Photo Credit: Daniel Winslade
In the weeks leading up to my seventieth birthday, the nights were fraught with recurring, anxiety infused dreams followed by periods of sleeplessness. For suddenly I was old, and the luxury of extended middle years could no longer provide shelter from age’s accumulating reminders. But, the great day passed, sleep improved and a new vista took hold, perhaps in recognition that the bulk of life’s experience had been amassed, and that the dialectic responsible for the formation of character had expended its sharpening effect. In particular, these late life clarifications have served to illuminate the shaping and refining of a career in medicine. With respect to these penultimate years in a long career, it has become evident that there have emerged unique distractions and moral quandaries, testing some of my most basic structural tenets, which in turn have served as a catalyst for what follows.
Medicine has seemed a calling, not a manufactured pursuit. Although the source of a calling may remain a mystery, I cannot ignore the shaping influences of, for example, my physician father, my internist uncle, my mother a registered nurse whose heart was always in the arts, her mother also a nurse and perhaps even my great, great grandfather, a nineteenth century pharmacist in Mississippi. The notion of a calling implies some otherworldly attraction, but as a humanistic rationalist, I find it difficult to accede to this premise. Nonetheless, as I willingly answer late night phone calls from rural and distant physicians, concerning patients that I will likely never see, the designation of calling often seems apropos.
Within me has coexisted a durable attraction to the biological and physical sciences, as well as to verse and literature. And today, I continue to enjoy selected articles both in the New England Journal of Medicine and also in my specialty journals, admixed with imaginative literature of the past two centuries. During the middle years, the pendulum had swung to the sciences and I recall hearing myself ask why, if a creative author possesses illuminating thoughts and insights, could he not simply spell them out rather than obscure them with the trappings of story or rhyme. Now that seems so philistine, but there it was as a midlife reality.
In contrast to the cornucopia of college, medical school, particularly the first years, seemed an exercise in internalization of massive amounts of information, much of which was verging on obsolescence. Where were the subtle and thought provoking professors, whose humanism was ever on display? Where were the teaching assistants who helped to smooth over the rough patches? Where were the afterhours discussions of ethical issues, both societal and humane?
Conversely, came the exciting and relevant clinical years, each four to eight week block permitting exposure to the array of disciplines. Despite this variegated exposure, I found it troublesome that these assumed roles seemed an imperfect fit, leading to the angst of indecision and to a recurring concern that I may have pursued the wrong path. Through the vagaries of scheduling, it was not until the final rotation of my fourth and final year that neurology was upon me. So, medical internship, lead to research at NIH, followed by residency and academic years, and finally to the point of maturation and self-identification as a neurologist, suitably trained for this most cognitive discipline.
The formative events along the way have been both clinical and personal. As a physician, I have had the honor of entering the life of my chosen community, and also into the lives of many hundreds of people. The perspective gained from each has been incalculable. Unexpectedly, this perspective was abruptly reversed when, at about age 50, I was found to have advanced intra-abdominal cancer. Definitive surgery was rendered at a tertiary medical center, far distant from my home. I opted to forego offered chemotherapy, and I have outlived the odds; a 50% five year survival rate has given new meaning to the coin toss. At that moment, my world turned inward and, for the first time, I witnessed medicine as a fragmented landscape, each participant providing care within carefully defined, perhaps protected, skillsets. Hospitalized, I encountered the despair and loneliness of the night, and I came to resent the desultory attentions of overworked nurses, many of whom, however well intentioned, spoke English as a second language. Wherever I turned, I had to look hard to find evidence of curiosity or caring. At this moment, I realized that without the love of immediate family, and the endless grace of a faithful neighbor, the experience would have verged on the unendurable. And, having seen the other side of the medical coin, I resolved to do better.
The practice of medicine has weathered the introduction of forces into the decision tree that have required compromise, often perverting the moral compass. These distractions and compromises, some market and policy driven, some as a consequence of employment, often do little to benefit either medical intent, or dedication to the best interests of the patient. As a physician and clinician, it is comforting to be able to fall back upon the permanent truism “at first, do no harm”. Additionally, in sorting through complex medical issues, most seek to embrace rationality and science, supported by a framework of functional anatomy. Thus, medical decisions can be run through well-practiced filters, permitting the achievement of relatively cogent conclusions. Occasionally, assuming complete parity, the medical decision tree may result in several equally compelling arguments.
Unfortunately, the beauty of this rationality is increasingly degraded by confounds and pitfalls. For example, in the context of medical therapeutics, several comparably effective options may coexist. As a physician, I am daily presented information, variable in scope and quality, ranging from peer-reviewed medical publications, to the persuasions of the pharmaceutical sales representatives, or as presented to me by patients who have consulted with “Dr. Google”. Regarding prescribing habits, drug makers are able to purchase prescription sales information from dispensing pharmacies, presented as a function of zip code, and occasionally identifying a prescribing physician. Thus, the sales representative may know who prescribes what and how often. This came as a surprise to me. Equally unsettling was that, if I wanted to opt out of identifiability, I was required to make application. In other words, the default position is both comprehensive reporting and occasionally to prescriber identifiability. I exercised the opt out because I could not see how this information was helpful to my patients, but rather seemed primarily a marketing instrument, providing the sales representative with the knowledge of which physicians would be fruitful targets.
In terms of steering a patient through the structure of the medical system, there exist multiple perverse incentives, many of which are too deeply buried to be readily visible to the patient. Some are superficial conflicts of interest. For example, the strength of a physician’s recommendation may be in proportion to his affiliation with a drug’s maker. Does the office accept samples? Is the prescriber on a drug maker’s speakers’ bureau? Is the physician’s recommendation limited by his employer’s formulary? Does he maintain an equity position such as stock ownership with a drug maker?
In addition to these prescribing issues, there are complicated organizational influences. When a physician is employed by a health care entity, it is in his best interest to ensure that his employer, be it a hospital or multidisciplinary clinic, utilize its own provided services. In fact, within the structure of electronic medical records, exist sets of medical orders that default into the utilization of the hospital’s or clinic’s internal resources. The inherent menu of options ignores costs and provides complex physician disincentives to refer a patient, for example, to a more cost effective outside imaging service, clinical laboratory, or independent consultant.
How can a patient hope to know real costs when these are concealed beneath layers of obfuscation? The phantasmagorical hospital bill is based on the hospital’s bill of fare, the so-called “chargemaster”, inaccessible to physicians and patients alike, wherein lives the $8 aspirin and the $30,000 knee prosthesis. This “chargemaster” is an economic construct allowing a hospital to arrive at suitable overall charges based on the use of certain services and wares. The line items have very little to do with salary or acquisition costs. Likewise, medication costs, often devastatingly high, are equally obscured by means independent of the chargemaster. Although many take comfort in a modest co-pay, little do they know that this recurring $10 payment may be a tiny offset against $ 5,000 -8,000 per month for the latest monoclonal, paid for through insurance. These pharmacy benefits we all depend on, offered through our insurance company, are arrived at only after extensive negotiations between the insurance company’s purchasing officer and the drug maker. These bulk purchase pricings are closely kept corporate secrets; the only accurate statement is that they have nothing to do with average wholesale pricing.
Each of us, both as patients and as a physician, would be so much better off if we could be provided such information. Were truth and transparency to be the operational, it would really be not too difficult to shine a light on these breath-taking, closely guarded realities.
Those who would maintain that the patient is just another customer are either disingenuous or have never been seriously ill. In what other “retail transaction” are hope and trepidation often the major factors shaping a decision? One cannot apply rational tools in the presence of such powerful distractors. To a great degree, the glue in this “transaction” is the trust imbued in the physician. And, to an equivalent degree, this implied trust becomes the physician’s responsibility.
Becoming an effective physician has seemed a continuous dialectic, shaped by the dialogue of parallel themes: empiricism and wonder, science and humanity, rational skepticism and humanism. But, to carry the metaphor, in violation of geometric principle, the two vectors have gradually shed their separation and have increasingly shared their attributes. One could posit that this approximation represents the selection process associated with forgetting, but I prefer to believe that it is a consequence of the unifying properties of wisdom. In turn, wisdom is achieved to a great degree by an unwillingness to discard the past, to value accumulated experience, and to commit to the vitality of the intellect, perhaps tempered by the moderating effect of age. One of the several consequences of this approximation is that each passing decade has allowed me to live closer to my tenets, and to be able to diminish the intrusion of unhelpful thoughts into the healing process.
Perhaps this is another way to simply say that, just as there is less of me, there is a more gratifying and valuable appreciation of the essence of the patient. When possible, I make an effort to see each patient as inhabiting a point along the arc of life, thus contextualized to circumstance. No longer is it just an elderly, retired laborer with a painful neuropathy, or a single mother, kiting two jobs and three children, with severe insomnia. Rather, each has lived and will live along their trajectories, within their social context.
I often think of these recognitions both in the context of American medical education, and more importantly, as they may apply to the bleak and deteriorating state of American medicine. I would offer that these perceptions are built on a wider understanding of a physician’s caring responsibility, as well as continued attention to the intellectual underpinnings of medicine. Moreover, the physician uniquely possesses the power of the pen, and thus controls the flow of revenue through the labyrinth, containing the $8 aspirin or the $30,000 prosthesis.
Much of the foregoing would require a young physician, whose identity has been, up to this point, the high achieving young adult making his mark with objectifiable academic success, to possess a healthy dose of confident humanism. In the same vein, when, if ever, can a busy physician take the time to contextualize the patient? What would be the reward? The cost? For whom?
I would like to offer that it is precisely this foregoing perspective that could allow us as physicians to provide more humane care, to be able to ignore the burgeoning diversions and the corrosive influences, to incorporate the essence of the patient into the rendering of the prescription.
In my pocket, I carry a touchstone, bearing the engraving “Take Medicine Back”.
This then is the prescription and we all hold the pen.
Stephen W. Asher MD, FAAN
