As we're barreling along toward Jan. 1 and the full implementation of Obamacare, it seems that questions of ethics are embedded in just about every discussion of the practice of medicine and how it will change in the coming years. San Francisco's Commonwealth Club asked me to explore the issue recently by moderating a discussion featuring three prominent Bay Area physicians that the club had invited to participate.
The formal title of the event was "Improving the Ethics and Practice of Medicine," but pretty quickly money came right into play.
Dr. Josh Adler, chief medical officer of UCSF, started off by talking about the "age-old principle in care of patients": Do no harm. And he spoke of patient safety. But then he got right into the cost of health care. We don't have unlimited resources, ranging from doctors and nurses to hospital beds, he pointed out. "We have to come up with the best possible distribution of those resources, so we do the greatest good for the greatest number."
He talked about "appropriate stewardship" of limited resources in considering both the health of the individual and the health of broader populations.
But being a good steward creates conflict for the doctor in the treatment room, argued Dr. Victoria Sweet, who practiced for 20 years at Laguna Honda Hospital. She is also a historian and author of the book "God's Hotel: A Doctor, a Hospital and a Pilgrimage to the Heart of Medicine," where she writes about the concept of what she calls "slow medicine." How can a doctor be both a steward to his patient and a steward of the nation's health care resources? "I can't believe how stressful these ... often opposing ethical imperatives are for a doctor," Sweet said.
Disruptive changes necessary
To reconcile those opposing imperatives (and righting much about what's wrong in American health care), we need a restructuring of the whole system, argued Dr. Robert Pearl, CEO of Kaiser Permanente Medical Group. He said this restructuring goes beyond Obamacare, which he said is about providing access to the uninsured. This restructuring would move the United States from "a system rewarding volume to one that focuses on outcomes, that we start to value prevention" as a way to not only keep patients healthy but also to reduce cost. (There it is again: money.)
Pearl said this "will be very disruptive. These changes will fundamentally alter how physicians practice and how patients receive care, but I think from an ethical perspective they are the right answer."
He linked this fundamental reorganization to improvements in patient safety -- too many patients are harmed while they are receiving care. (Start with sponges left inside a patient after surgery or a patient who picks up an infection while in the hospital.)
Pearl pointed specifically to how hospitals are reimbursed and how the way the money flows fights against patient safety. Right now, Pearl said, the typical U.S. hospital makes about a 4 percent profit margin. But ironically, "four percent of the people that are there are because of a medical error -- pressure sore, central line infections. If they'd avoided developing the complications, [the hospital] would be out of business." (A study published in JAMA on Wednesday confirmed how hospitals profit when patients suffer surgical errors.)
Sweet was doubtful about the prospect of radical systemwide overhaul, but then drew applause when she said Kaiser "does a fantastic job" and proposed turning over "the whole system to Kaiser and let them do it."
Even UCSF's Josh Adler was smiling and called Kaiser "groundbreaking," but still offered that "what universities bring to the pie is really pushing the next great thing that might happen" -- he named organ transplantation and genomic medicine for starters. He said,"The universities do have a role to create that innovation and exploration," and quipped that he felt his job was safe for a little longer.
More primary care providers needed -- but not just physicians
One specific area where Adler saw a role for systemwide change was to allow non-physician professionals -- nurse practitioners, pharmacists and medical assistants, to name a few -- to practice at the "top of their license." With more than 30 million currently uninsured Americans gaining health insurance through Obamacare starting in January, the United States will need a lot more primary care providers to treat those people. But doctors traditionally have been oriented toward protecting their incomes (money again) and have been opposed to letting other types of professionals in on their turf.
I asked Adler if he thought doctors were behaving ethically when they organized against allowing nurse practitioners or other non-MDs to provide expanded primary care.
"I think it's wrong," Adler said bluntly. "I think protecting patient care only within the realm of physicians is a bad strategy for the United States."
Calls for better end-of-life care
Perhaps nowhere in medicine is the question of ethics more challenging than in end-of-life care. Sweet urged everyone attending the panel to at the very least write a letter outlining "who you are as a person and how you value freedom, lack of pain, life." Absent some kind of specific directive to loved ones -- even a conversation, Sweet said -- the presumption is "you would want everything done."
Adler expanded on Sweet's point, saying that these discussions are not just for people at the "very, very end of life" but even the "very, very sick." He cited a program at UCSF where people with heart failure were talked to explicitly and clearly about their preferences. These were not patients who were terminally ill. Many of these people were frequently hospitalized. But, upon careful discussion, some of those patients opted not be hospitalized again and to simply go with comfort care. "But the amazing thing," Adler said, "is those patients lived longer than those people who kept coming back to the hospital for aggressive care."
Pearl agreed. "Physicians are very bad at telling patients bad news," he said. "Patients are much stronger than we as doctors believe. ... Once people feel like they have control, they're not victims ... they live longer and live better."
As the discussion wrapped up, we returned to the looming Jan. 1 implementation of Obamacare. "It's going to be a bumpy ride," Adler said, "but we are on the right path and our desire is to stay on the path until we get it right."
"There's a broad way that the American medical system is stuck in the 19th century and has to move into the 21st century," Pearl said. "To me that's an ethical issue, and it's not going to get resolved on Jan. 1, 2014. I think it will be an evolution in our society over a five-to-10-year period."
Watch the one-hour discussion: