System Archives - Page 37 of 51

Physician vs. State Paternalism

Medical students learn to despise paternalism. Patients must be given all information and helped to make their own decisions. It is better to cause pain and suffering with brutal honesty and unfettered autonomy than to presume benefit on a patient’s behalf. Students are taught that physicians must never bias patients in any way.

What about depressed, suicidal patients?
People who want to stop medications they need?
Demented patients who won’t eat?
Homeless people who won’t come in from the cold?
Diabetics who won’t comply with treatment?

Should physicians be paid more when patients make healthy decisions? Should the outcome of patients’ decisions determine physician payment?

Paternalism

Refers to the limitations of personal liberty/freedom for an individual’s own good by the state, an organization, or other individual (Wikipedia and Stanford Phil).

Soft versus Hard – Soft paternalism supports intervention when decisions are not truly voluntary (e.g. person does not understand a poison label). Hard intervenes even when people know what they are doing (e.g. suicide).
Broad versus Narrow – Narrow relates only to concerns about state paternalism.
Weak versus Strong – Weak paternalism interferes with freedom to promote an end valued by the individual (e.g., seatbelts; most people value safety). Strong interferes when an individual’s values are suspect (e.g., motorcycle helmet laws).
Pure versus Impure – Impure paternalism changes a whole system to benefit a group (e.g. preventing cigarette manufacturing).
Moral versus welfare – Welfare paternalism benefits health/safety only.

Should we force people to live healthy, safe lives?

Physicians get bonuses based on how many of their patients get flu shots, mammograms, and other screening tests. Definitions and explanations can steer patients, while giving the impression of free decision making.

Should patients be informed that physicians get rewarded for specific outcomes?
Would it call into question the physician’s advice?
Is this paternalistic?

Medicare provides, rations, and decides service based on beliefs about need/benefit. Medicare is paternalistic. Where do we draw the line between supporting state paternalism and opposing individual paternalism?

Please share your thoughts below!

(photo credit: wired.com)

Patient Interests Before Healthcare Finance

Conscientious providers get tied in knots balancing patient interests and healthcare sustainability.

We worry that Medicare won’t have money for the care patients need.

As the point of access for many patients, emergency providers feel pressured to manage system costs and make up for inefficiencies elsewhere, by putting costs before patient interests.

This has to stop.

Backup?

Those who congratulate your parsimony disappear when you get sued for not ordering enough tests, providing enough care, or making patients wait.

After a medical disaster, you get no official support acknowledging overcrowding created an environment for bad outcomes.

Providers experience heart-wrenching cases: mothers dying shortly after childbirth, toddlers who choke to death, kids clipped in traffic walking to school.

Sick patients create bad outcomes.

Sick patients require split second decisions that lie naked to dissection from the armchair of retrospect.

Emergency departments get ‘helped’ with hours of meetings and external reviews from one bad outcome, but no one – not one single person – wants to discuss egregious overcrowding and unconscionable waits that often play the major role in terrible outcomes.

No one.

Societal conscientiousness needs to be matched with our system leaders’ passion for change. If bureaucrats want decreased emergency department use, they need to work on system redesign such that patients are attracted to seek care elsewhere.

Emergency providers should not bear the responsibility of rationing care for the whole system.

Focus on Patient Interests

Paradoxically, abandoning obsession with system citizenship ends up refocusing providers on patient interests. It’s the first step to creating a more efficient emergency department. Costs per case goes down, patients’ length of stay plummets, and adverse outcomes decrease. EDs function best when we focus on patient interests and ignore fiscal/system peer pressure at the front line.

So, banish guilt. If it will help your patients, order tests liberally, welcome them back for care, and put patient interests first. It will improve the system for patients.

Have you tried to be a good citizen and avoided ordering a test? Have patients ever come to harm as a result? Please share your thoughts below.

(photo credit: network.mcmaster.ca Check out McMaster’s post on Geriatrics training.)

Great Article: When Medicare myths go viral | National Post

Bacchus Barua: When Medicare myths go viral | National Post.

I posted last week – Canadian Medicare: Toronto MD smacks down U.S. Senate – about Dr. Martin’s argumentative prowess. She avoided a tough question by delivering a rhetorical blow. It turns out her retort was false. Barua’s article shows why.

We have to move beyond Canada vs. US healthcare. This National Post article provides some balance to the rhetoric.

Do you think we need a debate on Medicare? Do you feel well informed by the polemics media prints?