Continuing the development of our theme how prevention often fails to prevent, we bring to your attention a patient care interaction from today. A background primer on our thesis here: no matter how much or how loudly someone screams and yells and pays and incentivizes doctors to extol the virtues of prevention, people may have a very different vision for their lives. That vision may not include in any way, your good advice to eat better, or stop smoking, or take better care to watch your blood sugar or whatever the advice. So, we speak, they listen and, this is the key, the are free to choose to listen or not. Despite what one may think: not everyone wants to necessarily be better, or worse, just cannot be better. They try, and they fail. So be it. So, in our world, we see this play out every day, every week with patients from all walks of life.
Today I met a 62 year old woman. She is a professional chef, educated and coming in for surgery to remove a lump from her breast (possible breast cancer). She had already been to our radiology department and had a marker placed, A marker is a wire that leads the surgeon to the small tumor deep inside the breast. The radiology people use advanced imaging techniques like MRI and CT scans in 3D to place the wire exactly through the tumor. So, when we met Jane Doe, she had a small wire (the thickness of a small line of fishing line but made of metal) coming out of the skin of her breast and we were taking her to the operating room to follow that wire to the lesion and remove both the lesion and the wire.
There was one problem though. This 62 year old educated, professional woman with possible breast cancer decided on Monday (4 days ago) that when she ran out of her oral diabetes drug intended to control her blood sugars, she decided that she did not want to renew it. So, when I met her, her blood sugars were very elevated. In fact, in a patient that did not have a wire sticking out of her breast, I would have canceled the case until we got her blood sugar under control. I could have easily given her insulin to fix the number, but the real concern was that when she got home, she was on no regimen to speak of. She had stopped taking her medication. So, whatever control I got in the hospital, would rapidly go away when she got home. The stress of the surgery combined with post-operative pain would have sent her blood sugar even higher, which could lead to serious problems that would interfere with wound healing and possibly endanger her life.
What do to? Well, this is the so-called knifes edge of our world. If you listen to the academic rhetoric being offer by Mr. Obama and Mr. Orzag and the rest, this would never happen. In their world with a new and improved health care system, people would be told in advance what is good for them and what is not, and we would never see an out of control diabetic that for all intents and purposes looked just like a 62 year old woman who had never been to a doctor for her diabates. In Mr. Obamas world this thing just does not happen. Well, in my world, it does, and every day. So, what should I do.
Option 1: Punish her. Chide her for being non-compliant and endangering her life and making my life difficult and say hey lady, we told you. We advised you, you told you how to prevent your diabetes from taking yout eyesight and your feeling in your feet and your kidney function. Sorry, you didnt listen to us and now, your government check writer says go away. You had your shot and you blew it.
Option 2: I admit her to the hospital, with wire and get her sugar under control. That costs money. Lots of it. A conversion of an outpatient surgery patient to an inpatient easily doubles or triples the cost. Her insurance may not pay, she may not be able to afford it. Under the Obama plans being bantered about, this decision would be considered poor quality and although best for the patient, was a bad idea and I am to be punished. My pay is cut, I get a black mark against me in the quality column. I get the blame and the penalty for a woman whom I never have met, but I am trying to do the right thing for.
Option 3: I take her to surgery and spend 4-6 hours after getting her blood sugar controlled enough to send her home with clear instructions on when to go to the Emergency Room. The chances that her sugars are high enough to get to an ER are high. If that happens, that is what Mr. Obama calls a re-admission to the hospital and according to most government guidelines for Medicare and some other programs, that is an entirely preventable thing. So, the hospital and the doctors are all punished in what is called pay for no-performance.
Option 4: Cancel the case, send her home with a wire in her breast and re-schedule for next week when her sugars are better controlled. Clearly a non-starter (Wow Jane!! I love the wire in the boob!! So avant garde!!)
I dont have the answer here. I cannot consider social policy in my day-to-day decisions. I have an obligation to help this woman do well, and that is the only factor that guides my choice. Under current rules my choices are challenging, but under the Obama plans, my options get even more limited.
So, what to do when a patient is not really interested in preventing anything? Consider this question as you watch this debate unfold.
This post was first published in DoctorSpring by a doctor. It has been reproduced here after due permission.