Lago. In February 2017, because of that location’s association with President Trump, some people associated with the organizations advocated boycotting those important fund-raisers. These past few months, it seems every action and every purchase has become a political statement. One restaurant mentioned immigrants on its receipt. The action went viral and caused other people to advocate boycotting the restaurant or not tipping the wait staff (“The new political battleground: Your restaurant receipt,” The Washington Post, by Maura Judkis, Feb. 14, 2017).
Secondary boycotts are an ethical quandary. In labor disputes, organized unions can go on strike. In the 1970s, Japanese cars were not welcome in the employee parking lot of a Ford assembly plant. People do vote with their pocketbook. But in labor disputes, there are legal restrictions on secondary boycotts against other companies. People do need to get along with their neighbors and so do businesses. Politics is the art of encouraging cooperation on one project amongst people who disagree about the goals of many other proposed projects. The Preamble to the United States Constitution enumerates the benefits of cooperation.
In any large-scale human endeavor, conflicts arise that may limit cooperation. Accommodating conscientious objection is the safety valve that permits cooperation when dealing with contested government endeavors such as war, abortion, and physician-assisted suicide. It is meant as a last ditch effort to maintain cohesion of both societal and individual moral integrity. But if every proposed action is met with votes divided along party lines, conscientious objection loses its moral high ground.
Judge Neil Gorsuch, the nominee for the U.S. Supreme Court, has a record of supporting religious freedom in Yellowbear v. Lambert (10th Cir. 2014). He would likely support conscientious objection in relation to assisted dying by physicians, contrary to the arguments made recently by bioethicists Julian Savulescu and Udo Schuklenk. In related news, the liberty of physicians to address gun safety was affirmed when a Florida appeals court upheld the overturning of the state’s Privacy of Firearm Owners Act.
Summing up a tumultuous month of medical ethics, I leave you with the words of Voltaire: “Cherish those who seek the truth but beware of those who find it.”
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@frontlinemedcom.com.
Scientific skepticism
Contrary to popular belief, great scientists do not spend their days proving that their new ideas are correct. That is just the romantic portrait of the field that is taught to schoolchildren. The reality is that great scientists do everything they can think of to disprove their theories. They exhaustively consider all other plausible explanations, challenge any potential bias in their methodology, rule out random flukes in the data collection, and refine any error in the data measurement. Only after doing all that, when no other conclusion is possible, do true scientists publish their new theories as truth. Then they await confirmation from their peers.
That is the philosophy behind the modern scientific method. In the hard sciences like chemistry and physics, this paradigm is reinforced because a scientist stakes his or her reputation on every publication. Funding from various government agencies often is controlled by peers in the field. If published work is inaccurate, the likelihood of receiving funding is markedly diminished.
Medicine has a long history of being biased by the belief that its therapies work. Even faith healers who consider themselves scientists will cite repeated examples of personal success as evidence that their approach works. However, they were looking for confirmation. To truly be a scientist, one cannot seek to affirm one’s beliefs. One must to the best of one’s ability seek to disprove them.
In 2016, postmodern voices have challenged the very existence of truth. The falsehoods rampant in politics have spilled over into a distrust of science. This distrust is manifest in vaccine deniers and the debate about climate change. There are a few charlatans and mercenaries in every field who sell their soul and skills to the highest bidder. Science is no exception. These disreputable scientists seek to obfuscate rather than clarify. They have been employed by the tobacco industry, the oil industry, and various groups with agendas other than seeking truth. They, with the help of weak journalism, have tainted the perception of science in the public arena. The uproar has prominent scientists defending the scientific method and arguing for science as the determiner of facts. Sen. Daniel Patrick Moynihan once said, “Everyone is entitled to his own opinion, but not to his own facts.”
In the 19th century, hawking snake oil was big business. In the early 20th century, the ethical drug industry was created in the United States. The Pure Food and Drug Act of 1906 and the Federal Food, Drug, and Cosmetic Act of 1938 empowered the Food and Drug Administration to regulate what has become 25% of U.S. industry. Those regulations demand honest labeling, good manufacturing processes, proof of efficacy, and an assessment of safety. The FDA deals with many stakeholders in the process for approving new drugs. The system is an imperfect balance between getting lifesaving new discoveries to market quickly while avoiding disasters. The most recent news has been the head of the FDA defending the need for proof of effectiveness in addition to proof of safety.
Even after a year in which truth seemed elusive and science hit a low point in prestige, it is still bizarre to me that the government would consider turning the drug industry into one in which proof of effectiveness is not a minimum requirement. That is postmodern thinking run amok. But the root of the problem lies deeper. When scientists stop being skeptics and instead focus on finding something publishable, the temptation is already leading them along the road illuminated by Dante Alighieri.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis.
Contrary to popular belief, great scientists do not spend their days proving that their new ideas are correct. That is just the romantic portrait of the field that is taught to schoolchildren. The reality is that great scientists do everything they can think of to disprove their theories. They exhaustively consider all other plausible explanations, challenge any potential bias in their methodology, rule out random flukes in the data collection, and refine any error in the data measurement. Only after doing all that, when no other conclusion is possible, do true scientists publish their new theories as truth. Then they await confirmation from their peers.
That is the philosophy behind the modern scientific method. In the hard sciences like chemistry and physics, this paradigm is reinforced because a scientist stakes his or her reputation on every publication. Funding from various government agencies often is controlled by peers in the field. If published work is inaccurate, the likelihood of receiving funding is markedly diminished.
Medicine has a long history of being biased by the belief that its therapies work. Even faith healers who consider themselves scientists will cite repeated examples of personal success as evidence that their approach works. However, they were looking for confirmation. To truly be a scientist, one cannot seek to affirm one’s beliefs. One must to the best of one’s ability seek to disprove them.
In 2016, postmodern voices have challenged the very existence of truth. The falsehoods rampant in politics have spilled over into a distrust of science. This distrust is manifest in vaccine deniers and the debate about climate change. There are a few charlatans and mercenaries in every field who sell their soul and skills to the highest bidder. Science is no exception. These disreputable scientists seek to obfuscate rather than clarify. They have been employed by the tobacco industry, the oil industry, and various groups with agendas other than seeking truth. They, with the help of weak journalism, have tainted the perception of science in the public arena. The uproar has prominent scientists defending the scientific method and arguing for science as the determiner of facts. Sen. Daniel Patrick Moynihan once said, “Everyone is entitled to his own opinion, but not to his own facts.”
In the 19th century, hawking snake oil was big business. In the early 20th century, the ethical drug industry was created in the United States. The Pure Food and Drug Act of 1906 and the Federal Food, Drug, and Cosmetic Act of 1938 empowered the Food and Drug Administration to regulate what has become 25% of U.S. industry. Those regulations demand honest labeling, good manufacturing processes, proof of efficacy, and an assessment of safety. The FDA deals with many stakeholders in the process for approving new drugs. The system is an imperfect balance between getting lifesaving new discoveries to market quickly while avoiding disasters. The most recent news has been the head of the FDA defending the need for proof of effectiveness in addition to proof of safety.
Even after a year in which truth seemed elusive and science hit a low point in prestige, it is still bizarre to me that the government would consider turning the drug industry into one in which proof of effectiveness is not a minimum requirement. That is postmodern thinking run amok. But the root of the problem lies deeper. When scientists stop being skeptics and instead focus on finding something publishable, the temptation is already leading them along the road illuminated by Dante Alighieri.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis.
Contrary to popular belief, great scientists do not spend their days proving that their new ideas are correct. That is just the romantic portrait of the field that is taught to schoolchildren. The reality is that great scientists do everything they can think of to disprove their theories. They exhaustively consider all other plausible explanations, challenge any potential bias in their methodology, rule out random flukes in the data collection, and refine any error in the data measurement. Only after doing all that, when no other conclusion is possible, do true scientists publish their new theories as truth. Then they await confirmation from their peers.
That is the philosophy behind the modern scientific method. In the hard sciences like chemistry and physics, this paradigm is reinforced because a scientist stakes his or her reputation on every publication. Funding from various government agencies often is controlled by peers in the field. If published work is inaccurate, the likelihood of receiving funding is markedly diminished.
Medicine has a long history of being biased by the belief that its therapies work. Even faith healers who consider themselves scientists will cite repeated examples of personal success as evidence that their approach works. However, they were looking for confirmation. To truly be a scientist, one cannot seek to affirm one’s beliefs. One must to the best of one’s ability seek to disprove them.
In 2016, postmodern voices have challenged the very existence of truth. The falsehoods rampant in politics have spilled over into a distrust of science. This distrust is manifest in vaccine deniers and the debate about climate change. There are a few charlatans and mercenaries in every field who sell their soul and skills to the highest bidder. Science is no exception. These disreputable scientists seek to obfuscate rather than clarify. They have been employed by the tobacco industry, the oil industry, and various groups with agendas other than seeking truth. They, with the help of weak journalism, have tainted the perception of science in the public arena. The uproar has prominent scientists defending the scientific method and arguing for science as the determiner of facts. Sen. Daniel Patrick Moynihan once said, “Everyone is entitled to his own opinion, but not to his own facts.”
In the 19th century, hawking snake oil was big business. In the early 20th century, the ethical drug industry was created in the United States. The Pure Food and Drug Act of 1906 and the Federal Food, Drug, and Cosmetic Act of 1938 empowered the Food and Drug Administration to regulate what has become 25% of U.S. industry. Those regulations demand honest labeling, good manufacturing processes, proof of efficacy, and an assessment of safety. The FDA deals with many stakeholders in the process for approving new drugs. The system is an imperfect balance between getting lifesaving new discoveries to market quickly while avoiding disasters. The most recent news has been the head of the FDA defending the need for proof of effectiveness in addition to proof of safety.
Even after a year in which truth seemed elusive and science hit a low point in prestige, it is still bizarre to me that the government would consider turning the drug industry into one in which proof of effectiveness is not a minimum requirement. That is postmodern thinking run amok. But the root of the problem lies deeper. When scientists stop being skeptics and instead focus on finding something publishable, the temptation is already leading them along the road illuminated by Dante Alighieri.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis.
The march of technology
Each year the American Academy of Pediatrics National Conference and Exhibition fills a huge convention hall with the latest products that can improve health and generate practice revenue.
Some products are solutions to the minor annoyances of everyday practice. For instance, there are ear curettes equipped with their own LED light and a magnifying lens. There are countless creams to treat rashes. There are new automated devices for testing hearing, vision, and attention. And at the far extreme, there are products with the potential to revolutionize clinical care or to bankrupt it. The latest technology in that category is whole exome sequencing.
A couple weeks earlier I had listened to a national meeting of pediatric ethicists discuss this technology. Some proponents discussed the possibility of doing whole exome sequencing (WES) for every newborn. Alas, many ethicists can’t do math. Even if the cost goes below $1,000 per test, at 4 million babies per year in the United States, that is $4 billion per year. That sounds like a small sum, compared with the current federal deficit, but the original budget for the entire, 10-year-long Human Genome Project (HGP) was $4.5 billion. There were complaints in that era that diverting such an enormous amount of money into the HGP would cut the funding of a lot of other very good research at the National Institutes of Health. Conversely, Medicare spends $4.5 billion on hepatitis C treatment.
Viewed differently, the yearly per capita payment to general pediatricians, excluding vaccine costs, is around $1,000. Perhaps I’m biased, but I think I provide much more value than a genetic sequence.
Precision medicine has a lot of potential. So far, it is mostly potential. One colleague related that, in the past year, he has done WES on three patients, at about $4,000 charge for each, and gotten positive results in two cases. He figures soon he will be ordering it on every child with symptoms of autism, developmental delay, or failure to thrive. Is that a wise idea? That, it seems, is the area in which there is the least illuminating research.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis.
Each year the American Academy of Pediatrics National Conference and Exhibition fills a huge convention hall with the latest products that can improve health and generate practice revenue.
Some products are solutions to the minor annoyances of everyday practice. For instance, there are ear curettes equipped with their own LED light and a magnifying lens. There are countless creams to treat rashes. There are new automated devices for testing hearing, vision, and attention. And at the far extreme, there are products with the potential to revolutionize clinical care or to bankrupt it. The latest technology in that category is whole exome sequencing.
A couple weeks earlier I had listened to a national meeting of pediatric ethicists discuss this technology. Some proponents discussed the possibility of doing whole exome sequencing (WES) for every newborn. Alas, many ethicists can’t do math. Even if the cost goes below $1,000 per test, at 4 million babies per year in the United States, that is $4 billion per year. That sounds like a small sum, compared with the current federal deficit, but the original budget for the entire, 10-year-long Human Genome Project (HGP) was $4.5 billion. There were complaints in that era that diverting such an enormous amount of money into the HGP would cut the funding of a lot of other very good research at the National Institutes of Health. Conversely, Medicare spends $4.5 billion on hepatitis C treatment.
Viewed differently, the yearly per capita payment to general pediatricians, excluding vaccine costs, is around $1,000. Perhaps I’m biased, but I think I provide much more value than a genetic sequence.
Precision medicine has a lot of potential. So far, it is mostly potential. One colleague related that, in the past year, he has done WES on three patients, at about $4,000 charge for each, and gotten positive results in two cases. He figures soon he will be ordering it on every child with symptoms of autism, developmental delay, or failure to thrive. Is that a wise idea? That, it seems, is the area in which there is the least illuminating research.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis.
Each year the American Academy of Pediatrics National Conference and Exhibition fills a huge convention hall with the latest products that can improve health and generate practice revenue.
Some products are solutions to the minor annoyances of everyday practice. For instance, there are ear curettes equipped with their own LED light and a magnifying lens. There are countless creams to treat rashes. There are new automated devices for testing hearing, vision, and attention. And at the far extreme, there are products with the potential to revolutionize clinical care or to bankrupt it. The latest technology in that category is whole exome sequencing.
A couple weeks earlier I had listened to a national meeting of pediatric ethicists discuss this technology. Some proponents discussed the possibility of doing whole exome sequencing (WES) for every newborn. Alas, many ethicists can’t do math. Even if the cost goes below $1,000 per test, at 4 million babies per year in the United States, that is $4 billion per year. That sounds like a small sum, compared with the current federal deficit, but the original budget for the entire, 10-year-long Human Genome Project (HGP) was $4.5 billion. There were complaints in that era that diverting such an enormous amount of money into the HGP would cut the funding of a lot of other very good research at the National Institutes of Health. Conversely, Medicare spends $4.5 billion on hepatitis C treatment.
Viewed differently, the yearly per capita payment to general pediatricians, excluding vaccine costs, is around $1,000. Perhaps I’m biased, but I think I provide much more value than a genetic sequence.
Precision medicine has a lot of potential. So far, it is mostly potential. One colleague related that, in the past year, he has done WES on three patients, at about $4,000 charge for each, and gotten positive results in two cases. He figures soon he will be ordering it on every child with symptoms of autism, developmental delay, or failure to thrive. Is that a wise idea? That, it seems, is the area in which there is the least illuminating research.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis.
Hospital medicine
It is important to step back occasionally to survey where one has been and to plot a new heading. In an online Aug. 10, 2016, release, the New England Journal of Medicine posted two opinion pieces that provide perspective on hospital medicine. As is often the case when journalism presents two opinions, the viewpoints represent opposite ends of a spectrum and the truth lies somewhere in between.
In one essay, Robert Wachter, MD, and Lee Goldman, MD, highlight the successful growth of hospital medicine (N Eng J Med. 2016, Aug 10. doi: 10.1056/NEJMp1607958). In just 2 decades, more than 50,000 physicians have changed their focus to the care of inpatients. The authors state that “many stars had to align” for hospital medicine to grow as rapidly as it has. I would argue instead that many talented leaders of the field have moved heaven and earth to create that alignment and birth this field.
In the other essay, Richard Gunderman, MD, focuses on what he sees as having been lost in this evolution (N Eng J Med. 2016, Aug 10. doi: 10.1056/NEJMp1608289). I believe Dr. Gunderman’s viewpoint nostalgically longs for the good old days and a model of an interpersonal doctor-patient relationship that never really existed for a large portion of the population. If you were wealthy, lived most of your life in one location, and had only intermittent or common diseases, then perhaps you had a trusted general internist to provide your medical care and provide the emotional reassurance that nourished both patient and doctor. But in modern medicine, that scenario is uncommon. With large group practices, there is only a small chance that your personal physician will be on call on the night of your admission to a hospital. The next day, as test results and specialty consults trickle in, that personal physician will be trapped in a busy outpatient clinic and not truly available at hospital bedside in “your moment of greatest need,” as Dr. Gunderman phrased it. When your personal physician finally does make rounds, s/he will find the hospital environment inefficient and repeating the same small mistakes that happened to his/her last patient.
I’ve been writing about and teaching professionalism for years. I agree with Dr. Gunderman about the importance of a doctor-patient relationship. I believe reducing physicians to being automatons in a hospital assembly line would be a bad idea. But this essay’s rose-colored and sienna-colored portrait of that relationship is not helpful guidance in the modern world. Surveyors and navigators need sharp, clear vision.
Trade-offs are being made. Many pediatricians in affluent communities do have the opportunity to establish long-term relationships with families, sometimes for multiple generations of children. Those relationships attract medical students into pediatrics and family medicine. I was fortunate enough to establish many of those relationships when I practiced outpatient pediatrics. During my last interstate move, the man packing the picture frames was amused to find amidst my many diplomas a framed crayon drawing. It was a gift to me from a young patient. I told the mover that I would be sadder to have that drawing damaged than if a diploma was damaged in the move. So he wrapped it with extra padding.
Those bonds established with families make up the emotional sustenance throughout a career that justifies the years of sacrifice spent becoming a physician. There is no doubt that it is easier to form those bonds in outpatient pediatrics. At a community hospital, with 7 days on/7 days off scheduling, I usually provide care for the entire hospitalization of a child. That provides emotional satisfaction for both the parents and for me as a physician in ways that 12-hour shifts usually don’t.
The diminishment of those relationships needs to be acknowledged, but not to the exclusion of what a hospitalist can provide. When I practiced general pediatrics and only admitted 1 or 2 children each week, I was often frustrated by inefficiency and errors in the hospital, but I had little recourse for changing it. As a hospitalist admitting 500 patients per year, I can perform problem solving and devote resources to continuously improve the quality and safety of inpatient care. I provide those improvements to all patients admitted to the hospital, whether they have a medical home or not. That fosters social justice. As a function-over-fashion person, that success is emotionally rewarding, too.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@frontlinemedcom.com.
It is important to step back occasionally to survey where one has been and to plot a new heading. In an online Aug. 10, 2016, release, the New England Journal of Medicine posted two opinion pieces that provide perspective on hospital medicine. As is often the case when journalism presents two opinions, the viewpoints represent opposite ends of a spectrum and the truth lies somewhere in between.
In one essay, Robert Wachter, MD, and Lee Goldman, MD, highlight the successful growth of hospital medicine (N Eng J Med. 2016, Aug 10. doi: 10.1056/NEJMp1607958). In just 2 decades, more than 50,000 physicians have changed their focus to the care of inpatients. The authors state that “many stars had to align” for hospital medicine to grow as rapidly as it has. I would argue instead that many talented leaders of the field have moved heaven and earth to create that alignment and birth this field.
In the other essay, Richard Gunderman, MD, focuses on what he sees as having been lost in this evolution (N Eng J Med. 2016, Aug 10. doi: 10.1056/NEJMp1608289). I believe Dr. Gunderman’s viewpoint nostalgically longs for the good old days and a model of an interpersonal doctor-patient relationship that never really existed for a large portion of the population. If you were wealthy, lived most of your life in one location, and had only intermittent or common diseases, then perhaps you had a trusted general internist to provide your medical care and provide the emotional reassurance that nourished both patient and doctor. But in modern medicine, that scenario is uncommon. With large group practices, there is only a small chance that your personal physician will be on call on the night of your admission to a hospital. The next day, as test results and specialty consults trickle in, that personal physician will be trapped in a busy outpatient clinic and not truly available at hospital bedside in “your moment of greatest need,” as Dr. Gunderman phrased it. When your personal physician finally does make rounds, s/he will find the hospital environment inefficient and repeating the same small mistakes that happened to his/her last patient.
I’ve been writing about and teaching professionalism for years. I agree with Dr. Gunderman about the importance of a doctor-patient relationship. I believe reducing physicians to being automatons in a hospital assembly line would be a bad idea. But this essay’s rose-colored and sienna-colored portrait of that relationship is not helpful guidance in the modern world. Surveyors and navigators need sharp, clear vision.
Trade-offs are being made. Many pediatricians in affluent communities do have the opportunity to establish long-term relationships with families, sometimes for multiple generations of children. Those relationships attract medical students into pediatrics and family medicine. I was fortunate enough to establish many of those relationships when I practiced outpatient pediatrics. During my last interstate move, the man packing the picture frames was amused to find amidst my many diplomas a framed crayon drawing. It was a gift to me from a young patient. I told the mover that I would be sadder to have that drawing damaged than if a diploma was damaged in the move. So he wrapped it with extra padding.
Those bonds established with families make up the emotional sustenance throughout a career that justifies the years of sacrifice spent becoming a physician. There is no doubt that it is easier to form those bonds in outpatient pediatrics. At a community hospital, with 7 days on/7 days off scheduling, I usually provide care for the entire hospitalization of a child. That provides emotional satisfaction for both the parents and for me as a physician in ways that 12-hour shifts usually don’t.
The diminishment of those relationships needs to be acknowledged, but not to the exclusion of what a hospitalist can provide. When I practiced general pediatrics and only admitted 1 or 2 children each week, I was often frustrated by inefficiency and errors in the hospital, but I had little recourse for changing it. As a hospitalist admitting 500 patients per year, I can perform problem solving and devote resources to continuously improve the quality and safety of inpatient care. I provide those improvements to all patients admitted to the hospital, whether they have a medical home or not. That fosters social justice. As a function-over-fashion person, that success is emotionally rewarding, too.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@frontlinemedcom.com.
It is important to step back occasionally to survey where one has been and to plot a new heading. In an online Aug. 10, 2016, release, the New England Journal of Medicine posted two opinion pieces that provide perspective on hospital medicine. As is often the case when journalism presents two opinions, the viewpoints represent opposite ends of a spectrum and the truth lies somewhere in between.
In one essay, Robert Wachter, MD, and Lee Goldman, MD, highlight the successful growth of hospital medicine (N Eng J Med. 2016, Aug 10. doi: 10.1056/NEJMp1607958). In just 2 decades, more than 50,000 physicians have changed their focus to the care of inpatients. The authors state that “many stars had to align” for hospital medicine to grow as rapidly as it has. I would argue instead that many talented leaders of the field have moved heaven and earth to create that alignment and birth this field.
In the other essay, Richard Gunderman, MD, focuses on what he sees as having been lost in this evolution (N Eng J Med. 2016, Aug 10. doi: 10.1056/NEJMp1608289). I believe Dr. Gunderman’s viewpoint nostalgically longs for the good old days and a model of an interpersonal doctor-patient relationship that never really existed for a large portion of the population. If you were wealthy, lived most of your life in one location, and had only intermittent or common diseases, then perhaps you had a trusted general internist to provide your medical care and provide the emotional reassurance that nourished both patient and doctor. But in modern medicine, that scenario is uncommon. With large group practices, there is only a small chance that your personal physician will be on call on the night of your admission to a hospital. The next day, as test results and specialty consults trickle in, that personal physician will be trapped in a busy outpatient clinic and not truly available at hospital bedside in “your moment of greatest need,” as Dr. Gunderman phrased it. When your personal physician finally does make rounds, s/he will find the hospital environment inefficient and repeating the same small mistakes that happened to his/her last patient.
I’ve been writing about and teaching professionalism for years. I agree with Dr. Gunderman about the importance of a doctor-patient relationship. I believe reducing physicians to being automatons in a hospital assembly line would be a bad idea. But this essay’s rose-colored and sienna-colored portrait of that relationship is not helpful guidance in the modern world. Surveyors and navigators need sharp, clear vision.
Trade-offs are being made. Many pediatricians in affluent communities do have the opportunity to establish long-term relationships with families, sometimes for multiple generations of children. Those relationships attract medical students into pediatrics and family medicine. I was fortunate enough to establish many of those relationships when I practiced outpatient pediatrics. During my last interstate move, the man packing the picture frames was amused to find amidst my many diplomas a framed crayon drawing. It was a gift to me from a young patient. I told the mover that I would be sadder to have that drawing damaged than if a diploma was damaged in the move. So he wrapped it with extra padding.
Those bonds established with families make up the emotional sustenance throughout a career that justifies the years of sacrifice spent becoming a physician. There is no doubt that it is easier to form those bonds in outpatient pediatrics. At a community hospital, with 7 days on/7 days off scheduling, I usually provide care for the entire hospitalization of a child. That provides emotional satisfaction for both the parents and for me as a physician in ways that 12-hour shifts usually don’t.
The diminishment of those relationships needs to be acknowledged, but not to the exclusion of what a hospitalist can provide. When I practiced general pediatrics and only admitted 1 or 2 children each week, I was often frustrated by inefficiency and errors in the hospital, but I had little recourse for changing it. As a hospitalist admitting 500 patients per year, I can perform problem solving and devote resources to continuously improve the quality and safety of inpatient care. I provide those improvements to all patients admitted to the hospital, whether they have a medical home or not. That fosters social justice. As a function-over-fashion person, that success is emotionally rewarding, too.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@frontlinemedcom.com.
