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Archive for September, 2009

The New Eugenics

Posted by MDViews on September 16, 2009

In the UK, a couple has a new baby girl without the high risk gene mutation for breast and ovarian cancer, cancers that have afflicted females in her father’s family for three generations. Paul Serhal, the fertility expert who treated the couple, said, “The parents will have been spared the risk of inflicting this disease on their daughter.”

And it was easy. After fertilizing bunches of eggs in a dish, he let them grow to the blastocyst stage, removed one cell, tested it for the gene mutation, found the perfect one, implanted it and let it grow. Now mom and dad have a brand-spanking-new baby girl, practically perfect in every way.

And her brothers and sisters who didn’t pass embryo muster? Well, let’s just say their three days of life were rudely interrupted. But, there was no blood, no guts and no annoying trips to the abortion clinic. The doctor probably just rinsed them down the sink. Easy.

I’ve wondered what one would have to believe to be an ethical Petri-dish “rinser-outer?” What would define the ethics of a person willing select the perfect embryo and discard the others?

I surmise one would have to believe in the absurdity of life and an absent or irrelevant God. One would have to deny a final accounting before a holy judge, acknowledge we are all we have and insist existential relativism defines life. One would have to hold that life has no value except the value placed on it by whoever has the money or power to use it or control it. One would have to believe in the value of genetically improving the human race.

Now, the parents of this designer child placed a value on her, so here she is. But no value on her siblings, so here they are not. And her doctor placed a value on a genetically superior child. (The money and fame probably didn’t hurt, either.)

Make no mistake; breast cancer is an expensive, terrible disease. Chemo, radiation, lost work, lost productivity, end-of-life care, hospice, ICU time—they all cost money. Patients with breast cancer face pain, despair and possible early death. So you may think reducing the risk of breast and ovarian cancer a valid argument for this type of genetic selection (and genetic de-selection).

But where does that argument take us? Do a little projection with me, if you would.

Maybe, just maybe, the government, in order to save money on health care, could strongly recommend (or even require?) such prenatal genetic diagnosis (PGD) for other families with such a cancer history. Maybe the government could keep a record—a gene record—on everyone; so those with known genetic “defects” could receive counseling before conceiving so appropriate prenatal testing could be done. Maybe for those who conceived without PGD, the government could recommend (or require?) prenatal diagnosis and abortion if the baby was found to be carrying one of these less-than-desirable genes. We (the government) wouldn’t want to “inflict” some poor soul with a less-than-perfect genetic make-up, would we?

Oh, what a wonderful world it would be! No people with disabilities clogging up the system—no cystic fibrosis, Down syndrome, spina bifida, or early-onset breast cancer—none of the up to 6,000 known adverse gene mutations! Why, just think. When they come up with the gene for those with an IQ less than, say 90, only “smart” people could be allowed to be born! And, you know, if your political party were in power, your party could decide what “inferior” meant. Why, it could include races, or religions, or height or weight. The sky is the limit!

Those chuckles you hear in the background are the spirits of Margaret Sanger, Adolf Hitler and all the other eugenicists from ages past quietly laughing as their ideas re-surface, the ideas of the perfect race and elimination of the less-than-perfect from among us. With PGD and prenatal diagnosis clinics, the techniques are not the same (yet), but the concept is the same.

As the Jewish people know first-hand, eugenics may start small, but can end in the unimaginable deaths.

And that is why we must defend life—human life—from conception to natural death, as God intended.

Posted in Uncategorized | 3 Comments »

Extreme Prematurity, Extreme Hard-Heartedness

Posted by MDViews on September 11, 2009

Extreme Prematurity, Extreme Hard-Heartedness

The Daily Mail (www.dailymail.co.uk) from the UK reports that a woman in Great Britain held her baby for two hours until he died while doctors stood by, refusing to help. Why? Because he was born two days too soon. Guidelines in Britain hold that any baby born prior to 22 weeks not be resusitated because such resustation would be futile and the baby would die anyway. Little Jayden was born at 21 weeks and 5 days.

Even if the mother pleads for help? Which she did? Sorry—no can do—was the message to her.

Such is the effect of clinical care guidelines on medical practice, guidelines in Britain developed by a think-tank called the Nuffield Council on Bioethics, guidelines which extinguish human compassion from the care equation and provide cover for doctors to deny care and for the NHS to save money.

I find it difficult to picture an actual physician refusing a patient’s plea in such a circumstance. Theory is one thing. But standing toe-to-bed watching a mother holding her dying child and saying, “No,” chills my soul.

Extreme prematurity is not an easy issue. The earliest survivals on record occurred at 21 weeks 5 days and 21 weeks 6 days. Many times, the babies who survive such prematurity are left with lifelong physical and mental disabilities and always the cost of such care startles our fudiciary sensibilities. (Over a million dollars is not unheard of.) Thus, those who see no value in imperfect life or fail to see the worth of expensive life often carry the day in committees that set guidelines.

The article describes the British Association of Perinatal Medicine doing some fast back-tracking following this incident and her complaint, saying the guidelines were not meant to be a “set of instructions.” But guidelines soon become protocols and protocols morph into rules; rules which, if broken, require explanations and result in discipline for the rule-breaker. Rules which, if followed, save the National Health Service (NHS) millions of pounds.

Looking back on my long years of practice, I’ve been in similar situations. There have been times I’ve told mom and dad that resusitation would be futile and that they should cherish the short time they have with their child prior to his passing. I’ve never fallen back on a guideline to justify my actions, however. I’ve simply told the parents the baby would not, could not survive our best efforts. But I’ve also never turned down a request to help a baby if asked. And I’ve also made sure my statements were true.

One night in my residency, a young woman experienced preterm labor. She was deemed too early for intervention (but was close to the line) and went on to experience an unsuspected breech birth which I attended. Unfortunately, the baby’s head became stuck in the mother’s cervix making delivery impossible and death certain for the struggling premature baby. I cut the mother’s cervix to release the baby’s head, much to the parent’s relief. The baby died in spite of resusitation efforts. Although my superiors criticized this intervention, I can still see the faces of the parents as their baby struggled and wiggled, half in and half out. I’ve no doubt I did the right thing.

The medical cutoff for extreme prematurity is a target in motion, with modern technology resulting in survival of more and more premature babies. Such a moving target contradicts hard and fast rules and should require the best judgment of those physicians at the bedside. Doctors should bring together all the information possible—the stage of the baby’s development, the parent’s wishes, the availabiltiy of treatment, the doctor’s skills—then reach a compassionate and appropriate decision with mom and dad on board.

Matt Anderson

Posted in Doctoring, Medical Issues, Politics | 5 Comments »

The Euthanasia Trojan Horse

Posted by MDViews on September 4, 2009

The Euthanasia Trojan Horse

 

The UK Telegraph reports a euthanasia scheme which now shocks the citizens of the UK. The British, beneficiaries of a one-payor, government system, have to wonder how this came to be. How could the government be killing all these people?

 

To summarize, the UK cancer charity, Marie Currie, developed a protocol called the Liverpool Care Pathway. Designed initially for terminal cancer patients, this pathway received the endorsement of NICE, the National Institute for Health and Clinical Excellence (I’m not making this up) and soon became a standard of care nationwide.

 

This pathway uses the judgment of a medical team including the senior doctor to determine when the end of life is near. (As you might imagine, if a “team” makes a decision, no one person can be held accountable.) At such a time, the doctor withholds food and fluids (starves and dehydrates the patient to death) while administering a sedative to usher the soon-to-be dear departed from this world to the next. (In Minnesota, you can’t starve or dehydrate an pet without risking jail time.)

 

Initially only for terminal cancer, the pathwway now applies to any critical illnes.

 

Some British doctors think the problem is this: How can one accurately determine when is the end near? How does a doctor determine that a patient is about to die? Such a determination is a guess at best, and sometimes just a hunch. So if a patient gets a large amount of sedation and is denied fluids and food, how would one know if the patient might have improved? One would not know and the patient would die a premature death.

 

So a group of experts in geriatrics and palliative care including Professor Peter Millard, Emeritus Professor of Geriatrics, University of London, Dr Peter Hargreaves, a consultant in Palliative Medicine at St Luke’s cancer center in Guildford, and four others have complained.

Dr Hargreaves, Millard and Katherine Murphy, head of the Patients Association, explain in the report,

[Dr. Hargreaves]“It is a very laudable idea. But the concern is that it is tick box medicine that stops people thinking.”

He said that he had personally taken patients off the pathway who went on to live for “significant” amounts of time and warned that many doctors were not checking the progress of patients enough to notice improvement in their condition.

Prof Millard said that it was “worrying” that patients were being “terminally” sedated, using syringe drivers, which continually empty their contents into a patient over the course of 24 hours.

In 2007-08 16.5 per cent of deaths in Britain came about after continuous deep sedation, according to researchers at the Barts and the London School of Medicine and Dentistry, twice as many as in Belgium and the Netherlands.

If they are sedated it is much harder to see that a patient is getting better,” Prof Millard said.

Katherine Murphy, director of the Patients Association, said: “ …There is no one size fits all approach.”

A spokesman for Marie Curie [advocates of the current systerm] said: “The Liverpool Care Pathway (LCP) is an established and recommended tool that provides clinicians with an evidence-based framework to help delivery of high quality care for people at the end of their lives.

So this “tick box” [check box for us] medicine, this “evidence-based framework”, this “Liverpool Care Pathway” embraced by NICE and implemented by the British NHS has resulted in active euthanasia of very ill citizens of the UK. It’s abortion at the other extreme of life, the very old and sick.  Who knows if those people killed by this protocol would have had time to impact their world or family prior to death? Who knows if fractured relationships may have been healed without the starvation, dehydration and sedation? Who knows if someone may have heard the gospel for the first time and responded had not the “evidence-based” death taken them too soon?

I am sickened. Sickened that this occurs in the UK. Sickened that the only problem seems to be killing people too soon. (Why kill them at all? What’s wrong with food and water?) I am sickened that medicine in these United States has embraced every buzzword mentioned above such as evidence-based medicine, best practices, care pathways and protocols. And each of these schemes places a rule-setting committee between the patient and the doctor. By removing the doctor’s judgment from the care of each individual patient, pushing medicine into euthansia, rationing of care and denial of service becomes easy.

Be glad, dear friend, that we in the U.S. are in the infancy of the evidence-based, best practice jugernaut. Be glad we do not have a one payor system (yet) that can foist such atrocities on our sick and dying with the heavy hand of governmental power. But worry, please. Worry and act to stop this from becoming reality.

Matt Anderson

Posted in Doctoring, Euthanasia, Faith and the Glory of God, Medical Issues, Politics | 5 Comments »

The Joy of Doctoring

Posted by MDViews on September 2, 2009

I wrote the following article last year and submitted it to The Minnesota Medical Journal for consideration for publication as part of a writing contest. I’m learning how to accept rejection graciously as it was not published. Anyway, this article is directed toward doctors, which is why I never posted it on my blog. But now, I’m working with the American Ass’n of Prolife OB/GYN’s (AAPLOG) helping recruit prolife medical students, residents and doctors in order to encourage, network and stay informed. Since I now have more MD readers, or soon-to-be MD readers, I’ll post it.

Those of you in medical school may recognize the cynicism, those in residency I know will recognize the cynicism and those in practice may be inspired to re-evaluate their perspective on medicine (I hope and pray).

Enjoy the read.

The Joy of Doctoring

I told my wife first. The letter from the medical school admissions committee landed in my college pigeon-hole mailbox on a January day in 1974. I opened it with my heart about to beat out of my chest. “We are pleased…” is all I read. I ran all the way to our apartment. I was in! Medical school! I couldn’t believe it. I would join the long line of doctors stretching from antiquity to the present, men and women who provided the most intimate and difficult and special care to human race. Men and women highly esteemed by society. What an opportunity! What an honor!

But a funny thing happened to me on the way to actual medical practice. “Funny” meaning tragic. I became a cynic.

I adopted a jaundiced, unsatisfied view of medicine. Since I was the first in my family to embark on a medical career, medicine and medical practice was a big unknown. So I reflected the attitudes and thinking of the attendings, residents, other students I encountered. And everywhere I went I ran into cynical and dissatisfied students, residents and attendings. To my discredit, I found myself becoming cynical and dissatisfied as well. Only my faith, which constantly reminded me of the worth of each individual life, kept me from embracing cynicism as a way of life.

Cynicism—it was contagious. Stereotyping the overweight, the poor, the unwashed, the uneducated, the non-compliant and the belligerent became easy and fun. Cutesy, degrading monikers for different classes of patients, none of which I will repeat, elicited sniggers and outright laughter from other doctors and doctors-in-training.

But the cynicism I encountered went beyond patients and their unpleasant characteristics and into the everyday activities of medical school, residency and then practice.

In medical school, we complained that teachers graded unfairly, organized classroom material poorly and required us to learn material which was irrelevant in nature or overwhelming in amount. In residency, we complained that scut and clerical work occupied too much valuable time and lazy attending staff unnecessarily burdened us with work so they could leave early. Brutal hours, low pay and constant criticism added to our angst. We longed for the nirvana of private practice which would yield fair compensation for our work, no more tests to take and schedules under our own control. Our patients would love us and would all have insurance and be thin and clean and intelligent.

Well, guess what.

Private practice just re-routed the cynicism.

As private practitioners, we discovered unfair insurance companies, high overhead expenses and surprisingly low paychecks. Call duty now seemed even more burdensome and our hours were still too long. Patients who experienced complications returned to us, not our attendings or our institution. And they asked, “Why did I have this complication, doctor?” We faced the real burden of patient care with the responsibility of our patients’ outcomes all our own. Many doctors in private practice worked with greedy or unreasonable partners, a problem I was spared. I now work for a large health care company and the complaints continue, principally that the corporation keeps us from receiving our just compensation. In our hospital, a nurse with a cookbook can now trump our reasoned clinical judgment. The unwashed patients are ever with us.

Furthermore, home life stress did not lessen as we expected. Nirvana never appeared. Husbands or wives who delayed gratification and sacrificed for our medical career now suddenly realized that the new doctor was still too busy, still detached, still not happy, still not a good communicator and still spending too much time at the office or the hospital. Private practice did little to improved one’s spousal relationship, and, in fact, often made it worse as raised expectations went unmet. Those who helped many survive the “hard times” realized that there was no end to the “hard times” and wanted out.

Oh dear.

JAMA in January, 2003, reported 18% of physicians nationwide were somewhat or very dissatisfied with their careers with higher dissatisfaction in physicians practicing in areas with higher proportions of managed care. Women fared lower on the satisfaction scale.1

Archives of Internal Medicine in July 22, 2002 reported 70% of physicians satisfied or very satisfied with their careers and about 20% dissatisfied. Specialties of pediatrics, perinatal medicine, neonatal care, geriatric internal medicine and dermatology showed the highest level of satisfaction and specialties of OB/GYN, ophthalmology, orthopedic surgery, internal medicine and otolaryngology showed higher levels of dissatisfaction. New England and the West North Central areas of the country were more satisfied. Older age, longer hours, specialist in solo practice and foreign medical graduates showed lower satisfaction scores.2

My own observations of physician satisfaction are somewhat at odds to those statistics.

When do I see happy doctors? That’s easy. In a social setting where mere mortal human beings are holding the doctor in high esteem, hanging on his or her every word. At medical meetings when hobnobbing with other immortals, meetings generally held in beautiful areas of the country with warm weather, usually near some attraction or in an interesting city and always in a very expensive hotel. When they get a big paycheck or buy a new car or move into an expensive house. When a health care team member of the opposite sex fawns over them. When they have time off to pursue expensive fun. Doctors like those parts of doctoring. I see them smile and watch their animated conversation when discussing such times.

When do I see them unhappy? That’s also easy. When they look at a very busy schedule. When they look at a not busy schedule. (It means the paycheck will be less.) When a nurse tells the doctor about a patient with an obvious problem and wants the patient worked in that day. When an emergency presents and threatens to make the doctor stay late. When the hospital calls about a patient with a problem, especially if the call is after-hours, even if the doctor is on call. When a doctor receives any call after 9:00PM. When a doctor receives any call that requires the doctor to go to the hospital. When a doctor sees a patient who talks too much, requires too much time in the office, is too complicated, is dirty or smelly or mean or non-compliant or belligerent. When a medical helper doesn’t have all the right equipment RIGHT NOW. When slow lab or X-ray turn-around occurs. When a doctor has to deal with employee issues. When a doctor feels ignored by administration. Even when facing the open-ended encounter, just walking into a room and saying, “What brings you to the office today?” causes unhappiness for many physicians.

You notice that the happy things have little to do with the practice of medicine. The unhappy things sound like a normal day.

So, who is satisfied with their career? I would contend that many, if not a majority of physicians are profoundly unhappy about medicine. But to admit unhappiness would mean that all that work and all that sacrifice maybe wasn’t worth it. It would mean that they really are in it for the money and status and not for caring and helping, which is what they told everyone starting with the admissions committee for medical school.

I believe telling if someone is happy about a career choice is just not that hard. People who like what they are doing, really like what they are doing and it shows, even through the hassles and difficulties of any job.

A satisfied physician might look like this: Busy day? A challenge I can handle. Pt takes too long? That is just how medicine is. Explain to the waiting patients that I’m late, but I will also give them the time they need. Or the waiting patients can reschedule. Need to add someone in? The clinical indication, not the schedule, dictates the yes or no. Stay late? If needed, OK. Caring for the unpleasant, the unwashed, the belligerent, the non-compliant? That’s why I’m here. Illness is not a respecter of persons and all God’s children need health care. On call? It’s my calling. Unnecessary nurse calls at night? A response with a pleasant demeanor and education, not an angry bark. Partner needs help? No questions asked—help is on the way. Hassles of managed care and electronic medical record, lack of autonomy and insurance companies? An inconvenience to the greater goal of patient care.

I read in journals how to improve physician satisfaction. They all talk about money, physician autonomy, hours worked—things like that—which do have validity.

But real joy from medical practice originates in the heart, from within. This joy transcends the hassles of patient care and finds fulfillment in relieving suffering in all its forms and improving the health and well-being of patients. What a glorious goal! This joy from doctoring comes from understanding and even meditating on the calling. It takes realizing that medicine, daily patient care and all it involves, satisfies more than the material rewards and accouterments of medicine. It takes realizing the honor of the job. It takes realizing that patients and their care are the point, not the problem. It takes realizing that a busy schedule does not translate into a burden, but into the satisfaction of being needed. (Unless the schedule is motivated by greed.) It takes realizing that normal medical practice means dealing with add-ons and emergencies at inconvenient times. It takes realizing that call means someone out there is desperate enough to seek your service at inconvenient hours, inconvenient for you and for them. It takes realizing that what medicine has to offer outweighs trying to wrestle the medicine monster to the mat forcing it fit your own ideal. The real satisfaction with doctoring comes from…actual doctoring. The hands-on, active-listening, emergency-seeing, patient-adding, medicine-embracing, call-taking, detail-attending and always-caring doctoring. Find someone practicing like that and you will find someone living the joy.

Trust me, I understand that medical practice is a difficult life. A busy OB/GYN practice, which I have, stresses the most satisfied of us. Hours, call, clinic, surgery, deliveries, partners, administration, liability, unhappy patients—all can be and often are sources of major stress and unhappiness. But I’ve found the joy of medical practice—all of medical practice—is a rock, a home, a calling, a mission and a blessing from God which provides stability and contentment through those times and keeps me excited and satisfied, supremely satisfied with where I am and what I am doing.

I would encourage you, if you are a physician, to embrace all of medicine—the good, the bad and ugly. The joy in your calling is there.

Matt Anderson, MD

Endnotes:

  1. JAMA. 2003;289:442-449.
  2. Arch Intern Med. 2002;162:1577-1584.

Posted in Uncategorized | 6 Comments »