Understanding palliative care

Excerpted from "Teaching doctors when to stop treatment," commentary by Diane E. Meier and Health Affairs in The Washington Post. May 19, 2014 — For years I had tried to understand why so many of my colleagues persisted in ordering tests, procedures and treatments that seemed to provide no benefit to patients and even risked harming them. I didn’t buy the popular and cynical explanation: Physicians do this for the money. It fails to acknowledge the care and commitment that these same physicians demonstrate toward their patients.

Patients and families often assume their doctors are trained and knowledgeable about end of life. Patients and families also assume that doctors will tell them when time is running out, what to expect and how best to navigate these unknown and frightening waters. But many doctors don’t do these things. Most, in fact, have no training in this. Medical school and residency have traditionally provided little or no instruction on how to continue to care for patients when treatments no longer work.

Physicians are trained to make diagnoses and to treat disease. Untrained in skills such as pain and symptom management, communication about what to expect in the future and achievable goals for care, physicians do what we have been trained to do: Order more tests, more procedures, more treatments, even when these things no longer help. Even when they no longer make sense.

So how do we fix this? To change behavior, we must change the education and training of young physicians and the professional and clinical culture in which they practice. New doctors should learn about the management of symptoms such as pain, shortness of breath, fatigue and depression, with intensive training on doctor-patient communication: how to relay bad news, how to stand with patients and their families until death and how to help patients and families make the best use of their remaining time together.

Commentary

CMDA Past President and Oncologist Al Weir, MD: “The author describes an unusual case history to suggest two important questions: As doctors, do we know how to resist making life longer when it’s no longer likely and instead focus profoundly on making life the best it can be? Do we know how to ask others to help us in this task?

“Sometimes we, and our patients, may cling to hopes that are no longer realistic. Instead, we should be open and honest and help our patients navigate their way through a new truth of life. Such a shift in effort does not come naturally for most of us; time, skills and compassion are required. Palliative care teams are often the best way to supplement the capabilities and time we may be lacking.

“Even experienced doctors should seek to sharpen their skills and become mentors for our next generation, so that these younger doctors may be more adept at compassionate end of life care than we have been.

“Today was an unusual day for me in which I had the privilege of sharing bad news and redirecting life goals with three patients, while a medical student leaned silently against the exam room wall. After the last such conversation I probably surprised him by saying, “You know, though the circumstances are horrible, I actually like having these conversations. In such moments, I can be the one who shares this awful truth with kindness and love. I trust myself to do this better than others, because I really care for them. I did the work to help them live longer. Now things have changed and I can do the work to help them live better.”

Resources
End of Life Care Resources
Medical Futility Ethics Statement
When Your Doctor Has Bad News by Al Weir, MD

Are you interested in learning more about bioethics? Join us in Deerfield, Illinois on June 19-21, 2014 at The Center for Bioethics & Human Dignity’s 21st Annual Summer Conference – Bioethics in Transition. With a variety of workshops and courses, you will examine the rapid advances in medicine, science and technology that continue to reshape the scope and landscape of bioethics.

The misery of healthcare

Excerpted from “How Being a Doctor Became the Most Miserable Profession,” The Daily Beast commentary by Daniela Drake, MD, MBA, April 14, 2014 — By the end of this year, it’s estimated that 300 physicians will commit suicide. While depression amongst physicians is not new—a few years back, it was named the second-most suicidal occupation—the level of sheer unhappiness amongst physicians is on the rise. Simply put, being a doctor has become a miserable and humiliating undertaking.

Not surprisingly, many doctors want out. In fact, physicians are so bummed out that 9 out of 10 doctors would discourage anyone from entering the profession. It’s hard for anyone outside the profession to understand just how rotten the job has become—and what bad news that is for America’s health care system.

Unfortunately, things are only getting worse for most doctors, especially those who still accept health insurance. To make ends meet, physicians have had to increase the number of patients they see. The end result is that the average face-to-face clinic visit lasts about 12 minutes. Neither patients nor doctors are happy about that. What worries many doctors, however, is that the Affordable Care Act has codified this broken system into law. While forcing everyone to buy health insurance, ACA might have mandated a uniform or streamlined claims procedure that would have gone a long way to improving access to care.

Yet physicians have to go along, constantly trying to improve their “productivity” and patient satisfaction scores—or risk losing their jobs. And now that Medicare payments will be tied to patient satisfaction—this problem will get worse. Doctors need to have the ability to say no. If not, when patients go to see the doctor, they won’t actually have a physician—they’ll have a hostage.

Almost comically, the response of medical leadership—their solution— is to call for more physician testing. In fact, the American Board of Internal Medicine (ABIM)—in its own act of hostage-taking—has decided that in addition to being tested every ten years, doctors must comply with new, costly, "two year milestones." In an era when nurse practitioners and physician assistants have shown that they can provide excellent primary care, it’s nonsensical to raise the barriers for physicians to participate. It is tone deaf. It is punitive. It is wrong. No wonder doctors are suicidal. No wonder young doctors want nothing to do with primary care. But for America’s health to be safeguarded, the wellbeing of America’s caretakers is going to have to start mattering to someone.

Commentary

CMDA Psychiatry Section Chair John Yarbrough, MD, MBA:“Working as a physician today is different than it was when my father began his practice in internal medicine nearly 40 years ago. Insurances, laws, decreased time with patients, board certifications and electronic medical records are amongst many potential contributors to making life miserable. The demands placed upon us can be overwhelming.

“Recent experiences on a trip to Am_an, Jord_n were unsettling and left me in need of spiritual and emotional refueling. One event in particular while treating Syri_n refugees was when, outside our building, a young 11-year-old girl emerged onto the street with her upper body lit on fire. She had poured kerosene on herself and lit herself on fire after receiving news that her abusive father was coming to pick her up and she would no longer live with her grandmother. This desperate child saw no other way of escaping her situation and is still in a Jord_nian hospital’s ICU with third-degree burns.

“As Christian physicians, the restoring love and grace offered by Jesus Christ dying on the cross for our sins is our path to salvation and an eternity in fellowship with God. While all of us have a wish list of things we would like to see change in our field, our higher calling is our antidote to misery. We are to focus on storing up treasures in heaven and not focus on earthly things."

Country names censored for security reasons

Resources

Faith and Health Resources
Contentment by Richard A. Swenson, MD

Quebec election may speed euthanasia legalization; doctors protest

Excerpted from "Doctors don't want euthanasia bill revived post-election," CTV Montreal, March 17, 2014) - The provincial election has put the provincial government's euthanasia bill on the back burner, but a group of doctors wants to remind the public about what it believes are the risks of Bill 52.

Doctors for Social Justice was joined by former state of New Hampshire representative Nancy Elliott to speak about why legislators in her state recently rejected its own assisted suicide bill. Dr. Paul Saba, head of Doctors of Social Justice, said if the government were to pass the bill physicians would leave Quebec.

"Some doctors will say no, we cannot be accomplices to this; we will not practice under those conditions," said Dr. Saba. Last year, the World Medical Association adopted a motion saying physician-assisted suicide is unethical and must be condemned by the medical profession.

Commentary

CMDA President Richard E. Johnson, MD – “I have spoken with Dr. Saba, and Larry Worthen, the executive director of CMDS Canada. Both are very concerned about the upcoming election in Quebec. If legislators with a pro-physician-assisted suicide leaning are elected, they fear that it will be very difficult to prevent Bill 52 (legalizing physician-assisted suicide) from passing. The language of this bill is quite broad and will make it very difficult for physicians who oppose it to maintain their freedom of conscience.”

Action

Pray for Dr. Paul Saba and those who are working to prevent the legalization of physician-assisted suicide. Pray for our colleagues in CMDS Canada. Pray for Larry Worthen, who desires to “speak the truth in love” while engaged in the battle. Pray that the public will vote for legislators who value life and keep physician-assisted suicide from becoming law.

Resources

Quebec Bill 52 to legalize euthanasia
World Medical Association opposition to euthanasia resolution
CMDA Euthanasia/Assisted Suicide Resources

Brain-dead patient taken off life-support

Excerpted from “Brain-dead Texas woman taken off ventilator,” CNN Health. January 27, 2014 — A wrenching court fight—about who is alive, who is dead and how the presence of a fetus changes the equation—came to an end Sunday, January 26 when a brain-dead, pregnant Texas woman was taken off a ventilator. The devices that had kept Marlise Munoz's heart and lungs working for two months were switched off about 11:30 a.m. Sunday, her family's attorneys announced.

Munoz was 14 weeks pregnant with the couple's second child when her husband found her unconscious on their kitchen floor November 26. Though doctors had pronounced her brain dead and her family had said she did not want to have machines keep her body alive, officials at John Peter Smith Hospital in Fort Worth had said state law required them to maintain life-sustaining treatment for a pregnant patient.

Sunday's announcement came two days after a judge in Fort Worth ordered the hospital to remove any artificial means of life support from Munoz by 5 p.m. Monday. The hospital acknowledged Friday that Munoz, 33, had been brain dead since November 28 and that the fetus she carried was not viable. Her husband, Erick Munoz, had argued that sustaining her body artificially amounted to "the cruel and obscene mutilation of a deceased body" against her wishes and those of her family. Marlise Munoz didn't leave any written directives regarding end-of-life care, but her husband and other family members said she had told them she didn't want machines to keep her blood pumping.

Commentary

Since there are a variety of opinions on this difficult ethical issue, we have included 2 commentaries.

CMDA CEO David Stevens, MD, MA (Ethics):"While the medical technology being applied to Mrs. Munoz’s body might be considered “organ support” for her, it was “life support” for her unborn child. At the time of her death the baby was a few days from reaching 24-weeks gestation when survival rates approach 50%. Every day of continued life support improved the odds of the baby’s survival.

"A few days ago, on February 9th, Robyn Benson had a premature baby boy. Just after Christmas she suffered a cerebral hemorrhage resulting in her own brain death. She was maintained on life support until her baby was delivered. The ventilator was disconnected the day after her child was born. According to reports, the baby is doing well in the NICU.

"I don’t have access to the medical records in either of these cases, but a CNN article on the Benson case makes an inadequate effort to ethically differentiate between her baby’s situation and Mrs. Munoz’s. First, they let you know that one child was wanted by its father but the other was not. The worth of a human being does not depend on whether it is wanted or not. Secondly, the Munoz lawyer’s reported that an incomplete ultrasound had shown the baby had hydrocephalus and possibly other malformations. We should recognize that disposing of the disabled is unethical and simply eugenics. Who decides when a person is disabled enough for elimination?

"CMDA does not have an official ethics statement dealing with this complex issue. Maybe we should. You can contribute to the discussion of what it should say by clicking on the comment link below."

Clinical Ethicist and CMDA Trustee Robert D. Orr, MD, CM:“Marlise Munoz was dead, but her 14-week old fetus was alive. If Mom’s organs could be successfully perfused for another 12-14 weeks, her unborn baby could survive and be delivered by C-section. It is possible, though clinically very challenging. But should it be done?

“Marlise’s family did not want artificial support continued, and they were convinced she would not want it. The hospital believed Texas law prohibited removing life support from a pregnant woman. The legal issue was straightforward: Marlise was dead, therefore the support was not ‘life support’ for her, but ‘organ support’ for the benefit of the fetus. Continued support was legally optional.

“But what about the ethical dilemma? Who should decide? What factors should be considered? Some believe it is morally obligatory to do everything possible to prevent fetal death. Others believe that ‘doing everything’ is not always obligatory, making this comparable to high risk, high burden prenatal fetal surgery, i.e., optional, decided by her family based on their understanding of her wishes and values.

“Not all believers will agree. We will agree that we are stewards of our lives, our bodies and our resources. And we will likely agree it is immoral to intentionally end prenatal life for trivial reasons. The intention in continuation was to possibly benefit a second life. The intention in stopping was to discontinue ineffective and unwanted treatment. I personally believe continued support in this case was discretionary. And I believe we should not harshly judge the Munoz family’s decision.”

Resources

CMDA Ethics Statement on Vegetative State
Resources on End of Life Care

Pro-life movement unites in march on Washington

Excerpted from "Annual 'March for Life' to go on despite ice and cold," USA Today, Jan. 22, 2014 - "We march because 56 million Americans never had a chance to experience snow," the March for Life's Twitter account posted Tuesday, referring to the estimated number of abortions since the 1973 Supreme Court decision that made abortion legal nationwide.

Veronika Johannsen, 22, of College Station, Texas, beat the weather and arrived safely for her second time at the march.

"The face is changing. It's not just white male politicians like the pro-choice people like to say," Johannsen said. "All kinds of people come. Religious groups of all different denominations, former abortion workers, women who have been raped or have been conceived in rape."

This is the 40th year that protesters will march from the National Mall to the Supreme Court, and 2014 is bringing changes like social media and a March For Life app. There is a "virtual march" on Facebook where users who can't make it can post a past March for Life photo as their cover photo to show support.

The theme this year is adoption. Speakers will include Republican House Majority Leader Eric Cantor of Virginia and Democratic Rep. Dan Lipinski of Illinois.

"We want to encourage women facing the option of abortion to choose adoption," said Jeanne Monahan, president of the March for Life Education & Defense Fund. "Adoption is at the center of motherhood. Motherhood is all about sacrifices. This is an ultimate sacrifice for the good of the baby."

Commentary

CMA VP for Govt. Relations Jonathan Imbody– “Respect for life need not be a partisan proposition, and thankfully some politicians challenge the notion that a party cannot simultaneously advance the interests of women and babies. That's crucial, because decades ago, a specious argument of radical feminists began to prevail in the courts and with many politicians and women--namely, that a woman cannot advance professionally apart from the ability to terminate the life of her unborn child. Thankfully, many pro-life professional women, including members of organizations like CMDA's Women in Medicine and Dentistry, are demonstrating the fallacy of that assertion.

“I enjoyed the privilege of joining my good friend Jeanne Monahan, president of the March for Life, on stage Wednesday. I felt heartened as I looked out on the enormous crowd on the National Mall in Washington, D.C.—women, children and men who had braved 18-degree cold to join our march to the Supreme Court to solemnly protest the Roe v. Wade 1973 abortion decision. Especially encouraging are the vast numbers of young men and women who have seen through the deception that separates women from their babies and have determined to see the horror of abortion on demand abolished in their lifetime.

“If you can make it to next year's March for Life, please do so and bring family and friends. I hope you will also winsomely engage others in personal conversations, social media networks and professional opportunities to help them unpack the deception of abortion rights and recognize the gift of life.

“You can also help build a culture of life by encouraging and supporting options for women in challenging pregnancies--including by serving as a medical advisor in your community's pregnancy center.”

"We are destroying speculations and every lofty thing raised up against the knowledge of God…" (2 Corinthians 10:5, NASB).

Action

1. Join the March for Life next year
2. Serve in a local pregnancy center (see Action under article below)

Resources

• Read Freedom2Care blog and view March for Life photos
• CMDA Abortion Resources

Religious freedom policies needed to protect conscience

Excerpted from "Why religious freedom matters" CNN commentary by Robert P. George and Katrina Lantos Swett, January 16, 2014 - Editor’s note: Robert P. George and Katrina Lantos Swett serve as chairman and vice chairwoman, respectively, of the U.S. Commission on International Religious Freedom.
Supporting religious freedom or belief abroad is not just a legal or moral duty, but a practical necessity that is crucial to the security of the United States – and the world – as it builds a foundation for progress and stability. Research confirms that religious freedom in countries that honor and protect this right is generally associated with vibrant political democracy, rising economic and social well-being, and diminished tension and violence. In contrast, nations that trample on religious freedom are more likely to be mired in poverty and insecurity, war and terror, and violent, radical extremism.

Given the compelling case for supporting religious freedom abroad, why is it still so often given short shrift?

Simply stated, powerful concerns and emotions and differing world views are in play. For example, some people erroneously believe that democratic governance requires the exclusion or marginalization of any public dialogue, debate or policy that includes religion. Others view religion and related issues as exclusively personal and thus belonging solely in private life.

Still others worry that, when connected to an issue, religion generates needless and/or unresolvable tensions and controversies and thus is best left alone, perhaps recalling some of history's worst excesses in religion's name. Some are uncomfortable specifically with "organized religion" and may prefer to frame issues in terms of general spirituality. And some who have an exclusively secular approach and a non-theistic perspective may think that promoting religious freedom infringes on their right not to believe.

What all of these concerns share is the view that religion and religious freedom should be off the radar and divorced from foreign policy.

The answer to such concerns is that advocating for freedom of religion overseas is not about supporting a privileged position for religion, but the right to follow one's conscience. It is about insisting that advocating for religious freedom abroad be viewed in the same way as advocating for other essential rights guaranteed under international law. And, contrary to popular myth, this view encompasses not just the freedom to practice peacefully any religion and all that is associated with it, but the freedom not to believe – the right to reject any and all religion, publicly and privately.

While religious freedom cannot be separated from religion, it is actually less about religion per se than affirming a bedrock, internationally-recognized human right, one that has proven time and again to be a foundational freedom for other freedoms.

Resources

CMDA Right of Conscience Resources

New public attitudes about access to medical information, bio tissue for research

Excerpted from “New public attitudes about access to medical information, bio tissue for research,” MedicalXpress. December 13, 2013 -- In this age of surveillance cameras, computer algorithms for tracking website visits and GPS-imbedded cell phones, many people feel their right to privacy is slipping away. This perception extends into the medical realm as well where information gleaned from Electronic Health Records and clinical tissues are being used for medical research purposes with and without patient consent in some situations, though compliant with federal regulations.

With the continued development and importance of the University of Utah's biobank of tissues acquired through research projects and through residual clinical specimens, lead investigator Jeff Botkin, MD, MPH, and his colleagues initiated a study to better understand public attitudes regarding these practices. "There are many technical and financial challenges to establishing a biobank, but we think the largest risk to the enterprise is a loss of public trust if the public is surprised and alarmed by how research is conducted at institutions like ours," says Botkin, associate vice president for research integrity at the University.

The results of the study, published this month in the Journal of Community Genetics, reveal that when the general public is educated about the intricacies involved in collecting and using this information in population-based research—particularly the safeguards and confidentiality measures in place to maintain anonymity—that they support it. "What was surprising is the public is generally not aware of the safeguards in place to assure that research is done in an ethically appropriate fashion," points out Botkin.

"The most important finding from this study was that people, when educated about the safeguards, were fine with their information or tissue being used for research without their signed consent. They were okay with it as long as they had the option to opt out if they wanted," explains co-investigator Erin Rothwell, PhD. The study indicates that once the general public is educated and understands that the risk to their privacy is low, and the option to say "no" (an opt-out) is available, then they are onboard with contributing to the research.

Commentary

Gastroenterologist Jeff Fenyves, MD: -- “While most of practicing clinicians would agree with Dr. Botkin in regard to the importance of public trust, there are many viewpoints as to the best path to take in the case of Biobanks and research. Educating the public, especially given the diversity of types of biobanks, would be impractical. Prior studies already show that the public generally supports the broad goals of genetic research.¹

“Boiled down, the real issue is a widely accepted consent process: opt-in or opt-out, and how much info to go with this? Most agree that formal opt-in, fully explained consent is probably overkill and cumbersome for de-identified specimens. But the public may be rightfully dubious of the assumption of participation, unless they sign an ‘opt-out’ section of a larger document, such as a hospital admission doc or blood draw consent. Or should we find some middle ground, with separate opt-out, or opt-in consent, along with a pamphlet or other informative material?”

¹Kaufman D, Murphy J, Scott J, Hudson K. Subjects matter: a survey of public opinions about a large genetic cohort study. Genet Med. 2008;10:831–839. doi: 10.1097/GIM.0b013e31818bb3ab.

Resources

1. Simon CM, L'Heureux J, Murray JC, Winokur P, Weiner G, Newbury E, et al. Active choice but not too active: Public perspectives on biobank consent models. Genetics in Medicine. 2011;13(9):821–831.
   
2. Project Mkultra: One of the Most Shocking CIA Programs of All Time
   
3. A Biobank for Genomics Research: Do we need Patient Consent?
   
4. Informed Consent for Biobanking
   
5. CMDA Ethics Statement – Human Research Ethics

Task Force: Ban Drug Reps From 'Ivory Towers'

Excerpted from Task Force: Ban Drug Reps From 'Ivory Towers' MedPage Today. December 11, 2013 -- Drug sales reps should be banned from academic medical centers, but mingling between faculty and pharma researchers is not a problem, according to a conflict-of-interest task force.

"Pharmaceutical sales representatives should not be allowed access to any faculty, students or trainees in academic medical centers or affiliated entities," the task force, convened by the Pew Charitable Trusts, wrote in a 30-page report released in December. "However, faculty may invite pharmaceutical scientists for specific educational or scientific discussions that do not involve marketing of a specific product."

The task force—with representatives from seven academic medical centers, various consumer organizations, the Association of American Medical Colleges (AAMC) and the American Medical Student Association—referenced a review of 29 studies that found physicians who interacted with sales reps prescribed lower-quality, higher-cost drugs compared with non-exposed doctors. Current AAMC policy recommends that sales reps only be allowed on academic medical centers by appointment and that they be prohibited from entering patient-care areas.

Banning sales reps is one of seven recommendations the task force made, all of which would tighten current AAMC recommendations. The conflict-of-interest policies should also apply to training sites such as affiliated hospitals and clinics, the task force recommended. Of the 15 recommendations made, several vary at least somewhat slightly from what the AAMC already recommends to its member schools.

The Pharmaceutical Research and Manufacturers of America (PhRMA), an industry trade group, said it was important for the development of new drugs and for patient safety that physicians and drug companies maintain collaborations. “While PhRMA is still reviewing the findings of the Pew Charitable Trusts’ report, it is important to stress the importance of collaborations between biopharmaceutical research companies and physicians, including at academic medical centers,” PhRMA Executive Vice President Bill Chin, MD, told MedPage Today in a statement. “These interactions improve patient care and contribute significantly to scientific innovation.”

Commentary

CMDA Member and Associate Professor of Anesthesiology J. Grady Crosland, MD, MAR: “‘Whatever it is, I fear Greeks even when they bring gifts’ (Virgil’s Aeneid).

“Thus was ‘there is no free lunch’ announced two millennia ago. Men have always expected a quid pro quo. Our fallen human nature leads us into temptation. The question is how do we respond to it? Social scientists say it doesn’t take much to create a sense of indebtedness in those who receive unsolicited gifts.¹ I much prefer to teach virtue ethics as a part of the core competency of professionalism. Make the ‘weaker brother’ stronger and leave personal choice to the individual physician.”

¹Information from Pharmaceutical Companies and the Quality, Quantity, and Cost of Physicians' Prescribing: A Systematic Review. Geoffrey K. Spurling et al. PLOS: Medicine, October, 2010.

Resources
Ethics Statement – Doctor and Pharmaceutical/Medical Device Industry Relationship
Professionalism in Peril

Therapists Explore Dropping Solo Practices to Join Groups

Excerpted from “Therapists Explore Dropping Solo Practices to Join Groups,” Shots: Health News from NPR. October 24, 2013 -- In the corporate world of American healthcare, psychologists and other mental health therapists are still mostly mom-and-pop shops. But the business model for therapists is shifting away from solo practices and toward large medical groups, say mental health experts. That change is propelled by the Affordable Care Act, which mandates mental health benefits in insurance coverage, and by the Mental Health Parity Law, which requires private and public insurers to cover mental health needs at the same level as medical conditions — by charging similar copays, for example.

Organizations that advocate for mental and behavioral health — groups that long complained that they were treated as second-class providers — have applauded the federal laws. But inclusion has come with some unhappy caveats, including less pay and more paperwork. Patients used to paying $150 in cash for a therapy session will, with some limitations, have sessions covered by their health plan. That means many therapists will have to figure out innumerable insurance plans and byzantine billing codes for the first time.

In many ways, therapists are encountering what medical doctors have complained about for years: the confusing, confounding and, some might say, hostile insurance bureaucracy that providers must tangle with in order to get paid. The increasing complexity of running a practice has meant more therapists are taking down their shingles or forming groups with other therapists to share the burden, executives at national mental health groups say. Others have joined large medical groups that offer mental health services as part of comprehensive care.

Commentary

CMDA Member and Psychiatrist Robert Rogan, DO, JD: “This article touches on several current issues in mental health affecting our society. One, the loss of autonomy, may be far more serious than we realize. The freedom to serve as we in conscience believe best is something we need as believing practitioners. Conscience issues are already prominent in current medical practice in general. If we can’t ‘choose our clients,’ we may find ourselves being asked to provide therapy in an area we find morally uncomfortable.

“People do seek mental health services and pay ‘out of pocket’ not just for insurance reasons but also for privacy. The HIPAA regulations with compliance that began on September 23, 2013 seem to reflect this possibility.

“Paperwork issues are not just documentation chores but very concerning potential legal traps. Billing is serious business for more than just reimbursement reasons. We need to be truthful but careful in what we write. Also, we need to be ultra-careful what we sign. We need to know every pitfall in contracts we sign. If there is legal terminology you don’t know, look it up or get legal counsel. A subtle term like ‘hold harmless,’ now in very common use, can be the entrance to a professional minefield.

“On the other side, solo practice can have physical dangers with our changing patient demographics. Group practice can provide more collegiality as ‘iron sharpens iron.’ We can be of great use in practices where mental health service is needed by other non-mental health practitioners.”

Resources
Healthcare Right of Conscience Ethic Statement
Augustine College at CMDA CD Set

Court upholds religious freedom in contraceptives mandate case

Excerpted from "Court strikes down birth control mandate," published in The Hill, November 01, 2013 - A federal appeals court on Friday struck down the birth control mandate in ObamaCare, concluding the requirement trammels religious freedom.

The D.C. Circuit Court of Appeals — the second most influential bench in the land behind the Supreme Court — ruled 2-1 in favor of business owners who are fighting the requirement that they provide their employees with health insurance that covers birth control.

Requiring companies to cover their employees’ contraception, the court ruled, is unduly burdensome for business owners who oppose birth control on religious grounds, even if they are not purchasing the contraception directly.

Legal analysts expect the Supreme Court to ultimately pick up an appeal on the birth-control requirement and make a final decision on its constitutionality. In the meantime, Republicans in Congress have pushed for a conscience clause that would allow employers to opt out of providing contraception coverage for moral or religious reasons.

The split ruling against the government on Friday was the latest in a string of court cases challenging the healthcare law’s mandate. Friday’s ruling centered on two Catholic brothers, Francis and Philip Gilardi, who own a 400-person produce company based in Ohio.

"They can either abide by the sacred tenets of their faith, pay a penalty of over $14 million, and cripple the companies they have spent a lifetime building, or they become complicit in a grave moral wrong," Brown wrote.

The Obama administration said that the requirement is necessary to protect women’s right to decide whether and when to have children.

Commentary

Matt Bowman, Senior Legal Counsel, Alliance Defending Freedom– “Two new cases have vindicated religious freedom for people in their everyday professions, and have upped the ante for another Supreme Court showdown, in 2014, with the Obama administration over religious liberty and Obamacare. The U.S. Courts of Appeals for the Seventh and D.C. Circuits, in Chicago and Washington, respectively, both ruled in the last few days that when people of faith engage in a business they do in fact possess the freedom to exercise their religious beliefs when the government commands them to violate those beliefs. The Gilardi family out of Ohio, the Korte family of Illinois and the Grote family in Indiana all run businesses and seek to do so consistent with their Christian faith. They object to the Obamacare mandate to provide abortifacient drugs, contraception and sterilization in their employee health plans.

“On November 9, the Seventh Circuit declared that the Korte and Grote families and their businesses can assert rights against the federal government under the Religious Freedom Restoration Act of 1993 (RFRA), which ‘operates as a kind of utility remedy for the inevitable clashes between religious freedom and the realities of the modern welfare state, which regulates pervasively and touches nearly every aspect of social and economic life.’

“The court went on to declare that the abortifacient/contraception mandate is not justified against religious objectors, because the government merely asserts that free contraception promotes ‘health’ and ‘equality.’ Rebutting the government’s assertion of a so-called ‘right’ to such things as abortion and contraception, the court declared that ‘the government has failed to demonstrate how such a right...can extend to the compelled subsidization of a woman’s procreative practices’ by private citizens.

“On November 26, the Supreme Court will look at three petitions from businesses that have filed similar challenges to the abortifacient/contraception mandate, and it could decide that afternoon to set one or more of those cases for argument in the spring of 2014.”

Resources
Court Cases summary

HHS contraception mandate vs. the Religious Freedom Restoration Act

Action

Urge your senators to support conscience rights - S.1204

Urge your Rep. to protect conscience rights - HR 940

Obamacare rollout highlights views of government

Excerpted from "An opening for the right," The Washington Post, commentary by Jennifer Rubin, October 27 - The Obamacare debacle challenges a number of liberal mantras that undergird a whole set of policies and campaign appeals. Here are the top 10 liberal tenets threatened by Obamacare:

1. If there is a problem, the federal government should attack it.
2. Government can compel people to act against economic self-interest by passing laws.
3. There is no downside to big government.
4. The welfare state is the best mechanism to help the poor.
5. Those opposed to big government hate the poor.
6. Government is capable of running highly complex systems effectively.
7. When addressing big problems it is best to centralize and standardize.
8. Unintended consequences of government programs are a small price to pay.
9. People will trust the government with private decisions and personal information.
10. Spending more and taxing more are evidence of concern for the poor.

All of these precepts have been challenged by conservatives, but there is nothing like a real example and personal experience to drive home a message. We don’t have just a few “glitches” or even a time crunch for putting up the exchanges, we have in Obamacare a fundamental misunderstanding of the limits of the government and citizens’ aversion to big, complicated entities. The effort to construct one big system with a highly regulated product (Obamacare-standard insurance) may in fact be the entire effort’s undoing.

Commentary

CMDA CEO David Stevens, MD, MA (Ethics):
“Our healthcare system is broken and badly in need of a fix. The root problem is that healthcare costs too much, so individuals and businesses can’t afford insurance. The Affordable Care Act, unfortunately, is built on the premise that most people’s health insurance programs are not adequate and all perceived inequities must be solved. So the law says preventative services and contraceptives must be free. It doesn’t allow surcharges for age or preexisting conditions. Children can stay on their parents’ plans until age 26. There are no lifetime cost ceilings. Plans must contain psychiatric, eye and other coverages that most insurance plans have not provided.

“I like all those things, just like I like all the bells and whistles on a Mercedes Benz 500 with its great ride and exquisite comfort. But I’ve never owned a Mercedes because I can’t afford one, just like most people in our country. I drive a Honda Civic and, you know what, it gets me there. We can’t afford the Affordable Care Act either. It will add a whopping $2.8 trillion to our healthcare costs over the next 10 years. Already, self-insured individuals are experiencing the reality of that sticker shock but they are no longer in a market-driven healthcare economy. They can’t buy a well-used insurance vehicle at an economical price. Only a Mercedes is adequate.

“We very well may be headed for a debacle. The ‘cure’ may be worse than the disease. If so, everyone may be so traumatized that they refuse to even give a hearing to a real solution.”

Proposed treatment to fix genetic diseases raises ethical issues

Excerpted from “Proposed treatment to fix genetic diseases raises ethical issues,” Shots: Health News from NPR. August 14, 2013 -- The federal government is considering whether to allow scientists to take a controversial step: make changes in some of the genetic material in a woman's egg that would be passed down through generations. Mark Sauer of the Columbia University Medical Center, a member of one of two teams of U.S. scientists pursuing the research, calls the effort to prevent infants from getting devastating genetic diseases "noble." Sauer says the groups are hoping "to cure disease and to help women deliver healthy, normal children."

But the research raises a variety of concerns, including worries it could open the door to creating "designer babies." Specifically, the research would create an egg with healthy mitochondrial DNA (mtDNA). Unlike the DNA that most people are familiar with—the 23 pairs of human chromosomes that program most of our body processes—mtDNA is the bit of genetic material inside mitochondria, living structures inside a cell that provide its energy.

Scientists estimate that 1 in every 200 women carries defects in her mtDNA. Between 1 in 2,000 and 1 in 4,000 babies may be born each year with syndromes caused by these genetic glitches; the syndromes range from mild to severe. In many cases, there is no treatment, and the affected child dies early in life. "We have developed a technique that would allow a woman to have a child that is not affected by this disease, and yet the child would be related to her genetically," says Dieter Egli of the New York Stem Cell Foundation.

But this is all still very controversial. First of all, the baby would be born with genes from three different people: from the father, from the woman trying to have a healthy baby, and from the woman who donated the healthy egg. There are even bigger concerns, which start with whether the technique is safe for the resulting infant, and whether by trying to fix one problem, scientists may inadvertently introduce mistakes into the human genetic code. That's why this sort of thing has always been off-limits — even banned in many countries, according to Marcy Darnovsky of the Center for Genetics and Society.

Commentary

CMDA CEO David Stevens, MD, MA (Ethics): “Germline genetic engineering, where a portion of the egg or sperm’s genome replaced, changed or supplemented, is unethical, unnecessary and unsafe. It crosses a bright line in the bioethical sand labeled, ‘That shalt not!’


“It is unethical because it permanently changes the child’s genes and any unforeseen consequences that occur are passed on to every generation that follows. Thus, it violates the ethical principle of autonomy. How does the doctor get informed consent from their grandchild yet to be conceived? Some of the techniques proposed involve destroying human embryos, not just manipulating women’s eggs. For example, some propose discarding female embryos created and only implanting male embryos to avoid the risk of passing on an inheritable defect.

“It is unnecessary. Women who have an identified high risk with a high mutation load, (under 18 percent mutations of mtDNA, there is 95 percent certainty of no risk) already have the option of not having children, adopting, utilizing a donated egg, preimplantation genetic diagnosis and prenatal diagnosis with abortion. Some of these options are unethical because they destroy life, but they are legal. Scientists are trying to justify germline manipulation so that women with this genetic liability might have the option of having a child with their genes. While this ambition is understandable, because there are alternatives, and because there are significant risks to generations of offspring, we should prohibit this option.

“It is unsafe. This type of genetic manipulation is not human cloning but uses similar techniques that have been associated with serious problems when used in animals—large organ syndrome, malformations and miscarriages.

“The ‘hard cases’ have been historically used to justify crossing the ‘bright lines’ in bioethics. We saw this in abortion, but once society agreed that abortion was justified because the mother didn’t want a child because of rape, incest or a genetic defect, it soon became justified for a woman not wanting a child for any reason. In other countries, physician-assisted suicide was justified for patients who had lives ‘not worthy to be lived’ because they were terminally ill and suffering. Now it is allowed for any reason the patient conceives that their life is unworthy to live. It is not unreasonable to predict if society says germ line manipulation is okay to avoid having a child with an imperfect genome that society will soon open the door for germline genetic engineering in the quest for perfect children.”

Resources
Novel techniques for the prevention of mitochondrial DNA disorders
Position Paper on Human Germline Manipulation
CMDA Resources on Reproductive Technology and Health

Physicians prepare to deal with increased demand, strain on practices under ObamaCare

Excerpted from “Physicians prepare to deal with increased demand, strain on practices under ObamaCare,” Fox News. October 1, 2013 -- As enrollment in ObamaCare begins, physicians throughout the country are preparing to deal with an influx of newly insured patients – as well as the increased financial demands this will place on their practices. While it will take a few years for doctors to fully determine how they will be affected by ObamaCare, some physicians are already anticipating the need to make major changes to the way they run their practices.

One of the most immediate changes that physicians in these areas expect to see is an increase in patients seeking preventive health care – something many avoided when uninsured. However, scheduling more routine check-ups and screenings may place a strain on already short-staffed practices in rural areas. As a result, some doctors are considering handing over some basic aspects of patient care and education to nurses, nurse practitioners, or physicians assistants in order to treat patients more efficiently. Dr. Jason Marker, of Wyatt, Indiana, is already looking to hire additional staff members in order to meet the increased needs in his community.

Rural areas throughout the country already face a shortage of primary care physicians and doctors like Marker fear that this problem might become exacerbated in coming years, as more patients have the means to seek regular care.

“We know definitively that health insurance coverage and access to a physician are what improve health care outcomes.” Marker said. “We’re about to get changes in coverage, but we don’t have a ready way to say, ‘Here’s another million family doctors.’ So there’s a pipeline problem where it will be another five to 10 years where we are able to get the volume of doctors to take all these patients.”

Marker said Congress will need to step up in order to help fix this problem. “The big weak link is whether or not Congress is willing to put additional dollars into family medicine residential training,” Marker said. “That’s the current bottleneck in the training pipeline, is having residency slots. It doesn’t do good to have residents interested if there aren’t slots to do training.”

Commentary

CMDA CEO David Stevens, MD, MA (Ethics): -- “When we went as missionaries to Africa, Jody knew we would be far from the grocery store yet entertaining many guests, so she bought a cookbook called More With Less. That phrase succinctly describes the focus that every healthcare professional will need as we move forward. There are going to be more patients to see than ever before but not enough physicians to see them. Though more medical schools are opening, including two Christian ones, there are not enough residencies being funded. Physician assistant and nurse practitioner schools are expanding to help fill in the gap, but the problem is bigger than that.

According to leading economic John Maudlin, reimbursement rates are going to plunge by 25 percent in the next five years. (I encourage you to read the eye-opening article.) The Cleveland Clinic now collects $6 billion a year and expends $5.5 billion. They are projecting their income to plunge to $4.4 billion by 2018, despite a significant increase in their patient load, as commercial insurance companies on average go from paying $.38 on the dollar billed to $.26. (Medicare now pays $.23 and Medicaid $.18.) Since 60 to 80 percent of their cost is for personnel, that is where cost savings will have to be realized. That is why you are already hearing of hospitals and practice groups laying off staff and if those staff are rehired elsewhere, they probably will be paid less.

CMDA’s Executive Vice President Gene Rudd, MD, told those attending the CMDA Midwest Regional Conference a few weeks ago that they would all need to become missionary doctors…but not necessarily by going overseas. They will have to have a missionary's mentality of working very hard and not getting paid as much, but doing it because God has called them to minister through medicine.

Though we will all being doing "more with less" I believe that the opportunities to minister through healthcare are going to be greater than ever! God does His best work in the midst of crisis and change if we simply rest and trust in Him!

Resources
From My Viewpoint: Healthcare Reform by David Stevens, MD, MA (Ethics)
Why HR 3200 is No Healthcare “Reform” by Gene Rudd, MD
Affordable Care Act Impact on Doctors and Patients

Doctors Look For A Way Off The Medical Hamster Wheel

Excerpted from “Doctors Look For A Way Off The Medical Hamster Wheel,” Shots: Health News from NPR. August 14, 2013 -- Doctors are on a hamster wheel these days. We're compelled to run faster just to stay in place. It's about to get worse. Obamacare means millions more people will want our services, with not enough primary care doctors to meet demand. Government incentives that are pushing us toward computer-based records mean that doctors now spend as much time documenting our visits with patients as we do examining them.

As the hassles have gotten worse, I've seen many colleagues jump ship. But there might be another way. Dr. Christine Sinsky, an internist in Dubuque, Iowa, has made it her mission to find ways to mitigate the drudgery of modern doctoring. With funding from the American Board of Internal Medicine Foundation, she and four colleagues traveled the U.S. in search of practices that provide top-notch, effective primary care, while making the work satisfying for the doctors and other health professionals. Sinsky and her team found 23 examples of innovative practices from coast to coast, and reported on them in both an academic journal and an in-depth white paper.

Dr. Ben Crocker was so burned out in in 2007 that he lamented, "Working at Starbucks would be better." Now, his practice at Massachusetts General Hospital employs health coaches to work with patients on making the lifestyle changes that doctors recommend but can't adequately teach or monitor. Virtual visits have replaced some in-person visits. Perhaps most incredibly, the practice offers staff downtime each week to come up with innovations.

Sinsky offers examples of tedious tasks that take doctors away from providing undivided attention. No. 1 among them is data entry. "Inbox management" — all the phone calls, emails, forms to sign and prescription refills — can take up to two-thirds of a physician's day. "All of this inbox work can and should be handled by nonphysician personnel, freeing us up," she says. "So many mandatory tasks are crowding out the work of real doctoring.”

Commentary

CMDA Member Julie Griffin, MD: -- “Demanding schedules, flawless precision and an enduring calm in calamity—these are expectations of physicians. We have often placed these ultimatums on ourselves with our detailed, driven personalities pushing us to unattainable perfection. Nevertheless, the culture increasingly demands a new maximum.

Hardly imaginable is Hippocrates rushing around the office, then being paged across town for a delivery. Medicine’s revered father never had to defend his decisions to a third-party payer. We prefer the tableau of a wise, forbearing professional to grateful patients and an engaging professor to eager students. In truth, we were in this picture ourselves as we entered medical school.

Have our dreams run amuck? Perhaps, if we lose the focus of our callings in light of career demands. Yet, if we are confident of our callings and moved with the same compassion which moved Jesus (Matthew 9:36), we will not be distracted from our opportunities to serve.

To be sure, we must employ new methods, including delegation of duties. Medicine is moving to team-based care. This change is neither revolutionary nor futuristic. It is an overdue move toward our biblical heritage. Jesus readily embraced teamwork in ministry, and we as physicians should do likewise.

We must remember our calling and the true Strength by which we fulfill it—paperwork, phone calls and all. We cannot be chased out of our ministries for there is no joy or peace in life apart from our appointments as God’s coworkers in the gospel of Christ (1 Thessalonians 3:2-3).

Resources
In Search of Balance by Richard Swenson, MD
Practical Practice Issues in Today’s Christian Doctor

Obamacare May Trigger Exodus of Christian Doctors

Excerpted from “Obamacare May Trigger Exodus of Christian Doctors,” CBN News. October 1, 2013 -- Thousands of Christian doctors across the nation are considering quitting medicine or working overseas because of concerns over the new healthcare law.

Dr. Gene Rudd, senior vice president of the Christian Medical Association, says they're worried they could be forced to facilitate abortions or prescribe drugs that violate their convictions.

Rudd says many of them have avoided hiring and taking on new patients due to uncertainty over Obamacare.

Thousands of the doctors provide care for the poorest areas of the United States and feel called by God to help the sick, but say they need to be able to do so with a clear conscience.

Commentary

CMDA Senior Vice President Gene Rudd, MD: “I rarely view or read media reports after I have been interviewed. (In part, this is because someone else at CMDA does that.) But being asked to comment on this article that was based on what I said to a reporter reminded me of how the media uses their perspectives and agendas to create the news. Too frequently I find a failure to report ‘the truth, the whole truth and nothing but the truth.’

“Timed to coincide with the beginning of the enrollment for Obamacare, my interview with this AP reporter covered many perspectives on healthcare reform, perspectives I classified as ‘the good, the bad and the ugly.’ My limited comments about Christian doctors were almost an afterthought. But only those comments made the news.

“Among the many perspectives I cited, one ‘good’ aspect of reform is that some of our neighbors who previously couldn't obtain health insurance coverage would now have some basic level of protection. A ‘bad’ aspect is that now healthy individuals and families who did not have coverage and had little healthcare costs will now have to pay either a penalty for failure to participate or pay premiums. Even with subsidies, one estimate placed the average family premium at more than $5,000. That will be a substantial burden to most family budgets.

“One of the ‘ugly’ aspects of the current reform bill is the permission assumed by the Administration to usurp individual rights and undermine the First Amendment. Already we have seen HHS interpret and implement legislation in a way that attempts to force employers to provide coverage that includes provisions they find morally objectionable. And under the guise of providing required services, we will be required to fund abortions. Only with the use of smoke and mirrors do they attempt to claim otherwise.

“Will reporters continue to filter the news to suit their agendas? Of course. But we will continue to speak the truth in love. Will Obamacare survive? I don’t know. But we will continue to contest provisions that are morally unacceptable and dangerous to our foundation of freedom."

Resources
Voice of Christian Doctors Media Training
From My Viewpoint: Healthcare Reform by David Stevens, MD, MA (Ethics)
Nationalized Healthcare – Prescription or Problem?

Using social media in clinical practice

Excerpted from "Docs Need to Get Up to Speed, Social Media Advocate Says," MedPage Today. August 15, 2013 -- Bertalan Mesko, MD, PhD, is counting on old media to convince more clinicians about the value of new media. The clinical genomics specialist has just published a handbook on social media in clinical practice -- and he hopes it will bring late adopters up to speed with their social-media-savvy colleagues, and even with some of their electronically empowered patients.

While "expert" patients voraciously pursue credible medical information and communities online, clinicians "usually lag behind," Mesko, who is based in Budapest, said in an email exchange with MedPage Today. Instead of disdaining this kind of behavior, doctors need to see themselves as a gatekeeper of vetted online information and activities, he said.

“Social media provides us with a lot of opportunities, but only if we know the potential limitations and security issues. Acquiring such knowledge takes years, and my goal with the handbook was to shorten this time significantly for those medical professionals who would like to become a bit more digital, but at the same time use these online tools in a secure way,” said Mesko in an online engagement via email.

“I think communication methods in real life and in the online world are the same. If medical professionals understand this and create a proper online presence, as well as give their patients a chance to communicate with them through certain online channels, the doctor-patient relationship can become more efficient by saving time for both parties. Using digital technologies, especially social media, is now an integral part of medical communication, and as more and more patients use these platforms, their physicians must be able to deal with this in an evidence-based manner,” said Mesko.

Commentary

CMDA Vice President and National Director of Campus & Community Ministries J. Scott Ries, MD: "Mention 'social media' during a conversation with one of your colleagues and observe the resulting reaction of the facial muscles. I predict you'll identify a subtle pupillary dilation, upturning of the corners of the mouth and an increase in pace of speech...or else you'll view a burrowing of the forehead creases, tightening of the lips and clenching of the jaw. When in past history has any other 'tool' ever evoked such emotional response from its users (or haters)?

"At its core, social media is indeed simply a tool—a forum to communicate, share ideas, explore information, engage conversation and create community. If you already embrace social media at some level, you won't be surprised to hear that I'm more likely to be contacted via Facebook than email by students, residents and even some doctors.

"If you find yourself beset with the clenched jaw, here are a few things that might help you dip your toe in the social media waters without catching a cold.

1. Recognize that social media does not equal Facebook. Not all of social media is Facebook. As social media expands, the relative amount of the landscape occupied by Facebook is diminishing. If Facebook seems daunting to you, choose another option to explore.
2. Peruse areas of CMDA’s social media engagement. CMDA is actively engaged with social media with both the current and upcoming generations of doctors.
3. Consider following just one blog, along with following their Twitter and/or Facebook posts. This will let you ease into the foray a bit without becoming overloaded.

For more practical insight into how to use social media, the benefits it can offer you and your practice and other information, check out Social Media in #Healthcare: Why You Should (Like) Social Media by Bill Reichart, MDiv.

"But won't social media consume any vestiges of time remaining in our overloaded schedules? Only if we let it. It's like when I was taking driver's ed as an inexperienced 15-year-old. In attempting to pass a slow moving truck, I was hesitant to exceed the speed limit. Seeing the approaching car, the instructor promptly pushed her 'instructor’s accelerator' to quickly get us by the truck, while calmly saying 'Control the car. Don't let the car control you.' So it is with social media. However you choose to engage, control it...don’t let it control you."

Resources
Social Media in #Healthcare: Why You Should (Like) Social Media by Bill Reichart, MDiv

CMDA's Social Media Pages

• Facebook
  
• CMDA Student Life Facebook
  
• Twitter
  
• YouTube

Doctors Badmouthing Doctors

Excerpted from “Doctors Badmouthing Other Doctors,” The New York Times. July 11, 2013 -- A physician friend recently disclosed that she was named in a malpractice lawsuit. Her revelation was rattling not only because there were no discernible errors in the care she provided, but also because another doctor had provoked the patient to hire a lawyer. “I’m shocked that nothing was done sooner,” the other doctor had said when the patient went for a second opinion. “You could have died.”
Surely, the doctor who had trashed his colleague was out of line. Throughout training and regularly at work, we are reminded of the importance of professionalism and respect. Shifting blame demoralizes other clinicians, undermines patient trust and compromises patient outcomes.

But it didn’t take long for me to recall instances when friends and I had been equally critical about other doctors’ work. Are we all capable of talking like that in front of patients? The answer, according to a recent study in The Journal of General Internal Medicine, is an unqualified and disturbing, “Yes.” “Doctors will throw each other under the bus,” said Susan H. McDaniel, lead author of the study and a professor of psychiatry and family medicine at the University of Rochester Medical Center. “I don’t think they even realize the extent to which they do that or how it can affect patients.”

“There is probably something reassuring in saying, ‘Boy, your doctor didn’t do a good job and now I’m going to take care of you,’” Dr. McDaniel noted. “But those kinds of comments are bad for the patient.” To help remedy this problem, Dr. McDaniel began a physician coaching program at the University of Rochester Medical Center a year and a half ago. “There’s a lot of attention focused on the patient experience, but I think we need to work on improving the clinician experience as well,” Dr. McDaniel said.

Commentary

CMDA Vice President and National Director of Campus & Community Ministries J. Scott Ries, MD -- “When I first read the title of this article, my initial reaction was, ‘I don’t do that.’ Then the rubber met the road. Just last week, a 7-year-old girl accompanied by her grandmother came to my clinic with the same abdominal pain that had been plaguing her for four days. Initially evaluated by her grandmother’s family physician, she had been diagnosed with a urinary tract infection and treated with antibiotics. Three days later, when the pain had not improved, she returned to that doctor. A repeat urinalysis was normal and they were sent home with instructions on how to treat constipation. “Later that day, they came to me. I had the advantage of both urinalysis results (neither remarkable) as I evaluated the healthy appearing child in front of me. But something didn’t seem quite right. A couple hours later, I whisked her off to meet the surgeon at the OR to intervene for her ruptured appendix. But before they left the clinic, the question came: ‘Should the other doctor have diagnosed this on Monday?’ Two things hit at me at once, freezing any potential response. The first was the reaction, ‘I’m just glad you brought her to me. She could have died.’ The second was the article adducing that very phrase.

“How should we respond when we encounter and disagree with the work of a colleague? Try answering these three questions before responding:

1. Will my response benefit my patient?
2. Will my response attempt to inflate trust in me, by diminishing that in another?
3. Am I representing well with my words the Physician I desire to emulate?

“If we are honest, our pejorative off-the-cuff responses are often (if not subconsciously) geared at building our own ego. Confident in our abilities, we want to make sure our patient shares our confidence in our prowess. But is this how the Great Physician treated His colleagues? Is this the grace with which the Great Physician has treated me? Ephesians 4:29 offers the answer that we need at this precise moment, ‘Do not let any unwholesome talk come out of your mouths, but only what is helpful for building others up according to their needs, that it may benefit those who listen’ (NIV 2011).”

Resources
Christian Physician's Oath
Christian Dentist's Oath
The Cry of the Patient--Are We Listening?

Outcry in America over prohibitive cost of birth

Excerpted from “Outcry in America over prohibitive cost of birth,” BioEdge. July 6, 2013 -- A report by data analytics company Truven has revealed that the cost of giving birth in the U.S. is the highest of any industrialized nation. The average total price charged for pregnancy and newborn care was about $30,000 for a vaginal delivery and $50,000 for a C-section, with commercial insurers paying an average of $18,329 and $27,866.


One factor contributing to the high birth cost is the “charge for service” policy of U.S. hospitals, whereby patients are charged for each service they receive during their stay.

There have also been claims of a lack of transparency and regulation in the pricing of services provided by hospitals. Hospitals are able to set prices extremely high with little fear of retribution. Charges for delivery have nearly tripled since 1996 and out of pocket costs are four times higher. Some women have reported that they are very reluctant to have a caesarean due to the hefty price attached.

American commentators have reacted strongly to the report. "It's a truly sad state of affairs," wrote Sasha Brown-Worsham of The Stir. “There is something so damaged about a country that claims to support families and wants people to procreate and then does absolutely nothing to support them once they do.”

Commentary

CMDA Executive Vice President Gene Rudd, MD: “The cost of healthcare has become a plague in and of itself. The burden of paying for healthcare is the leading cause of bankruptcy with childbirth-related costs, resulting in seven percent of those bankruptcies. Too many young families face lifelong economic marginalization due to these excessive costs.


“Why is U.S. healthcare so costly? There are many reasons: overutilization, for example. The threat of malpractice adds many ‘routine’ but unhelpful tests and procedures. There are too many cooks in the kitchen—business entities waiting in line to make profits. And the uninsured are most severely affected. They are expected to pay the chargemaster costs while those with third-party payers pay discounted rates often at one-third of the chargemaster.

“It is further disturbing to know that we are not getting a good return on our healthcare investmentⁱ. Shameful, in fact. We pay a higher amount of our social and family budgets than any other developed country, but rank well below in outcomesⁱⁱ.

“Personally, I oppose the current healthcare reform plan, but not because I oppose reform. Reform must occur. I oppose the current plan because it does not adequately address our economic burden of health care as reflected in the cost of childbirth. Starting with already unacceptably high costs, the planned reforms only exasperate the problem, likely collapsing the system. Was this intended by social engineers as a means of getting what they ultimately want, a single-payer, universal system? I do not know, but I am growing suspicious.”

ⁱHealth care spending, delivery, and outcome in developed countries: a cross-national comparison. American Journal of Medical Quality
ⁱⁱ For Americans Under 50, Stark Findings on HealthThe New York Times