Preemptive Action in End of Life Care

In Timmermans’ “Social Death as Self-Fulfilling Prophecy,” it is argued that in a decision between life or death in the absence of patient choice, as a result of incapacitation, medical professionals find more worth in saving one patient over another. Said worth is arguably influenced by the age of the patient, as well as his or her overall condition at the moment. Furthermore, said choice is swayed under consideration of the patient’s projected condition following a particular procedure, be it from initial CPR to emergency surgery. In some cases, individuals either prone to sudden consequence from a particular condition or of old age sign a DNR (do not resuscitate) which serves as a preemptive step for the inevitable situation of life or death in which he or she is unable to express consent. Also, there is an advance directive which, in essence, provides a doctor with the requested care and desired ramifications of end of life care under the pre-written consent of a patient.

Thus, in order to alleviate the pressure upon the emotionally charged choice of immediate family and advice of a medical professional, how can an individual be urged to prepare, if willing, for a situation of life or death? Is the consideration of the emotional toll upon one’s family enough? Or is the unwillingness of an individual to sign an advanced directive unrelated to the consideration of close ones, but rather a result of indifference or blind confidence in one’s health? Continue reading “Preemptive Action in End of Life Care”

Process Reflection 1

The Sociology of Healthcare class and the materials covered have opened my eyes to the corrupt and unjust nature of the United States Healthcare system. Before taking this class, I was not very familiar with the healthcare system or all of the different types of coverage or even the history of healthcare or insurance policy. Today, I have a better understanding of the healthcare system and the way it is organized. After reading about different healthcare plans and different experiences in the system,  I often look back at my own healthcare experience for context. However, I feel that I am unique in the sense that my coverage is provided by the government; specifically the military. This system is not perfect by any means but I have not had a problem gaining access to healthcare and have never had to pay any off the wall charges. For instance, I had a thumb surgery for a tumor removal. The bill came out to $6,000 but my family only had to pay a small copay of about $40.

I do not pay for individual visits to see a healthcare provider and medications are also covered under my insurance. I simply cannot imagine being an individual who does not have insurance or who is denied coverage. Why is it so difficult to convert to an overarching system that provides access and care to all people regardless of income or age? If it is costing us billions of dollars each year then why can’t we find any cheaper alternatives or stop over-utilizing and wasting money on unnecessary procedures and tests? This fact alone makes me think that the healthcare system is not in the business of making people better but instead is in the business of profiting from illness. For example, the article that struck me most was the article that discussed the “chargemasters” payment system. This was a database that determined cost of services from surgeries performed and down to the instruments being used.  It surprised me that this database basically came from no where. It was based on theory and had no real context. This makes me question who really determines cost? Why is there so much inflation?

Our healthcare system needs a serious overhaul.  Who or what will change it? Only time will tell.

Process Reflection: 1

Throughout life, I often considered myself well informed in regards to the topic of health care and administration, largely as a result of my interest in media ranging from articles and books to documentaries and movies centered on the United States medical field. My interest was so great that I decided early on to obtain a doctorate in medicine. However, upon entrance into Boston University’s Sociology in Healthcare class, I realized I had much to learn about my future career path, especially in terms of what defines a doctor and a patient, their roles in the socioeconomic and political spheres of America, as well as the effects of commercialism on the costs of treatment.

To begin, my ideal image of a doctor always depicted a wise individual in a white coat, whose ultimate desire was to cure and ease the minds of his/her patients by extolling his/her medical wisdom and skills. While the patient was free to discuss their issues, the doctor was the one who held most authority in the care process. While I understood that economic gain played a part as well in the behavior of the medical specialist, I assumed such influences engaged in a somewhat smaller role in comparison to moral compassion. After reading Rothman’s article “A Century of Failure: Healthcare Reform in America” and portions of the textbook such as the influence of “Big Pharma,” I was shocked by the extent of my misconceptions. Disappointingly, rather than my ideal, most doctors of today were more entrepreneurs than anything else, seeking to increase hospital profit and in turn their own paychecks by over-treating patients, recommending more expensive medication sponsored by large pharmaceutical corporations, and etc. Even more heart wrenching though was that such a situation was not simply the fault of the corrupt, but of the US health care system as a whole as it valued and promoted individual profit over social benefit and widespread access to affordable care. Thus, patients were and will perhaps remain delegated to the role of weak consumers with little ability to negotiate the costs of treatment due to social, economic, and political forces beyond their control.

The business of medicine has greatly altered my perception of the doctor-patient relationship, as well as my goals as a future practitioner. Rather than a sole authoritative position, I realized that, as a current “consumer,” perhaps it is more helpful and cost-reducing for patients to play a more interactive role with their primary care providers. Thus, as I age and ultimately make my way into medicine, I hope to more equilibrate such roles by allowing my patients to have greater say in the routes they take in treatment.

Transparency in Healthcare Costs: Benefit Value Advisor?

Consumerism is a rising concept in today’s healthcare system. Patient-centeredness and so called “independence” increase the patients’ responsibility in their healthcare demands and choices for treatment and hospital visits. However, as the article states, the healthcare market is not like the others: patients “consumers find it very difficult to assess the relative value (quality versus cost) of the different care options and providers that are available to them”. Because unlike simple markets,”health care marketplace generally lacks price transparency”.

Acknowledging the difficulty of measuring healthcare quality vs the cost, the article proposes a solution or an idea to overcome the ambiguity in the healthcare market, or at least for what patients are actually paying for. The rising costs and overutilization still remain a problem in consumerism because “more healthcare is thought to be better healthcare”. But if patients were aware of the raw costs of their treatment, they would realize that what they were paying for is actually mainly for the profit of the hospital. Therefore a transparency in hospital bills or other healthcare costs is necessary to inform the patients, since in today’s individualist world they hold more responsibility in their expenses. The article highlights such a demand:  “A growing number of employers are asking for tools to help members in their health-benefit plans gain insight into prices and quality so that they can become more informed consumers of health care.” It also presents a tool called “Benefit Value Advisor” to inform the employers or healthcare “consumers” about the true value or true cost of the treatment they are getting as well as the median value of the treatment, so that they can compare the value given to them and be more eligible to make a decision about their “consumption”.

Such a system is necessary because in a healthcare system where patients carry the burden of being true consumers, they must be given the actual rights to act like one. That is, they should know the variety of options to choose from, as well as getting access to a maximixed quality with minimized cost. However, even though such a tool can be standardized, the healthcare is still in essence very different from other markets because it is mankind’s utmost right and need. So what will fight the rising costs in the first place, and how will people get the “highest-value option” in an emergency?

Why are medical bills so outrageously high? Who comes up with these high “charges”?

                In the article ““Bitter Pill: Why Medical Bills are Killing Us,” Steven Brill discusses the outrageous cost of hospital bills and the large disparity between healthcare costs in the US versus other countries. The prices that hospitals set in place for various services appear to be arbitrary in nature and lacking context. The name of this so called database of charges is called the “chargemasters”. I have honestly never heard of such a system. Who is in charge of establishing these costs and why are they so abnormally high? According to Brill’s research,  it appears that the hospital system is charging patients way above market price and, in turn, receiving a significant revenue while putting most of its patients into debt. Brill even comments on the fact that nonprofit hospitals make millions in revenue while their presidents make a hefty salary. To account for the revenue, Brill states, “the hospitals improve and expand facilities (despite the fact that the U.S. has more hospital beds than it can fill), buy more equipment, hire more people, offer more services, buy rival hospitals.” But what about quality of care for the patient? Despite, a large revenue we don’t seem to care about making the efficiency of the healthcare system better. We continue to struggle with problems of over utilization. Brill discusses the issue of overuse of CT scans for people who don’t always need it. Is this done for the purpose of avoiding lawsuits of malpractice and making sure that all the bases are covered or is this to help pay for the cost of the machinery since these CT scan machines can be very expensive?

Whatever the case may be, the healthcare system is a current mess and chivalry does seem dead.

When it comes to an end — Health care for the dying

By Zeya Qiu (Denis)

One The Economist article in September One door closes, another opens (Sep 19, 2015; Vol. 416, accessible on BU library page) touched the heated topic on physician-assisted suicide legislation.  Recently, “by narrow margins, California’s state assembly and senate passed the bill on legalising such procedure. It will soon be legal if the governor, Jerry Brown, does not veto the bill within 30 days.” The article also made a contrast between the voting results of similar bills in California and in the UK and called for the same protection of patients’ liberty.

What potential impacts could this legislation have on the health care system? Short answer is that this could help reduce the huge amount of costs in some way.

Costs and coverage are the two main concerns in health care system. When talking about the high medical costs in the United States, the first things some people would complain about are the unnecessary tests, over-prescription and overuse of expensive drugs, and over-treatment in the hospital. It is not rational to blame this problem on the profit-seeking of the medical providers. Patients mentality also plays an important role in shaping this medical landscape. Patients as consumers, lacking the expertise on medical science, generally believe that more treatments equal better treatments.

Our focus here is how patient mentality shapes another scenario of over-utilisation, a less mentioned one. The costs of care for patients in the hospital near the end of their life usually soar in very short period. According to the documentary Money & Medicine, sometimes the patient and/or family would ask for highly risky and expensive surgery to give a relatively short time for the patients. Or they may require expensive medical care to sustain the extremely low-quality life of the dying person. The medical bills from this kind of care are usually unbearable for a non-wealthy family, even if they have health insurance.

What I found interesting is people’s attitude towards health care in this special time, or also related, towards death. For example, what is a good “last days’ health care”? What is a good death?

Patients themselves have diverse opinions on the demarcation of a “good death”. Or maybe, death is never good. Some would love to stay in this world as long as possible, despite the pain, suffering and possible financial distresses. Some would prefer to “let nature takes its course”. Some would ask for a death with dignity. We should understand that all these dying wishes derive from human nature and all of them should be respected. Many of the overwhelmed families would love to sustain their loved ones’ life or to fulfil their wishes at any cost. As a result, there come piles and piles of medical bills.

Cultural factors could also influence the family’s decisions. For example, in traditional Chinese culture, “filial piety (孝道 xiao dao)” is very important. The care for a dying family member is one good presentation of this moral. Nevertheless, sometimes in very extreme cases, some people ritually put more energy and money towards the “last days’ care” than in the daily care before their family member gets into severe medical situations. This phenomenon surely attracts moral criticisms. By providing premium or even excessive health care for the dying person, those families who are still alive feel better about them and their guiltiness is partly relieved because they have given a good death to him/her.

Although we mainly discuss the issues concerning financial costs here, a legislation like this apparently involves more dimensions such as bioethics and religion. In places where doctor-assisted dying is abandoned, many patients are not surviving with dignity because the pain and sufferings they have exceeded all the emotions of death, which is the main drive for the legalisation process.

This legislation might not only relieve the families who are currently bearing the financial burdens from last days’ care, but also gradually change people’s perception towards death and care for the dying by offering an alternative.

The Art of Fearmongering by Elizabeth Wurtzel

Analyzed by Eve Zuckoff

Earlier this week, author Elizabeth Wurtzel wrote an opinion piece for the New York Times, titled The Breast Cancer Gene and Me, in which she describes discovering she had breast cancer as a result of the BRCA mutation. She underwent chemotherapy, radiation, and three surgeries in a six-month period that ended in a double mastectomy. Her conclusion to her ordeal was that all Ashkenazi Jewish women (like herself) should be tested for the BRCA mutation because some studies suggest the risk is ten times higher among this population than the general public.

My concern with articles such as this comes in two parts.

First, although the genetic risk of the BRCA mutation may be higher among women of Ashkenazi Jewish descent, there is still a large body of evidence that the mutation may not lead to breast cancer. In fact, Wurtzel acknowledges “the statistics vary wildly” but goes on to make her point that  “they are scary at the low end…[and] if you are BRCA-positive, you get breast cancer.” Not only do inaccurate statements like this reflect the quick reflex of overtreatment in the current system, they serve as effective scare tactics to make patients—and their families—all the more paranoid.

Wurtzel’s piece directly contributes to the fear mongering of diagnoses, which leads to overtreatment. Already, women who may or may not at some point in their life find that they have breast cancer, are opting for double mastectomies when the more proper response may simply be more frequent screenings, further testing, and other low-impact methods.

Even Hadassah, one of the most influential Jewish Women’s groups, has supported research on BRCA, only to have its president come out and say “testing is not for everyone,” giving a side-eye to the overtreatment of the BRCA mutation among Ashkenazi Jewish women.

My second concern is based on how this article takes advantage of the concern of loved ones, and what it says in general about the future of the American health care system. I realized how important it was for me to choose this article after my Dad sent it in an email to me, my sister, and my mother, three Ashkenazi Jewish women, noting “on your next visit to a doctor, I hope you will set this in motion.” My Dad, a well-educated journalist and father of a young woman with a master’s degree in public health, bought it. And I don’t blame him. We, the public, the patients, would do anything to protect our loved ones. I fear that even with policy changes, even if pharmaceutical companies and insurance companies change their practices, we, out of love, will continue to over-treat ourselves out of fear for the worst. The “too much love” problem is one that even this ambitious public health student has no idea how to solve.

The Breast Cancer Gene and Me is simply one of many of articles written by well-intentioned people affected by a terrible illness. That said, it inherently hits a sensitive spot among readers and feeds into a culture of fear, overtreatment, and increased costs to everyone as a result of a broken system.

Can Incorrect Diagnosis of Alzheimer’s Lead to Over-treatment?

A 73-year-old widow was sent to visit Dr. David Goodman, an assistant professor in the psychiatry and behavioral sciences department at Johns Hopkins School of Medicine. Her daughter had noticed symptoms that she thought resembled early signs of Alzheimer’s disease. This 73-year-old woman began frequently losing items such as her keys and her pocketbook. She also began to have a hard time following conversations due to short-term memory issues.

Upon Dr. Goodman’s investigation and diagnosis, he expected something that surprised and relieved the widow’s family. Since the widow’s daughter and granddaughter had both been diagnosed with A.D.H.D. a few years earlier, the doctor hypothesized that the widow may also have A.D.H.D., even at her age of 73. When A.D.H.D was first discovered, it was believed to only effect young children. However through an extensive interview process, Dr. Goodman discovered that the widow displayed trigger symptoms for A.D.H.D. originating in her childhood and extending up to her current age of 73.

Continue reading “Can Incorrect Diagnosis of Alzheimer’s Lead to Over-treatment?”

To what extent does the patient’s fear play into overtreatment?

In Atul Gawande’s article “Overkill,” he describes the case of Mrs. E, a woman who was found to have a microcarcinoma in her thyroid. When she came to see him, she insisted on getting her thyroid removed based on the advice of her previous surgeon, despite Gawande’s objections that it was an unnecessary procedure. Continue reading “To what extent does the patient’s fear play into overtreatment?”

Over-treatment: Does the benefit outweigh the risk?

Many patients are willing to go through with a surgery for the relief of anxiety over the medical issue they are facing. In his article “Overkill,” Gawande tells the story of a patient named Mrs. E who had an extremely small carcinoma on her thyroid that would not have been an issue if it hadn’t been found. For Mrs. E, the relief she obtained was worth the serious health risks of her surgery.Even though she had a “turtle”, she took her chances and went through with the surgery. From a financial standpoint, the surgery is viewed as wasteful and unnecessary. From a medical standpoint, it seems like an overreaction to a small and unthreatening problem. But from the patients standpoint, the surgery was worth the money and risks associated with it. Gawande even points out that after the surgery, Mrs. E came back  and “thanked me profusely for relieving her anxiety.” On the other side of the coin, over-treatment can bring about more anxiety than there was to begin with. In the case of Bruce, a colleague of Gawande’s who experienced the negative repercussions of over treatment. When Bruce’s 82-year old father began having fainting episodes his doctors told him he had severe atherosclerotic blockages and recommended doing a three-vessel cardiac-bypass operation as soon as possible, followed, a week or two later, by surgery to open up one of his carotid arteries. However, this surgery posed serious risk factors, including stroke. Leaving the decision to his son, it was not until after that Bruce realized the mistake of agreeing to the surgery. The surgery was not meant to relieve the fainting episodes because the blockages weren’t the cause of these episodes. Bruce’s father had a stroke during the surgery, losing his ability to talk coherently, and was moved into a nursing home, where he died 9 months later. For the patient, or in this case the patients family, things would have been better without the surgery ever taking place. Bruce not only had to deal with the worry and anxiety caused by effects of this unnecessary surgery, but also the regret of agreeing to the surgery that ultimately accelerated his fathers death.  In Mrs. E’s case, the benefit of expelling her anxiety did outweigh the risks associated with her surgery. For Bruce, the opposite was true. So the truth is, although over-treatment is wasteful and unnecessary, in some cases it can can relieve anxiety and worry for the patient and in others it can bring about more.